(46) Endometrial Intraepithelial Neoplasia in a 14-year-old Adolescent Presenting with Heavy Menstrual Bleeding

Background: Endometrial Intraepithelial Neoplasia (EIN) is a precursor lesion of type 1 endometrioid adenocarcinoma that usually presents as abnormal uterine bleeding (AUB). EIN in adolescents is rare but may become more frequent due to the increasing prevalence of risk factors like obesity. Here we present the case of a 14-year-old female with EIN, the youngest patient reported to have this diagnosis based on a review of available literature.

Case: A 14-year-old menarchal female with a BMI of 32.9 and lifelong history of heavy menstrual bleeding (HMB) with regular cycle presented with an acute episode of HMB, tachycardia, and a hemoglobin of 5.6. The hemoglobin did not improve despite greater than 24 hours of IV estrogen, tranexamic acid, and transfusion of packed red blood cells. PT/INR, PTT, fibrinogen and Von Willebrand panel were normal. A pelvic ultrasound was normal with an endometrial stripe of 8 mm. On hospital day 2, a syncopal episode prompted an emergent dilation and curettage (D&C) with intrauterine balloon placement for tamponade. The intrauterine balloon was removed as planned two days post-procedure with no further bleeding. The patient was transitioned from IV estrogen and tranexamic acid to a combined-oral-contraceptive (COC) taper with 0.3 mg norgestrel/0.03 mg of ethinyl estradiol. Pathology noted “endometrial hyperplasia with focal atypia,” also termed EIN. Factor XIII level was notably low but nearly normalized on repeat testing after the acute event. After consultation with Gynecologic Oncology and subsequent counseling, the patient elected fertility-sparing treatment with a plan for repeat D&C and levonorgestrel intrauterine system placement in 3 months. Interim treatment was started with intramuscular depo medroxyprogesterone acetate and metformin XR 1000 mg daily.

Comments: This case highlights the importance of retaining a high index of suspicion for pre-malignancy and malignancy in the differential for AUB in adolescents. Literature is sparse regarding EIN and endometrial cancer in this demographic due to its relative rarity. However, given increasing rates of risk factors such as obesity, preventive efforts including counseling and prompt, thorough work-up of AUB are critical for early detection and optimal outcomes. In this patient, we chose to add metformin, as it has shown potential to work synergistically with progestins in preventing disease progression. Additional attention and resources are warranted to develop standardized counseling and surveillance protocols as well as further fertility-sparing treatment options in this young population.