Endometrium characteristics in morbidly obese bariatric surgery candidates: an explanatory analysis

Introduction: Endometrial cancer (EC) is the most prevalent gynecologic malignancy in the US and is strongly associated with obesity. With the increasing number of morbidly obese women of reproductive age, endometrial health and prevention of endometrial malignancies is a pressing public health concern. \ud Objective: To explore the rate of endometrial pathology in a small cohort of cancer free, morbidly obese, female bariatric surgery candidates and to determine the success rate of Pipelle endometrial sampling in this group. \ud Methods: Thirty-seven bariatric surgery candidates provided informed consent for endometrial sampling in an outpatient setting. Women were eligible to participate if they were considering bariatric surgery, had an intact uterus, had no history of EC, and had not undergone endometrial ablation. Endometrial samples were obtained using a Pipelle endometrial suction curette and processed at the Pathology Department of Magee-Womens Hospital. \ud Results: We were unable to obtain samples from five women due to anatomical anomalies, such as cervical stenosis. Of the 32 collected samples, 8 were classified as insufficient to evaluate; therefore, 24 readable biopsies were analyzed. Of these 24, 1 was diagnosed as hyperplasia without atypia, 1 hyperplasia with atypia, 3 suggestive endometrial polyps, 1 endometrial tubal metaplasia, 5 normal secretory, 8 proliferative pattern, and 2 benign atrophic endometrial tissue. Four samples revealed hormonal effect likely due to pharmacologic treatment for uterine bleeding. While histologic evidence of unopposed estrogen was prevalent, no one presented with cancer. Thus, this study found an overall rate of subclinical pathology of 20% among women who could be sampled and an overall 35% Pipelle failure rate, including the 5 technically impossible biopsies suggesting morbidly obese patients may be difficult to evaluate with Pipelle biopsy. \ud Conclusion: Morbidly obese women are at a higher risk of having undiagnosed endometrial pathology, at rates greater than previously reported. Results suggest the importance of additional research to more thoroughly examine relationships between levels of obesity and endometrial pathology, as well as to explore underlying mechanisms. This line of research may open new avenues for endometrial cancer prevention and control, and possibly revert this major public health problem