Relationship Between Adenomyosis And Endometrial Hyperplasia And Cancer

Background and Objectives Adenomyosis is a benign gynecological disease caused by the invasion of endometrial glands and interstitial in the myometrium.The main clinical presentation of adenomyosis are menorrhagia,prolonged menstrual periods and dysmenorrhea.It is one of the main causes of abnormal uterine bleeding.Endometrial hyperplasia is a common gynecological endocrine disease,its main clinical manifestations are abnormal uterine bleeding and abnormal vaginal fluid.It is a pathological endometrial glandular hyperplasia,which is divided into endometrial atypical hyperplasia and hyperplasia without atypia.Endometrial hyperplasia is not accompanied by two types of atypical hyperplasia,and both of them have a tendency to endometrial cancer.At present,endometrial atypical hyperplasia is considered to be a precancerous lesion of endometrial cancer.Abnormal uterine bleeding also often occurs in endometrial cancer,which is divided into estrogen-dependent and non-estrogen-dependent types.Type I estrogen-dependent endometrial cancer is more common.In recent years,some studies have pointed out that the clinical manifestations and pathogenesis of the three diseases have a certain degree of similarity,suggesting that adenomyosis may be related to the occurrence of endometrial hyperplasia and endometrial cancer.Therefore,this study will explore whether adenomyosis increases the risk of endometrial hyperplasia or endometrial cancer,and further explore the risk factors for endometrial hyperplasia or cancer in adenomyosis.Methods Excluding adenomyosis coexisted with adenomyosis,a retrospective analysis reviewed the adenomyosis or myoma cases who underwent a total/subtotal hysterectomy in Women's Hospital,Zhejiang University School of Medicine from January 2017 to August 2019.In order to reduce the interference of confounding factors,we applied strict exclusion criteria and 1035 cases were finally included.According to the pathological results,patients were divided into adenomyosis group(149 cases)and myoma group(886 cases).All the patients in the study had no history of cancer except endometrial cancer,history of any other gynecological diseases,history of hormone medical or surgical treatment within three months,history of smoking or drinking.Otherwise,pathological data of all case involved in the study is complete.According to the endometrial pathological results,the endometrial hyperplasia includes hyperplasia without atypia(including complex endometrial hyperplasia,simple endometrial hyperplasia)and endometrial atypical hyperplasia.The endometrial atypical hyperplasia includes endometrial atypical hyperplasia;The hyperplasia without atypia includes endometrial complex hyperplasia and simple hyperplasia;The endometrial cancer includes endometrial cancer and endometrial atypical hyperplasia with local malignant transformation;The endometrial hyperplasia coexisted with cancer includes endometrial hyperplasia with local malignant transformation;The endometrial atypical hyperplasia /cancer includes endometrial atypical hyperplasia,endometrial atypical hyperplasia with local malignant transformation and endometrial cancer.The chi-square test was used to compare the incidence of each endometrial pathological types in the adenomyosis group and the myoma group so as to explored whether adenomyosis increased the risk of endometrial hyperplasia,cancer and endometrial atypical hyperplasia / endometrial cancer.Logistic regression analysis and the receiver operating characteristic curve were used to compare the clinical characteristics and examination results of 149 patients in the adenomyosis group aiming to find risk factors for endometrial cancer in adenomyosis.In addition,this study also separately compared the clinical characteristics and examination results of 118 patients without endometrial cancer to explore the risk factors of endometrial hyperplasia in adenomyosis patients.Results1.Of the 871 patients aged no less than 45 years old,there was 106 in the adenomyosis group and 765 in the myoma group.The incidence of endometrial hyperplasia in adenomyosis was 14.2%,and 7.3% in the myoma group,P =0.016.The incidence of endometrial hyperplasia was 3.8% in adenomyosis and 4.2% in myoma,P >0.999.The incidence of hyperplasia without atypia in adenomyosis was 10.4% and 3.1% in the myoma group,P <0.001.The incidence of endometrial atypical hyperplasia/ cancer was 30.2% in adenomyosis and 11.2% in myoma,P<0.001.The incidence of endometrial cancer was 26.4% in adenomyosis and 7.1%in myoma,P <0.001.The incidence of endometrial atypical hyperplasia coexisted with cancer in adenomyosis was 12.3%,and 2.0% in myoma,P < 0.001.The above differences were all significant except the incidence of endometrial atypical hyperplasia.2.Of the 164 patients younger than 45 years old,there was 43 in the adenomyosis group and 121 in the myoma group.The incidence of endometrial atypical hyperplasia/ cancer in adenomyosis was significantly higher than myoma(14.0%VS3.3%,P=0.033).The incidence of endometrial cancer(7.0%VS0.8%,P=0.095)and endometrial atypical hyperplasia coexisted with cancer(4.7%VS0.0%,P=0.068)was higher in adenomyosis without significance.The incidence of endometrial hyperplasia(14.0%VS5.0%,P=0.109),endometrial atypical hyperplasia(7.0%VS2.5%,P=0.381)and hyperplasia without atypia(7.0%VS2.5%,P=0.381)all higher in adenomyosis without significant difference.3.Univariate Logistic regression analysis revealed that age,BMI,and endometrial thickness were risk factors for endometrial hyperplasia in adenomyosis while CA199 was negatively correlated with it(P <0.050);The incidence of endometrial hyperplasia in patients with history of endometrial polyps also increased(P <0.050).Multivariate regression analysis indicated that the endometrial thickness(OR =3.585,95% CI = 1.223-10.505,P = 0.020),BMI(OR = 1.159,95% CI =1.021-1.317,P = 0.023),and age(OR = 1.099,95% CI = 1.005-1.203,P = 0.039)was positively correlated with the endometrial hyperplasia.4.Univariate Logistic regression analysis revealed that age was positively correlated with the endometrial cancer(P <0.050).Platelet,prothrombin time,and CA199 were negatively correlated with it(P <0.050).Multivariate Logistic regression analysis indicated that age(OR = 1.133,95% CI = 1.067-1.203,P = 0.048),prothrombin time(OR=0.379,95%CI=0.176-0.816,P=0.013)was related with the endometrial cancer.5.ROC curves related to endometrial hyperplasia in adenomyosis showed the AUC of age,BMI,endometrial thickness was 0.565,0.679,0.669.When the prediction model including age>47,BMI? 24.36,endometrial thickness ? 1.15 cm,it showed a good diagnostic accuracy(AUC=0.756).The sensitivity of the model was 76.2%and specificity was 75.3%.6.ROC curves related to endometrial cancer in adenomyosis showed the AUC of age was 0.767 and the prothrombin time was 0.667.When the prediction model including age>47,prothrombin time ?12.75 s,it showed a moderate diagnostic accuracy(AUC=0.795).The sensitivity of the model was 64.5% and specificity was83.1%Conclusions1.Adenomyosis may be related to endometrial atypical hyperplasia/ cancer.2.Adenomyosis may be related to the occurrence of endometrial cancer and endometrial atypical hyperplasia.Among people no less than 45 years old,the risk of endometrial cancer,the endometrial atypical hyperplasia and the hyperplasia without atypia are increased in adenomyosis compared to uterine myoma.3.Among people no less than 45 years old,the incidence of endometrial atypical hyperplasia coexisted with endometrial cancer in adenomyosis increases compared to uterine myoma.For adenomyosis patients whose curettage pathology suggesting endometrial atypical hyperplasia,the possibility of conexisted endometrial cancer or the malignant transformation should be considered.4.For adenomyosis patients,age,BMI and endometrial thickness are risk factors for endometrial hyperplasia and can be used as prediction index before surgery.5.For adenomyosis patients,age is a risk factor for endometrial cancer while prothrombin time is a protective factor.Both of them have certain predictive value.Elderly patients or prolonged prothrombin time all suggest that the risk of endometrial cancer increases.