What are the causes of endometrial hyperplasia?
Endometrial hyperplasia is mainly the result of excess estrogen. It usually occurs at menopause or shortly before, when menstrual cycles are not always followed by ovulation. Risk factors for endometrial hyperplasia include:
- Age >35 years
- Nulliparity
- The onset of menstruation at a young age and the delay of menopause
- Family history of colon, uterine or ovarian cancer
- Ovulation disorders, such as polycystic ovary syndrome
- Obesity
- Use of tamoxifen by women with a history of breast cancer
- Long-term estrogen medication by postmenopausal women who haven’t had a hysterectomy
How is endometrial hyperplasia classified?
In the past, endometrial hyperplasia was divided into 4 categories, each of which had a different chance of developing endometrial cancer:
- Simple hyperplasia without atypia (1% chance of developing endometrial cancer)
- Complex hyperplasia without atypia (3% chance of developing endometrial cancer)
- Simple atypical hyperplasia (8% chance of developing endometrial cancer)
- Complex atypical hyperplasia (28% chance of developing endometrial cancer)
Nowadays, endometrial hyperplasia is classified into two categories:
- Benign hyperplasia
- Endometrial intraepithelial neoplasia, which is a precancerous condition
What are the symptoms of endometrial hyperplasia?
The most common symptom of endometrial hyperplasia, including its intraepithelial neoplasia, is the abnormal vaginal bleeding. The woman should consult her doctor immediately, if she has any of the following symptoms:
- Greater quantity of blood during period than usual
- Longer periods than usual
- Period more often than every 21 days
- Vaginal bleeding between periods
- Vaginal bleeding after menopause
How is endometrial hyperplasia diagnosed?
The initial evaluation of the patient with symptoms suspected of endometrial hyperplasia includes genital ultrasound. Depending on the findings and her general history, the doctor may recommend an endometrial biopsy, usually with a diagnostic abrasion. In some cases, hysteroscopy is recommended before diagnostic abrasion. That way, under direct vision, it is possible to identify very small areas inside the endometrial cavity with suspicious features, thus take more targeted biopsies.
What is the treatment for endometrial hyperplasia?
The treatment selected is determined by the type of endometrial hyperplasia, the woman’s age and her desire to remain fertile. Pharmaceutical medication options are dominated by progestogens, which are administered orally or in the form of an intrauterine device (MIRENA). In case of hyperplasia with atypia or, based on the new classification, endometrial intraepithelial neoplasia, the possibility of coexisting with or developing endometrial cancer is significant. Therefore, removal of the uterus (total hysterectomy) is the treatment of choice.
I was diagnosed with endometrial hyperplasia with atypia (endometrial intraepithelial neoplasia), but I want to remain fertile. What options do I have?
Although total hysterectomy is the treatment of choice, progestogen administration in these cases is an acceptable alternative, as long as there are no contraindications to taking them. The probability of regression of the lesions is high (about 80%), as well as, unfortunately, the probability of their recurrence in the future. Progestogens can be administered orally or in the form of an intrauterine device (MIRENA). In order to evaluate the response to treatment, histological examination of the endometrium every 3-6 months is required, or earlier, in case of disturbing symptoms. If the lesions persist for more than 6-12 months from the beginning of the treatment or if they develop into endometrial cancer, surgery is required. Finally, in the event of regression of the disease, confirmed by successive histological examinations, conservative therapy (e.g., birth control pills, progestogens) is important until the patient begins conception efforts.
What prevents the development of endometrial hyperplasia?
To prevent the occurrence of endometrial hyperplasia, the following options are useful:
- Hormone replacement therapy after menopause based on the simultaneous intake of estrogen and progesterone
- In case of menstrual disorders (e.g., anovulatory cycles), administration of conraceptives or progestogens
- In case of obesity, efforts to lose weight
