Endometrial Hyperplasia

Endometrial hyperplasia is an abnormality of the lining of the uterus where the lining is abnormally thickened and can range from a simple abnormality to complex abnormality with an increased risk of endometrial cancer. Endometrial hyperplasia is usually caused by excess oestrogen.

It is divided into two categories:

1. Hyperplasia without atypia

2. Hyperplasia with atypia

Its incidence is 3 times that of endometrial cancer and if left untreated can progress to cancer.

Risk factors include increased BMI, perimenopause, Polycystic ovarian syndrome (PCOS), oestrogen secreting tumours and drug induced for example by tamoxifen.

Patients usually present with heavy and sometimes irregular menses and some patients don’t respond to normal medical management of their heavy menses.

The increase in this abnormality is seen over the age of 45 and that is why if any female has any menstrual irregularity over this age like bleeding in between menses for more than six months, irregular heavy bleeding and being diagnosed with the perimenopause or if it is suspected on ultrasound like the lining of the womb is thickened and has cystic spaces within it should have a biopsy taken of the lining of the womb.

Endometrial hyperplasia is diagnosed by taking a sample of the lining of the womb either by pipelle alone (done as an outpatient) or in conjunction with hysteroscopy(procedure where camera is placed in the womb) which can be done in an outpatient basis or in the office .

Hysteroscopy is the gold standard along with a biopsy and is especially recommended if the initial sample is inadequate or inconclusive and it has the advantage of visualising the endometrial cavity and one can take directed biopsies and diagnose polyps which can be missed by blind biopsy.

Once diagnosed if there is no atypia one can recommend the mirena coil or a progestogen and repeat endometrial biopsy and hysteroscopy in 6 months as most of these abnormalities return to normal.

If there is hyperplasia with atypia then hysterectomy is recommended because of the risk of cancer. This is done via open or laparoscopic route.

The laparoscopic route is associated with quicker recovery, less blood loss and quicker return to normal activities and is recommended especially in patients with elevated BMI as their recovery is quicker.

In summary if a patient is diagnosed with endometrial hyperplasia they are at some risk for cancer, once the histology is noted then management can be planned accordingly.

Hysteroscopy is the gold standard and is now available in St Vincent to aid diagnosis and treatment by Mirena or other medical management and laparoscopic surgery is recommended in relation to hysterectomy.

Article is done by Dr John Barker Bsc MBBS MRCOG, Dip (Risk Management). Obstetrician/Gynaecologist at Arnos Vale Medical Center, Consultant Obstetrician/Gynaecologist UK

He has completed the Advanced Training Skills Module in Gynaecological Oncology in the UK and runs gynaecological oncology clinics for diagnosis and management of suspected and confirmed female genital cancers.
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