Type 2 diabetes mellitus facilitates endometrial hyperplasia progression by activating the proliferative function of mucin O-glycosylating enzyme GALNT2

OBJECTIVE

Type 2 diabetes mellitus (T2DM) is thought to be a risk factor for endometrial hyperplasia, but potential links between the two diseases are unknown. This study aims to evaluate the role of T2DM in the progression of endometrial hyperplasia.

METHODS

Female Sprague-Dawley rats were randomly divided into normal (N) group, endometrial hyperplasia (NH) group, T2DM (T) group, and endometrial hyperplasia with T2DM (TH) group. Proteomics analysis was performed to determine the protein profile of endometrial tissues. Proliferation, migration, and invasion of cells with/without GLANT2-knockdown were assessed. Immunohistochemical staining and ELISA were used to examine the expression of GALNT2 in endometrial tissues and serum of clinical samples.

RESULTS

The highest uterus index and endometrial thickness were observed in TH group, with the expression of proliferation marker PCNA increased significantly, indicating that T2DM facilitates the progress of endometrial hyperplasia. Proteomics analysis showed that there were significant differences in protein profiles among groups and differential proteins were mainly enriched in metabolic pathways. Further verification by molecular biology analysis indicated that GALNT2 is the key target for T2DM facilitating endometrial hyperplasia. The expression of GALNT2 was significantly decreased in high glucose environment. T2DM could synergize the proliferative function of GALNT2 aberration by activating EGFR/AKT/ERK pathway. The decreased expressions of GALNT2 in clinical samples were associated with worse subtypes of endometrial hyperplasia.

CONCLUSION

T2DM promoted the progression of endometrial hyperplasia by regulating the GALNT2-mediated phosphorylation of EGFR and enhancing cell proliferation. GALNT2 has the potential to be a novel biomarker in the treatment of endometrial hyperplasia.

Is there any difference between endometrial hyperplasia and endometrial carcinoma in terms of expression of TRPM2 and TRPM7 ion channels?

Background/aim

This study compared TRPM2 and TRPM7 ion channel gene expression and immunohistochemical staining in endometrial hyperplasia and endometrium adenocarcinoma.

Materials and methods

Sections were taken from paraffin blocks of 120 patients who were divided into 6 groups as follows: G1 (n = 20), proliferative endometrium (PE); G2 (n = 20), EH without atypia; G3 (n = 20), EH with atypia; G4 (n = 20), stage 1A, grade 1 EC; G5 (n = 20), stage 1A, grade 2 EC; and G6 (n = 20), stage 1A, grade 3 EC. TRPM2 and TRPM7 genes were analyzed with qRT-PCR in paraffin-embedded tissue samples. Under light microscopy, TRPM2 and TRPM7 immunostaining scores of the samples taken from polylysine slides were evaluated.

Results

Compared to G1, TRPM2 mRNA gene expression was significantly downregulated in G3 and G5. TRPM2 immunoreactivity scores were similar in all groups. TRPM7 mRNA gene expression was significantly downregulated in G2, G3, and G6 when compared to G1. TRPM7 immunoreactivity scores were similar in G1, G2, and G3, but significantly decreased in G4, G5, and G6

Conclusion

Reduction in TRPM7 ion channel activity may be a progression marker for endometrial hyperplasia regardless of the atypical criteria.

Complex non atypical hyperplasia and the subsequent risk of carcinoma, atypia and hysterectomy during the following 9-14 years

INTRODUCTION

The aim of this study was to evaluate the long-term risk of developing atypical hyperplasia/endometrial cancer or having a hysterectomy after being diagnosed with complex non-atypical hyperplasia (CH).

MATERIAL AND METHOD

A historic cohort study of 114 women diagnosed with CH between January 1st 2000 and December 31st 2005. All patient records and pathologic reports were reviewed with complete follow up on all patients in the national pathologic database until September 1st 2014. Kaplan-Meier analysis was used to determine (1) no hysterectomy and (2) no diagnosis of endometrial cancer or atypia after the CH diagnosis.

RESULTS

15% (n = 17) were diagnosed with endometrial cancer and 7% (n = 8) with atypia, most during the first year (10 cancer, 7 atypia). 9% (8/85) of the remaining women at risk developed cancer or atypia in the follow-up period after one year. By Kaplan-Meier the five-year risk for cancer or atypia was 20% (CI; 14-21). The risk of having undergone hysterectomy within five years was 30% (CI; 22-39).

CONCLUSION

The long-term risk of being diagnosed with atypia or cancer after a CH diagnose is not insignificant, when disregarding patients having undergone hysterectomy. More than half the women with atypia or cancer are diagnosed or operated during the first year. This could indicate the presence of concomitant but unidentified cancer or atypia at the time of initial sampling. This study reinforces the importance of follow up or treatment of women with CH - especially, but not only during the first year.

KEY MESSAGE

The risk of having a hysterectomy or diagnosed with atypical hyperplasia/cancer endometrie is high after a diagnosis of complex hyperplasia without atypia.

Efficacy of the levonorgestrel intrauterine system (LNG-IUS) in the prevention of the atypical endometrial hyperplasia and endometrial cancer: retrospective data from selected obese menopausal symptomatic women

The aim of this retrospective study was to evaluate the efficacy of levonorgestrel intrauterine system-releasing (LNG-IUS) insertion in preventing atypical endometrial hyperplasia (AH) and endometrial cancer (EC) in symptomatic postmenopausal overweight/obese women. A total of 34 overweight/obese postmenopausal women, presenting abnormal uterine bleeding (AUB) and endometrial hyperplasia (EH), and who were submitted to LNG-IUS insertion, were identified from registry data. Endometrial histology at LNG-IUS insertion showed simple EH in 20 cases (58.8%), complex EH in 14 cases (41.2%). At 36 months, 91% of patients showed no recurrence of AUB and a significant reduction in the mean endometrial thickness (from 8.2 ± 2.2 to 3.2 ± 1.5 mm, p < 0.05) was observed. Histologic regression of EH was observed in 27 (79.4%) and 33 (97.5%) cases at 12 and 36 months, respectively. None of the women in which EH persisted, reported cellular atypia or cancer progression at 12 and 36 months of follow-up. LNG-IUS represents an effective treatment option to manage postmenopausal obese women affected by AUB and EH. The device seems to be able to prevent the onset of AH and EC in women at high risk. Further prospective controlled studies in a well selected group of women are needed.

Fertility-sparing treatment of endometrial cancer precursors among young women: a reproductive point of view

BACKGROUND

Early-stage endometrial cancer and complex atypical hyperplasia are treated with hysterectomy and bilateral salpingo-oophorectomy. An emerging issue among younger women affected is the possibility of a fertility-sparing treatment with progestative therapy and close follow-up.

AIM

To assess the possibility of conceiving after a diagnosis of atypical endometrial hyperplasia among women younger than 40 years old, in term of delaying definitive treatment and achieving pregnancy.

MATERIALS AND METHODS

15 women younger than 40 years old with complex CAH or early carcinoma of the endometrium and a wish to preserve fertility. Progestins were administered orally for at least a 12 weeks period. Endometrial biopsies were used at follow-up.

RESULTS

In 11 women, a complete pathological remission of the disease was observed. 4 pregnancies were attained in 4 women. 3 showed progression and underwent definitive surgery at 18 months. 1 showed no response at 24 months and 3 cycles and was counseled to receive a hysterectomy.

CONCLUSIONS

A conservative approach in patients younger than 40 years appears a valid option, and a progestative therapy trial should be attempted whether a valid consensus is attained. Considering the risk to find AEH at biopsies and eventually a carcinoma at hysterectomy (25% of cases) a careful management is strictly required.

The role of hypertension, body mass index, and serum leptin levels in patients with endometrial hyperplasia during premenopausal period

OBJECTIVES

to investigate whether body mass index (BMI), hypertension (HTN), diabetes, age, and physical activity can be considered risk factors for endometrial simple hyperplasia in premenopausal women. Furthermore this study was undertaken to determine whether serum concentration of leptin in patients with BMI>or= 30 kg / m2 with endometrial hyperplasia deviate from values in patients with normal endometrium.

MATERIALS AND METHODS

The authors enrolled 167 hyperplasia cases and 282 controls. Demographic characteristics and data on age, diabetes, hypertension, BMI, physical activity, and anthropometric parameters were collected. Leptin concentration in serum was measured with immunoenzymatic test kit from IBL. Univariable and multivariable analysis were performed to verify the association among age, HTN, BMI, physical activity, diabetes, and the presence of uterine hyperplasia. Furthermore the authors evaluated the correlation between BMI and leptin level (with Pearson's linear correlation) in women with simple hyperplasia and in controls.

RESULTS

The prevalence of hyperplasia found was 34.4%. The following factors were independently associated with increased risk of endometrial hyperplasia: HTN (odds ratio 3.19, 95% confidence interval 1.20-8.48, p<0.020) and BMI>or=30 Kg/m2 (odds ratio 6.43, 95% confidence interval 3.92-10.53, p<0.000). Mean leptin concentration in serum was higher in patients who had endometrial hyperplasia than in controls (p<0.005) and the leptin levels depended on BMI.

CONCLUSIONS

The following are risk factors for endometrial hyperplasia in premenopausal women: BMI>or=30 kg/m2 and HTN (blood pressure>or=130/85 or in therapy). Leptin appears to participate in proliferative processes of the endometrium, depending on BMI. Current guidelines may need to be reconsidered.

The diagnostic value of evaluating the maximum velocity of blood flow in the uterine arteries of women with postmenopausal bleeding

PURPOSE

The aim was to evaluate the utility of ultrasonographic examinations, such as the Doppler technique, in diagnosing women with postmenopausal bleeding.

METHODS

Specifically, maximum end-diastolic velocity of blood flow (MEDV), time-averaged maximum velocity of blood flow (TAMXV) and peak systolic velocity of blood flow (PSV) were evaluated. Data were obtained and analyzed from a group of 100 female patients diagnosed and treated because of abnormal bleeding from the genitals in the Gynecological-Obstetrics Clinical Hospital of Poznan University of Medical Sciences. The following packages were used for statistic analyses: STATISTICA v 7.1 (StatSoft, Inc. 2005), StatXACT v.5.0.3, CYTEL SOFTWARE CORPORATION and Analyse-it Software v.1.68.

RESULTS

The parameters evaluated were highest in the carcinoma group, lower when proliferation was diagnosed and the lowest in the control group.

CONCLUSIONS

Transvaginal ultrasonography diagnostics using the Doppler technique was found to play an important role in the diagnostic process of pathologies within the endometrium.

Body mass index of patients with endometrial hyperplasia: comparison to patients with proliferative endometrium and abnormal bleeding

OBJECTIVE

Endometrial hyperplasia is a known risk factor for the development of endometrial cancer, particularly atypical hyperplasia, with a subsequent risk of up to 30%. Of the known risk factors for endometrial hyperplasia, obesity is the most preventable, but there is a paucity of data addressing the association. We tested the hypothesis that patients with endometrial hyperplasia have a higher body mass index (BMI) than patients with abnormal bleeding who are found to have proliferative endometrium.

STUDY DESIGN

This was an Institutional Review Board-approved retrospective study using University Hospital Department of Pathology records. All patients who had endometrial sampling performed between January 1, 2001, and July 30, 2008, were included. The experimental group consisted of patients with endometrial hyperplasia including simple, complex and atypical hyperplasia. The control group consisted of patients who underwent endometrial sampling for abnormal bleeding during the same time period and were diagnosed with proliferative endometrium. BMI was calculated based on documented height and weight within 30 days of endometrial sampling.

RESULTS

Forty-two patients with hyperplasia and 103 patients with proliferative endometrium met inclusion criteria, including documented height and weight and nonexposure to hormones. The median BMI in the hyperplasia group was 38 kg/m2 (95% CI 34.8-42.4) and 30 kg/m2 (95% CI 29.9-33.3) in the proliferative group (p < 0.0001).

CONCLUSION

These data suggest that higher BMI is associated with endometrial hyperplasia as compared to women with lower BMIs and abnormal bleeding.

Characteristics of abnormal menstrual cycle and polycystic ovary syndrome in community and hospital populations

BACKGROUND

Polycystic ovary syndrome (PCOS) is considered to be the most common endocrine disorder in women of reproductive age. The involvement of an abnormal menstrual cycle in the etiology of PCOS remains unclear. We aimed to analyze the characteristics of abnormal menstrual cycles and their association with PCOS in community and hospital patient populations.

METHODS

Women with PCOS identified from 2111 permanent female residents in the community of Beijing and 506 outpatients obtained from the reproductive clinic of Peking University Third Hospital were recruited for this study, comprising the PCOS community group and the PCOS hospital group, respectively. Each group was further divided into four subgroups according to the length of menstrual cycles: <21 days; 21-34 days; 35-60 days; and >60 days. Women in each group were interviewed using a questionnaire to assess factors including age, age of menarche, menstrual cycle history, related family history, and modified Ferriman-Gallwey (mF-G) score. All women received transvaginal ultrasound scan and had fasting blood samples taken for endocrine evaluation. A two-tailed P value of <0.05 was considered significant.

RESULTS

In the community population, the prevalence of abnormal menstrual cycle was 27.19% (574/2111). The prevalence of PCOS in the community was 6.11% (129/2111) according to Rotterdam criteria. In the community group, the most common menstrual cycle length was 35-60 days, whereas for the hospital group, it was >60 days. In both the community and hospital groups, the most common phenotype of PCOS was that of Oligo/amenorrhea+PCO+ hyperandrogenism (HA) (O+P+H) (P=0.000). With increasing cycle length of 35-60 days to >60 days, the percentages of Oligo/amenorrhea+PCO (O+P) and O+P+H were found to significantly decrease in the community group and significantly increase in the hospital group (P=0.000 for each). In the hospital group, as the menstrual cycle length increased from 35-60 days to >60 days, the rate of spontaneous abortion increased significantly (P=0.000), meanwhile the rate of poorly-secreted endometrium and abnormal endometrial hyperplasia increased significantly (P=0.000).

CONCLUSIONS

The prevalence of PCOS in the Beijing community of women was 6.11%. Oligo/amenorrhea was the most common type of abnormal menstrual cycle and may be an indicator for PCOS and endometrial lesions. Gynecologists should seek relevant medical information from women in the community to promptly diagnose PCOS and then follow up patients for potential development of subsequent complications.

Successful twin pregnancy achieved by assisted reproductive technology in a patient with polycystic ovary syndrome with complex atypical endometrial hyperplasia treated with levonorgestrel-releasing intrauterine system

Polycystic ovary syndrome (PCOS) is one of the most common reproductive endocrinopathy and a major cause of infertility. PCOS may be associated with chronic anovulation and endometrial hyperplasia. Conservative treatment should be considered in young women wishing to preserve their fertility. Standard treatment for complex endometrial hyperplasia is the use of high-dose progesterone, whereas we preferred levonorgestrel-releasing intrauterine system (LNG-IUS) as a last resort in our patient who was resistant to oral gestagens. We present a case with complex atypical endometrial hyperplasia treated conservatively in a long-term period first by oral gestagens, then by LNG-IUS. In our case, LNG-IUS was more effective than oral systemic progestins, not only for reducing the menstrual blood loss but also for improving the pathological findings. After extraction of LNG-IUS rapid achievement of pregnancy was carried out by intracytoplasmic sperm injection and embryo transfer and she took home twin babies. To the best of our knowledge, this is the first successful twin pregnancy case with ICSI and ET in a patient with oral gestagen resistant endometrial complex/atypical hyperplasia achieved after application of LNG-IUS. In complex atypical hyperplasia, LNG-IUS should be kept in mind as an effective alternative treatment modality before assisted reproductive technology (ART).

Immunohistochemical expression of PTEN in normal, hyperplastic and malignant endometrium and its correlation with hormone receptors, bcl-2, bax, and apoptotic index

PTEN is a tumor suppressor gene that is frequently mutated in type I endometrioid endometrial carcinomas (EECs), and is involved in the control of cell proliferation, differentiation, and apoptosis. In this study, we aimed to assess the relationship between PTEN expression and estrogen, progesterone receptors (PRs), other apoptosis-related proteins, such as bcl-2 and bax, and apoptotic index (AI) in EEC, its precursor lesion hyperplasia, and cyclical endometrium. We also evaluated the relationship between PTEN expression and clinicopathologic parameters. PTEN, estrogen receptor (ER), PR, and bcl-2 and bax expressions were evaluated immunohistochemically, and AI was evaluated in hematoxylin and eosin (HE)-stained slides in 23 cyclical and 37 hyperplastic endometria and in 35 EECs. PTEN expression was higher in cyclical endometrium than in the carcinomas (p<0.05). The PTEN expression level was significantly higher in non-atypical hyperplasias than in EEC, but there were no differences between atypical complex hyperplasia (ACH) and EEC and between hyperplasias. In the carcinomas, there was a negative correlation between grade and PTEN expression (r=-0.338, p=0.047). In conclusion, we presume that PTEN is involved in the early phases of endometrial tumorigenesis, and it can be speculated that decreased PTEN expression with loss of differentiation in carcinoma can contribute to the emergence of tumors with a more aggressive phenotype.

Patterns of loss of heterozygosity at 10q23.3 and microsatellite instability in endometriosis, atypical endometriosis, and ovarian carcinoma arising in association with endometriosis

Genetic aberrations, such as loss of heterozygosity (LOH) and mutations leading to functional inactivation of the PTEN tumor suppressor gene, located on chromosome 10q23.3, have been shown to be associated with approximately one third of ovarian adenocarcinomas. In addition, microsatellite instability (MSI) leading to the functional inactivation of the PTEN gene has also been reported for ovarian adenocarcinomas with frequencies varying from 6 to 37%. However, the frequency of PTEN gene abnormalities has not been well studied or evaluated in lesions such as typical and atypical endometriosis. The aim of this study was to investigate a possible sequential progression from endometriosis through atypical endometriosis to ovarian carcinoma by assessing LOH at 10q23.3 and MSI in those entities. Genomic DNA was analyzed for LOH and MSI at 3 loci on chromosome 10, using polymerase chain reaction amplification. Significant differences in LOH were seen between endometriosis (4.3%) and ovarian carcinoma (23.5%) at D10S608. The differences at the other 2 loci were not significant. A high frequency of MSI was found in endometriosis (82.6%) and atypical endometriosis (75%); however, the differences were not significant. These results suggest that LOH at D105608 may possibly be an important molecular event in the progression of endometriosis to carcinoma. This study highlights that endometriosis and atypical endometriosis might act as precursor lesions that have the potential to progress into ovarian adenocarcinoma.

Orphan nuclear receptor DAX-1 in human endometrium and its disorders

DAX-1 (dosage-sensitive sex reversal adrenal hypoplasia congenita critical region on the X chromosome gene 1) is a recently characterized member of the orphan nuclear receptor family. DAX-1 functions as a global negative regulator of steroid hormone production. It inhibits adrenal 4 binding protein (Ad4BP)/steroidogenic factor-1 (SF-1) pathway-dependent P450arom expression in cultured human endometriotic stromal cells and acts as a corepressor for estrogen receptors (ER). In this study we first examined the localization of DAX-1 in 46 normal cycling endometria, 36 cases of endometrial hyperplasia and 103 cases of endometrial carcinoma by using immunohistochemistry to elucidate the possible involvement of DAX-1 and its correlation to the status of Ad4BP/SF-1, a universal transcription factor of steroidogenesis. We then evaluated DAX-1 mRNA expression, using quantitative reverse transcription-polymerase chain reaction for DAX-1 in 33 cases of endometrial carcinoma for further characterization. We subsequently correlated these findings with various clinicopathological parameters of the cases. Ad4BP/SF-1 immunoreactivity was not detected in any human endometria examined. A significant inverse correlation was detected between the status of DAX-1 immunoreactivity and histological grade (P = 0.0003) in endometrial carcinoma. The labeling index (LI) values of DAX-1 in normal endometrium during the secretory phase (P < 0.0001) and hyperplasia (P < 0.0001) were significantly higher than that of carcinoma. No significant correlations were detected between DAX-1 immunoreactivity and amounts of aromatase mRNA. There was a statistically significant positive correlation between DAX-1 and ERalpha (P = 0.006) and ERbeta LI (P < 0.001). These findings suggest that DAX-1 may inhibit the proliferation and progression of endometrial carcinoma through inhibition of estrogenic actions, possibly by interacting with ER present in carcinoma cells, rather than regulating in situ steroidogenesis.

The molecular genetics and morphometry-based endometrial intraepithelial neoplasia classification system predicts disease progression in endometrial hyperplasia more accurately than the 1994 World Health Organization classification system

BACKGROUND

The objective of this study was to compare the accuracy of disease progression prediction of the molecular genetics and morphometry-based Endometrial Intraepithelial Neoplasia (EIN) and World Health Organization 1994 (WHO94) classification systems in patients with endometrial hyperplasias.

METHODS

A multicenter, multivariate analysis was conducted on 477 patients with endometrial hyperplasia who were required to have a 1-year minimum disease-free interval from the time of the index biopsy (1-18 years of follow-up). The results from that analysis were compared with the results from 197 patients who had < 1 year of follow-up.

RESULTS

Twenty-four of 477 hyperplasias (5.0%) progressed to malignant disease over an average of 4 years (maximum, 10 years). According to the WHO94 classification, 16 of 123 atypical hyperplasias (13%) and 8 of 354 nonatypical hyperplasias (2.3%) progressed (hazard ratio [HR] = 7). Twenty-two of 118 EINs (19%) and 2 of 359 non-EINs (0.6%) progressed (HR = 45). EIN was prognostic within each WHO94 subcategory. Progression rates were 3% in simple hyperplasias, 22% in complex hyperplasias, 17% in simple atypical hyperplasias, and 38% in complex atypical hyperplasias with EIN, compared with progression rates of 0.0-2.0% in all hyperplasias if EIN was absent. EIN detected precancerous lesions (sensitivity, 92%) better than WHO94 atypical hyperplasias collectively (67%) or complex atypical hyperplasias alone (46%). In a Cox regression analysis, EIN was the strongest prognostic index of future endometrial carcinoma. The same was true for patients with < 1 year of follow-up (HR for EIN, atypical hyperplasia, and complex atypical hyperplasia: 58, 7, and 8, respectively).

CONCLUSIONS

The EIN classification system predicted disease progression more accurately than the WHO94 classification and identified many women with benign changes that would have been regarded as high risk according to the WHO94 classification system.

Clinical and pathological responses of progestin therapy for non-atypical endometrial hyperplasia: A prospective study

AIMS

To evaluate the clinical and pathological responses and factors predicting non-responders to various progestins currently prescribed for the treatment of non-atypical endometrial hyperplasia.

METHODS

A prospective observational study was conducted in the Gynecologic Endocrinology Unit, Faculty of Medicine, Siriraj Hospital, Thailand, from 1998 to 2003. A 6-month course of progestin therapy was offered to all patients. The clinical response was evaluated from the vaginal bleeding pattern during the first 4 months of treatment. The pathological response was evaluated from the histopathology of the endometrium after completion of the 6-month therapy.

RESULTS

Of 250 registered patients, the number of cases qualified for the evaluation of the clinical and pathological response were 198 and 134 cases, respectively, revealing the overall clinical and pathological response rates of 93.4% and 92.5%, respectively. Among 13 clinical non-responders, 84.6% might have associated pelvic pathology. Among 10 pathological non-responders, three had surgical treatment, and progressive disease was found in one case. Significant factors predicting clinical non-responders included a history of prior bleeding (odds ratio [OR] = 8.79, 95% confidence interval [CI] = 1.63, 47.53), the presence of associated pelvic pathology (OR = 25.52, 95% CI = 3.21, 203.01), and treatment using progestins other than medroxyprogesterone acetate. Factors predicting pathological non-responders were not statistically significant.

CONCLUSIONS

The current regimens of progestin therapy for non-atypical endometrial hyperplasia have high response rates. Patients who fail to have a clinical response should be evaluated for associated pelvic pathology. Follow-up endometrial biopsy should be offered to the patients, because 7.5% have persistent or progressive lesions, necessitating aggressive treatment.

Endometrial Hyperplasia: A Review

Endometrial hyperplasia is a precursor to the most common gynecologic cancer diagnosed in women: endometrial cancer of endometrioid histology. It is most often diagnosed in postmenopausal women, but women at any age with unopposed estrogen from any source are at an increased risk for developing endometrial hyperplasia. Hyperplasia with cytologic atypia represents the greatest risk for progression to endometrial carcinoma and the presence of concomitant carcinoma in women with endometrial hyperplasia. Abnormal uterine bleeding is the most common presenting symptom of endometrial hyperplasia. Specific Pap smear findings and endometrial thickness per ultrasound could also suggest the diagnosis. Unopposed estrogen in women taking hormone replacement therapy increases the risk of endometrial hyperplasia. Tamoxifen has demonstrated its efficacy in treating women at risk for breast cancer, but it increases the risk of endometrial hyperplasia. The choice of treatment for endometrial hyperplasia is dependent on patient age, the presence of cytologic atypia, the desire for future childbearing, and surgical risk. Endometrial hyperplasia without atypia responds well to progestins. However, women with atypical hyperplasia should be treated with hysterectomy unless other factors preclude surgery.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to describe the definition and classification of endometrial hyperplasia, to outline the clinical features of a patient with endometrial hyperplasia, to point out the natural history of endometrial hyperplasia, and to summarize the diagnostic options for patients with endometrial hyperplasia.

Expression of steroid receptor coactivators and corepressors in human endometrial hyperplasia and carcinoma with relevance to steroid receptors and Ki-67 expression

BACKGROUND

To examine the steroid hormone dependent growth mechanism of human endometrial hyperplasia and carcinoma, expression levels of steroid receptor cofactors, such as coactivators (steroid receptor coactivator 1 [SRC-1] and p300/cyclic AMP-response element-binding protein (p300/CBP]) and corepressors (nuclear receptor corepressor [NCoR] and silencing mediator for retinoid and thyroid-hormone receptors [SMRT]), were investigated.

METHODS

The expression levels of cofactors were examined immunohistochemically using 20 samples of normal endometria, 36 samples of hyperplastic endometria, and 58 of malignant endometria and were compared with the expression levels of estrogen receptor (ER), progesterone receptor (PR), and a proliferation marker, Ki-67.

RESULTS

In samples of normal endometria, the expression of coactivators was observed diffusely in glandular cells in the proliferative phase, with a mean positivity index (PI) of 81.8 for SRC-1 and 91.3 for p300/CBP, whereas expression levels decreased in endometrial hyperplasia (PI: SRC-1, 58.9; p300/CBP, 83.8) and endometrial carcinoma (PI: SRC-1, 45.0; p300/CBP, 55.4). In endometrial hyperplasia, there was a significant correlation between the expression of ER and SRC-1 or p300/CBP. In contrast, there were no significant statistical or topologic correlations between the expression of coactivators and the expression of ER/PR in endometrial carcinoma. The expression of corepressors generally was limited, except for elevated expression of NCoR in endometrial hyperplasia (PI, 23.8).

CONCLUSIONS

The current study showed that expression levels of the steroid receptor coactivators SRC-1 and p300/CBP were reduced in endometrial carcinoma compared with normal and hyperplastic endometrium. In addition, topologic coexpression of both coactivators and ER/PR was lost in endometrial carcinoma. Accordingly, limited response to sex steroids in patients with endometrial carcinoma may be ascribed to the dissociation of cofactors and ER/PR.

Endometrial blood flow mapping using transvaginal power Doppler sonography in women with postmenopausal bleeding and thickened endometrium

OBJECTIVE

To evaluate the role of transvaginal power Doppler sonography to discriminate between benign and malignant endometrial conditions in women presenting with postmenopausal bleeding and thickened endometrium at baseline sonography.

METHODS

Ninety-one postmenopausal women (median age, 58 years; range, 47-83 years) presenting with uterine bleeding and a thickened endometrium (> or = 5-mm double-layer endometrial thickness) on transvaginal sonography were included in this prospective study. Endometrial blood flow distribution was assessed in all patients by power Doppler immediately after B-mode transvaginal sonography. Three different vascular patterns were defined: Pattern A: multiple-vessel pattern, Pattern B: single-vessel pattern and Pattern C: scattered-vessel pattern. Histological diagnoses were obtained in all cases. No patient taking tamoxifen citrate or receiving hormone replacement therapy was included.

RESULTS

Histological diagnoses were as follows: endometrial cancer: 33 (36%), endometrial polyp: 37 (41%), endometrial hyperplasia: 14 (15%), endometrial cystic atrophy: 7 (8%). Blood flow was found in 97%, 92%, 79% and 85% of cases of carcinoma, polyp, hyperplasia and endometrial cystic atrophy, respectively. A total of 81.3% of vascularized endometrial cancers showed Pattern A, 97.1% of vascularized polyps exhibited Pattern B and 72.7% of vascularized hyperplasias showed Pattern C. Sensitivity and specificity for endometrial cancer were 78.8% and 100%. For endometrial polyp these respective values were 89.2% and 87% and for hyperplasia they were 57.1% and 88.3%.

CONCLUSIONS

Transvaginal power Doppler blood flow mapping is useful to differentiate benign from malignant endometrial pathology in women presenting with postmenopausal bleeding and thickened endometrium at baseline sonography.

Endometrial hyperplasia with secretory changes

OBJECTIVE

Secretory changes in endometrial hyperplasia are uncommon. The aim of this study is to review the morphologic and clinical findings of 24 cases of endometrial hyperplasia with secretory changes.

METHODS

In 24 patients diagnosed with endometrial hyperplasia with secretory changes during 6 years, clinical characteristics such as menopausal status and hormone treatment were correlated with morphological features. A matched age control group of 24 women with conventional endometrial hyperplasia was used to compare the hormonal effect.

RESULTS

Nineteen patients were premenopausal. Nine women showed simple hyperplasia without atypia and 15 complex hyperplasia, 7 of them with atypia. Seventeen women were under hormonal treatment at the time of diagnosis, 10 of them with progestins. In 7 patients endometrial adenocarcinoma could be seen, 5 coexisting with endometrial hyperplasia with secretory changes and in 2 appearing after 1 and 4 months. In control group only 2 patients were undergoing progestin hormonal treatment.

CONCLUSIONS

Secretory changes can be found in hyperplastic endometrium, particularly in premenopausal women under hormonal treatment with progestins, with the risk of misdiagnosis.

Activation of the receptor protein tyrosine kinase EphB4 in endometrial hyperplasia and endometrial carcinoma

BACKGROUND

Members of the Eph family of tyrosine kinases have been implicated in embryonic pattern formation and vascular development; however, little is known about their role in the adult organism. We have observed estrogen-dependent EphB4 expression in the normal breast suggesting its implication in the hormone-controlled homeostasis of this organ. Since the endometrium is a similarly hormone dependent organ and endometrial carcinoma is thought to result from estrogenic stimulation, we have investigated EphB4 expression in normal human endometrium and during its carcinogenesis.

PATIENTS AND METHODS

EphB4 expression was analyzed immunohistochemically in 26 normal endometrium specimens, 15 hyperplasias and 102 endometrioid adenocarcinomas and correlated with clinical and prognostic tumor characteristics.

RESULTS

In normal endometrial tissue no EphB4 protein was detected. Strikingly, we observed a drastic increase (P <0.0001) in the number of EphB4 protein-expressing glandular epithelial cells in the majority of hyperplasias and carcinomas. Moreover, we found a statistically highly significant positive correlation between EphB4 expression and post-menopausal stage of the patient (P = 0.007).

CONCLUSIONS

These findings indicate that in the endometrium, EphB4 is an early indicator of malignant development and, thus, EphB4 may represent a potent tool for diagnosis and therapeutic intervention.

[Pathogenetic basis of hormonal endometrial hypertrophy in early spontaneous abortions]

Pathogenetic role of hormonal dissociation produced by disturbances of biochemical transformation of testosteron to estradiol in the mechanism of deficient gestational endometrial transformation is shown.

Function of insulin-like growth factor (IGF-I) and its binding protein (IGFBP-1) in pathological proliferation of endometrium

The purpose of this project was the investigation of insulin, IGF-I and IGFBP-1 concentrations in the serum of patients with pathological changes in endometrium. IGF-I and its binding protein (IGFBP-1) stimulate cell growth and differentiation of the normal and neoplastic endometrium. The mean values of IGF-I concentrations in the group of patients with atypical hyperplasia and endometrial carcinoma were significantly higher than in the control group with normal endometrium. Significantly higher IGFBP-1 concentrations were found in the serum of patients with the atypical hyperplasia of endometrium and endometrial carcinoma. The correlation between insulin concentration and changes in endometrium in the examined groups was not found.

Quantitative analysis of estrogen receptor-alpha and -beta and exon 5 splicing variant mRNA in endometrial hyperplasia in perimenopausal women

We used real-time reverse transcription-polymerase chain reaction (QRT-PCR) to detect wild-type ERalpha and ERbeta and their isoforms as well as exon 5 splicing variant mRNA ERalpha in various types of endometrial hyperplasia in perimenopausal women. Our data suggest that the exon 2 and 7 deletion ERalpha mRNA isoforms are present in endometrial tissue undergoing various hyperplastic states. Wild type ERbeta mRNA and their isoforms 2, 4, 5, 6 were observed in each type of assessed endometrial specimens, and ERalpha/delta5 was found only in hyperplasia complex group.

[Nucleolar organizers and mitotic conditions in endometrial hyperplasia and carcinomaĭ]

The study deals with the levels of nucleolar organizers (NO) and mitotic conditions in 85 samples of the endometrium (proliferative stage of menstrual cycle--5; glandular hyperplasia--10; adenomatosis--15; atypical hyperplasia--25 and adenocarcinoma--25). These findings point to a significant increase in NO number in atypical hyperplasia and especially in adenocarcinoma. The latter showed an inverse correlation between the index under study and cell differentiation stage. Endometrial mitosis displayed a higher mitotic index, a larger fraction of pathological mitoses and cells passing through metaphase as well as a variety of pathological forms of karyokinesis. A high correlation between NO number and mitotic index was observed for different conditions of the endometrium.

Oestrogen and progesterone receptors in the uterine wall of bitches with cystic endometrial hyperplasia/pyometra

Fresh samples of uterine wall and peripheral plasma were obtained from 13 bitches of different breeds when they were treated for cystic endometrial hyperplasia/pyometra by ovariohysterectomy. The plasma samples were assayed for progesterone and 17beta-oestradiol, and the tissue samples were examined histopathologically and for the presence of oestrogen and progesterone receptors by an immunocytochemical method. The immunoreactivity was scored semiquantitatively, taking into account both the intensity and distribution of the specific staining of the receptors, by using a simplified scoring system. The scores for both oestrogen and progesterone receptors in the glandular epithelium were much lower, and in the endometrial stroma a mean (sd) score for oestrogen receptors was 46.0 (44.7) compared with 0 in comparable endometrial tissues from normal bitches at the same stage of the oestrous cycle.

Angiogenesis of the endometrium

OBJECTIVE

To present current data pertaining to angiogenesis of the endometrium throughout the normal menstrual cycle and in benign and neoplastic diseases of the endometrium.

SOURCES

We conducted a computerized search of MEDLINE, Current Contents, and Index Medicus for relevant studies in the English literature published between January 1966 and October 1998.

STUDY SELECTION

We reviewed all studies that included human and animal models of angiogenesis of normal cyclic endometrium and benign and neoplastic endometrial diseases.

TABULATION, INTEGRATION, AND RESULTS

Angiogenesis is important to cyclic, regenerating endometria and disease processes including dysfunctional uterine bleeding, response to exogenous hormonal treatment, bleeding associated with intrauterine contraceptive devices, uterine leiomyomata, endometriosis, complex endometrial hyperplasia, and endometrial carcinoma.

CONCLUSION

In the future, knowledge of specific angiogenic patterns of various disease processes might improve application of antiangiogenic medications in therapies for benign and neoplastic diseases of the endometrium.

The effect of medroxyprogesterone acetate on angiogenesis in complex endometrial hyperplasia

OBJECTIVE

To evaluate the effect of orally administered medroxyprogesterone acetate upon angiogenesis in the myometrium of patients with complex endometrial hyperplasia.

METHODS

Microvessel counts in the myometrium of consecutive patients with complex endometrial hyperplasia, treated with oral medroxyprogesterone acetate prior to hysterectomy (n = 12), were compared with microvessel counts of consecutive control patients with complex endometrial hyperplasia without prehysterectomy medroxyprogesterone acetate treatment (n = 15). All specimens were stained immunohistochemically for factor VIII-related antigen as a sensitive and specific marker for vascular endothelium. Areas with the highest angiogenic intensity, within the myometrium immediately underlying complex endometrial hyperplasia, were selected. Three fields (x400) were selected for each slide, and the mean microvessel count per high-power field was calculated. Statistical analysis included factorial analysis of variance/covariance, and multiple regression analysis with P < 0.05 considered significant throughout.

RESULTS

Microvessel counts of uterine specimens of patients with complex endometrial hyperplasia treated with oral medroxyprogesterone acetate were significantly lower than microvessel counts of control patients with complex endometrial hyperplasia without medroxyprogesterone acetate therapy (median 20, range 11-37 versus median 38, range 20-130, respectively, P < 0.001).

CONCLUSION

Orally administered medroxyprogesterone acetate has a significant antiangiogenic effect upon myometrium immediately underlying complex endometrial hyperplasia.

[The correction of immunoendocrine disorders in patients with hyperplastic processes in the endometrium]

Effects were studied of extremely high-frequency electromagnetic radiation (EHF EMR) on indices for the immune and endocrine systems in a series of 48 patients presenting with hyperplastic processes in endometrium. EHF EMR-related normalization of values for the above systems was found out to take place together with a return of correlations back to normal, which fact makes it possible to use this modality as an immunocorrective factor.

Endometrial cancer: current concepts and management

Endometrial cancer is the most common pelvic gynecologic cancer in women. Its occurrence is associated with endometrial hyperplasia, unapposed estrogen therapy, and more recently, tamoxifen. The staging uses information obtained at the time of surgery. Hysterectomy continues to be the primary treatment for most patients with endometrial cancer, whereas postoperative radiation therapy is used in the treatment of patients with other than low-risk prognostic factors.

Towards the prevention of vein graft failure

Improved outcome after coronary bypass surgery over the last decade has been attributed largely to the increasing use of arterial conduits and their superior patency rates over that of saphenous vein grafts. In spite of this trend, autologous saphenous vein has remained an important and convenient conduit for a variety of operative scenarios, and is still used for more than 70% of grafts. As a result, vein graft failure continues to represent a significant clinical and economic burden upon the health care service. Between 15 to 30% of saphenous vein grafts occlude within the first year of surgery, increasing to over 50% after 10 years. By this time, more than 10% of patients will require further intervention to alleviate symptoms arising from occluded grafts and progression of native disease. Graft occlusion arises either from early thrombosis or the later onset of 'vein graft disease' and subsequent atherosclerotic changes.

Dysmenorrhea and dysfunctional uterine bleeding

Dysfunctional uterine bleeding is a diagnosis of exclusion. Endometrial cancer and endometrial precursor lesions must be excluded before a diagnosis of anovulatory bleeding is made. Treatment consists of intravenous estrogen therapy, oral contraceptive pills, and progestational agents. Menorrhagia is excessive menstrual bleeding treated with antiprostaglandins, levonorgestrel-releasing intrauterine contraceptive devices, endometrial ablation, and danazol. Dysmenorrhea results from the release of prostaglandin 2alpha and is treated with antiprostaglandin agents such as nonsteroidal anti-inflammatory drugs.

Growth factors and myointimal hyperplasia in experimental aortic allografts

OBJECTIVES

To analyse the role of growth factors (platelet derived growth factor, PDGF; basic fibroblast growth factor, bFGF; interleukin 1, IL-1) in the genesis of myointimal hyperplasia in arterial allografts.

MATERIALS

Two groups of experiments were performed: isografts and allografts. The isograft group consisted of 15 inbred Lewis rats in which a 1 cm long segment of aorta was inserted as an abdominal aortic interposition graft. The aortic segments were obtained from syngenic Lewis rats. The allograft group consisted of 15 inbred Lewis rats, in which a 1 cm long segment of aorta was interposed at the abdominal aorta level. The aortic segments were obtained from allogenic Brown-Norway rats.

CHIEF OUTCOME MEASURES

The animals were killed 4 weeks after surgery and were analysed by morphometric analysis (n = 3 for each group). In addition, production of PDGF, bFGF and IL-1 by aortic segments (n = 12 for each group) in organ culture was assessed.

MAIN RESULTS

Allografts had more myointimal hyperplasia, than isografts (p < 0.05). PDGF and bFGF production, generally considered to be the cause of myointimal hyperplasia, was not increased in allografts. IL-1 production was higher in allografts (p < 0.001).

MAIN CONCLUSIONS

Myointimal hyperplasia in aortic allografts is dependent on growth factors produced by the graft itself. These growth factors are different from PDGF and bFGF that generally have been implicated in the genesis of naturally occurring myointimal hyperplasia and atherosclerosis. IL-1 may have a principal role in the genesis of myointimal hyperplasia in arterial allografts.

Expression of angiotensin II and its receptor subtypes in endometrial hyperplasia: a possible role in dysfunctional menstruation

Dysfunctional uterine bleeding is associated with hyperplastic endometrium, and angiotensin II may affect cyclic menstruation. Cellular distribution of angiotensin II and its receptor subtypes (AT1 and AT2) in hyperplastic endometria from patients who had dysfunctional uterine bleeding with or without progestogen treatment was investigated by immunocytochemistry and quantitative receptor autoradiography. Angiotensin II-like immunoreactivity decreased in the hyperplastic endometrial stroma and glandular epithelia compared with normal cyclic endometria. The pattern of angiotensin II immunostaining on perivascular stromal cells in hyperplastic endometria was markedly different from that detected in the normal endometrium. The angiotensin II-like immunostaining was more intense in the progestogen-treated endometria compared with normal endometria. In the progestogen-treated endometrium from patients who had regular menstrual cycles, the angiotensin II-like immunostaining was localized in the perivascular stromal cell, as seen in the normal cyclic endometrium. Both AT1 and AT2 receptor levels in the hyperplastic and progesterone-treated endometria were significantly lower than the levels detected in normal endometrium. The results suggest that the normal function of angiotensin II in endometrium may be essential for regular cyclic menstruation and that alteration in the distribution of angiotensin II and/or the levels of its receptors are likely to be involved in dysfunctional uterine bleeding associated with hyperplastic endometria.

A comparative study of risk factors for hyperplasia and cancer of the endometrium

A cohort study has been carried out to investigate risk factors for cancer as well as hyperplasia of the endometrium. Over the 13 years for which we followed 25,000 women aged 40-65 (who took part in a population-based screening programme for breast cancer), 111 cases of endometrial cancer and 109 cases of endometrial hyperplasia were diagnosed. A comparison of the outcome between the two disease entities revealed that large body weight among postmenopausal women and the use of oestrogenic drugs at all ages were risk factors for both cancer and hyperplasia of the endometrium. However, reproductive histories and premenopausal steroid profiles differed. Steroid excretion determinations in urine samples collected years before diagnosis provided further evidence in favour of the hypothesis of unopposed action of oestrogens in the aetiology of endometrial cancer. In women who were to develop endometrial hyperplasia or cancer the obesity-oestrogen relationship was stronger than in those who remained free of endometrial disease during the period of follow-up. The possible significance of differences in aromatase activity among the obese is considered.

Localized endometrial proliferations associated with pregnancy: clinical and histopathologic features of 11 cases

Eleven cases of an unusual endometrial glandular proliferation associated with early pregnancy are reported. All lesions were incidental discoveries in first-trimester gestational endometria (two elective abortions; five spontaneous abortions; three hydatidiform moles; one tubal ectopic pregnancy). Most patients (nine of 11; 82%) were older than 30 years of age; associated clinical features included oligoovulation (two), hypertension (one), and obesity (one). All lesions were small and localized, and displayed similar histological features of variable severity including glandular expansion with smooth external contours; epithelial stratification (4 to 15 layers); cribriforming (focal to extensive); mitotic activity; bland nuclear cytology; and prominent intraglandular calcifications (eight cases; 72%). Although the natural history of these distinctive pregnancy-associated endometrial lesions was unknown, nine lesions were initially classified as benign, and two were interpreted as atypical endometrial hyperplasia or focal adenocarcinoma. Follow-up for an average of 34 months (range, 18 to 56) in nine patients showed no residual endometrial lesion (seven endometrial curettages and two hysterectomies). Three patients followed by curettage have subsequently completed successful pregnancies. This unusual lesion may represent a localized, endometrial proliferation induced by pregnancy; although some endometrial lesions may display striking architectural complexity, follow-up to date suggests a benign behavior.

Transvaginal color Doppler assessment of endometrial status in normal postmenopausal women: the effect of hormone replacement therapy

We used transvaginal color Doppler sonography to study the effects of hormone replacement therapy on the endometrial structure and vascular flow of 345 normal postmenopausal women. We studied women taking estrogen replacement alone, continuous combined estrogen and progestogen, and estrogen followed sequentially by estrogen-progestogen combination. Endometrial measurements prior to the initiation of hormone replacement therapy were used as baseline values. An increase in endometrial thickness was seen soon after initiation of hormone replacement therapy (P < 0.0001). Hyperplasia or adenocarcinoma was found only when endometrial thickness was greater then 9 mm. No correlation was found between hormone replacement therapy and the occurrence of endometrial hyperplasia or adenocarcinoma.

Use of vaginosonographic measurements of endometrial thickness in the identification of abnormal endometrium in peri- and postmenopausal bleeding

One hundred and seventy seven women with peri- and postmenopausal bleeding were subjected to vaginosonographic examination followed by thorough pathological examination of the uterine curetting samples. A mean endometrial thickness (double layer) of 13.2 +/- 3.6 mm and 8.2 +/- 4.8 mm were found in those with and without histological abnormalities, respectively. Endometrial thickness of less than 7 mm, however, was found to be predictive of normal endometrium (100% sensitivity, 46% specificity) and can, therefore, be used to separate those who require diagnostic curettage from those who do not. These findings suggest that this relatively simple, noninvasive procedure can be used as a screening test for patients with peri- or postmenopausal bleeding.

Basement membrane in human endometrium: possible role of proteolytic enzymes in developing hyperplasia and carcinoma

Basement membranes (BM) are elements of the extracellular matrix that are essential for growth and differentiation of tissues. Several collagenolytic enzymes of tumor cells are involved in degradation of the extracellular matrix; growth and inhibitor factors [e.g. Epidermal Growth Factor (EGF), Transforming Growth Factors alpha and beta (TGF-alpha, beta)] seem to be involved in the extracellular matrix formation and degradation. To establish a possible association between the presence of collagenase (C), urokinase-type plasminogen activator (uPA) and the neoplastic growth of the endometrium, 44 endometrial specimens (14 proliferative, 11 secretive, 7 adenomatous hyperplasia, 12 adenocarcinoma) were studied using immunohistochemistry with antisera for C, uPA, EGF receptors and TGF-alpha. Immunostaining for collagenase revealed a positive reaction in moderately differentiated adeno-carcinoma without staining the normal and hyperplastic endometrium. A progressive increase in uPA immunostaining was observed in proliferative and neoplastic endometrium. TGF-alpha and its receptor (EGFr) were stained in proliferative and more clearly in hyperplastic and carcinomatous endometrium. In conclusion, BM play an important role in proliferation and differentiation of human endometrium; their degradation influences estrogen transportation from blood to the stroma. Endometrial BM degradation is associated with the presence of collagenolytic enzymes and growth factors.

Pathophysiology and management of endometrial hyperplasia and carcinoma

Endometrial cancer is currently the commonest pelvic malignancy affecting American women, most of whom share the same pathophysiologic basis, that is, unopposed estrogenic stimulation. The initial result of hyperestrogenism is the development of endometrial hyperplasia, which is reversible in most cases by appropriate hormonal therapy. Persistent stimulation eventually leads to atypical hyperplasia with nuclear atypia and invasive carcinoma. Because there is no cost-effective screening method for the detection of endometrial hyperplasia and carcinoma, it is essential to survey the high-risk population with appropriate diagnostic techniques. After diagnosis, therapy should be individualized based on pathologic findings (cell type and histologic grade) and extent of disease (International Federation of Gynaecologists and Obstetricians stage, depth of myometrial invasion, and pelvic and para-aortic lymph node status). Recent studies suggest that sex hormone receptors and nuclear DNA ploidy patterns provide useful prognostic information independent of histologic grade.

[Effect of thymalin on the immunological indices and morphofunctional structure of the uterus in guinea pigs with endometrial hyperplasia]

The efficiency of usage of the preparations of thymalin in hyperplasia of endometrium has been studied in the experiment on 125 female guinea pigs. Indicated pathology was caused by the introduction of oil solution of synestrol during 19 weeks. It is determined that marked hyperplasia of endometrium is developing as a result of prolonged introduction of synestrol in experimental animals and the decrease of the amount of T- and B-lymphocytes takes place. The use of thymalin results in normalization of indexes of immune system and in partial normalization of morphologic structure of endometrium.

The pattern of epithelial mucin secretion in normal, hyperplastic, and adenocarcinomatous endometrium

Stains for mucosubstances were performed on endometrial curetting material of normal and pathological endometrium. The study included normal proliferative and secretory endometrium, cystic and adenomatous hyperplasia, and endometrial adenocarcinoma. It was attempted to characterize the epithelial mucin in each of these conditions and to differentiate between them. The stains used were Alcian blue at pH 0.5 and 2.5; PAS with and without diastase digestion; and Toluidine blue. It was concluded that the Alcian blue stain at pH 2.5 was preferable for differentiating two groups: group one included benign conditions--normal endometrium, cystic hyperplasia, and adenomatous hyperplasia without atypia--in which the cytoplasm did not show any staining reaction. Group two included premalignant and malignant conditions, namely adenomatous hyperplasia with severe atypia and endometrial adenocarcinoma. In these conditions, definite staining of the cytoplasm was visible with Alcian blue at pH 2.5. The difference was statistically significant. In addition, strongly positive staining of the apical border was noted in both groups. Alcian blue at pH 0.5, PAS stain, and Toluidine blue were of no aid in differentiating the two groups. PAS stain resulted in positive apical and cytoplasmic staining in a large percentage of cases of all the different conditions. Toluidine blue did not show consistent staining of the cells. It was deduced that the cytoplasm of the premalignant and malignant group contained sulphated and nonsulphated acid mucopolysaccharides, as opposed to the benign conditions, in which the cytoplasm contained neutral mucopolysaccharides and glycogen. In each of the conditions acid and neutral mucopolysaccharides were present at the apical border. The finding of stainable cytoplasmic mucosubstances in endometrial adenocarcinoma is in contrast to what has been generally reported that such mucosubstances were characteristic of adenocarcinoma of endocervical origin only. Our study enabled us to differentiate endometrial adenomatous hyperplasia with severe atypia and adenocarcinoma from the more benign conditions by staining of cytoplasmic mucin with Alcian blue at pH 2.5.

Variations in the levels of secretory component in human uterine fluid during the menstrual cycle

To determine whether variations in the level of secretory component (SC) occur during the menstrual cycle, we compared the amounts of SC in human uterine secretions during the proliferative, secretory, and menstrual phases. Uterine washes were obtained from women (ages: 18-49) with histologically normal endometria by lavage with Gravlee jet wash device using isotonic glycine. SC was measured by a radioimmunoassay which recognizes primarily free SC. Levels of uterine luminal SC, when expressed as the percentage of total wash protein, were highest during the secretory phase, significantly reduced during the proliferative phase and lowest during menstruation. The mean protein concentration in uterine fluids did not vary significantly during the menstrual cycle. Total amounts of SC were also greatest during the secretory phase, averaging two times higher than SC levels in proliferative samples. These results demonstrate that fluctuations do occur in the SC content of human uterine secretions during the menstrual cycle and suggest that hormones play an important role in the secretory immune system of the human uterus.

Cytodynamics of endometrial hyperplasia and neoplasia, Part II: in vitro DNA histoautoradiography

The cytokinetics of normal, hyperplastic, and neoplastic human endometrium were evaluated by in-vitro double labeling with low- and high-dose radiothymidine. Relative to cyclic, proliferative endometrium, the mean S-phase duration was shorter in anovulatory, persistent proliferative endometrium, cystic glandular hyperplasia, and adenomatous hyperplasia without atypia, similar in adenomatous hyperplasia with severe atypia (AAH), and significantly prolonged in carcinoma in situ and invasive carcinoma. The S-phase patterns suggest a pathogenetic relationship between hyperplasias of increasing atypia as well as between hyperplasia and carcinoma, with carcinoma in situ as a transitional state between AAH and invasive carcinoma.

Paradoxical hypersecretion of growth hormone in patients with endometrial atypical hyperplasia and carcinoma. Effect of hysterectomy

Paradoxical hypersecretion of human growth hormone (HGH) followed a glucose load in patients with endometrial cancer and atypical hyperplasia of the endometrium. All patients had normal fasting plasma glucose and serum HGH concentration with a normal glucose tolerance curve. Their urinary estrogen concentrations were within the normal postmenopausal range. 6 months after abdominal total hysterectomy and bilateral oophorectomy, the glucose load was repeated. Following surgery all patients showed a normal suppression of HGH secretion during the hyperglycemic period. These findings suggest the existence of a HGH-releasing factor in the neoplastic and preneoplastic endometrial tissue. This factor might be related to the abnormal HGH responses observed.

[Studies on the abnormal proliferation of the uterine endometrium, with reference to the cell surface electric charge density (author's transl)]

It has been observed that the surface charge of cells may increase during cell multiplication. Therefore, the studies were performed to investigate the cytopathogenesis of the endometrial abnormal proliferation by tracing cell microelectrophoretic changes. The studies consist of: 1. The comparison of surface charges on cells between proliferative and secretory phases of endometrium. 2. Changes of the surface charge in cases of the endometrial cells after curretage, and of cystic hyperplasia and/or differentiated adenocarcinoma of endometrium. 3. Those hormonal effects on cell surface charge as estrogen, progesterone, testosterone and cortisol on cases above mentioned in vivo and in vitro. 4. Relationship between electric charge and sialic acid on cell surface. 5. Quantitative variation of sialic acid on cell surface when those hormonal agents were applied. The results were as follows: 1. The negative charge on endometrial cell surface increased according to the cell proliferation and decreased in differentiation. 2. Estrogen usually increased the surface charge while progesterone decreased it in both normal and abnormal states of the endometrium, in both in vivo and in vitro experiments. Testosterone showed effects similar to those of progesterone, while no cortisol affected the surface charge density of endometrial cells. 3. Sialic acid were even more in cases of higher surface charge on cells. 4. Estrogen increased sialic acid an progesterone decreased it. Testosterone showed similar effects to progesterone and cortisol did not affect the sialic acid quantity. 5. Anticarcinogenic agents generally decreased the electric charge of cell surface. As a result, it was known that the density of surface charge on endometrial cells determined by cell microelectrophoresis increased in cell proliferation and decreased in differentiation of endometrial cells. Those variation may depend upon some steroid hormones such as estrogen or progesterone.