What is endometrial hyperplasia?
Endometrial hyperplasia is a condition where the lining of the womb (endometrium) becomes abnormally thickened. This is not cancer but in some cases can lead to cancer of the lining of the womb (endometrial cancer).
What is endometrium and why is it important?
The endometrium is the inner lining of the womb. This lining is important as it receives and nourishes the embryo (fertilised egg). The endometrium responds to female hormones. In the initial part of a woman’s menstrual cycle the oestrogen hormone rises and leads to building up of the endometrium. Following release of the egg (ovulation) hormone progesterone prepares the endometrium for a pregnancy. If pregnancy does not occur, levels of both these hormones go down and the lining of the womb undergoes shedding. This shedding leads to menstruation. Regular menstruation prevents excessive thickening of the womb lining in premenopausal women.
What causes endometrial hyperplasia?
Endometrial hyperplasia is caused by excessive or unbalanced effect of the hormone oestrogen. This can happen in obese women (oestrogen is produced by fat cells), women on unbalanced oestrogen treatment and in some women because of the natural imbalance that happens in the years leading to the menopause.
What are the risk factors?
The following risk factors are known:
- Age more than 35.
- Caucasian race.
- Early onset of mentruation (menarche) and late menopause.
- Infertility and not having been pregnant.
- History of polycystic ovarian syndrome, diabetes and thyroid disease.
- Obesity.
- Cigarette smoking.
- Use of certain medication like tamoxifen or oestrogen without progestogen in women with an intact womb. Tamoxifen is a drug used in breast cancer treatment which in some cases can cause overgrowth of the lining of the womb.
- Family history of colonic, ovarian or uterine cancer.
What symptoms would I have?
Abnormal menstruation is the most common symptom. You should look for the following:
- Menstruation that is consistently heavier in flow than what is normal for you. You may find that you are passing clots and flooding.
- You bleed or have spotting between periods.
- You bleed or have spotting after sex.
How is this condition diagnosed?
Ultrasound scan of the female organs may show thickening and/or abnormal appearance of the lining of the womb. A biopsy of the lining of the womb can be taken in the clinic by your gynaecologist (endometrial biopsy). This is done using a very fine tube which passes through the next of the womb into the womb cavity. This procedure is well tolerated by most women who describe the discomfort similar to that of period cramps. The standard investigation however is a hysteroscopy with biopsy of the womb lining.
What is hysteroscopy?
Hysteroscopy is a when a fine telescope is used by the gynaecologist (or specialist nurses) to check the inside cavity of the womb. This can be done with you awake (outpatient hysteroscopy) or sometimes with you under anaesthesia (GA hysteroscopy, where GA stands for general anaesthesia). The trust has patient leaflets for both these procedures, which you may find useful.
Are there different types of endometrial hyperplasia?
Yes, they vary from simple to complex with atypia and are based on microscopic assessment of the womb lining biopsy by a specialist (Pathologist). Atypia refers to abnormal changes in the cells (of the lining of the womb) which can be turn into cancer if untreated. In the absence of atypia the risk of progression to cancer is small (1-3%). In the presence of atypia 8-30% of women, if untreated, will go on to develop cancer.
How is endometrial hyperplasia treated?
Endometrial hyperplasia is treated by hormones which can be given either by mouth (Oral progestogens) or in the form of a hormone intrauterine device (Mirena®). You will also be asked to attend for follow up over a prolonged period of time and may have to undergo further hysteroscopy and/ or biopsy of the lining of the womb. If complex hyperplasia with atypia has been diagnosed, you may be offered hysterectomy with removal of the ovaries and fallopian tubes, if you do not plan to have more babies.
References
- Kurman RJ, KaminskiPF, et al. The behavior of endometrial hyperplasia. A Long term study of “untreated” hyperplasia in 170 patients. Cancer 1985;56(2):403-12.
- SIGN guideline number 61 – available online at http://www.sign.ac.uk/pdf/sign61.pdf (accessed 23 January 2015).
- American college of obstetricians and gynaecologists patient information leaflet – available online at http://www.acog.org/Patients/FAQs/Endometrial-Hyperplasia (accessed 23 January 2015).
- SOGC (society of obstetricians and gynaecologists of Canada) guideline on abnormal uterine bleeding in postmenopausal women. J Obstet Gynaecol Can 2013;35(5 eSuppl):S1–S28.