Endometrial hyperplasia – excessive growth of the layer lining the uterus from the inside. This layer undergoes constant cyclical changes associated with the woman’s menstrual cycle.
The endometrium consists of vessels, connective tissue, and 2 layers of the epithelium (lower basal and upper functional). It is the functional layer that is actively involved in menstruation.
How often does endometrial hyperplasia occur?
Endometrial hyperplasia is a fairly common pathology that occurs in 5 percent of gynecological patients. This diagnosis in recent years sounds more and more often for various reasons. The life expectancy of women has increased, the number of patients with metabolic syndrome and other pathologies has increased, the environmental situation has worsened. All this affects the reproductive health of the population. Most often, hyperplasia occurs in adolescent girls or in women in the premenopause period, that is, when hormonal changes occur in the body.
How is hyperplasia related to the menstrual cycle?
The normal menstrual cycle consists of 3 phases:
- increase in the thickness of the functional layer of the endometrium – proliferation
- endometrial maturation – secretion
- functional layer rejection leading to bleeding – desquamation
The first phase begins on the first day of menstruation. Approximately in the middle of the cycle, ovulation occurs – the process of the release of an egg from the ovary, during this period a woman can pay attention to the appearance of stretching mucous transparent secretions. If at this moment fertilization does not occur, then under the action of hormones the functional layer, together with the egg cell, is rejected – menstruation occurs, bloody discharge occurs. All processes during the menstrual cycle are controlled by sex hormones:
In addition, during cell proliferation, planned cell death occurs – apoptosis, which does not allow the endometrium to grow more than necessary. This happens only if a woman has ovulation, that is, when the ratio of hormones allows her to come. If there was no ovulation (anovulatory cycle), there is a prolonged effect of estrogen on the endometrium and it thickens – as a result, endometrial hyperplasia is formed.
Why does it arise?
The starting factor for the development of endometrial hyperplasia is an absolute or relative increase in the content of estrogen in the blood – hyperestrogenism, which occurs for various reasons:
- age-related changes in the central regulation of sex hormones – change in the amount of estrogen before menopause
- hormonal disorders – excess estrogen with progesterone deficiency
- hormone-producing ovarian tumors, polycystic ovary syndrome
- adrenal gland dysfunction
- misuse of hormonal drugs
- frequent abortions (complications), diagnostic curettage
- genetic predisposition
- inflammation of the female genital organs
- Concomitant diseases – hypertension, breast diseases, obesity, diabetes, thyroid diseases.
What types of hyperplasia exist?
According to the type of structure, the scale of distribution and the presence of abnormal cells, all hyperplastic processes of the endometrium are divided into groups:
- Glandular cystic hyperplasia of the endometrium
- Endometrial polyps (focal form of hyperplasia)
- Glandular cystic
- Ferrous fibrous
Glandular forms of hyperplasia are characterized by a large number of glands, sometimes forming cysts. The structure of cells in such a focus is not broken. Symptoms of glandular hyperplasia of the endometrium and cystic forms are exactly the same. In the atypical form of hyperplasia (adenomatosis and adenomatous polyp), changes occur in the structure of cells, which begin to divide at high speed, as a result of which the number of glands grows very quickly.
Can hyperplasia turn into cancer?
Hyperplastic processes should always cause oncological vigilance, but only in a few cases are they malignant. There are certain conditions under which hyperplasia is considered a precancerous condition:
- atypical hyperplasia at any age. According to statistics, in 40 percent of cases without treatment, such hyperplasia is malignant, endometrial cancer occurs.
- frequent postmenopausal glandular hyperplasia
- glandular hyperplasia in hypothalamic dysfunction at any age, as well as in the metabolic syndrome.
Metabolic syndrome is a special condition of the body in which the ability of the immune system to damage cancer cells is sharply reduced, and the tendency to hyperplasia is great. It is characterized by anovulatory infertility, diabetes, obesity.
What are the symptoms of endometrial hyperplasia?
The most noticeable and frequent symptom of endometrial hyperplasia is uterine bleeding.
- More than half of patients report menstrual delays for 1–3 months, which are replaced by prolonged bleeding of varying intensity.
- In rare cases, bleeding can be cyclical, that is, manifested in the form of heavy and prolonged menstruation, painful periods (causes)
- Most often, patients note an unstable menstrual cycle for a long time, against the background of which bleeding occurs.
- In 5 percent of cases, bleeding occurs on the background of the absolute absence of menstruation.
An important companion of endometrial hyperplasia is metabolic syndrome. In such cases, the symptoms of bleeding join:
- Symptom complex of male traits – the appearance of increased hair growth, changes in the tone of voice and other signs of male hormones
Other common symptoms
Often women with hyperplasia also call other satellites of the disease:
- secondary infertility – the absence of pregnancy after a year of regular unprotected sex
- miscarriage – early miscarriages
- chronic inflammatory diseases of the genital organs
- mastopathy and fibroids
Other, more rare symptoms
- contact bleeding during intercourse or hygiene procedures
- cramping pain in the lower abdomen (more often – with polyps)
What research is needed to determine it?
- Anamnesis It is necessary to tell the doctor in detail about the peculiarities of the menstrual cycle: at what age menstruation began, how long and how much did it go on, were there any irregularities and delays. Anamnesis will allow a specialist to determine all the symptoms of endometrial hyperplasia of the uterus.
- Transvaginal ultrasound in the first phase of the cycle (for 5-7 days). The examination determines the thickness of the endometrium, its homogeneity and structure. Hyperplasia can be suspected at a thickness of more than 7 mm. If the endometrium is thicker than 20 mm, the doctor may suggest a malignant process. If the bleeding is prolonged, then an ultrasound scan is performed regardless of the day of the menstrual cycle.
- Hysteroscopy and separate diagnostic curettage (brushing) – at the same time play the role of research and treatment. Read about the state after hysteroscopy.
- The study of the level of hormones in the blood in suspected metabolic syndrome and polycystic ovary syndrome. Usually determine the level of FSH, LH, estradiol, testosterone, progesterone. It is also possible the level of adrenal hormones and thyroid gland.
- Mammography – often the doctor prescribes an x-ray examination of the mammary glands to exclude proliferative processes.
With endometrial hyperplasia, the information content of an ultrasound with a vaginal sensor is estimated at 68%, and hysteroscopy at 94%.
Treatment of endometrial hyperplasia
Therapy of hyperplastic processes depends on the woman’s age, the characteristics of the endometrium, associated diseases. With endometrial hyperplasia, treatment can be carried out in several ways.
These include estrogen-progestin drugs, pure gestagens, gonadotropin releasing hormone agonists and antagonists, androgen derivatives. These drugs are prescribed only by a doctor, individually and strictly according to indications. The doctor takes into account all possible contraindications to the use of hormonal drugs: rheumatism, thrombophlebitis, hypertension, diabetes mellitus, diseases of the biliary tract and liver, smoking and alcohol increase the risk of side effects. Before treatment and during treatment, the state of the immune system, vascular, endocrine glands, liver should be examined and blood tests should be done.
- Small or conservative surgery
Removal of the endometrium (functional and basal layers) using a resectoscope. The controversial method, as it gives frequent recurrences of the disease and is contraindicated in cases of suspicion for atypia.
This is the removal of the uterus with or without the ovaries. Indications for surgery:
- ineffectiveness of conservative treatment for precancerous forms of hyperplasia
- repeated cases of precancerous hyperplasia
- contraindications for hormone therapy
- atypical hyperplasia in peri and postmenopausal
Stage I treatment – scraping
The first stage is the medical-diagnostic curettage of the uterine mucosa under the control of a hysteroscope (cleaning) and the study of the material obtained in cytological laboratories.
Scraping – removal of the functional layer of the endometrium, along with its pathological formations. The study is conducted under anesthesia, visualization of the contents of the uterine cavity is carried out using a special apparatus – a hysteroscope. It is an optical system equipped with a light source, having a channel for inserting surgical instruments into the uterus. Thanks to the hysteroscope, the curettage procedure is safe and effective.
The cleaning itself is carried out with a curette, sometimes a mechanism is used to stop the bleeding. The functional layer of the endometrium is removed completely, the contents of the uterus are sent for histological examination, it will determine the nature of the process and tactics for further treatment of endometrial hyperplasia after curettage.
II stage of treatment
Depending on the results of histological examination, drug therapy is prescribed to prevent recurrence. For this purpose, hormonal drugs are used, taken in a specific dosage and according to suitable schemes.
Treatment of glandular cystic hyperplasia
- In girls at puberty and women under 35 years old, drugs containing estrogens and progestogens, for example, combined oral contraceptives (for and against their use). Preference is given to single-phase drugs with progesterone, which have a continuous effect on the endometrium, preventing its growth. Treatment lasts from three months to six months. Endometrial glandular cystic hyperplasia usually does not recur with proper therapy.
- In women from 35 years to perimenopause (the process of stopping menstruation). In therapy, gestagens are used, without the use of estrogen-containing components. Assign hormones in the second phase of the menstrual cycle, from 14 to 26 days after scraping, or from the beginning of menstruation. Usually, endometrial hyperplasia is treated with duphaston and utrogestan. Therapy also lasts 3-6 months.
- In postmenopausal women (after cessation of menstruation). Hyperplasia at this age is a rare occurrence, usually associated with hormone-producing ovarian formations. For endometrial hyperplasia in menopause, treatment should be prescribed only after a thorough examination of the ovaries (ultrasound and, if necessary, a laparoscopic examination). If there are no tumors, then 17-hydroxyprogesterone caproate is prescribed at a dosage of 125 mg 2 times a week, for six months – eight months. After the end of therapy, it is necessary to perform an endometrial biopsy and examine the sample obtained in the laboratory.
Treatment of atypical hyperplasia
Women of reproductive age and perimenopause. Therapies of choice are gonadotropin releasing hormone agonists for six months. Some drugs must be taken every day (buserelin acetate), some have a prolonged effect and require taking 1 time in 28 days.
After 6 months from the start of treatment, re-curettage of the endometrium with a histological examination is usually required. In addition, each month of treatment ends with an ultrasound study, which controls the thickness of the endometrium (less than 5 mm).
When combining atypical hyperplasia with myoma or metabolic syndrome, surgical treatment with careful ovarian examination is necessary. Constant monitoring requires the state of the mammary glands.
Plan of follow-up atypical hyperplasia:
- Ultrasound of the endometrium 1 time per month
- curettage with histological examination every 3 months
- Ultrasound of the ovaries every 3 months (with doplerometry)
- Breast ultrasound and mammography every 6 months
- control signs of metabolic syndrome (cholesterol and blood glucose)
Postmenopausal women are indicated for prompt treatment with a thorough revision of the ovaries.