Endometrial Hyperplasia | familydoctor.org

What is endometrial hyperplasia?

Endometrial hyperplasia is a condition in which the endometrium (lining of the uterus) is abnormally thick. There are four types of endometrial hyperplasia. These vary by the amount of abnormal cells and the presence of cell changes. The types are:

• Simple
• Complex
• Simple atypical
• Complex atypical

Symptoms 

The primary symptom of endometrial hyperplasia is abnormal menstrual bleeding. Contact your doctor if you experience:

• Menstrual bleeding that is heavier or longer-lasting than usual
• Menstrual cycles (amount of time between periods) that are shorter than 21 days
• Menstrual bleeding between periods
• Not having a period (pre-menopause)
• Post-menopause bleeding

What causes of endometrial hyperplasia?

Endometrial hyperplasia is caused by too much estrogen and/or not enough progesterone. Both hormones play a role in the menstrual cycle. Estrogen makes the cells grow, while progesterone signals the shedding of the cells. A hormonal imbalance can produce too many cells or abnormal cells.

Diagnosis

Abnormal uterine bleeding can be a symptom for many things. Contact your doctor if you experience this. They can perform a physical exam and tests to diagnose the main condition. A transvaginal ultrasound measures your endometrium. It uses sound waves to see if the layer is average or too thick. A thick layer may indicate endometrial hyperplasia. Your doctor will take a biopsy of your endometrium cells to determine if cancer is present.

Prevention Tips

You cannot completely prevent endometrial hyperplasia. It is more common in people who have gone through menopause. This is because your body’s hormones and menstrual cycles change. Other risk factors for this condition include:

• Long-term use of medicines that contain high levels of estrogen or chemicals that act like estrogen
• Irregular menstrual cycles, which can be caused by infertility or polycystic ovary syndrome (PCOS)
• Obesity
• Tobacco use
• First menstrual cycle at an early age
• Menopause at an older age
• Never having been pregnant
• Family history of uterine, ovarian, or colon cancer

To help lower your risk, you can:

• Lose weight, if you are obese
• Take progestin (synthetic progesterone), if you already are taking estrogen, due to menopause or another condition
• Take birth control or another medicine to regulate your hormones or menstrual cycle

Treatment

Treatment options for endometrial hyperplasia depend on what type you have. The most common treatment is progestin. This can be taken in several forms, including pill, shot, vaginal cream, or intrauterine device (IUD).

Atypical types of endometrial hyperplasia, especially complex, increase your risk of cancer. If you have these types, you might consider a hysterectomy. This is a surgery to remove your uterus. Your doctor will only recommend this if you no longer want to become pregnant. There are more conservative treatments for younger women who do not wish to have a hysterectomy.

Talk to your doctor who will help you decide which treatment option is best for you.

Living with endometrial hyperplasia

In most cases, endometrial hyperplasia is very treatable. Work with your doctor to create a treatment plan. If you have a severe type or if the condition is ongoing, you might need to see your doctor more often to monitor any changes.

Questions to ask your doctor

• How do I know if my bleeding is caused by endometrial hyperplasia?
• What is the most common age to get endometrial hyperplasia?
• What is my best treatment option for endometrial hyperplasia?
• What are my chances of developing cancer?

Resources

American Congress of Obstetricians and Gynecologists: Endometrial Hyperplasia

Copyright © American Academy of Family Physicians

This information provides a general overview and may not apply to everyone. Talk to your family doctor to find out if this information applies to you and to get more information on this subject.

Endometrial Hyperplasia > Fact Sheets > Yale Medicine

Overview

Endometrial hyperplasia is a precancerous condition in which there is an irregular thickening of the uterine lining. This may cause uncomfortable symptoms for women, including heavy menstrual periods, postmenopausal bleeding, and anemia due to the excess bleeding.  

Endometrial hyperplasia is most common among women in their 50s and 60s who have experienced menopause. It may also occur in women who are in perimenopause, a transitional state during which women still have their menstrual periods but on an irregular basis.  

Left untreated, endometrial hyperplasia may develop into endometrial cancer. Treatments are available to effectively manage the condition, which, in turn, helps to lower the risk that endometrial hyperplasia will advance to cancer.

“All women with changes in menstrual bleeding should be evaluated to see if they are at risk for endometrial hyperplasia. If they are, they can potentially be treated to reduce the chances of it progressing to endometrial cancer,” says Shefali Pathy, MD, MPH, a Yale Medicine obstetrician-gynecologist. 

What is endometrial hyperplasia?

During a woman’s childbearing years, her uterus develops a lining every month. If conception occurs, the uterine lining serves as a cushion for the fetus as it grows within the uterus. If conception does not occur, the uterine lining is shed through menstruation. Each month the cycle begins anew.

The root cause of endometrial hyperplasia is an imbalance between estrogen and progesterone; the condition may mean that the lining is not fully shed each month. When there is an unusual thickening of the uterine lining, it can result in what is known as endometrial hyperplasia. The condition is associated with heavy menstrual periods, short menstrual cycles (oligomenorrhea), and postmenopausal bleeding.

In women with endometrial hyperplasia, cells that amass in the uterine lining are abnormal and may, over time, become cancerous. For this reason, women with heavy periods and other symptoms of endometrial hyperplasia should not wait to seek diagnosis and treatment.

What causes endometrial hyperplasia?

Endometrial hyperplasia develops when a woman has an imbalance of estrogen and progesterone. There are a number of reasons this can occur:

• Having irregular menstrual periods, being obese, or having polycystic ovary syndrome (PCOS) may interfere with ovulation, which reduces progestin exposure.
• During perimenopause, when a woman is not ovulating regularly, her exposure to progesterone is reduced.
• After menopause, a woman no longer ovulates, so she is no longer exposed to progesterone.
• The breast cancer medication tamoxifen mimics the effects of estrogen, without progestin (a synthetic chemical that mimics the effects of progesterone on the body). Some people take prescription estrogen without also taking progestin.

What are the symptoms of endometrial hyperplasia?

Women who have endometrial hyperplasia may experience:

• Heavier-than-normal menstrual periods
• Lengthier-than-normal menstrual periods
• Bleeding between menstrual periods
• Menstrual cycles that are shorter than 21 days
• Menstrual-type bleeding after menopause
• Anemia, in some instances, due to heavy menstrual bleeding

What are the risk factors for endometrial hyperplasia?

Women are more likely to develop endometrial hyperplasia after age 35, particularly if they:

• Started getting their menstrual periods at a young age
• Never became pregnant
• Were diagnosed with infertility
• Went through menopause at an older age
• Are obese
• Take tamoxifen, a breast cancer medication
• Take prescription estrogen without progesterone

Additionally, having these medical conditions may increase risk of endometrial hyperplasia:

• Diabetes
• Polycystic ovary syndrome (PCOS)
• Thyroid disease
• Gallbladder disease
• Lynch syndrome
• Cowden syndrome
• Being diagnosed with a tumor that excretes estrogen
• A personal or family history of uterine cancer, ovarian cancer, or colorectal cancer

How is endometrial hyperplasia diagnosed?

Doctors are able to determine whether or not a woman has endometrial hyperplasia by learning about her medical history and symptoms, performing a physical exam, and offering diagnostic tests.
 

During a medical history, doctors will ask about a woman’s history of irregular menstrual bleeding, as well as details about her menstrual history: When her menstrual periods began, when they ended (if applicable), how long her menstrual cycle is/was and whether she has ever been pregnant. The doctor should also ask about medication usage, specifically tamoxifen or estrogen.
 

A pelvic exam may be normal, because endometrial hyperplasia doesn’t cause physical changes to the reproductive system.  

When a doctor suspects endometrial hyperplasia, they may recommend some additional tests.  A transvaginal ultrasound is an imaging tool that shows the inside of the uterus and allows doctors to see if the uterine lining is thicker than it should be.
 

If the uterine lining is too thick, a biopsy of it will be offered to diagnose the condition. This can be done in the office in most cases. In some cases, however, a procedure, known as dilation and curettage (called a D&C) and hysteroscopy, can be performed with some sedation. In this procedure, a doctor inserts a hysteroscope—a tube equipped with a camera and a light—into the vagina, through the cervix, and into the uterus. This enables  the doctor to see inside the uterus. During the D&C portion of the procedure, the cervix is opened, or dilated, to allow the doctor to access the uterus. The doctor then uses a device called a curette to remove of the lining of the uterus. The results may show that the uterine lining cells are:

• normal
• abnormal yet non-cancerous
• abnormal and precancerous
• abnormal and cancerous

Abnormal findings that are non-cancerous and pre-cancerous indicate endometrial hyperplasia.

How is endometrial hyperplasia treated?

For women with endometrial hyperplasia who have abnormal, non-cancerous cells, progestin therapy may be recommended. This synthetic hormone helps to balance out the effects of estrogen in the system, which should eliminate or minimize symptoms of endometrial hyperplasia.

Women who have not yet reached menopause may be prescribed:

• Birth control pills containing progestin
• Birth control pills containing estrogen plus progestin
• Progestin injections
• Vaginal cream containing progestin
• An intrauterine device (IUD) that gradually releases a progestin (levonorgestrel)

Women who have reached menopause should not take birth control pills containing estrogen plus progestin. They may be prescribed:

• Progestin-only birth control pills
• Progestin injections
• Vaginal cream containing progestin
• An IUD that gradually releases progestin

For women with endometrial hyperplasia who have abnormal, pre-cancerous cells, hysterectomy may be recommended. This procedure removes the uterus, eliminating the possibility that endometrial cancer could develop. It’s important to note that having a hysterectomy means a woman is no longer able to get pregnant.

What is the outlook for people with endometrial hyperplasia?

Treatment helps endometrial hyperplasia to resolve in most patients, so that women no longer experience heavy or abnormal menstrual bleeding. If endometrial hyperplasia is not diagnosed and treated, it may develop into endometrial cancer. For this reason, it’s important for women with symptoms of endometrial hyperplasia to seek treatment.

What makes Yale unique in its treatment of endometrial hyperplasia?

“Yale doctors are experts in evaluating abnormal bleeding and can effectively treat women with hyperplasia,” says Dr. Pathy. “Our team of gynecologists work with the patient to identify their goals and then develop treatment plans accordingly.” 

Pathology of the uterine cavity. Causes.

Home » Infertility treatment » Pathology of the uterine cavity. Causes.

The uterus is a pear-shaped muscular organ located in the small pelvis. The uterus is represented by three layers – internal (endometrium, uterine cavity mucosa), middle (myometrium, muscular layer of the uterus), external (serous, visceral peritoneum covering the uterus from the abdominal cavity).

The uterus consists of the body of the uterus and the cervix. The body of the uterus communicates with the vagina through the cervical canal of the cervix and with the abdominal cavity through the fallopian tubes. Of all three layers of the uterus, only the inner lining of the uterine body undergoes cyclic changes – the mucous membrane of the uterine cavity – the endometrium.

The endometrium is divided into 2 layers: functional (upper) and basal (lower). On the first day of menstruation, there is a sharp decrease in the level of progesterone and the rejection of the functional layer of the endometrium occurs, which is manifested by menstrual bleeding. In the first phase of the menstrual cycle (from 1 to 14-16 days of the cycle), under the action of estradiol, proliferation (thickening) of the endometrium occurs up to 11-13 mm. When a smaller size of the endometrium is reached, pregnancy is unlikely or subsequently leads to the threat of termination of pregnancy. After ovulation and due to the changing hormonal background for progesterone, the endometrium matures and prepares for the adoption of a fertilized egg. When pregnancy occurs, under the action of chorionic gonadotropin (hCG), the endometrium continues to function in order to provide the embryo with nutrients. In the absence of pregnancy, endometrial rejection occurs. There are certain limits to the thickness of the endometrium for each day of the menstrual cycle. If the thickness of the endometrium is less than normal, we can talk about thin endometrium (endometrial hypotrophy), with an increase in the size of the thickness of the endometrium, we can talk about pathological thickening of the endometrium (endometrial hyperplasia). Normally, the thickness of the endometrium in the first 2 days after the end of menstruation should be no more than 3 mm, and on periovulatory days, at least 10 mm.

Both congenital anomalies in the development of the uterus and acquired diseases of the uterine cavity are the cause of infertility.

Such developmental anomalies and diseases include the following diseases:

• Unicornuate and bicornuate uterus.
• Hypoplasia (underdevelopment) of the uterus, rudimentary uterus.
• Complete and incomplete septum of the uterine cavity.
• Pathology of the uterine cavity (endometrial hyperplasia, endometrial polyposis, endometrial polyp).
• Endometriosis of the uterus.
• Intramural uterine fibroids with centripetal growth.
• Submucosal uterine fibroids.

The above pathology occurs in 10% of cases of infertility and miscarriage.

Uterine infertility is associated with the presence of pathology not only in the endometrium, but also in the myometrium (the muscular layer of the uterus).

1. Endometrial polyp – pathological focal growth of the uterine mucosa due to inflammatory diseases of the uterine cavity (endometritis), hormonal disorders (hyperandrogenism, hyperestrogenemia, hyperprolactinemia), ovarian tumors (ovarian cysts), uterine tumors (uterine fibroids). An endometrial polyp is a pathological structure in the uterine cavity that prevents the implantation of an embryo. Sometimes the formation of an endometrial polyp occurs without obvious reasons. In this case, the formation of an endometrial polyp is due to the presence of a pathological receptor apparatus that perversely perceives the normal level of female sex hormones. When an endometrial polyp is detected in women planning a pregnancy, surgical treatment should be performed strictly with the help of hysteroresectoscopy. Hysteroresectoscopy is a method of surgical treatment of intrauterine pathology using an electric loop. Only performing hysteresectoscopy in patients of reproductive age makes it possible to avoid recurrence of the endometrial polyp and return to pregnancy planning after 2 months. During hysteroresectoscopy, the pedicle of the polyp is treated with high-frequency energy, which helps prevent the recurrence of the endometrial polyp due to its performance under visual control with high magnification. Performing the removal of a polyp by scraping the uterine cavity in women planning a pregnancy is unacceptable, as this leads to unnecessary trauma to the healthy endometrium around the polyp with the development of infertility and miscarriage.
2. Endometrial hyperplasia is a diffuse thickening of the endometrium with a change in structure that does not correspond to the day of the menstrual cycle. The cause of the development of endometrial hyperplasia is hyperestrogenism, dysfunction of the hypothalamic-pituitary system, diseases of the thyroid gland and adrenal glands. Both endometrial hyperplasia itself and the causes leading to it cause infertility. Treatment of endometrial hyperplasia consists of two stages – surgical and anti-relapse hormonal. In the surgical treatment of endometrial hyperplasia, diagnostic hysteroscopy is necessarily performed first, the diagnosis of endometrial hyperplasia is confirmed or refuted, and only then the issue of the advisability of performing therapeutic and diagnostic curettage of the uterine cavity is resolved. Anti-relapse hormonal treatment is prescribed upon receipt of the results of the histological conclusion and depending on the desire to plan a pregnancy in the near future. In the absence of adequate treatment, atypical endometrial hyperplasia occurs with the subsequent development of endometrial cancer.
3. Intrauterine synechia (adhesions in the uterine cavity) – adhesions of the anterior and posterior walls of the uterus with limitation of the volume of the uterine cavity. In this case, implantation and subsequent pregnancy becomes impossible. Most often, the cause of the development of intrauterine synechia is inflammation in the uterine cavity, trauma to the uterine cavity during abortion or curettage of the uterine cavity, endometriosis of the uterus. The destruction of intrauterine synechia is carried out by hysteroresectoscopy – in the aquatic environment under visual control using an electric loop, adhesions in the uterine cavity are dissected. With pronounced synechia in the uterine cavity, the dissection can be performed in two stages under the control of laparoscopy. After dissection of intrauterine synechia, hormone therapy is necessarily prescribed for 6 months, after which pregnancy planning is carried out.
4. Chronic endometritis is an inflammation of the uterine mucosa after an infection or traumatic interventions in the uterine cavity (complicated childbirth, accompanied by intrauterine intervention – manual examination of the uterine cavity, curettage of the uterine cavity with the remains of placental tissue). Acute endometritis is always accompanied by fever, purulent discharge from the uterine cavity, sharp sharp pains in the lower abdomen. In chronic endometritis, such a clinical picture was not noted – minor pulling or aching pains in the lower abdomen and scanty spotting spotting before and after menstruation are disturbing. The main symptom of endometritis is infertility and miscarriage. Very often, in the presence of chronic endometritis, according to ultrasound of the small pelvis, a thin endometrium is noted. Endometrium in chronic endometritis not only does not reach normal thickness, but also does not undergo cyclic changes. In order to correct endometritis before conception, it is recommended to carry out hormonal and physiotherapeutic treatment along with antibacterial and anti-inflammatory therapy.
5. Endometriosis of the uterus is the penetration and growth of the endometrium into the muscular layer of the uterus. There are diffuse and diffuse-nodular forms of adenomyosis. The main clinical symptoms in the presence of uterine endometriosis are uterine bleeding and debilitating pain in the lower abdomen. In the presence of endometriosis, leading to deformation of the uterine cavity, surgical treatment is performed followed by hormonal treatment.
6. Uterine fibroids – a benign tumor of the muscular layer of the uterus. Like submucosal uterine fibroids, large fibroids prevent pregnancy and gestation. The exact mechanism of the effect of uterine fibroids on the embryo has not been clarified. In the presence of large uterine fibroids and submucosal location, it is required to remove it before planning a pregnancy. Planning for pregnancy after removal of uterine fibroids should be carried out only after 12 months from the date of surgical treatment. Location and size have a very strong influence. In the presence of uterine fibroids of small size and its subserous location, planning of pregnancy and childbirth through the natural birth canal is possible. Most of the drugs used in IVF are contraindicated in the presence of uterine fibroids, as they cause the growth of tumors. The behavior of uterine fibroids during pregnancy is unpredictable, but most often there is an increase in myomatous nodes. In the surgical treatment of uterine fibroids in women of reproductive age, it is always possible to perform the removal of only tumors, that is, to perform a conservative myomectomy.
7. Complete and incomplete septum of the uterine cavity is a congenital anatomical change that most often interferes with the full bearing of pregnancy. When pregnancy attaches to the uterine septum in the early stages, the death of the embryo occurs due to inadequate blood supply. When planning pregnancy, the intrauterine septum is dissected using hysteroresectoscopy, followed by the appointment of hormone therapy. Planning for pregnancy after dissection of a complete or incomplete intrauterine septum should be carried out strictly after 6 months.
8. Thin endometrium can be noted as an individual feature of the patient throughout the entire menstrual cycle or develop as a result of endometritis, uterine endometriosis. Also, a thin endometrium can be the cause of impaired blood supply to the uterus or inferiority of the receptor apparatus of the uterus. In the presence of a thin endometrium, the likelihood of pregnancy is reduced. When planning a pregnancy, the thin endometrium is corrected by the use of hormonal and vascular drugs.
9. Pathology of the uterine cavity is detected and treated by hysteroscopy. This method is divided into two types: diagnostic (to confirm or refute the disease) and surgical (therapeutic). Diagnostic hysteroscopy refers to office hysteroscopy, which does not require general anesthesia. It is carried out on an outpatient basis. The cost of an operation to remove a polyp and uterine fibroids depends on the chosen treatment method, the number and size of formations, their location, comorbidities, and many other factors.

Endometrial hyperplasia – symptoms and treatment, causes, diagnosis, prevention

The inner lining of the uterus in a woman of reproductive age is subject to changes under the influence of sex hormones – estrogens. With their excessive stimulation, endometrial hyperplasia occurs – its excessive growth, an increase in thickness and a change in cells. This condition is benign, but in some cases it can lead to uterine cancer. The disease is more common in women with menstrual irregularities, as well as in the postmenopausal period.

Endometrial hyperplasia: causes and classification

The main cause of the disease is an imbalance between the two sex hormones – estrogen and progesterone. Active estrogenic stimulation with a lack of gestagens leads to the growth of endometrial cells, as happens in the first phase of the menstrual cycle, but more pronounced.

Factors that can cause hormonal imbalance:

• polycystic ovary syndrome;
• postmenopausal condition;
• overweight.

Other causes of endometrial hyperplasia:

• endocrine diseases – diabetes, obesity;
• diseases of the ovaries;
• taking tamoxifen for breast cancer.

The following classification of the disease is often used in Russia:

• endometrial polyps;
• simple glandular endometrial hyperplasia;
• glandular cystic focal endometrial hyperplasia;
• diffuse glandular cystic endometrial hyperplasia;
• atypical endometrial hyperplasia (adenomatosis), focal or diffuse, including adenomatous polyps.

According to WHO, there are 2 main types of this pathology – without atypia and atypical. Each of them can be simple or complex. The cells that form the glands of the endometrium undergo changes of varying severity – from minor to precancerous. This classification is useful in that it shows the relationship of the disease with the development of malignant neoplasms.

Endometrium with glandular hyperplasia grows, but its cells do not undergo changes. Cystic restructuring – the formation of rounded formations (cysts) from some glands. This is the least dangerous of all forms of the disease, it responds well to hormone therapy.

Simple atypical endometrial hyperplasia is accompanied by a change in the properties of cells in a separate area. It is amenable to hormone therapy and has a low risk of malignancy. The complex form of this type of pathology is the most dangerous and often transforms into endometrial cancer. Treatment often consists of removing the uterus.

Endometrial hyperplasia – symptoms

The most common signs of endometrial hyperplasia are associated with changes in the menstrual cycle. They can be observed daily or at certain phases of the cycle, their severity can also be different.

Main symptoms of endometrial hyperplasia:

• irregular menses;
• acne on the skin;
• vaginal dryness;
• spotting between periods;
• pain during intercourse;
• hot flushes;
• absence of menstruation;
• palpitations, fatigue;
• mood instability;
• increased body hair growth;
• too copious or prolonged menstruation;
• pain in the lower abdomen.

If you experience these symptoms, you should consult a gynecologist. The specialists of the clinic on Barclay, located in Moscow, will provide such patients with qualified assistance in the diagnosis and treatment of this serious disease.

Diagnosis and treatment of endometrial hyperplasia

The main task of diagnosing the disease is to confirm the thickening of the endometrium and the presence of altered cells in it. This can be done on ultrasound and by taking a biopsy.

Material for microscopic examination can be obtained during diagnostic curettage of the uterine cavity. An aspiration biopsy is also performed – taking material using a probe inserted into the uterus, from which air is removed and thus a vacuum is created. Many patients with this disease require hysteroscopy – examination of the inner surface of the uterus using an optical instrument; during the procedure, you can take a biopsy or remove a polyp.

Ultrasound is used to determine the thickness of the endometrium. The transvaginal method is more informative when the sensor is inserted into the vagina. The doctor evaluates the echo signs of the disease, including in terms of the possible development of cancer.

Endometrial glandular hyperplasia and a simple form of atypical hyperplasia are treated with hormonal drugs. Usually, these are progestogen-based drugs that are taken orally, or regularly in the form of injections, or by inserting an intrauterine hormonal coil. During such a course, pregnancy is not possible.

Other groups of drugs are also used – antigonadotropic drugs and gonadotropin-releasing hormone agonists.

Doctors also use curettage of the uterine wall to remove overgrown tissue. Treatment of endometrial hyperplasia without curettage is possible in mild forms of the disease and includes ablation (removal) of the endometrium by diathermocoagulation or laser exposure.

In severe cases, not amenable to medical treatment, with persistent bleeding, recurrent hyperplasia, or with a complex atypical form of pathology, surgical treatment of endometrial hyperplasia – removal of the uterus may be recommended.

Removal of polypoid formations is performed using hysteroscopy.

Prevention of endometrial hyperplasia

To reduce the risk of this pathology, it is necessary: ​​

• in the perimenopausal period, prescribe estrogens to women only in combination with progestin preparations;
• in case of irregular menstruation, as prescribed by a doctor, use oral contraceptives that normalize the cycle;
• maintain normal weight.

Treatment at the clinic on Barclay

Therapy of endometrial hyperplasia is quite complex and depends on the age of the patient, the severity of the disease, the severity of its symptoms, the ability to take drugs, their tolerance and many other factors.