Endometrial hyperplasia is a condition that many women might not be familiar with until it affects them. If not treated on time, endometrial hyperplasia can lead to serious complications including cancer. Hence, for women in Malaysia, understanding this condition is essential to maintaining reproductive health and preventing potential complications.

Let’s discover this condition in detail in this comprehensive guide and understand whether it poses a cancer risk.

Understanding the Endometrium’s Role

The endometrium is a dynamic tissue that thickens and sheds during the menstrual cycle. Its primary role is to prepare for a potential pregnancy by providing a nourishing environment for a fertilized egg. If pregnancy does not occur, the endometrial lining sheds during menstruation.

Endometrial Hyperplasia Causes

Endometrial hyperplasia develops when the endometrial lining continues to grow excessively, without the typical shedding process. This usually happens due to prolonged exposure to oestrogen without the balancing effect of progesterone, which is responsible for stabilizing the growth of the endometrium.

Below are the key causes of this condition:

Hormonal Imbalance

Oestrogen stimulates the growth of the endometrium during the first half of the menstrual cycle. Without adequate progesterone (produced after ovulation), the lining of the uterus does not shed properly, leading to its overgrowth. This is often caused by irregular or absent ovulation, which is common in certain conditions.

Anovulation (Lack of Ovulation)

In women with PCOS, irregular ovulation disrupts the balance of oestrogen and progesterone. As women approach menopause, ovulation becomes less frequent, leading to prolonged exposure to unopposed oestrogen.

Obesity

Fat cells produce oestrogen, which can lead to higher-than-normal levels of the hormone. Women with obesity are at a greater risk due to increased oestrogen production from adipose tissue.

Hormone Replacement Therapy (HRT)

Women who use oestrogen-only hormone therapy for menopause symptoms without combining it with progesterone are at increased risk.

Prolonged Exposure to Oestrogen

Extended exposure to oestrogen due to delayed menopause increases risk. Starting menstruation at an early age leads to more cumulative exposure to oestrogen.

Other Health Conditions

Some metabolic disorders can increase the risk of endometrial hyperplasia. Hormonal imbalances caused by thyroid dysfunction may indirectly affect the endometrium.

Types of Endometrial Hyperplasia

Endometrial hyperplasia is classified based on the structure and appearance of the cells in the endometrial lining. This classification helps determine the risk of progression to endometrial cancer and guides treatment. Below are the primary types of endometrial hyperplasia:

1.    Endometrial Hyperplasia Without Atypia

In this form, the endometrial lining thickens due to an increased number of glands, but the cells retain their normal appearance. It is often referred to as “benign hyperplasia”. It is less likely to progress to cancer. The treatment of this kind of endometrial hyperplasia often includes hormonal therapy and lifestyle changes, such as weight loss, to lower oestrogen levels.

2.    Endometrial Hyperplasia with Atypia

The endometrial glands increase in number and size, thus becoming crowded and irregular. But the cells still look normal under a microscope. This form is more advanced than simple hyperplasia but still lacks cellular atypia. It requires closer monitoring and more aggressive treatment, including possible surgery.

This can be of two types:

Endometrial Hyperplasia Symptoms

Now that you have an idea about endometrial hyperplasia, let’s look at some of the common symptoms which include:

• Abnormal uterine bleeding, such as heavy or prolonged periods
• Prolonged menstrual periods
• Bleeding between periods
• Postmenopausal bleeding
• Pelvic pain or discomfort
• Unusual vaginal discharge

Diagnosing Endometrial Hyperplasia

Endometrial hyperplasia is a condition characterised by the thickening of the uterine lining (endometrium), often due to excess oestrogen without sufficient progesterone. Early diagnosis is crucial as certain types of hyperplasia, particularly atypical endometrial hyperplasia, can progress to endometrial cancer.

Here’s an overview of the diagnostic process:

1. Medical History and Symptoms

The diagnostic process begins with a thorough review of the patient’s medical history and symptoms. Common symptoms prompting evaluation include:

• Abnormal uterine bleeding (AUB), such as heavy or prolonged menstrual periods
• Irregular menstrual cycles
• Postmenopausal bleeding
• A history of hormone therapy, polycystic ovary syndrome (PCOS), obesity, diabetes, or a family history of endometrial cancer may raise suspicion.

2. Imaging Tests

Several imaging tests are used to diagnose endometrial hyperplasia:

3. Endometrial Sampling

Two types of endometrial sampling are used for diagnosing endometrial hyperplasia:

4. Histopathological Evaluation

Pathology distinguishes between:

• Glandular proliferation without significant atypia.
• Increased gland-to-stroma ratio, more crowding of glands.
• Cellular abnormalities that may indicate precancerous changes.

5. Hormonal and Risk Factor Assessment

This assessment involves evaluating hormonal imbalances and risk factors, including:

• Serum hormone levels (oestrogen, progesterone, and androgens).
• Assessment for underlying conditions like PCOS or obesity.

Is Endometrial Hyperplasia a Cancer Risk?

Now let us come to an important point in consideration – can endometrial hyperplasia lead to cancer?

While not all cases of endometrial hyperplasia lead to cancer, it is a condition that requires attention. The likelihood of progression depends on the type of hyperplasia:

• Endometrial Hyperplasia Without Atypia: Low cancer risk and often reversible with treatment.
• Endometrial Hyperplasia with Atypia: Higher risk of developing into endometrial cancer if left untreated.

Importance of Early Diagnosis

When it comes to cancer, it is no secret that early diagnosis can make a huge difference in prognosis and treatment. Endometrial hyperplasia is no exception.

Early detection and management of endometrial hyperplasia are crucial to prevent its progression to endometrial cancer, particularly in cases of atypical hyperplasia, which carries a significant risk of malignancy. Timely diagnosis allows for the identification of hormonal imbalances or underlying risk factors and enables targeted interventions such as progestin therapy or surgical options.

Early management not only alleviates distressing symptoms such as abnormal uterine bleeding but also reduces the risk of complications, preserving fertility in younger women when desired. Regular monitoring and prompt treatment improve outcomes and enhance overall reproductive and gynaecological health.

How Long Does It Take for Endometrial Hyperplasia to Turn into Cancer?

The progression of endometrial hyperplasia to endometrial cancer depends on the type of hyperplasia and the presence of atypical cells.

• Simple or Complex Hyperplasia Without Atypia: These types have a very low risk of progression to cancer, estimated at less than 5% over 10-20 years. Many cases are resolved with appropriate hormonal treatment or lifestyle changes.
• Atypical Hyperplasia (Simple or Complex): This type has a significantly higher risk, with studies suggesting a 20-30% chance of developing into endometrial cancer over approximately 1-5 years if left untreated.

The progression rate varies among individuals and is influenced by factors such as age, obesity, hormonal imbalances, and genetic predispositions. Early detection and timely treatment are essential to prevent malignancy and ensure better outcomes.

Endometrial Hyperplasia Treatment

Treatment depends on the type of hyperplasia, the patient’s age, and reproductive goals. Common treatment options include:

1.  Hormonal Therapy

Hormonal therapy is the first-line treatment for most cases of endometrial hyperplasia.

• Progestin Therapy: Progestin therapy includes oral progestins (medroxyprogesterone acetate, norethindrone), progesterone-releasing intrauterine devices (IUDs) like Mirena, or injectable progestins. They balance the effects of estrogen, induce shedding of the endometrial lining, and prevent further thickening. This treatment is particularly effective for hyperplasia without atypia and for patients wishing to preserve fertility.
• Oestrogen-Progestin Combination Therapy: This therapy is occasionally used in premenopausal women to regulate menstrual cycles. It includes continuous intake of combined hormone replacement therapy where oestrogen and progesterone are taken daily, especially by postmenopausal women.

2.  Lifestyle Changes

Along with hormone therapy, the treatment of endometrial hyperplasia may involve making several lifestyle changes including:

• Weight loss and management: Obesity contributes to excess oestrogen production, so reducing weight can significantly improve outcomes.
• Managing co-existing conditions: Addressing diabetes, hypertension, and other metabolic issues is essential.

3.  Surgery

Surgical treatment may be necessary for certain cases, particularly for atypical hyperplasia or recurrent hyperplasia. The surgical options include:

• Dilation and Curettage (D&C): This is performed to remove excess tissue and provide a definitive diagnosis. It is often combined with hysteroscopy for better visualisation.
• Hysterectomy: A commonly used surgical option for treating endometrial hyperplasia, hysterectomy is recommended for women with atypical hyperplasia with a high risk of cancer or for those who do not respond to hormonal therapy. This is a definitive treatment, especially for postmenopausal women or those not desiring future fertility.

4.  Monitoring and Follow-Up

Regular follow-up is essential to ensure the effectiveness of treatment and detect any progression. This includes:

• Repeat biopsies every 3–6 months.
• Ultrasound monitoring of endometrial thickness.
• Ongoing management of risk factors like obesity and hormone imbalances.

5.  Fertility-Sparing Approaches

For women who wish to conceive, progestin therapy is the primary option, and ovulation induction or assisted reproductive techniques may be considered once hyperplasia resolves.

Preventing Endometrial Hyperplasia

Prevention is always better than cure. Women can take several steps to reduce the risk of developing endometrial hyperplasia such as:

• Maintaining a healthy weight
• Managing conditions like PCOS and diabetes
• Using hormone replacement therapy responsibly
• Regular gynaecological check-ups, especially for postmenopausal women

Malaysia is witnessing lifestyle changes that contribute to rising obesity rates and related health issues, including hormonal imbalances. Additionally, women often delay seeking medical attention for abnormal bleeding which increases the risk of complications.

Hence, women need to be aware of the symptoms of endometrial hyperplasia and the importance of early diagnosis to take charge of their reproductive health.

Sources:

• https://www.yalemedicine.org/conditions/endometrial-hyperplasia
• https://www.ncbi.nlm.nih.gov/books/NBK560693/
• https://my.clevelandclinic.org/health/diseases/atypical-endometrial-hyperplasia
• https://www.verywellhealth.com/endometrial-hyperplasia-risk-factors-types-and-treatments
• https://patient.info/womens-health/endometrial-hyperplasia-leaflet
• https://innovativegyn.com/conditions/endometrial-hyperplasia/
• https://familydoctor.org/condition/endometrial-hyperplasia/
• https://www.mayoclinic.org/diseases-conditions/endometrial-cancer/symptoms-causes