Following our team’s work on the Tambre blog about pathologies that affect women (such as adenomyosis or fibroids), Dr. Esther Marbán turns her attention to endometrial hyperplasia, answering 5 common questions. Endometrial hyperplasia is an overgrowth of glandular cells in the endometrium (the inner layer of the uterus that sheds with menstruation) caused by chronic and prolonged exposure to oestrogen. Some risk factors for endometrial hyperplasia are obesity, chronic anovulation, or estrogen-only hormone replacement therapy. In all cases there is a chronic hyper estrogenic environment that is not naturally addressed by progesterone. Endometrial hyperplasia is rare in women under 30 years of age and increases in frequency from the ages of 45-50.
How is it diagnosed?
The most frequent symptom is abnormal uterine bleeding, although not all patients present with this. Ultrasound can detect issues when the endometrium is excessively thick (greater than approximately 15 mm in women with periods and greater than 5 mm in post menopausal women). Confirmatory diagnosis is always histological, meaning that it is achieved by taking a sample of the endometrium by means of an endometrial biopsy (obtained by hysteroscopy, curettage, etc.) and after evaluation by a Pathological Anatomy service, a definitive diagnosis can be given. The importance of having a diagnosis is important as it is something that could progress to endometrial cancer in the worst case scenario.
Are there degrees to the condition or is there a classification according to how mild or severe it is?
Yes, hyperplasia is classified accordingly:
- Simple endometrial hyperplasia: exaggerated growth of endometrial cells but with benign characteristics. Very low potential to become malignant over time.
- Complex endometrial hyperplasia: greater cellular alterations and greater potential to become malignant than the simple form.
- Atypical endometrial hyperplasia: atypical cellular alterations but no invasion. The classification of simple or complex hyperplasia is in turn subclassified as ‘with’ or ‘without atypia’. Those hyperplasias (simple or complex) with atypia carry a greater potential for malignancy and progression to endometrial cancer.
Is it usually related to other pathologies?
Yes, endometrial hyperplasia is more frequently diagnosed in women with:
– Obesity and Diabetes
– Polycystic Ovary Syndrome
– Certain estrogen-producing ovarian tumours
– Certain types of familial cancer that associate colon cancer with endometrial cancer (Lynch syndrome)
Is there a cure or treatment?
Yes, in most cases of endometrial hyperplasia without atypia, the lesion reverses with progestin treatment within 3-6 months. A control biopsy must always be performed to confirm the disappearance of the lesion. Additionally, it is recommended that added risk factors are eliminated: weight loss should be promoted in patients suffering from obesity and issues that cause patients not to ovulate regularly should be addressed to reduce the hyper estrogenic environment.
In cases of hyperplasia with atypia, the treatment of choice is hysterectomy (removal of the uterus) because these are considered pre-malignant lesions. Younger patients who are trying for a pregnancy who have regular periods and who exhibit no additional risk factors for familial cancer, can be offered conservative treatment with progestogen, ensuring that frequent and comprehensive checks are undertaken to evaluate if the lesion improves.
Does it affect fertility? If so, when we see a woman with endometrial hyperplasia at Tambre, is there a specific protocol we follow?
All pathologies that affect the endometrium, the environment in which the pregnancy will develop, can have a negative effect on the implantation of an embryo. For this reason, when a diagnosis is made, it is essential that relevant treatment is undertaken to resolve the condition before commencing the chosen indicated assisted reproduction technique.