Disordered proliferative

Editorial Board Member: Carlos Parra-Herran, M.D.
Deputy Editor-in-Chief: Jennifer A. Bennett, M.D.
Ruby Chang, M.D.
Hao Chen, M.D., Ph.D.

Last author update: 5 April 2021
Last staff update: 27 May 2021

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PubMed search: disordered proliferative endometrium

Ruby Chang, M.D.
Hao Chen, M.D., Ph.D.
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Cite this page: Chang R, Chen H. Disordered proliferative. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/uterusdisorderedproliferative.html. Accessed June 16th, 2024.
Definition / general
Essential features
  • Continuum of the spectrum of changes seen with persistent, unopposed estrogen stimulation, which can lead to hyperplasia without atypia
  • Presence of irregularly shaped or cystic dilated glands with relatively normal gland to stroma ratio
  • Endometrium
  • Unopposed estrogen → disordered proliferative endometrium (early phase) → hyperplasia without atypia (later phase) (Mod Pathol 2000;13:309)
Clinical features
  • Asymptomatic or abnormal uterine bleeding
  • Endometrial biopsy or curettage
Radiology description
  • Ultrasound may show irregularly thickened endometrium
Microscopic (histologic) description
  • Cystically dilated glands (> 2x normal size) randomly interspersed among proliferative endometrial glands
  • Dilated glands usually with irregular shape (branched, convoluted, scalloped outer contours)
  • > 10% of overall glands
  • Relatively normal gland to stroma ratio (glands occupy < 50% of the surface area)
  • Metaplastic changes common, including tubal metaplasia, eosinophilic syncytial metaplasia, etc.
  • Stromal hemorrhage and breakdown common
  • Lack of cytologic atypia
Microscopic (histologic) images

Contributed by Hao Chen, M.D., Ph.D.

Irregular dilated glands

Irregular dilated glands with tubal metaplasia

Sample pathology report
  • Endometrium, biopsy:
    • Disordered proliferative endometrium
    • Anovulatory type endometrium
Differential diagnosis
  • Proliferative endometrium:
    • Irregular glands may be present but only focal (< 10%) and small and only mildly dilated
    • Vast majority of glands: round donut or straight tubular shape, lined with tall pseudostratified columnar epithelium; mitotic figures commonly seen
  • Endometrial hyperplasia without atypia:
    • Continuum with disordered proliferative endometrium
    • Irregular dilated glands, more diffusely distributed
    • Gland to stroma ratio > 1 (glands occupy ≥ 50% of the surface area)
  • Endometrial polyp:
    • Often with dilated glands and metaplasia
    • Polypoid
    • Dense fibrotic stroma
    • Thick walled vessels
  • Endometrioid intraepithelial neoplasm (EIN) / atypical hyperplasia (AH):
    • Clonal growth
    • Gland to stroma ratio > 1 (glands occupy ≥ 50% of the surface area)
    • Cytologically distinct from background endometrium
    • Nuclear atypia
    • Often loss of expression of PAX2, PTEN
  • Chronic endometritis:
    • Can result in glandular crowding, abnormal gland shapes and variable degrees of cytologic atypia
    • Presence of stromal plasma cells
    • Presence of stromal spindling and edema
Board review style question #1

Which of the following is true about disordered proliferative endometrium?

  1. Associated with a significantly elevated risk of malignancy
  2. May contain foci of atypia
  3. Most common with women in their 20s
  4. Treatment is with exogenous estrogens
  5. Typically seen in patients with factors leading to unopposed estrogen stimulation (obesity, anovulation)
Board review style answer #1
E. Typically seen in patients with factors leading to unopposed estrogen stimulation (obesity, anovulation)

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