The condition called endometrial hyperplasia is a condition in which the cells forming the endometrium (the inner lining of the uterus) grow larger than normal due to excessive estrogen (female hormone) activity. It is also commonly referred to as a thickening of the uterine lining.
Hyperplasia literally means an increase in the number of cells. This is usually due to unopposed estrogen hormone activity by progesterone hormone. The most important reason for this is the absence of ovulation. The most typical known reason for the absence of ovulation is polycystic ovary disease. In addition, endometrial hyperplasia is more common in the presence of factors such as obesity, liver disease, and estrogen-secreting tumors in which circulating estrogen is high.
What are the symptoms?
Since endometrial hyperplasia is a result of unopposed estrogen stimulation by progesterone, this endometrium becomes thick and cannot be shed easily, meaning that the patient's menstrual bleeding is delayed. The most common finding in such cases is excessive bleeding following a long-term delay in menstruation. Apart from this, prolonged menstrual bleeding along with irregular bleeding is the second most common symptom. In some patients, there are no abnormal symptoms. The diagnosis is made incidentally after a biopsy or surgery performed for another reason.
How Many Types of Endometrial Hyperplasia Are There?
The classification accepted today is the classification proposed by WHO (World Health Organization) in 1985. The classification is basically based on the status of the cells involved in hyperplasia. According to this classification, endometrial hyperplasia is first divided into simple and complex. These are again divided into two as atypia and non-atypia. All these definitions are evaluations according to cell structure. It is not possible to detect them with ultrasound or examination. We doctors become very worried about hyperplasia with atypia because the deviation from the typical cellular appearance, that is, the appearance of cells with different appearances, is considered a sign of a possible shift towards cancer. While the rate of transformation into cancer is between 1-3% in hyperplasia without atypia, this probability is between 8-29% in the presence of atypia. So hyperplasia with atypia is a precancerous condition. If the patient is in the post-menopausal period, the probability of transformation into cancer is higher than in women of reproductive age. The process of turning into cancer in hyperplasia without atypia takes 10 years, and in hyperplasia with atypia it takes on average 3-4 years.
How to Diagnose?
A definitive diagnosis of endometrial hyperplasia can only be made by taking an intrauterine sample, that is, by curettage, and its pathological examination. In other words, this diagnosis is not a clinical picture but a pathological diagnosis. In addition, if the thickness of the inner layer of the uterus is measured by transvaginal ultrasonography and a thickness greater than it should be for that day is detected, endometrial hyperplasia is suspected.
What is Treatment?
All types of hyperplasia, that is, thickening of the uterine lining, whether with or without atypia, need to be treated. Since obesity is a risk factor in endometrial hyperplasia, the person should be directed to lose weight. If the hyperplasia is due to an ovulation disorder such as polycystic ovary, eliminating the underlying cause can solve the problem. The most important issue in treatment is to follow the person. In other words, a sample must be taken for control purposes after treatment and the course of the disease must be determined. In cases that do not regress, surgical treatment should be considered. The definitive treatment is planned according to the type of hyperplasia and the age of the patient. In hyperplasia without atypia, medical treatment is preferred if the woman is of reproductive age. In these patients, diagnostic curettage can also provide treatment. The response to abortion and 3-6 months of drug treatment is around 90%. Medical treatment aims to reverse this change by giving the missing progesterone hormone. In the post-menopausal period, hysterectomy is the most appropriate treatment option. When hyperplasia with atypia is detected in the post-menopausal period or at ages close to menopause, surgery must be performed without wasting too much time. For women who want children but are found to have atypia hyperplasia, the decision to be made requires careful consideration. In these cases, high dose drug therapy can be tried under close monitoring. However, following birth, removal of the uterus may be on the agenda again.
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