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Endometrial hyperplasia

Complex hyperplasia

Reviewer: Nat Pernick, M.D. (see Reviewers page)
Revised: 25 March 2013, last major update November 2011
Copyright: (c) 2002-2013, PathologyOutlines.com, Inc.


● Increase in number and size of endometrial glands with crowding of stroma and budding
● By definition, some normal stromal cells are present between adjacent glands
● ~16% without atypia progress to carcinoma; ~47% with atypia progress to carcinoma
● Complex pattern may be secretory with eosinophilic metaplasia
High grade (with atypia): rounding of nuclei and formation of nucleoli; stratification, scalloping, tufting, loss of polarity, cytomegaly, hyperchromatism, pleomorphism and mitotic figures; may resemble adenocarcinoma but no stromal invasion or desmoplasia; 23% progress to endometrial adenocarcinoma
● Progestin-treated changes include decreased gland-to-stroma ratio, decreased glandular cellularity, no/decrease mitotic activity, loss of cytologic atypia, and a variety of cytoplasmic changes including mucinous, secretory, squamous and eosinophilic metaplasia (Am J Surg Pathol 2007;31:988)


● Progestins (Obstet Gynecol 2010;116:365), possibly hysterectomy

Micro images

Complex endometrial hyperplasia without atypia
Without atypia
Complex non-atypical
secretory hyperplasia
Complex endometrial hyperplasia with atypia

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

Fig 1: The endometrial glands are more closely packed than in simple hyperplasia and have more architectural irregularity, with numerous bud-like projections. Stroma is present between all glands
Fig 2: The nuclei are uniform in size and shape and show normal polarity with their axes perpendicular to the basement membrane. All glands are separated by stromal cells
Fig 3: These glands are more closely crowded together than in simple hyperplasia but lack architectural complexity. This case is probably borderline between simple and complex hyperplasia
Fig 4: The glands are fairly widely separated by stroma (as in simple hyperplasia) but show considerable architectural complexity. Cytologic atypia is absent. Some observers might classify this lesion as simple hyperplasia
Fig 5: This specimen from a 28 year old woman with clinical features of the Stein-Leventhal syndrome shows complex hyperplasia with extensive morular metaplasia. The glands around the periphery of this large focus of spindle-celled morular metaplasia lack cytologic atypia and are separated by at least thin wisps of residual endometrial stroma

Additional references

Mod Pathol 2000;13:309

End of Uterus > Endometrial hyperplasia > Complex hyperplasia

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