Endometrial hyperplasia

Endometrial hyperplasia is a condition of the uterus whereby the endometrial cells proliferate and become too numerous.

The endometrium is made up of special cells that ‘grow’ your menstrual period (the endometrial cells); the lining of the uterus that feeds a growing foetus or is shed during menstruation as your period.

If this lining is not shed, it can build up. If you have a lot of endometrium growing every month, it can cause pain, heavy bleeding and other uncomfortable symptoms.

Why you get your period My Vagina Animation

A normal menstrual cycle

During a normal menstrual cycle, the uterine lining grows and sheds as hormones dictate.

First, oestrogen thickens the endometrium to make a nutritious nest for a fertilised egg that may or may not appear. Then, an egg is released (ovulation), after which progesterone increases.

If a fertilised egg does not implant on the uterine wall, both oestrogen and progesterone drop off and you bleed with your period. Once your period is over, it starts all over again.

That’s your menstrual cycle in a nutshell. Endometrial hyperplasia often occurs when there is too much oestrogen and not enough progesterone. If for some reason a woman doesn’t ovulate, then progesterone is kept at bay and the lining is not triggered to shed, resulting in a build-up of ‘period’ in the uterus.

Who gets endometrial hyperplasia?

Menopausal women are the most at risk, when ovulation stops, meaning progesterone stops being released. This can occur just prior to menopause too, when ovulation is less frequent. ​1​

Women who use oestrogen-like medicines may also be at risk, along with women who don’t ovulate regularly. This might be related to polycystic ovarian syndrome or other infertility problems. Women who are obese also suffer from more endometrial hyperplasia. ​2​

Risk factors for endometrial hyperplasia:​3​

  • Age – those over 35 are more at risk
  • Caucasian (white) women
  • Those who have never been pregnant
  • Those who go through menopause later in life
  • Those who started their periods earlier in life
  • Diabetes, PCOS, gallbladder disease, thyroid disease
  • Obesity
  • Smoking
  • Family history of ovarian, uterine, or colon cancers

Symptoms of endometrial hyperplasia

  • Abnormal uterine bleeding – longer or heavier periods
  • Shorter cycle length (less than 21 days)
  • Bleeding after menopause

Diagnosis of endometrial hyperplasia

There are a lot of reasons why you may be bleeding abnormally, so it’s important that you get checked to eliminate other problematic conditions, including cancer.

Endometrial hyperplasia is usually diagnosed using an ultrasound to measure endometrial thickness, with a small device inserted into the vagina and sound waves that create an image of your insides.

If the endometrium is thick, then endometrial hyperplasia is an option. Next, you may get a biopsy to test for cancer, with a small tissue sample taken using one of three techniques: endometrial biopsy, dilation and curettage, or a hysteroscopy. ​4​

Why is this happening?

Excess oestrogens are thought to be the main cause of endometrial hyperplasia, but the condition is also contributed to by low levels of progesterone, which would normally balance out oestrogen by opposing it. ​5​

Excess oestrogens can appear from certain conditions such as being overweight (fat cells convert testosterone to oestrogens), polycystic ovarian syndrome, oestrogen-producing tumours, and some hormone replacement therapy (HRT) concoctions.

This condition must be treated promptly since it can be a risk factor for the development of endometrial cancer.​6​

Classifications of endometrial hyperplasia

The World Health Organisation (WHO) uses four categories to classify endometrial hyperplasia:

  1. Simple hyperplasia without atypia
  2. Complex hyperplasia without atypia
  3. Simple atypical hyperplasia
  4. Complex atypical hyperplasia

Simple or complex endometrial hyperplasia means the glands are irregular and grow with cysts, or in the complex cases, glands crowd or bubble. There is no change to the appearance of each gland cell. The risks of cancer developing with these classes are less than two per cent.

Simple or complex atypical endometrial hyperplasia means changes in gland cells are extensive and of concern. The changes are much more in line with other cancerous changes that occur in other cell types throughout the body, but there is no invasion of nearby tissues, which normally determines the presence of cancer.

The likelihood of developing cancer from this class of endometrial hyperplasia is just over 20 per cent.

Diagnosing endometrial hyperplasia

Initial suspicion of endometrial hyperplasia usually occurs from an abnormal pap smear or abnormal bleeding, like heavy periods (menorrhagia).  A biopsy can take endometrial tissues to be transferred to the lab to confirm any changes in the cells.

Treatments available for endometrial hyperplasia

Each woman will need to be evaluated individually for treatment options. Due to the hormone dependence of this condition, hormone therapies are usually included on the menu. If the condition is severe, medical doctors may suggest a hysterectomy.

Generally you will be treated with progestin, either orally, in an injection, in a hormonal intrauterine device (IUD), or a cream that you insert into your vagina. ​7,8​

It is up to your physician as to how much you take. Taking progestin may trigger bleeding, which in fact is what you’re after, as it sheds the lining of the uterus appropriately.

The oral contraceptive pill to treat endometrial hyperplasia

You may be prescribed the oral contraceptive pill, and if you are menopausal, you will need to carefully monitor your hormone intake. Your risk of cancer is increased if you have endometrial hyperplasia, so it’s important to be treated promptly, and to keep an eye on it. ​9​

Don’t treat yourself for hormonal conditions – always get help from a professional, as taking hormones can really do some damage if it’s not done correctly.

If you are overweight, losing weight may help, and it also decreases your risk of endometrial cancer – remember, fat cells convert testosterone to oestrogen, so the more fat you have, the more oestrogen you have.

References

  1. 1.
    Petersdorf K, Groettrup-Wolfers E, Overton PM, Seitz C, Schulze-Rath R. Endometrial hyperplasia in pre-menopausal women: A systematic review of incidence, prevalence, and risk factors. European Journal of Obstetrics & Gynecology and Reproductive Biology. Published online April 2022:158-171. doi:10.1016/j.ejogrb.2022.02.015
  2. 2.
    Furness S, Roberts H, Marjoribanks J, Lethaby A. Hormone therapy in postmenopausal women and risk of endometrial hyperplasia. Cochrane Database of Systematic Reviews. Published online August 15, 2012. doi:10.1002/14651858.cd000402.pub4
  3. 3.
    Clark TJ, Neelakantan D, Gupta JK. The management of endometrial hyperplasia: An evaluation of current practice. European Journal of Obstetrics & Gynecology and Reproductive Biology. Published online April 2006:259-264. doi:10.1016/j.ejogrb.2005.09.004
  4. 4.
    Clark TJ, Mann CH, Shah N, Khan KS, Song F, Gupta JK. Accuracy of outpatient endometrial biopsy in the diagnosis of endometrial hyperplasia. Acta Obstet Gynecol Scand. Published online September 2001:784-793. doi:10.1034/j.1600-0412.2001.080009784.x
  5. 5.
    Goad J, Ko YA, Kumar M, Jamaluddin MFB, Tanwar PS. Oestrogen fuels the growth of endometrial hyperplastic lesions initiated by overactive Wnt/β-catenin signalling. Carcinogenesis. Published online June 15, 2018:1105-1116. doi:10.1093/carcin/bgy079
  6. 6.
    Sanderson PA, Critchley HOD, Williams ARW, Arends MJ, Saunders PTK. New concepts for an old problem: the diagnosis of endometrial hyperplasia. Hum Reprod Update. Published online December 4, 2016. doi:10.1093/humupd/dmw042
  7. 7.
    Chae-Kim J, Garg G, Gavrilova-Jordan L, et al. Outcomes of women treated with progestin and metformin for atypical endometrial hyperplasia and early endometrial cancer: a systematic review and meta-analysis. Int J Gynecol Cancer. Published online November 16, 2021:1499-1505. doi:10.1136/ijgc-2021-002699
  8. 8.
    Chandra V, Kim JJ, Benbrook DM, Dwivedi A, Rai R. Therapeutic options for management of endometrial hyperplasia. J Gynecol Oncol. Published online 2016. doi:10.3802/jgo.2016.27.e8
  9. 9.
    HEE L, KETTNER LO, VEJTORP M. Continuous use of oral contraceptives: an overview of effects and side‐effects. Acta Obstet Gynecol Scand. Published online December 5, 2012:125-136. doi:10.1111/aogs.12036


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Jessica Lloyd - Vulvovaginal Specialist Naturopathic Practitioner, BHSc(N)

Jessica is a degree-qualified naturopath (BHSc) specialising in vulvovaginal health and disease, based in Melbourne, Australia.

Jessica is the owner and lead naturopath of My Vagina, and is a member of the:

  • International Society for the Study of Vulvovaginal Disease (ISSVD)
  • International Society for the Study of Women's Sexual Health (ISSWSH)
  • National Vulvodynia Association (NVA) Australia
  • New Zealand Vulvovaginal Society (ANZVS)
  • Australian Traditional Medicine Society (ATMS)
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