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Endometrial Hyperplasia

Endometrial hyperplasia occurs when the endometrium, the lining of the uterus, becomes thick and has abnormal cells. It is not cancer, but in some cases, it can lead to cancer of the uterus with persisting triggers if not treated. It is best considered a “pre-cancer” at this stage.

It can be classified as with or without atypia, which refers to how abnormal the tissue look under a microscope.

Endometrial hyperplasia most often is caused by excess estrogen without progesterone. Estrogen and progesterone are hormones secreted by the ovaries that control the growth and shedding of the uterine lining. Estrogen causes the growth of the uterine lining and progesterone counterbalances this growth. If ovulation from the ovaries each month does not occur, progesterone is not made, and the lining is not shed. The endometrium may continue to grow in response to estrogen. The cells that make up the lining may crowd together and may become abnormal. This condition is called hyperplasia and may progress to cancer if not treated.

Endometrial hyperplasia usually occurs after menopause, when ovulation stops, and progesterone is no longer made. It also can occur during perimenopause when ovulation may not occur regularly. Sometimes it occurs in younger women, particularly in those who have polycystic ovarian syndrome and a personal history of diabetes mellitus and obesity or a family history of uterine, colon or ovarian cancers. 

The type of hyperplasia differs based on the characteristics of the cells found in the biopsy sample. It is important to identify the type because some patients will have a significant risk of coexistent uterine cancer.

Endometrial hyperplasia can be seen on a transvaginal ultrasound. Women with abnormal bleeding should initially be evaluated with a transvaginal ultrasound. In post-menopausal women, a transvaginal ultrasound is used to assess the thickness of the lining. Lining thickness of greater than 4 mm with post-menopausal bleeding is suspicious for hyperplasia or cancer and this must be ruled out (other benign conditions, such as polyps, can also cause this appearance). Biopsy of the uterine lining is essential for diagnosis of hyperplasia. This can be done in the rooms via a pipelle biopsy, or via hysteroscopy with D & C under sedation in the rooms or under a general anaesthetic in theatre.

Progesterone therapy can be used to treat endometrial hyperplasia. Oral progesterone, Depo Provera (injection) or the Mirena IUD are all possible treatment options. Progesterone counteracts the effects of estrogen and thins the uterine lining. Endometrial sampling after the progesterone treatment should be used to assess resolution.

If you have atypical hyperplasia, the risk of cancer is increased. Hysterectomy usually is the best treatment option if you do not want to have any more children. If you are hoping to have children, you may be suitable for a trial of progesterone treatment and if your endometrium responds you may be able to delay having a hysterectomy.

Dr Desai and Dr Carswell are experienced in managing women with hyperplasia and discussing the best options of investigation and treatment for you.