Do I need an Endometrial Biopsy?

Question

My doctor is insistent that I have to have surgery-I guess a D & C or an endometrial biopsy. I'm a perfectly healthy, although a little heavy, woman in my early 50s and was sure that I was in menopause because I had been without a period for 20 months. Then I felt my libido spike, my breasts get sore and the mucus went gooey for days, and then constipation. The next morning I awoke to bleeding, just as if there had been no 20-month break. And, as recently as last week there had been another change in the mucus, but no other symptoms.

Answer

Thank you for your question. It is an important one because your doctor's concern is very real-he/she is worried that you have endometrial cancer (in the lining of the uterus).

I want to reassure you right off-I don't think you need worry, nor do you need any further investigation. You had an additional vaginal bleeding like a "period" after the usual one-year without a period that makes the diagnosis of menopause. How can I be so sure you're fine? Because you clearly noticed high estrogen changes before your flow started-increased sexual interest, sore breasts and clear stretchy mucus are all evidence of a quite high estrogen level. These high levels stimulated the lining of the uterus to grow-when they dropped as that "rogue" follicle making those levels aged-the lining shed. The typical way that endometrial cancer shows itself is asymptomatic bleeding or spotting after sex, not bleeding you know is coming.

However, you have a higher risk than average for endometrial cancer because you are heavy. Being overweight or obese increases your risk for endometrial cancer. Both through stimulating the hypothalamus in the brain and because fat cells, themselves, make estrogen. Obesity makes estrogen and male hormone levels higher and, paradoxically, progesterone levels lower. You would also be at increased risk if you had diabetes, although here we don't quite understand why that increases endometrial cancer.

We know that endometrial cancer is caused by high/high-normal estrogen levels without enough progesterone to counterbalance it. That means, estrogen within a menstrual cycle but consistently not ovulating and therefore making no progesterone. Or it could mean taking a prescription for estrogen without having a prescription for enough progestin or progesterone. How much is enough progesterone to counterbalance daily estrogen treatment? To be sure, you need two weeks of a full dose (like 300 mg of Prometrium or 10 mg of Provera) each month, or a daily amount in a half dose (200 mg of Prometrium or 5 mg of Provera).

Endometrial cancer is increased in perimenopause because this transition is a time of very high estrogen swings often not accompanied by normal progesterone. That's one reason the risk for endometrial cancer is increased in the early years of menopause.

You had vaginal bleeding when you'd been without a period for almost two years. Doctors are taught that any bleeding when women have been one year without flow means endometrial cancer and must be investigated. However, that magical one-year is a statistical thing-not an absolute. Here's what we know, based on analysis of several thousand women who kept menstrual calendars for many years (from the Treloar/Tremin Trust data):

• A woman 45 years old or older-has a 10% normal chance for further flow

• A woman younger than 45 years-has a 20% normal chance for further flow

So-you are one of those 10% who have an extra flow after 12-months without bleeding. You can be reassured. However, should you have a further flow, given that you are heavy, you should either have an endometrial biopsy (a somewhat painful, but an office procedure) or take Prometrium 300 mg a day for three to six months.

Hope this is helpful for you,
All the best,
Jerilynn