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Endometrial hyperplasia
Endometrial hyperplasia occurs in about 130 out of 100,000 women. It occurs most often in women in perimenopause and menopause, although it can also occur in younger people.
What is endometrial hyperplasia?
Endometrial hyperplasia is "excessive growth" of endometrial cells. When such endometrium is analyzed under a microscope, the findings can range from normal cells to endometrial cancer.
Hyperplasias are divided into two categories:
- Endometrial hyperplasia;
- Endometrial intraepithelial neoplasia (EIN).
There is another classification from 1994. According to that old classification, hyperplasias are classified as follows:
- Simple hyperplasia;
- Complex hyperplasia without atypia;
- Simple hyperplasia with atypia;
- Complex hyperplasia with atypia;
Cells with atypia are precancerous cells with a risk of developing into cancer.
Simple and complex hyperplasias belong to the group of endometrial hyperplasia according to the new classification, while simple and complex hyperplasia with atypia belong to the group of endometrial intraepithelial neoplasia (EIN).
Symptoms of endometrial hyperplasia
Endometrial hyperplasia can be asymptomatic, but it is often manifested as:
- postmenopausal bleeding;
- irregular and heavy bleeding;
- short interval between menstrual bleedings (21 days and shorter);
- endometrial polyp;
- tumors that produce estrogen.
Diagnostics of endometrial hyperplasia in the Gyn. Fertility Clinic Milenković
We apply the cutting-edge diagnostic methods to ensure an accurate and quick diagnosis of endometrial hyperplasia.
Hyperplasia is diagnosed by histopathological analysis. A sample of the endometrium is taken by biopsy/aspiration (pipelle) or by exploratory curettage.
Before taking a sample for histopathological analysis an ultrasound examination with a vaginal probe is always performed.
Endometrial biopsy (Pipelle) is done in outpatient settings.
No anesthesia is required.
An endometrial biopsy is taken with a single-use plastic instrument in the form of a thin tube, which creates a vacuum and thus extracts a tissue sample.
The patient may have menstrual-like pain, scanty bleeding for 1-2 days and return to normal activities on the same day.
Exploratory curettage is most often performed under short-term general anesthesia, and it can also be performed under local anesthesia.
Before the intervention, blood tests and an examination by the anesthesiologist are performed.
The intervention lasts for about 15 minutes and the patient stays in the Clinic for two hours.
Scanty bleeding may occur several days after the intervention.
Hysteroscopy along with exploratory curettage, represents the "gold standard" for the diagnosis of pathological changes in the endometrium.
Exploratory curettage is not an intervention to treat endometrial hyperplasia, but only a diagnostic method.
There are no exact criteria for the ultrasound diagnosis of endometrial hyperplasia, but if a woman in menopause has a thickened endometrium of more than 4 mm, or if there is " thickening" of the endometrium in a woman of reproductive age, a biopsy or exploratory curettage is recommended, especially if along with such a finding there is a bleeding disorder as well.
Three-dimensional ultrasound and hydrosonography are performed at the Milenković Clinic.
Hydrosonography is a method when a saline solution is inserted into the uterine cavity for better visualization and then an examination is performed with a transvaginal ultrasound probe.
These methods increase the accuracy of ultrasound diagnostics.
Risk factors for endometrial hyperplasia
- drug used in breast cancer therapy;
-obesity;
-absence of ovulation during a longer period (most often in women with polycystic ovary syndrome);
- hormone therapy with estrogen, without progesterone;
- dysfunction of the thyroid gland;
-diabetes;
-gallbladder disease;
-Lynch syndrome (genetic risk for colon and endometrial cancer);
- endometrial , ovarian and colon cancer in the family.
Treatment of endometrial hyperplasia
- Endometrial hyperplasia without atypia is treated with a hormonal coil (Mirena, Levosert) containing levonorgestrel or medroxyprogesterone tablets (trade name Primolut N, Provera). Levonorgestrel and medroxyprogesterone belong to the group of artificial progesterones. Studies have shown that the success of treatment with a hormonal coil is 100 % after 3-6 months, but that 40% of patients get hyperplasia again after stopping treatment.
- Endometrial hyperplasia with atypia or EIN is treated surgically by removing the uterus. Women who have not given birth and want to preserve their fertility are treated with a hormonal coil or pills with high doses of artificial progesterone, with endometrial sampling for histopathological analysis every third month.
Hysteroscopy is always performed before taking a sample of the endometrium and any suspicious change is removed in its entirety.
When two consecutive histopathological analysis are without pathological changes, pregnancy is advised. After giving birth, the uterus is removed.
The risk of developing cancer in women diagnosed with endometrial hyperplasia is 2-50%, depending on the type of hyperplasia.
Endometrial thickening and menopause
The appearance and thickness of the endometrium in women in the reproductive period change throughout the menstrual cycle. Immediately after the end of the bleeding, the endometrium is in the form of a thin line 1 mm thick and then gradually acquires a three-layered appearance and grows to about 10 mm, so that after ovulation it has a uniform appearance 10 to 20 mm thick. After getting menstrual bleeding, the whole cycle is repeated.
In menopausal women, the endometrium is in the form of a thin line with straight edges up to 3-4 mm thick.
Any deviation in the appearance and thickness of the endometrium may indicate some pathological process, especially if there is also a bleeding disorder.
Endometrial thickening over 4 mm in menopausal women indicates endometrial hyperplasia or a malignant process. Evenly, that is, uniform thickening of the endometrium that is clearly separated from the surrounding endometrium indicates a polyp in the uterine cavity.
Expert advice: frequently asked questions
Answers by: Milan Milenković. MD, PhD
Is endometrial hyperplasia the same as "thickening" of the endometrium?
No, hyperplasia is a histopathological diagnosis established by microscopic analysis, while "thickening" of the endometrium is a deviation from the normal ultrasound image of the endometrium. Any thickening of the endometrium should be further investigated.
What does thickening of the endometrium in menopause mean?
In menopausal women, endometrial thickening over 4 mm may indicate endometrial hyperplasia or a malignant process. Any deviation in the appearance and thickness of the endometrium should be investigated.
Does endometrial hyperplasia affect the possibility of conception?
Endometrial hyperplasia can make it difficult to conceive because the abnormal growth of endometrial cells can disrupt the normal functions of the uterus and embryo implantation.
Can women with endometrial hyperplasia plan a pregnancy?
Yes, women with endometrial hyperplasia can plan a pregnancy, but it is important to treat the hyperplasia first. The risk of developing cancer in women with endometrial hyperplasia is 2-50% and is highest when there is hyperplasia with atypia, that is, endometrial intraepithelial neoplasia (EIN). If EIN is diagnosed, pregnancy is planned after two consecutive histopathological findings without hyperplasia and uterus is removed after delivery.
What are the risks for pregnancy in women with a history of endometrial hyperplasia?
Women who have had hyperplasia with atypia have a slightly higher risk of postpartum hemorrhage. Induction of labor and cesarean delivery are also quite common.
