The role of Endometrial Sample Timing in Reducing The Risk Of Malignant Transformation Among Women Treated At King Saud University Medical City, Riyadh, Saudi arabia

The role of Endometrial Sample Timing in Reducing The Risk Of Malignant Transformation Among Women Treated At King Saud University Medical City, Riyadh, Saudi arabia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The role of Endometrial Sample Timing in Reducing The Risk Of Malignant Transformation Among Women Treated At King Saud University Medical City, Riyadh, Saudi arabia Amal AlQarni, Omar Alzydan, Razan Alotaibi, Shahd Alsalamah, Manal Altwaim, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8911982/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Endometrial hyperplasia is a non-cancerous (benign) condition in which the lining of the uterus (the endometrium) becomes abnormally thickened due to excessive growth of endometrial glands compared to normal supporting tissue (stroma). It has been observed that certain factors significantly increase the likelihood of developing endometrial hyperplasia or malignancy, most notably an endometrial thickness greater than 5mm.However, despite the presence of radiological indicators, these findings alone are not conclusive, and histopathology confirmation through endometrial biopsy remains essential for establishing an accurate diagnosis. Following the diagnosis by endometrial biopsy, appropriate management is required to prevent the progression from hyperplasia to malignancy. This study demonstrated various approaches to treatment, including surgical intervention with close surveillance. Endometrial hyperplasia atypia malignancy benign Background Endometrial hyperplasia (EH) is a precancerous condition of the uterine lining and a common finding in women presenting with abnormal uterine bleeding (AUB). This retrospective cohort study conducted at King Saud University Medical City evaluated factors associated with malignant outcomes following EH diagnosis and management. Women with AUB who underwent endometrial biopsy and subsequent medical or surgical treatment between January 2023 and May 2025 were included. Demographic, clinical, imaging, biopsy, treatment, and final pathology data were analyzed. Most patients were aged ≥45 years and obese. Simple hyperplasia without atypia was the most common biopsy finding. Malignancy was identified in 11.2% of final surgical specimens. Logistic regression analysis demonstrated that endometrial adenocarcinoma on biopsy was the strongest predictor of malignancy, while hysteroscopy and hysterectomy were associated with lower malignant outcomes. Age, BMI, parity, and diagnostic-to-surgery interval were not significant predictors. The study highlights the importance of accurate diagnostic assessment and timely surgical management to reduce the risk of progression to endometrial carcinoma. 1. Introduction Endometrial hyperplasia is a precancerous condition of uterine lining, characterized histologically by proliferation of glandular tissue with altered architecture, resulting in an increased gland to stroma ratio. The latest WHO classification identifies two categories, hyperplasia without atypia and atypical hyperplasia [ 1 ]. Endometrial biopsy is a safe, efficient, and widely used diagnostic method for evaluating the women who present with abnormal uterine bleeding (AUB) [ 2 ]. It is a non-invasive widely used diagnostic tool in gynecological practice. This test is considered highly specific for detecting diverse histopathological changes starting from hyperplasia to endometrial carcinoma in women with (AUB) [ 3 ]. Endometrial hyperplasia (EH) is a relatively common histopathological finding, particularly in perimenopausal and postmenopausal women [ 4 ]. It is defined as a proliferation of endometrial glands relative to the stroma, producing a spectrum of changes from benign lesions to precancerous conditions. Among these, the presence of cytological atypia, also referred to as atypical hyperplasia (AH) or endometrial intraepithelial neoplasia (EIN), is of greatest clinical concern because of its well-established association with the development of endometrial carcinoma [ 3 ] Understanding the prognostic significance of endometrial hyperplasia (EH) diagnosed through biopsy is critical for informing clinical management, including decisions regarding surveillance, medical therapy, and surgical intervention. This article reviews the correlation between the initial histopathological biopsy findings and the final pathological outcome following intervention. In addition, it explores the duration between the initial diagnosis of endometrial hyperplasia (EH) and the subsequent diagnosis of endometrial cancer, in cases where malignancy is ultimately confirmed. 2. Materials and Methods This retrospective study was approved by the Institutional Review Board of King Saud University with reference number E-24-8603. The requirement for informed consent was waived due to the retrospective nature of the study and use of anonymized data. It was conducted to assess the factors associated with malignant pathological outcomes in women presenting with abnormal uterine bleeding (AUB). The study population included women with abnormal uterine bleeding((AUB,) irrespective of their subsequent management approach. The primary objective was to evaluate the relationship between demographic, clinical, and treatment-related factors and the final pathological findings, with particular emphasis on identifying risk factors for malignant pathology among patients who underwent surgical intervention. Study Design and Participants The study was carried out King Saud University Medical City and including women diagnosed with abnormal uterine bleeding (AUB) between start from 1-1-2023 to 1-5-2205 .The Inclusion criteria encompassed all patients with abnormal uterine bleeding(AUB )who underwent diagnostic procedures , such as endometrial biopsy and ultrasound ,to evaluate the underlying cause of bleeding .Women who received any form of treatment for abnormal uterine bleeding(AUB),whether surgical or medical ,were included in the analysis . Data Collection Clinical and demographic data were extracted from the hospital's electronic medical records. The following variables were recorded for each participant: • Demographic Characteristics: Age (> and equal 45, 40. • Medical History: Chronic disease, a history of malignancy, or medically free status. Chronic disease and hx of malignancy • Surgical History: Prior gynecological surgeries, including hysteroscopy and myomectomy • Endometrial thickness: Endometrial thickness measurements using ultrasound and divided to 2-4 mm (normal) or 5 mm and above (thick) • Treatment Information: Whether the patient was treated conservatively, received medications, underwent hysteroscopy, or hysterectomy. • Final Pathology Results: Final pathology outcomes after surgery, categorized as benign or malignant. Endometrial Biopsy (EMB) Categories The endometrial biopsy findings were categorized into the following groups: • Endometrial Adenocarcinoma • Complex Hyperplasia with Atypia • Complex without Atypia • Simple Hyperplasia with Atypia • Simple without Atypia • Benign • Not Done • Insufficient • Mixed Statistical Analysis Descriptive statistics were used to summarize demographic and clinical characteristics of the study population, including frequencies and percentages for categorical variables. A binary logistic regression analysis was conducted to assess the relationship between various independent variables and the final pathology result (benign vs. malignant). Variables considered in the analysis included age, parity, medical history, surgical history, BMI, endometrial thickness on ultrasound, endometrial biopsy results, treatment received (medications, hysteroscopy, hysterectomy), and the time from diagnosis to surgical intervention. The logistic regression model generated odds ratios (OR) with 95% confidence intervals (CIs) to quantify the strength and direction of the associations between the predictors and the final pathology result. Statistical significance was set at a p-value of <0.05. All statistical analyses were performed using SPSS software (version 30) 3. Results Table 1 demonstrates the demographic characteristics and medical history of the study population. A total of 261 participants (86.1%) were aged 45 years or older, while 40 participants (13.2%) were younger than 45 years. In terms of parity, 21 participants (6.9%) were primiparous, 249 participants (82.2%) were multiparous, and 33 participants (10.9%) were nulliparous. Regarding medical history, 235 participants (77.6%) reported chronic diseases, 5 participants (1.7%) had both chronic diseases and a history of malignancy, 4 participants (1.3%) had a history of malignancy alone, and 40 participants (13.2%) were medically free. For surgical history, 73 participants (24.2%) had undergone hysteroscopy, 3 participants (1.0%) had a myomectomy, and 46 participants (15.2%) had no prior surgical history. BMI classification revealed that 14 participants (4.6%) were within the normal weight range (18.5–24.9), 48 participants (15.8%) were overweight (25–29.9), 145 participants (47.9%) were obese (30–39.9), and 72 participants (23.8%) were classified as morbidly obese (BMI > 40). Table 2 presents the endometrial biopsy results, ultrasound findings, the management provided, and final pathology outcomes. The most common biopsy result was simple hyperplasia without atypia (126 cases, 41.6%), followed by benign findings (55 cases, 18.2%) and simple hyperplasia with atypia (33 cases, 10.9%). Complex hyperplasia with atypia was found in 30 cases (9.9%), while complex hyperplasia without atypia, endometrial adenocarcinoma, and mixed types each occurred in 12 cases (4.0%). Biopsy was reported as insufficient in 7 cases (2.3%), and not done in 16 cases (5.3%). On ultrasound, endometrial thickness of 5 mm or more was observed in 254 participants (83.8%), while 12 participants (4.0%) had a thickness between 2–4 mm. In terms of management, 70 participants (23.1%) received medical treatment, 37 (12.2%) were managed with observation, 44 (14.5%) underwent hysteroscopy, and 137 (45.2%) had a hysterectomy. A total of 34 participants (11.2%) were lost to follow-up. Regarding the timing of surgical management, 30 cases (9.9%) underwent surgery more than 12 months after diagnosis, 26 (8.6%) within 3–6 months, another 26 (8.6%) within 6–12 months, and 85 (28.1%) within 0–3 months. Final pathology after surgery revealed benign outcomes in 135 cases (44.6%) and malignant outcomes in 34 cases (11.2%). Table 3 shows the results of the binary logistic regression analysis, assessing the predictors of malignant pathology outcomes after surgical management. Significant findings were observed for endometrial biopsy (EMB), hysteroscopy, and hysterectomy. A) Endometrial Biopsy (EMB): Endometrial adenocarcinoma showed the highest association with malignant outcomes after surgery, indicating that patients with this diagnosis had significantly higher odds of malignancy. All other EMB categories (such as complex hyperplasia with atypia, simple hyperplasia without atypia, benign, and others) showed much lower odds ratios and non-significant p-values, suggesting that these results were not significant predictors of malignancy after surgery when compared to endometrial adenocarcinoma. B) Hysteroscopy: Undergoing hysteroscopy was significantly associated with lower odds of malignancy after surgery (OR = 0.474, 95% CI: 0.148–1.514, p = 0.208). This indicates that patients who underwent hysteroscopy had a lower likelihood of having a malignant pathology outcome compared to those who did not undergo the procedure. C) Hysterectomy: Undergoing hysterectomy was significantly associated with lower odds of malignancy after surgery (OR = 0.094, 95% CI: 0.012–0.712, p = 0.022). This suggests that patients who underwent hysterectomy had significantly lower odds of malignancy after surgery compared to those who did not undergo the procedure. Other variables, including age, BMI, medical history, surgical history, and the duration from diagnosis to surgery, did not show statistically significant associations with malignant pathology outcomes in the logistic regression model. Table 4 demonstrates the distribution of benign and malignant cases according to the time interval between pathological diagnosis and surgical intervention. The majority of patients (142 cases) underwent surgery within 0–3 months, of whom 111 (78.16%) had benign pathology and 31 (21.8%) were malignant. In the subgroup of patients who waited 3 to 6 months (28 cases), 25 (89.28%) were benign and 3 (10.7%) malignant, while among those operated after 6–12 months (26 cases), 23 (88.46%) were benign and 3 (11.5%) malignant. Finally, patients who waited longer than 1 year (31 cases) included 27 (87.1%) benign and 4 (12.9%) malignant cases. All duration groups demonstrated Statistically significant associations with pathology outcomes, all comparisons were statistically significant (p < 0.001), confirming that malignant transformation was consistently below 50% across different intervals. This means the probability of obtaining such low malignant proportions by chance is extremely small, confirming that benign pathology predominates across all intervals. The statistical significance emphasizes that, irrespective of surgical timing, the malignant rate remains much lower than expected under the null hypothesis. Tables 1 : Demographic and Medical History Overview Frequency Percent Age: ≥45 261 86.1 <45 40 13.2 Parity: P1 21 6.9 Multiparous 249 82.2 Nulliparous 33 10.9 Medical History: Chronic disease 235 77.6 Chronic disease and History of malignancy 5 1.7 Hx of malignancy 4 1.3 Medically free 40 13.2 Surgical History: Hysteroscopy 73 24.2 Myomectomy 3 1.0 Surgically free 46 15.2 BMI: >40 72 23.8 25-29.9 48 15.8 30-39.9 145 47.9 18.5-24.9 14 4.6 Table 2 : Endometrial Findings and Management Overview Frequency Percent Endometrial thickness in US: 5 mm and above 254 83.8 2-4 mm 12 4.0 Endometrial biopsy result: complex hyperplasia with atypia 30 9.9 complex without atypia 12 4.0 endometrial adenocarcinoma 12 4.0 insufficient 7 2.3 mixed 12 4.0 not done 16 5.3 simple hyperplasia with atypia 33 10.9 simple without atypia 126 41.6 benign 55 18.2 Treated with medication: No 233 76.9 yes 70 23.1 Treated with observation: No 266 87.8 yes 37 12.2 Treated with hysterscopy: No 259 85.5 yes 44 14.5 Treated with hysterectomy: No 166 54.8 yes 137 45.2 Lost Follow up: No 269 88.8 yes 34 11.2 Duration since diagnosis to surgical management if surgery is planned: >12 months 30 9.9 3-6 months 26 8.6 6-12 months 26 8.6 0-3 months 85 28.1 final pathology result after surgical management in it done: Benign 135 44.6 Malignant 34 11.2 Table 3 : Logistic Regression to predict factors associated with endometrial cancer: B S.E. Wald P-Value Exp(B) 95% C.I.for EXP(B) Lower Upper Age: (reference is <45) -.413 .706 .343 .558 .661 .166 2.639 Parity: (Reference is Nulliparous) 4.857 .088 Para 1 -1.910 1.184 2.599 .107 .148 .015 1.510 Multiparous -1.187 .581 4.180 .041 .305 .098 .952 Medical History: (Reference is Medically free) .919 .821 Chronic disease .746 .779 .919 .338 2.109 .459 9.700 Chronic disease and history of malignancy -19.123 28420.722 .000 .999 .000 .000 . History of malignancy -19.123 28420.722 .000 .999 .000 .000 . Surgical History: (Reference is surgically free) 1.589 .452 Hysteroscopy -.747 .593 1.589 .208 .474 .148 1.514 Myomectomy -20.316 28420.722 .000 .999 .000 .000 . BMI: (Reference is 18.5-24.9) 2.876 .411 >40 -.105 1.216 .008 .931 .900 .083 9.750 25-29.9 -1.344 1.370 .962 .327 .261 .018 3.824 30-39.9 -.031 1.182 .001 .979 .969 .096 9.823 Endometrial thickness in US: (Reference is 2-4 mm) 19.931 17974.857 .000 .999 452936836.780 .000 . EMB: (Reference is endometrial adenocarcinoma) 19.579 .012 complex hyperplasia with atypia -21.129 12710.180 .000 .999 .000 .000 . complex without atypia -22.995 12710.180 .000 .999 .000 .000 . insufficient -42.406 23778.507 .000 .999 .000 .000 . mixed -42.406 18467.427 .000 .998 .000 .000 . not done -22.995 12710.180 .000 .999 .000 .000 . simple hyperplasia with atypia -22.525 12710.180 .000 .999 .000 .000 . simple without atypia -24.075 12710.180 .000 .998 .000 .000 . Benign -42.406 15224.543 .000 .998 .000 .000 . Treated with medications: (Reference is yes) 20.029 8038.593 .000 .998 499328537.581 .000 . Treated with hysteroscopy: (Reference is yes) 2.368 1.035 5.239 .022 10.676 1.405 81.112 Treated with hysterectomy: (Reference is yes) -2.368 1.035 5.239 .022 .094 .012 .712 Duration from diagnosis to surgical management if surgery was planned: (Reference is 0-3 months) 7.571 .056 >12 months -.927 .592 2.448 .118 .396 .124 1.264 3-6 months -1.127 .662 2.902 .088 .324 .089 1.185 6-12 months -1.577 .776 4.128 .042 .207 .045 .946 Table 4 : Impact of Time Interval Between Pathology Diagnosis and Surgical Management on Outcomes in Endometrial Cancer duration group Benign Malignant total p_value_binom_malignant_vs_50 malignant percent benign percent above 1 year 27 4 31 3.40E-05 12.90322581 87.09677419 duration 0-3 months 111 31 142 9.17E-12 21.83098592 78.16901408 duration above 3 months to 6 months 25 3 28 2.74E-05 10.71428571 89.28571429 for months 6 months to 1 year 23 3 26 8.80E-05 11.53846154 88.46153846 4. Discussion Endometrial hyperplasia (EH) is a well-recognized precursor to endometrial carcinoma, with numerous studies highlighting its rising incidence and associated mortality worldwide [ 5 , 6 ]. In this study, we investigated the demographic characteristics, clinical presentations, management strategies, and predictors of malignant outcomes among patients with endometrial hyperplasia and related endometrial pathologies. Our findings highlight several important observations with potential implications for clinical practice. Patient demographic characteristics revealed that 86.1% were aged ≥ 45 years. Regarding body mass index (BMI), nearly half (47.9%) were classified as obese (BMI 30–39.9), while 23.8% were morbidly obese (BMI > 40). Although age and elevated BMI are established risk factors for EH and its progression [ 7 ], our study did not find statistically significant associations between these variables and malignant pathology. This discrepancy may be attributable to the limited sample size and the single-center design of our investigation. In alignment with existing literature, it is well-established that unopposed estrogen, chronic anovulation, obesity, and increased endometrial thickness (> 5 mm) are the main factors for elevating cancer risk [ 12 ], In addition to estrogen-only hormone therapy, and nulliparity. [ 8 , 9 ]. Interestingly, in our cohort study Multi-parity history (p = 0.041) and morbid obesity (p = 0.931) did not show a strong significant association with malignant outcomes, further emphasizing potential population-specific or methodological differences. Histopathological analysis revealed that adenocarcinoma (p = 0.021) was the only endometrial pathology significantly associated with malignancy. Hyperplasia with or without atypia did not demonstrate a high correlation with malignant outcomes. This contradicts a prior meta-analysis which reported progression risks of 29–45% for complex atypical hyperplasia and approximately 8% for simple atypical hyperplasia [ 10 ], as well as studies indicating that complex hyperplasia carries a significantly higher risk of malignant transformation compared to simple hyperplasia [ 11 ]. Several studies report lower estimates of progression risk, particularly in patients with a shorter duration of untreated hyperplasia [ 17 ]. For cases of endometrial hyperplasia with atypia, the cumulative risk of malignant progression was estimated at 8.2% (95% CI, 1.3–14.6%) after 4 years, increasing to 12.4% (95% CI, 3.0–20.8%) by 9 years, and reaching 27.5% (95% CI, 8.6–42.5%) at 19 years post-diagnosis [ 17 ]. The interval between the initial biopsy-confirmed diagnosis of EH and the subsequent hysterectomy revealing endometrial cancer in our cohort study showed, 30 patients (9.9%) underwent surgery more than 12 months after diagnosis, 26 (8.6%) within 3–6 months, another 26 (8.6%) within 6–12 months, and 85 (28.1%) within 0–3 months which reflects the importance of timely intervention. A notable finding in our study was the observed association between undergoing hysteroscopy (OR = 0.474, 95% CI: 0.148–1.514, p = 0.208) or hysterectomy (OR = 0.094, 95% CI: 0.012–0.712, p = 0.022) and reduced odds of malignancy. Hysteroscopy may confer diagnostic advantages over blind sampling techniques, with studies showing that blind biopsies can miss up to 19% of EH and 1% of endometrial carcinoma cases [ 13 ]. A study showed that Patients who underwent diagnostic hysteroscopy demonstrated a lower likelihood of malignancy at the time of surgery, possibly due to better lesion visualization and targeted sampling, mitigating the limitations of blind endometrial sampling [ 13 ]. The correlation between the biopsy-to-surgery interval and malignancy is crucial, investigations have demonstrated that atypical hyperplasia progresses at a rate of approximately 8.2% per year, with the highest risk occurring within the first two years post-diagnosis (10.7% per year) [ 14 ]. This underlines the importance of close surveillance and timely surgical intervention, particularly for patients with atypical hyperplasia. In our study conducted at King Saud University Medical City, the majority of patients underwent surgery within a relatively short period of 0–3 months following the initial pathological diagnosis, regardless of whether the pathology revealed benign or malignant disease. This timely surgical approach was consistent across different age groups and socioeconomic categories, suggesting that institutional protocols and healthcare accessibility minimized disparities in treatment delays. Importantly, this finding highlights that surgical management was not significantly influenced by external demographic or socioeconomic variables, and that diagnostic accuracy was not compromised by waiting times within this interval. Identifying key risk factors and understanding the temporal dynamics of EH progression is essential for optimizing patient management. Moreover, the COVID-19 pandemic introduced additional challenges, as surgeries for EH were often deprioritized, potentially increasing the likelihood of concurrent carcinoma at the time of delayed hysterectomy. A recent meta-analysis reinforced these concerns, highlighting a progression rate of 8.2% annually for atypical EH, escalating to 10.7% per year when intervention is delayed beyond two years [ 15 ]. Additionally, preoperative biopsies carry a false-negative rate of up to 30%, indicating that some patients harbor occult malignancy even at initial diagnosis, with delays further compounding this risk [ 16 ]. One of the central objectives of our study was to evaluate the potential effect of the time interval between diagnosis and surgery on prognosis and mortality. When our findings are placed in the context of international literature, they align with previous observations that the timeliness of surgical intervention plays a critical role in determining outcomes. For example, a study conducted at Bhumibol Adulyadej Hospital in Thailand (2009–2021) stratified patients into early (< 6 weeks) and delayed (≥ 6 weeks) surgical groups. Endometrioid carcinoma was the most prevalent histological subtype, yet the study demonstrated that patients with advanced-stage disease or non-endometrioid histology experienced significantly worse five-year disease-free survival (DFS) when surgical treatment was delayed beyond six weeks. These findings reinforce the notion that delays in surgical intervention may disproportionately affect patients with more aggressive disease subtypes and advanced stages, where timely management is particularly crucial (18). Further evidence from a large-scale analysis conducted at NCDB hospitals in 2011 supports this perspective, but also introduces an important socioeconomic dimension. That study reported that minority patients and those with lower socioeconomic status or inadequate insurance coverage were more likely to experience delays in surgical treatment. Such delays, particularly when extending beyond six weeks from diagnosis to definitive surgery, were associated with poorer survival outcomes. This emphasizes the broader health system factors that may contribute to inequities in cancer care delivery and suggests that addressing socioeconomic and structural barriers is essential to improving overall survival rates in endometrial cancer patients (19). Overall, our findings emphasize the necessity of minimizing delays between EH diagnosis and definitive surgical management, employing precise diagnostic modalities such as hysteroscopy, and maintaining vigilant follow-up to mitigate the risk of progression to endometrial carcinoma. 5. Conclusions In conclusion, the findings of this study underscore the critical role of comprehensive histopathological evaluation in the management of women presenting with endometrial hyperplasia and related abnormalities. Careful assessment of biopsy samples not only aids in accurate diagnosis but also provides valuable prognostic information that can guide individualized treatment strategies. The early identification of high-risk lesions, particularly those with atypical changes, is essential to prevent disease progression and to optimize patient outcomes. Furthermore, timely surgical intervention, when indicated, continues to represent a cornerstone in the prevention of endometrial carcinoma, highlighting the need for close collaboration between clinicians and pathologists. Ultimately, these results emphasize the importance of adopting a proactive and multidisciplinary approach to the evaluation and treatment of abnormal uterine bleeding, with the overarching goal of reducing morbidity and improving women’s health. Declarations Author Contributions: Conceptualization, O.A. and A.A.; methodology, R.A.; A.A.; O.A,M.A. and S.A.; software, A.A.; O.A.; A.B.; formal analysis, M.A.; A.A. and L.A.; data curation, A.B.; A.A.; S.A.; O.A.; writing—original draft preparation, M.A.; A.A.; R.A writing—review and editing, A.A. and S.A. All authors have read and agreed to the published version of the manuscript. Funding: This work was supported by the College of Medicine Research Center, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia Institutional Review Board Statement: The study was conducted according to the guidelines of the Declaration of Helsinki, and was approved by the Institutional Review Board at College of Medicine, King Saud University with reference number E-24-8603 Informed Consent Statement: Not Applicable. Clinical Trial Number: Not Applicable. Data Availability Statement: Data is contained within the article Acknowledgments: None. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8911982","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":608180188,"identity":"646c777d-eea1-42da-9b26-ac458a72677a","order_by":0,"name":"Amal AlQarni","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIie3RIQvCQBTA8TsGpoF1gn6HBxabH8QyixZPjAs6LmkRrANlfgVXzHcczDK1WVa0G7QtGLwdDiw7jYL3Dw8O3o/jOIRMph+sghBmaOSoA3M9OS2Lakk130RQkCQnWE9qVJHXCU/V1BM4iTPLoNVYLPecXcJJpzqTJPO25STtAZ+D0wwOQ5d1tzsSCEzxPEk1xAVmg9OliQ2SxIRKYuFpOWmn/Rt/SLJWZBWT9ScC6QBEfstGETommy/ISNTlW6KcuDEjkSRc/5Z+dLl6fiNM7OY9G/skPAp+zrxyUlT8hVCTfdx/I/43yyaTyfRnPQHioWZ8/ASRqgAAAABJRU5ErkJggg==","orcid":"","institution":"King Saud University","correspondingAuthor":true,"prefix":"","firstName":"Amal","middleName":"","lastName":"AlQarni","suffix":""},{"id":608180189,"identity":"e6fe17f9-901e-4a94-9203-f206b8f89953","order_by":1,"name":"Omar Alzydan","email":"","orcid":"","institution":"King Saud University","correspondingAuthor":false,"prefix":"","firstName":"Omar","middleName":"","lastName":"Alzydan","suffix":""},{"id":608180190,"identity":"80112f88-96ab-4e13-bdf2-f15be038bf8f","order_by":2,"name":"Razan Alotaibi","email":"","orcid":"","institution":"King Saud University","correspondingAuthor":false,"prefix":"","firstName":"Razan","middleName":"","lastName":"Alotaibi","suffix":""},{"id":608180191,"identity":"e59ac2e4-7357-400e-b1eb-3d35a92d0cd3","order_by":3,"name":"Shahd Alsalamah","email":"","orcid":"","institution":"King Saud University","correspondingAuthor":false,"prefix":"","firstName":"Shahd","middleName":"","lastName":"Alsalamah","suffix":""},{"id":608180192,"identity":"cdadea19-477a-4ecd-8afc-e251fc7a44e0","order_by":4,"name":"Manal Altwaim","email":"","orcid":"","institution":"King Saud University","correspondingAuthor":false,"prefix":"","firstName":"Manal","middleName":"","lastName":"Altwaim","suffix":""},{"id":608180193,"identity":"e4dc1acf-c770-4ee1-9207-1fb1afce45f1","order_by":5,"name":"Modhi ALJumah","email":"","orcid":"","institution":"King Saud University","correspondingAuthor":false,"prefix":"","firstName":"Modhi","middleName":"","lastName":"ALJumah","suffix":""},{"id":608180194,"identity":"e5d26669-e699-45b6-972a-b05f4665ce71","order_by":6,"name":"Lolowah Alghuson","email":"","orcid":"","institution":"King Saud University","correspondingAuthor":false,"prefix":"","firstName":"Lolowah","middleName":"","lastName":"Alghuson","suffix":""},{"id":608180195,"identity":"121a9707-2176-4cfc-9e65-6adc431dffe2","order_by":7,"name":"Abdulrahman Bogis","email":"","orcid":"","institution":"King Saud University","correspondingAuthor":false,"prefix":"","firstName":"Abdulrahman","middleName":"","lastName":"Bogis","suffix":""}],"badges":[],"createdAt":"2026-02-18 19:38:46","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8911982/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8911982/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105035247,"identity":"04fc42a7-d781-4575-9b0d-b9687457622b","added_by":"auto","created_at":"2026-03-20 07:25:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1061686,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8911982/v1/21f70c67-00f7-49bc-8573-99e706c7729d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The role of Endometrial Sample Timing in Reducing The Risk Of Malignant Transformation Among Women Treated At King Saud University Medical City, Riyadh, Saudi arabia","fulltext":[{"header":"Background","content":"\u003cp\u003eEndometrial hyperplasia (EH) is a precancerous condition of the uterine lining and a common finding in women presenting with abnormal uterine bleeding (AUB). This retrospective cohort study conducted at King Saud University Medical City evaluated factors associated with malignant outcomes following EH diagnosis and management. Women with AUB who underwent endometrial biopsy and subsequent medical or surgical treatment between January 2023 and May 2025 were included. Demographic, clinical, imaging, biopsy, treatment, and final pathology data were analyzed. Most patients were aged \u0026ge;45 years and obese. Simple hyperplasia without atypia was the most common biopsy finding. Malignancy was identified in 11.2% of final surgical specimens. Logistic regression analysis demonstrated that endometrial adenocarcinoma on biopsy was the strongest predictor of malignancy, while hysteroscopy and hysterectomy were associated with lower malignant outcomes. Age, BMI, parity, and diagnostic-to-surgery interval were not significant predictors. The study highlights the importance of accurate diagnostic assessment and timely surgical management to reduce the risk of progression to endometrial carcinoma.\u003c/p\u003e"},{"header":"1. Introduction","content":"\u003cp\u003eEndometrial hyperplasia is a precancerous condition of uterine lining, characterized histologically by proliferation of glandular tissue with altered architecture, resulting in an increased gland to stroma ratio. The latest WHO classification identifies two categories, hyperplasia without atypia and atypical hyperplasia [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Endometrial biopsy is a safe, efficient, and widely used diagnostic method for evaluating the women who present with abnormal uterine bleeding (AUB) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It is a non-invasive widely used diagnostic tool in gynecological practice. This test is considered highly specific for detecting diverse histopathological changes starting from hyperplasia to endometrial carcinoma in women with (AUB) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEndometrial hyperplasia (EH) is a relatively common histopathological finding, particularly in perimenopausal and postmenopausal women [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. It is defined as a proliferation of endometrial glands relative to the stroma, producing a spectrum of changes from benign lesions to precancerous conditions. Among these, the presence of cytological atypia, also referred to as atypical hyperplasia (AH) or endometrial intraepithelial neoplasia (EIN), is of greatest clinical concern because of its well-established association with the development of endometrial carcinoma [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eUnderstanding the prognostic significance of endometrial hyperplasia (EH) diagnosed through biopsy is critical for informing clinical management, including decisions regarding surveillance, medical therapy, and surgical intervention. This article reviews the correlation between the initial histopathological biopsy findings and the final pathological outcome following intervention. In addition, it explores the duration between the initial diagnosis of endometrial hyperplasia (EH) and the subsequent diagnosis of endometrial cancer, in cases where malignancy is ultimately confirmed.\u003c/p\u003e "},{"header":"2. Materials and Methods","content":"\u003cp\u003eThis retrospective study was approved by the Institutional Review Board of King Saud University with reference number E-24-8603. The requirement for informed consent was waived due to the retrospective nature of the study and use of anonymized data. It was conducted to assess the factors associated with malignant pathological outcomes in women presenting with abnormal uterine bleeding (AUB). The study population included women with abnormal uterine bleeding((AUB,) irrespective of their subsequent management approach. The primary objective was to evaluate the relationship between demographic, clinical, and treatment-related factors and the final pathological findings, with particular emphasis on identifying risk factors for malignant pathology among patients who underwent surgical intervention.\u003c/p\u003e\n\u003cp\u003eStudy Design and Participants The study was carried out King Saud University Medical City and including women diagnosed with abnormal uterine bleeding (AUB) between start from 1-1-2023 to 1-5-2205 .The Inclusion criteria encompassed all patients with abnormal uterine bleeding(AUB )who underwent diagnostic procedures , such as endometrial biopsy and ultrasound ,to evaluate the underlying cause of bleeding .Women who received any form of treatment for abnormal uterine bleeding(AUB),whether surgical or medical ,were included in the analysis .\u003c/p\u003e\n\u003cp\u003eData Collection Clinical and demographic data were extracted from the hospital\u0026apos;s electronic medical records. The following variables were recorded for each participant:\u003c/p\u003e\n\u003cp\u003e\u0026bull; Demographic Characteristics: Age (\u0026gt; and equal 45, \u0026lt;45), parity (nulliparous, para 1, multiparous), and body mass index (BMI) categorized as: 18.5\u0026ndash;24.9, 25\u0026ndash;29.9, 30\u0026ndash;39.9, and \u0026gt;40.\u003c/p\u003e\n\u003cp\u003e\u0026bull; Medical History: Chronic disease, a history of malignancy, or medically free status. Chronic disease and hx of malignancy\u003c/p\u003e\n\u003cp\u003e\u0026bull; Surgical History: Prior gynecological surgeries, including hysteroscopy and myomectomy\u003c/p\u003e\n\u003cp\u003e\u0026bull; Endometrial thickness: Endometrial thickness measurements using ultrasound and divided to 2-4 mm (normal) or 5 mm and above (thick) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026bull; Treatment Information: Whether the patient was treated conservatively, received medications, underwent hysteroscopy, or hysterectomy.\u003c/p\u003e\n\u003cp\u003e\u0026bull; Final Pathology Results: Final pathology outcomes after surgery, categorized as benign or malignant.\u003c/p\u003e\n\u003cp\u003eEndometrial Biopsy (EMB) Categories The endometrial biopsy findings were categorized into the following groups:\u003c/p\u003e\n\u003cp\u003e\u0026bull; Endometrial Adenocarcinoma\u003c/p\u003e\n\u003cp\u003e\u0026bull; Complex Hyperplasia with Atypia\u003c/p\u003e\n\u003cp\u003e\u0026bull; Complex without Atypia\u003c/p\u003e\n\u003cp\u003e\u0026bull; Simple Hyperplasia with Atypia\u003c/p\u003e\n\u003cp\u003e\u0026bull; Simple without Atypia\u003c/p\u003e\n\u003cp\u003e\u0026bull; Benign\u003c/p\u003e\n\u003cp\u003e\u0026bull; Not Done\u003c/p\u003e\n\u003cp\u003e\u0026bull; Insufficient\u003c/p\u003e\n\u003cp\u003e\u0026bull; Mixed\u003c/p\u003e\n\u003cp\u003eStatistical Analysis Descriptive statistics were used to summarize demographic and clinical characteristics of the study population, including frequencies and percentages for categorical variables. A binary logistic regression analysis was conducted to assess the relationship between various independent variables and the final pathology result (benign vs. malignant). Variables considered in the analysis included age, parity, medical history, surgical history, BMI, endometrial thickness on ultrasound, endometrial biopsy results, treatment received (medications, hysteroscopy, hysterectomy), and the time from diagnosis to surgical intervention.\u003c/p\u003e\n\u003cp\u003eThe logistic regression model generated odds ratios (OR) with 95% confidence intervals (CIs) to quantify the strength and direction of the associations between the predictors and the final pathology result. Statistical significance was set at a p-value of \u0026lt;0.05. All statistical analyses were performed using SPSS software (version 30)\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eTable 1 demonstrates the demographic characteristics and medical history of the study population. A total of 261 participants (86.1%) were aged 45 years or older, while 40 participants (13.2%) were younger than 45 years. In terms of parity, 21 participants (6.9%) were primiparous, 249 participants (82.2%) were multiparous, and 33 participants (10.9%) were nulliparous. Regarding medical history, 235 participants (77.6%) reported chronic diseases, 5 participants (1.7%) had both chronic diseases and a history of malignancy, 4 participants (1.3%) had a history of malignancy alone, and 40 participants (13.2%) were medically free. For surgical history, 73 participants (24.2%) had undergone hysteroscopy, 3 participants (1.0%) had a myomectomy, and 46 participants (15.2%) had no prior surgical history. BMI classification revealed that 14 participants (4.6%) were within the normal weight range (18.5\u0026ndash;24.9), 48 participants (15.8%) were overweight (25\u0026ndash;29.9), 145 participants (47.9%) were obese (30\u0026ndash;39.9), and 72 participants (23.8%) were classified as morbidly obese (BMI \u0026gt; 40).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2 presents the endometrial biopsy results, ultrasound findings, the management provided, and final pathology outcomes. The most common biopsy result was simple hyperplasia without atypia (126 cases, 41.6%), followed by benign findings (55 cases, 18.2%) and simple hyperplasia with atypia (33 cases, 10.9%). Complex hyperplasia with atypia was found in 30 cases (9.9%), while complex hyperplasia without atypia, endometrial adenocarcinoma, and mixed types each occurred in 12 cases (4.0%). Biopsy was reported as insufficient in 7 cases (2.3%), and not done in 16 cases (5.3%). On ultrasound, endometrial thickness of 5 mm or more was observed in 254 participants (83.8%), while 12 participants (4.0%) had a thickness between 2\u0026ndash;4 mm.\u003c/p\u003e\n\u003cp\u003eIn terms of management, 70 participants (23.1%) received medical treatment, 37 (12.2%) were managed with observation, 44 (14.5%) underwent hysteroscopy, and 137 (45.2%) had a hysterectomy. A total of 34 participants (11.2%) were lost to follow-up. Regarding the timing of surgical management, 30 cases (9.9%) underwent surgery more than 12 months after diagnosis, 26 (8.6%) within 3\u0026ndash;6 months, another 26 (8.6%) within 6\u0026ndash;12 months, and 85 (28.1%) within 0\u0026ndash;3 months. Final pathology after surgery revealed benign outcomes in 135 cases (44.6%) and malignant outcomes in 34 cases (11.2%).\u003c/p\u003e\n\u003cp\u003eTable 3 shows the results of the binary logistic regression analysis, assessing the predictors of malignant pathology outcomes after surgical management. Significant findings were observed for endometrial biopsy (EMB), hysteroscopy, and hysterectomy.\u003c/p\u003e\n\u003cp\u003eA) Endometrial Biopsy (EMB): Endometrial adenocarcinoma showed the highest association with malignant outcomes after surgery, indicating that patients with this diagnosis had significantly higher odds of malignancy. All other EMB categories (such as complex hyperplasia with atypia, simple hyperplasia without atypia, benign, and others) showed much lower odds ratios and non-significant p-values, suggesting that these results were not significant predictors of malignancy after surgery when compared to endometrial adenocarcinoma.\u003c/p\u003e\n\u003cp\u003eB) Hysteroscopy: Undergoing hysteroscopy was significantly associated with lower odds of malignancy after surgery (OR = 0.474, 95% CI: 0.148\u0026ndash;1.514, p = 0.208). This indicates that patients who underwent hysteroscopy had a lower likelihood of having a malignant pathology outcome compared to those who did not undergo the procedure.\u003c/p\u003e\n\u003cp\u003eC) Hysterectomy: Undergoing hysterectomy was significantly associated with lower odds of malignancy after surgery (OR = 0.094, 95% CI: 0.012\u0026ndash;0.712, p = 0.022). This suggests that patients who underwent hysterectomy had significantly lower odds of malignancy after surgery compared to those who did not undergo the procedure.\u003c/p\u003e\n\u003cp\u003eOther variables, including age, BMI, medical history, surgical history, and the duration from diagnosis to surgery, did not show statistically significant associations with malignant pathology outcomes in the logistic regression model.\u003c/p\u003e\n\u003cp\u003eTable 4 demonstrates the distribution of benign and malignant cases according to the time interval between pathological diagnosis and surgical intervention. The majority of patients (142 cases) underwent surgery within 0\u0026ndash;3 months, of whom 111 (78.16%) had benign pathology and 31 (21.8%) were malignant. In the subgroup of patients who waited 3 to 6 months (28 cases), 25 (89.28%) were benign and 3 (10.7%) malignant, while among those operated after 6\u0026ndash;12 months (26 cases), 23 (88.46%) were benign and 3 (11.5%) malignant. Finally, patients who waited longer than 1 year (31 cases) included 27 (87.1%) benign and 4 (12.9%) malignant cases. All duration groups demonstrated Statistically significant associations with pathology outcomes, all comparisons were statistically significant (p \u0026lt; 0.001), confirming that malignant transformation was consistently below 50% across different intervals. This means the probability of obtaining such low malignant proportions by chance is extremely small, confirming that benign pathology predominates across all intervals. The statistical significance emphasizes that, irrespective of surgical timing, the malignant rate remains much lower than expected under the null hypothesis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTables 1\u003c/strong\u003e\u003cstrong\u003e: Demographic and Medical History Overview\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e261\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e86.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParity:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eP1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMultiparous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e249\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e82.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNulliparous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedical History:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eChronic disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e235\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e77.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eChronic disease and History of malignancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHx of malignancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedically free\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical History:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHysteroscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMyomectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSurgically free\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25-29.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30-39.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e145\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e47.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.5-24.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u003cstrong\u003e: Endometrial Findings and Management Overview\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEndometrial thickness in US:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 mm and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e254\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e83.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2-4 mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEndometrial biopsy result:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ecomplex hyperplasia with \u0026nbsp;atypia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ecomplex without atypia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eendometrial adenocarcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003einsufficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003emixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003enot done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003esimple hyperplasia with atypia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003esimple without atypia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e41.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ebenign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreated with medication:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e233\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e76.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreated with observation:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e266\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e87.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreated with hysterscopy:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e259\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e85.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreated with hysterectomy:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e45.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLost Follow up:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e269\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e88.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration since diagnosis to surgical management if surgery is planned:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3-6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6-12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0-3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003efinal pathology result after surgical management in it done:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBenign\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e135\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMalignant\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e\u003cstrong\u003e: Logistic Regression to predict factors associated with endometrial cancer:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eS.E.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eWald\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP-Value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eExp(B)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e95% C.I.for EXP(B)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eLower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eUpper\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge: (reference is \u0026lt;45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-.413\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.706\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.343\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.558\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.661\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.639\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eParity: (Reference is Nulliparous)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.857\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.088\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePara 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-1.910\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.184\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.599\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.510\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMultiparous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-1.187\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.581\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.305\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.952\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedical History: (Reference is Medically free)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.919\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.821\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eChronic disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.746\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.779\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.919\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.338\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.109\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.459\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.700\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eChronic disease and history of malignancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-19.123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28420.722\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHistory of malignancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-19.123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28420.722\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSurgical History: (Reference is surgically free)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.589\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.452\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHysteroscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-.747\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.593\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.589\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.208\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.474\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.514\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMyomectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-20.316\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28420.722\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBMI: (Reference is 18.5-24.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.876\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.411\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-.105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.216\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.931\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.900\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.083\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.750\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25-29.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-1.344\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.370\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.962\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.327\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.261\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.824\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30-39.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.182\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.979\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.969\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.096\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.823\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEndometrial thickness in US: (Reference is 2-4 mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19.931\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17974.857\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e452936836.780\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEMB: (Reference is endometrial adenocarcinoma)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19.579\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ecomplex hyperplasia with \u0026nbsp;atypia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-21.129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12710.180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ecomplex without atypia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-22.995\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12710.180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003einsufficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-42.406\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23778.507\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003emixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-42.406\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18467.427\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.998\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003enot done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-22.995\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12710.180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003esimple hyperplasia with atypia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-22.525\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12710.180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003esimple without atypia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-24.075\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12710.180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.998\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBenign\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-42.406\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15224.543\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.998\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTreated with medications: (Reference is yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20.029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8038.593\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.998\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e499328537.581\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTreated with hysteroscopy: (Reference is yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.368\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.035\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.239\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.676\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.405\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e81.112\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTreated with hysterectomy: (Reference is yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-2.368\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.035\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.239\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.094\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.712\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDuration from diagnosis to surgical management if surgery was planned: (Reference is 0-3 months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.571\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-.927\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.592\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.448\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.396\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.264\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3-6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-1.127\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.662\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.902\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.088\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.324\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.089\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.185\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6-12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-1.577\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.776\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.042\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.207\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.045\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.946\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e\u003cstrong\u003e: Impact of Time Interval Between Pathology Diagnosis and Surgical Management on Outcomes in Endometrial Cancer\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eduration group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBenign\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMalignant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003etotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep_value_binom_malignant_vs_50\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003emalignant percent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ebenign percent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eabove 1 year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.40E-05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12.90322581\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e87.09677419\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eduration 0-3 \u0026nbsp; \u0026nbsp; months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.17E-12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.83098592\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e78.16901408\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eduration above 3 months to 6 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.74E-05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.71428571\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e89.28571429\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003efor months 6 months to 1 year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.80E-05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.53846154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e88.46153846\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"4. Discussion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eEndometrial hyperplasia (EH) is a well-recognized precursor to endometrial carcinoma, with numerous studies highlighting its rising incidence and associated mortality worldwide [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, we investigated the demographic characteristics, clinical presentations, management strategies, and predictors of malignant outcomes among patients with endometrial hyperplasia and related endometrial pathologies. Our findings highlight several important observations with potential implications for clinical practice.\u003c/p\u003e \u003cp\u003ePatient demographic characteristics revealed that 86.1% were aged\u0026thinsp;\u0026ge;\u0026thinsp;45 years. Regarding body mass index (BMI), nearly half (47.9%) were classified as obese (BMI 30\u0026ndash;39.9), while 23.8% were morbidly obese (BMI\u0026thinsp;\u0026gt;\u0026thinsp;40). Although age and elevated BMI are established risk factors for EH and its progression [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], our study did not find statistically significant associations between these variables and malignant pathology. This discrepancy may be attributable to the limited sample size and the single-center design of our investigation.\u003c/p\u003e \u003cp\u003eIn alignment with existing literature, it is well-established that unopposed estrogen, chronic anovulation, obesity, and increased endometrial thickness (\u0026gt;\u0026thinsp;5 mm) are the main factors for elevating cancer risk [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], In addition to estrogen-only hormone therapy, and nulliparity. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Interestingly, in our cohort study Multi-parity history (p\u0026thinsp;=\u0026thinsp;0.041) and morbid obesity (p\u0026thinsp;=\u0026thinsp;0.931) did not show a strong significant association with malignant outcomes, further emphasizing potential population-specific or methodological differences.\u003c/p\u003e \u003cp\u003eHistopathological analysis revealed that adenocarcinoma (p\u0026thinsp;=\u0026thinsp;0.021) was the only endometrial pathology significantly associated with malignancy. Hyperplasia with or without atypia did not demonstrate a high correlation with malignant outcomes. This contradicts a prior meta-analysis which reported progression risks of 29\u0026ndash;45% for complex atypical hyperplasia and approximately 8% for simple atypical hyperplasia [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], as well as studies indicating that complex hyperplasia carries a significantly higher risk of malignant transformation compared to simple hyperplasia [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral studies report lower estimates of progression risk, particularly in patients with a shorter duration of untreated hyperplasia [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. For cases of endometrial hyperplasia with atypia, the cumulative risk of malignant progression was estimated at 8.2% (95% CI, 1.3\u0026ndash;14.6%) after 4 years, increasing to 12.4% (95% CI, 3.0\u0026ndash;20.8%) by 9 years, and reaching 27.5% (95% CI, 8.6\u0026ndash;42.5%) at 19 years post-diagnosis [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The interval between the initial biopsy-confirmed diagnosis of EH and the subsequent hysterectomy revealing endometrial cancer in our cohort study showed, 30 patients (9.9%) underwent surgery more than 12 months after diagnosis, 26 (8.6%) within 3\u0026ndash;6 months, another 26 (8.6%) within 6\u0026ndash;12 months, and 85 (28.1%) within 0\u0026ndash;3 months which reflects the importance of timely intervention.\u003c/p\u003e \u003cp\u003eA notable finding in our study was the observed association between undergoing hysteroscopy (OR\u0026thinsp;=\u0026thinsp;0.474, 95% CI: 0.148\u0026ndash;1.514, p\u0026thinsp;=\u0026thinsp;0.208) or hysterectomy (OR\u0026thinsp;=\u0026thinsp;0.094, 95% CI: 0.012\u0026ndash;0.712, p\u0026thinsp;=\u0026thinsp;0.022) and reduced odds of malignancy. Hysteroscopy may confer diagnostic advantages over blind sampling techniques, with studies showing that blind biopsies can miss up to 19% of EH and 1% of endometrial carcinoma cases [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. A study showed that Patients who underwent diagnostic hysteroscopy demonstrated a lower likelihood of malignancy at the time of surgery, possibly due to better lesion visualization and targeted sampling, mitigating the limitations of blind endometrial sampling [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe correlation between the biopsy-to-surgery interval and malignancy is crucial, investigations have demonstrated that atypical hyperplasia progresses at a rate of approximately 8.2% per year, with the highest risk occurring within the first two years post-diagnosis (10.7% per year) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This underlines the importance of close surveillance and timely surgical intervention, particularly for patients with atypical hyperplasia.\u003c/p\u003e \u003cp\u003eIn our study conducted at King Saud University Medical City, the majority of patients underwent surgery within a relatively short period of 0\u0026ndash;3 months following the initial pathological diagnosis, regardless of whether the pathology revealed benign or malignant disease. This timely surgical approach was consistent across different age groups and socioeconomic categories, suggesting that institutional protocols and healthcare accessibility minimized disparities in treatment delays. Importantly, this finding highlights that surgical management was not significantly influenced by external demographic or socioeconomic variables, and that diagnostic accuracy was not compromised by waiting times within this interval.\u003c/p\u003e \u003cp\u003eIdentifying key risk factors and understanding the temporal dynamics of EH progression is essential for optimizing patient management. Moreover, the COVID-19 pandemic introduced additional challenges, as surgeries for EH were often deprioritized, potentially increasing the likelihood of concurrent carcinoma at the time of delayed hysterectomy. A recent meta-analysis reinforced these concerns, highlighting a progression rate of 8.2% annually for atypical EH, escalating to 10.7% per year when intervention is delayed beyond two years [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Additionally, preoperative biopsies carry a false-negative rate of up to 30%, indicating that some patients harbor occult malignancy even at initial diagnosis, with delays further compounding this risk [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne of the central objectives of our study was to evaluate the potential effect of the time interval between diagnosis and surgery on prognosis and mortality. When our findings are placed in the context of international literature, they align with previous observations that the timeliness of surgical intervention plays a critical role in determining outcomes. For example, a study conducted at Bhumibol Adulyadej Hospital in Thailand (2009\u0026ndash;2021) stratified patients into early (\u0026lt;\u0026thinsp;6 weeks) and delayed (\u0026ge;\u0026thinsp;6 weeks) surgical groups. Endometrioid carcinoma was the most prevalent histological subtype, yet the study demonstrated that patients with advanced-stage disease or non-endometrioid histology experienced significantly worse five-year disease-free survival (DFS) when surgical treatment was delayed beyond six weeks. These findings reinforce the notion that delays in surgical intervention may disproportionately affect patients with more aggressive disease subtypes and advanced stages, where timely management is particularly crucial (18).\u003c/p\u003e \u003cp\u003eFurther evidence from a large-scale analysis conducted at NCDB hospitals in 2011 supports this perspective, but also introduces an important socioeconomic dimension. That study reported that minority patients and those with lower socioeconomic status or inadequate insurance coverage were more likely to experience delays in surgical treatment. Such delays, particularly when extending beyond six weeks from diagnosis to definitive surgery, were associated with poorer survival outcomes. This emphasizes the broader health system factors that may contribute to inequities in cancer care delivery and suggests that addressing socioeconomic and structural barriers is essential to improving overall survival rates in endometrial cancer patients (19).\u003c/p\u003e \u003cp\u003eOverall, our findings emphasize the necessity of minimizing delays between EH diagnosis and definitive surgical management, employing precise diagnostic modalities such as hysteroscopy, and maintaining vigilant follow-up to mitigate the risk of progression to endometrial carcinoma.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eIn conclusion, the findings of this study underscore the critical role of comprehensive histopathological evaluation in the management of women presenting with endometrial hyperplasia and related abnormalities. Careful assessment of biopsy samples not only aids in accurate diagnosis but also provides valuable prognostic information that can guide individualized treatment strategies. The early identification of high-risk lesions, particularly those with atypical changes, is essential to prevent disease progression and to optimize patient outcomes. Furthermore, timely surgical intervention, when indicated, continues to represent a cornerstone in the prevention of endometrial carcinoma, highlighting the need for close collaboration between clinicians and pathologists. Ultimately, these results emphasize the importance of adopting a proactive and multidisciplinary approach to the evaluation and treatment of abnormal uterine bleeding, with the overarching goal of reducing morbidity and improving women\u0026rsquo;s health.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e Conceptualization, O.A. and A.A.; methodology, R.A.; A.A.; O.A,M.A. and S.A.; software, A.A.; O.A.; A.B.; formal analysis, M.A.; A.A. and L.A.; data curation, A.B.; A.A.; S.A.; O.A.; writing—original draft preparation, M.A.; A.A.; R.A writing—review and editing, A.A. and S.A. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This work was supported by the College of Medicine Research Center, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement:\u0026nbsp;\u003c/strong\u003eThe study was conducted according to the guidelines of the Declaration of Helsinki, and was approved by the Institutional Review Board at College of Medicine, King Saud University with reference number E-24-8603\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement:\u0026nbsp;\u003c/strong\u003eNot Applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number:\u003c/strong\u003e Not Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e Data is contained within the article\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e The author declares no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclaimer/Publisher\u0026rsquo;s Note:\u003c/strong\u003e None.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEmons G, Beckmann MW, Schmidt D, Mallmann P, Uterus commission of the Gynecological Oncology Working Group (AGO). 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Survival implications of time to surgical treatment of endometrial cancers. Am J Obstet Gynecol. 2017;216(3):268e. 1-268.e18.\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Endometrial, hyperplasia, atypia, malignancy, benign","lastPublishedDoi":"10.21203/rs.3.rs-8911982/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8911982/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eEndometrial hyperplasia is a non-cancerous (benign) condition in which the lining of the uterus (the endometrium) becomes abnormally thickened due to excessive growth of endometrial glands compared to normal supporting tissue (stroma). It has been observed that certain factors significantly increase the likelihood of developing endometrial hyperplasia or malignancy, most notably an endometrial thickness greater than 5mm.However, despite the presence of radiological indicators, these findings alone are not conclusive, and histopathology confirmation through endometrial biopsy remains essential for establishing an accurate diagnosis. Following the diagnosis by endometrial biopsy, appropriate management is required to prevent the progression from hyperplasia to malignancy. This study demonstrated various approaches to treatment, including surgical intervention with close surveillance.\u003c/p\u003e","manuscriptTitle":"The role of Endometrial Sample Timing in Reducing The Risk Of Malignant Transformation Among Women Treated At King Saud University Medical City, Riyadh, Saudi arabia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-19 13:16:36","doi":"10.21203/rs.3.rs-8911982/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-20T10:58:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T10:16:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116129247762942788857143135356387199466","date":"2026-03-18T09:04:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309420920897069004164359966904877736843","date":"2026-03-17T18:03:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-17T10:30:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-20T11:13:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-19T22:24:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-19T22:24:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2026-02-18T19:25:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"da0744fe-019e-44e7-8753-05448e3c5bb7","owner":[],"postedDate":"March 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-19T13:16:36+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-19 13:16:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8911982","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8911982","identity":"rs-8911982","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}