Endometrial Hyperplasia

Endometrial hyperplasia is a condition affecting the lining of the uterus, causing it to thicken abnormally. This unusual thickening of the uterus wall has an impact on many women worldwide and can lead to serious health concerns if left untreated. Understanding endometrial hyperplasia is crucial for early detection and effective management, as it can sometimes progress to more severe conditions. 

This article explores the critical aspects of endometrial hyperplasia to help readers better understand this condition. 

What is Endometrial Hyperplasia? 

Endometrial hyperplasia impacts the uterus lining (endometrium), causing it to become abnormally thick. This overgrowth of the endometrium is usually caused by hormonal imbalance and can cause uncomfortable symptoms for women. This hyperplasia uterus commonly occurs in women around menopause (late 40's and 50's), but it can affect younger women as well. Although it is not cancer itself, this condition can sometimes progress to endometrial cancer if left untreated. 

Types of Endometrial Hyperplasia 

The World Health Organisation's 2014 classification system divides endometrial hyperplasia into two main categories: 

• The first type is hyperplasia without atypia, also known as benign endometrial hyperplasia. This form has normal-looking cells and a lower risk of becoming cancerous. It often responds well to hormonal treatment or may improve without intervention. 
• The second type is atypical hyperplasia, also called endometrial intraepithelial neoplasia. This form has abnormal cells and has a higher chance of progressing to endometrial cancer. 

Symptoms of Endometrial Hyperplasia 

• Abnormal uterine bleeding is among the most common endometrial hyperplasia symptoms. 
• Women may experience heavy menstrual bleeding or bleeding between periods. 
• Short menstrual cycles, lasting less than 21 days, can also indicate this condition. 
• Postmenopausal bleeding is another significant sign that requires immediate medical attention. 

Causes of Endometrial Hyperplasia 

Endometrial hyperplasia primarily results from an imbalance between oestrogen and progesterone hormones. This condition impacts the uterine lining, causing it to thicken abnormally. The leading cause is excess oestrogen without sufficient progesterone to counteract its effects. This hormonal imbalance often occurs during perimenopause or menopause when ovulation becomes irregular or stops entirely. Other causes of thickening of endometrium are gynaecological conditions and medications, such as tamoxifen used in breast cancer treatment. 

Risk Factors 

Several factors increase the likelihood of developing endometrial hyperplasia, including: 

• Age plays a significant role, with women over 35 facing a higher risk. 
• Obesity has a substantial impact, as excess body fat stimulates oestrogen production. 
• Chronic anovulation, often associated with polycystic ovary syndrome (PCOS), contributes to hormonal imbalances. 
• Early menarche and late menopause extend the period of oestrogen exposure. 
• Certain medical conditions, such as diabetes and thyroid disease, also raise the risk. 
• Hormone replacement therapy using oestrogen alone in postmenopausal women with an intact uterus influences the development of this condition. 

Complications 

• The most significant concern is the potential development of endometrial cancer, particularly in cases of endometrial hyperplasia. Untreated atypical endometrial hyperplasia has a higher chance of becoming cancerous, with up to 30% of complex atypical cases progressing to cancer without treatment. 
• Another complication is chronic anaemia, resulting from abnormal and heavy bleeding. This condition has an influence on overall health, causing fatigue and impaired physical functioning. 
• Additionally, endometrial hyperplasia can exacerbate hormonal imbalances, potentially leading to further reproductive health issues. 

Diagnosis for Endometrial Hyperplasia 

Doctors diagnose endometrial hyperplasia by examining medical history and symptoms and performing diagnostic tests. 

• Transvaginal Ultrasound: This diagnostic test helps to see if the uterine lining is thicker than usual. 
• Biopsy: If thickening is detected, doctors may recommend a biopsy to confirm the diagnosis. 
• Procedures: Sometimes, dilation and curettage (D&C) procedures or hysteroscopy may be necessary. This allows the doctor to view the uterus and remove a sample of the lining. 

Endometrial Hyperplasia Treatment 

Doctors often recommend progestin therapy to balance out the effects of oestrogen in the system. This approach reduces abnormal bleeding and minimises the risk of cancer development. Options include birth control pills, progestin injections, vaginal creams, and intrauterine devices that release levonorgestrel. 

For women with atypical hyperplasia or those who have completed childbearing, doctors may advise surgical interventions, dilation and curettage procedures (D& C)or hysteroscopy. 

When to See a Doctor 

Women should seek medical attention if they experience changes in their menstrual patterns. This includes heavier or longer-lasting periods, menstrual cycles shorter than 21 days, or bleeding after menopause. These symptoms may indicate endometrial hyperplasia. 

Women aged 35 or older with abnormal bleeding should consult their obstetrician- gynaecologist for diagnostic tests. 

Younger women whose abnormal bleeding has not improved with medication should also seek medical advice. Urgent referral to a gynaecological cancer service is necessary for women over 55 experiencing postmenopausal bleeding. 

Prevention 

Preventing endometrial hyperplasia involves addressing modifiable risk factors. 

• A healthy weight can reduce the risk of this condition. Overweight or obese women should be encouraged to lose weight through diet and exercise. 
• Regular physical activity, even light to moderate, helps lower the risk. 
• Hormonal balance plays a crucial role in prevention. Women taking oestrogen after menopause should also take progestin or progesterone to counteract oestrogen's effects. 
• Avoiding sugar-sweetened beverages and diets with high glycemic load can help prevent endometrial hyperplasia. 

Conclusion 

Endometrial hyperplasia has a significant impact on women's health, affecting the uterine lining and potentially leading to severe complications. This condition stems from hormonal imbalances, primarily excess oestrogen without sufficient progesterone to counteract its effects. Getting knowledge of the types, endometrial thickening symptoms, causes, and risk factors associated with endometrial hyperplasia is crucial to early detection and effective management. Prompt medical attention and appropriate treatment have an influence on preventing the progression to more severe conditions, including endometrial cancer. 

FAQ's 

1. Is endometrial hyperplasia severe? 

Endometrial hyperplasia can be severe, especially if left untreated. Atypical endometrial hyperplasia elevates the risk of endometrial & uterine cancer. 

2. How do you remove endometrial hyperplasia? 

Endometrial thickening treatment options include birth control pills, progestin injections, vaginal creams, and intrauterine devices that release levonorgestrel. For women with atypical hyperplasia or those who have completed childbearing, a hysterectomy might be considered to eliminate the possibility of endometrial cancer development. 

3. Is 1.5 cm endometrial thickness normal? 

Endometrial thickness varies during the course of the menstrual cycle and with age. Generally: 

• For premenopausal women during the secretory phase of the menstrual cycle), 1.5 cm can be normal 
• For postmenopausal women, thickness greater than 0.5 cm may warrant further investigation 

4. What can you avoid when you have endometrial hyperplasia? 

If diagnosed with endometrial hyperplasia: 

• Avoid excess oestrogen exposure (including some herbs and supplements) 
• Limit processed foods and refined sugars 
• Reduce alcohol consumption 
• Avoid smoking 
• Minimise exposure to environmental toxins 
• Avoid delaying treatment or ignoring symptoms 

5. Can thickened endometrium be cured? 

Yes, thickened endometrium can often be treated effectively: 

• Hormonal treatments (e.g., progestin therapy) 
• Lifestyle changes 
• In some cases, surgical interventions like D&C or hysterectomy 
• Regular monitoring and follow-up with doctors 

Dr. Neha V Bhargava

MS, DNB (obgyn), MNAMS, Fellow (Gynae Oncology)
Ganga CARE Hospital Limited, Nagpur

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