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Endometrial Hyperplasia

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Endometrial hyperplasia occurs when the cells lining the endometrium (the inner lining of the uterus) multiples and becomes thickened. Endometrial hyperplasia is a pre-cancerous condition. There are two types of hyperplasia, endometrial hyperplasia without aypia and endometrial hyperplasia with atypia. 

How does endometrium change during menstruation?

  • The innermost lining for the uterus is known as endometrium. Under the influence of hormones, the endometrium changes throughout the menstrual cycle.

  • Menstrual cycle is divided into two phase and is divided by ovulation. After menses it is known as proliferative phase and after ovulation it is known as secretory phase.

  • During the first part of the menstrual cycle, oestrogen hormone  is released by the ovaries. Oestrogen causes the cells lining the endometrium to grow and thicken to prepare the uterus for pregnancy and this phase is called proliferative phase.

  • During mid-cycle at the time of an ovulation, an egg is released from one of the ovaries.

  • Following ovulation, the second part of menstruation starts and levels of another hormone called progesterone begin to increase. Progesterone prepares the endometrial cells to receive and nourish a fertilized egg this is known as secretory phase.

  • If fertilisation and pregnancy does not occur, oestrogen and progesterone levels will drop and this will trigger menstruation, or shedding of the lining. Once the lining is completely shed during menstruation, a new menstrual cycle begins.

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What are the causes?

Endometrial hyperplasia occurs due to hormonal imbalance when excess oestrogen is secreted in comparison to progesterone. When ovulation doesn’t happen progesterone is not secreted so the endometrium continues to grow and the cells lining the uterus becomes thick and causes hyperplasia. This usually happens in menopausal and pre-menopausal women.

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Some risk factors for endometrial hyperplasia have been noted such as:

  1. Conditions in which women may have high levels of oestrogen and not enough progesterone such as:

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Polycystic ovarian syndrome (PCOS) – here ovulation doesn’t happen so they have lot of oestrogen in the body and causes irregular menstrual cycles and endometrial hyperplasia. 

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Use of HRT (hormonal replacement therapy): HRT is of two types; oestrogen + progesterone or only oestrogen. If someone is on long-term use of only oestrogen HRT after menopause this can cause endometrial hyperplasia.

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Obesity: excess of fat in the body gets converted into oestrogen hormone and thus causes endometrial hyperplasia. 

  2. Other risk factors are:

  • Age older than 35 years

  • Never been pregnant (nulligravida)

  • Late menopause i.e. older age at menopause

  • Early menarche (early age when menstruation started)

  • Personal history of certain conditions, such as diabetes, hypertension and obesity. This combination is known as metabolic syndrome

  • Cigarette smoking increase the risk

  • Family history of cancers such as ovarian, colon, or uterine cancer

  • If you have a hormone producing ovarian tumor such as granulosa cell tumor

What are the symptoms?

Abnormal uterine bleeding is the principal symptom of endometrial hyperplasia. Abnormal bleeding such as

  • Post-menopausal bleeding 

  • Menstrual cycle occurring less than 21 days 

  • Menstrual bleeding that last longer and heavier than usual

  • Inter menstrual bleeding i.e. bleeding occurring in-between menstrual periods

What tests will be required for diagnosis?

  1. Physical examination:

  • Your doctor will need to do a thorough physical examination, which includes feeling your tummy and an internal examination to check if your uterus is bulky. An internal examination will be required to ensure that there are no other conditions which could be leading to your symptoms (such as cancer of the vagina and cervix), hence a through physical examination is important. Ultrasound scan to measure endometrial thickness.

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  2. Ultrasound: An ultrasound will help your doctor to take      endometrial thickness measurement. 

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  3. Biopsy of the endometrium: In this procedure a small endometrial tissue is taken for testing and this procedure can be done in the  clinic without any anesthesia, if you are sensitive then mild anaesthesia will be given. Biopsy report is gold standard for confirmation of endometrial hyperplasia.

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  4. Hysteroscopy: This is a procedure wherein a thin telescope is passed into the uterus (womb) to visualise the inner part of the womb. This is done under anaesthesia and is a day care procedure. Sometimes, doctor may take biopsy to confirm the diagnosis.

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  5. CT / MRI scan may be required

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What are the treatment options?

There are two types of endometrial hyperplasia and treatment will depend on the type of hyperplasia. 

  • Endometrial hyperplasia without atypia

  • Endometrial hyperplasia with atypia

 

Treatment for endometrial hyperplasia without atypia:

  1. Hormonal treatment: 

This type of hyperplasia means that the cells lining the uterus have

undergoing changes and are in the very beginning stage and very

rarely turns into cancer, so treatment is not always needed. 

  • One option is to do nothing and repeat the biopsy in a few
    months to see if it has settled back to normal on its own. In many
    cases, this can happen. However, it is more likely to return to
    normal (regress) if you have treatment. The best treatment for
    this type of endometrial hyperplasia is to have an intrauterine
    device (just like copper T coil, but this is a medicated coil). This
    intrauterine device has progesterone in it and releases this
    hormone inside the uterus and thus suppressing the oestrogenic
    effect.  This can be retained in the uterus for stays in for up to five
    years. It has a good success rate in treating endometrial
    hyperplasia.

  • Another option is to have progestogen tablets each day for six
    months. These are not quite as effective as the IUS and they may
    have more side-effects.

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  2. Surgery:

Occasionally an operation to remove the womb (a hysterectomy) is

needed. This operation is not normally needed for this type of

endometrial hyperplasia. However, it may be indicated if:

  • The hormone treatments are not working after 6-12 months, this
    will be evident on the repeat biopsy.

  • The condition comes back again after treatment.

  • The condition can progress and go on to develop atypical
    hyperplasia.

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  • Your choice, if you prefer to have an operation than to take regular medication or have an IUS. However, a hysterectomy is major operation, so you would need to know the pros and cons with your doctor.

  3. Alternative treatment: 

  • Being overweight puts you at more risk of endometrial hyperplasia. So, if you are overweight, it seems likely that losing weight will make it less likely that the hyperplasia will return in future after treatment.

Treatment for endometrial hyperplasia with atypia:

  • If your biopsy confirms that you have atypical endometrial hyperplasia, your doctor will probably recommend you have surgery (hysterectomy). This is because it has been noted that in 30% of this condition could be associated with endometrial hyperplasia. If you are in the age group for menopause, you will be offered removal of your both ovaries and fallopian tubes as well; this is called a hysterectomy and bilateral salpingo-oophorectomy (THBSO).

  • If you wish to retain the uterus to be able to get pregnant, you can discuss the options with your doctor. You may be advised to have hormone treatment for six months and if a repeat biopsy shows it has worked, you may be able to delay a hysterectomy until after you have completed your family. However, it’s important for you to understand that you will still be advised to have a hysterectomy at some point, as there is a high chance that the endometrial hyperplasia will return, and can change to cancer.

Options for prevention

Research has shown that certain factors can lower the risk of endometrial hyperplasia:

  • If your menstrual periods are irregular as it happens due to PCOS, birth control pills (oral contraceptives / OCP) may be recommended. They contain both estrogen and progestin pills are taken cyclically to produce a monthly menstrual period, which reduces the risk of an overgrowth of the uterine lining, especially when taken over a long period of time.

  • Using a progestin-secreting intrauterine device (IUD) like Mirena, which is a form of birth control.

  • After menopause if you are considering starting HRT, use a combination of estrogen and progesterone for HRT instead of only estrogen HRT.

  • Maintaining a healthy weight, because obese women are at risk for both hyperplasia and endometrial cancer.

  • If you have diabetes and hypertension, good disease management, such as regularly monitoring can lower risk of hyperplasia.

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