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Endometrial Hyperplasia
Definition
Endometrial hyperplasia is an abnormal proliferation of the endometrium (ie greater than the normal proliferation
that occurs during the menstrual cycle). It is a risk factor for the development of endometrial carcinoma.
Pathogenesis
There are four types of endometrial hyperplasia:
Simple
Complex
Simple atypical
Complex atypical
For simple and complex hyperplasia, the risk of progression to carcinoma is less than 5%. The risk in atypical
hyperplasia is around 30%. [1] Statistics vary, which may be due to the poor diagnostic reproducibility. [2]
Risk factors
Exogenous oestrogen use (without cyclical progesterone).
Oestrogen-secreting ovarian tumour.
Tamoxifen use; it has an anti-oestrogen effect on the breast, but a pro-oestrogen effect on the uterus
and bones.
Polycystic ovarian syndrome.
Hereditary non-polyposis colorectal carcinoma.
Obesity combined with diabetes.
Presentation
Endometrial hyperplasia usually presents clinically as abnormal vaginal bleeding - intermenstrual,
polymenorrhoea or postmenopausal. The risk of endometrial hyperplasia in a polyp that also involves
non-polypoid endometrium is significant. [3]
Vaginal discharge.
Glandular abnormalities on a cervical smear
Investigations
Transvaginal ultrasound (TVUS)
TVUS is an appropriate first-line procedure to identify which women with postmenopausal bleeding are at higher
risk of endometrial cancer.
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The mean endometrial thickness in postmenopausal women is much thinner than in premenopausal women.
Thickening of the endometrium may indicate the presence of pathology. In general, the thicker the endometrium,
the higher the likelihood of important pathology, ie endometrial cancer, being present. The threshold in the UK is 5
mm; a thickness of >5 mm gives 7.3% likelihood of endometrial cancer. [4] In a woman with postmenopausal
bleeding, if endometrial thickness is less than 5 mm uniformly, the probability of carcinoma is less than 1%. [5]
Some pathology may be missed and it is recommended that hysteroscopy and biopsy should be performed if
clinical suspicion is high. [6] Models have been developed to take personal characteristics into account when
predicting the risk of cancer to improve predictive accuracy. [7]
Endometrial biopsy
A definitive diagnosis in postmenopausal bleeding is made by histology.
Historically, endometrial samples have been obtained by dilatation and curettage. Nowadays it is more usual to
obtain a sample by outpatient endometrial sampling, most commonly a pipelle biopsy. Occasionally this has to be
performed under general anaesthetic (GA). All methods of sampling the endometrium will miss some cancers.
Hysteroscopy
Hysteroscopy and biopsy (curettage) is the preferred diagnostic technique to detect polyps and other benign
lesions. Hysteroscopy may be performed as an outpatient procedure, although some women will require GA.
Where they are available, direct referral to 'one-stop' specialised clinics is ideal. [8] At such clinics several
investigations are available to complement clinical evaluation, including ultrasound, endometrial sampling
techniques and hysteroscopy. Following such assessment, reassurance can be given, or further investigations or
treatment can be discussed and arranged. National Institute for Health and Care Excellence (NICE) guidelines
advise postmenopausal women not on HRT and presenting with postmenopausal bleeding should be referred
urgently. [9]
MRI scan
This can also demonstrate endometrial hyperplasia and, though not often used, may be helpful in cases where
TVUS is not possible, or when superimposed invasive endometrial carcinoma is suspected. It is more helpful in
the staging of established carcinoma.
Management
Medical
Simple endometrial hyperplasia without atypia responds to high-dose progestogens, with repeat histology after
three months.
This can be effectively delivered by the levonorgestrel intrauterine system (IUS). [10] [11] It is also given orally, if
desired. Studies suggest the IUS is more effective, with higher regression rates and reduced need for
hysterectomy, even for atypical hyperplasia. [12] However, a Cochrane review in 2013 concluded there is not yet
the evidence of safety and efficacy to be convincing in patients with atypical hyperplasia. [13]
Relapse occurs relatively frequently (approximately 14% with the IUS and 30% with oral treatment) after
regression, especially in complex hyperplasia, so long-term follow-up is advised. [14]
Surgical
Transcervical resection of the endometrium (TCRE).
Hysterectomy - usually advised for atypical endometrial hyperplasia.
Complications
Recurrence after treatment may occur. Endometrial hyperplasia may develop into endometrial carcinoma.
Women who don't have atypical changes have a very small risk of developing a cancer. As many as 30-40% of
women diagnosed with atypical hyperplasia are found to have a concurrent carcinoma. [15] The rest with atypical
changes are at significant risk as above. Risk increases after menopause.
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Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical
conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its
accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions.
For details see our conditions.
Original Author:
Dr Colin Tidy
Current Version:
Dr Mary Harding
Peer Reviewer:
Prof Cathy Jackson
Document ID:
2096 (v22)
Last Checked:
18/02/2014
Next Review:
17/02/2019
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