Endometrial Hyperplasia a Living Nightmare

Endometrial hyperplasia is extremely common. This is something that will typically occur in perimenopausal women (the period of a woman's life shortly before the occurrence of the menopause), but it tends to predominate in older women. One does not see so much in younger women. The reason we do not see it in younger women is that the endometrium normally gets larger during the menstrual cycle. So what would be endometrial hyperplasia in a postmenopausal woman, (having undergone the menopause or occurring after menopause) would be, let us say 10 mm, would be a normal thickness of the endometrium for a woman who is going through her cycle. The endometrium in a premenopausal woman can vary between 4 mm right after menses and up to 16 mm or more during the secretory stage of the menstrual cycle. So, although, it is possible to have endometrial hyperplasia at any age, it tends to be symptomatic in women who are perimenopausal in their late 40s, early 50s, and beyond.

A Case Study in Brief

A 55-year-old woman presents to the clinic complaining of spotting (in some women, menstrual spotting between period occurs as a normal, and harmless part of ovulation) over the last 3 months. She has no history of gynecologic problems. Menarche was at age 11. She is a G1 P1-0-0-1. She denies pelvic pain. Her past medical history is significant for hypertension (controlled) and obesity (body mass index 30.5). She has been overweight since she was in grade school. She does not smoke, or drink alcohol. Her medications include lisinopril, and escitalopram, which is also known as Lexapro and SSRI (selective serotonin reuptake inhibitor). She has never used COC (combined oral contraceptive). She has no family history of cancer. Her last Pap was 6 months ago, and was negative for pathology. Speculum and bimanual examinations were unremarkable, though a small amount of blood was present on the glove. So, this is a woman that presents with postmenopausal bleeding. She may have hit menopause around 52 or 53 years, which is the average age of menopause. So, if a woman is starting to bleed or has any bleeding whatsoever, and she has not had her period in over a year, then it is considered that to be postmenopausal bleeding.

The first thing she is asked to get a hCG (human chorionic gonadotrophin). After getting that she is also going to get CBC, because it is possible the patient could be bleeding from low platelets. She gets a CBC that is normal. The next test is going to be thyroid test or TSH (thyroid stimulating hormone). This is very important to get because thyroid disturbances, both hypothyroidism, and hyperthyroidism can both cause abnormal uterine bleeding. She gets all that and it looked normal. Depending on the woman’s history, we may get liver function tests, if she has a history of alcohol abuse, she could have cirrhosis that could cause hyperestrogenism and that can cause endometrial hyperplasia, and it is essential to know that because it could a sign of liver failure. Transvaginal sonography is the next step, why because endometrial hyperplasia is one of the most common causes of postmenopausal bleeding. There are other causes. The most common cause of postmenopausal bleeding would be endometrial atrophy, which can cause this spotting. Endometrial hyperplasia can herald endometrial cancer, so it is important to assess that by getting sonography. The patient gets the sonography and it gets the endometrial stripe measuring 6.2 mm. The cut-off is 5 mm. So, simply saying anything less than 5 mm is not going to be considered endometrial hyperplasia and anything more than that will be considered. This measurement is only for a postmenopausal woman. It shows that she has no polyps, polyps are a little less common in postmenopausal women, but it is a possible cause. Around 5 to 10 percent of bleeding in postmenopausal women will be caused by polyps. Adnexa appears normal. Another cause of postmenopausal bleeding would be an ovarian tumor which can secrete estrogen and that can be there in consort with endometrial hyperplasia. Here we would be talking about the fecal lutein tumor, and that would then cause endometrial hyperplasia, which can be a cancerous tumor of the ovary.

The major risk factor is hyperestrogenism. The most common cause of hyperestrogenism is the use of estrogen-containing supplements, and women who are postmenopausal will take these supplements a lot of times to abate some of the symptoms of menopause, that could be things like vaginal dryness, or mood swings, hot flashes. Taking estrogen will help with overcoming some of those problems. By doing this one might be paving a way for endometrial hyperplasia. It can also cause endometrial cancer. It may also increase the risk of breast cancer.

Being overweight is a risk for being hyperestrogenic, because adipose tissue creates estrogenic, gets converted to estrogen. The risk for endometrial hyperplasia comes along with lifetime exposure to estrogen. So longer one is exposed to estrogen and more likely she is to develop endometrial hyperplasia. Using combined oral contraceptives sort of relieves the body of that estrogen exposure temporarily for so long one is using oral contraceptives, so it does provide a sort of benefit, it reduces the risk of endometrial hyperplasia.

Pathophysiology

Endometrial hyperplasia is endometrial thickening with a proliferation of irregularly-sized and shaped glands. Endometrial hyperplasia can vary its heterogeneous. The tissue can look like normal endometrium, or it can be very, very ominous looking with unusual cell shapes, unusual nuclei, unusual geography, and that is why a biopsy is ordered. The class of hyperplasia is determined histologically. Endometrial biopsy is the test of choice when endometrial hyperplasia is suspected based on clinical presentation, and imaging. Endometrial hyperplasia is a response and many women will have factors that cause them to be hyperestrogenic. It may be precancerous lesion. All endometrial adenocarcinomas develop from endometrial hyperplasia. At least 1 in 39 women in U.S. will develop endometrial cancer in their lifetime. This is the fourth most common type of cancer in women.

Risk factors

Hyperestrogenism

1. High-dose menopausal estrogens.
2. Nulliparity.
3. Obesity.
4. Early menarche.
5. Late menopause.
6. Use of tamoxifen.
7. PCOS, (polycystic ovary syndrome).

Medical conditions: Type 2 diabetes mellitus, hypertension, gallbladder disease.

1. White race.
2. Higher SES.
3. Older age.
4. Living in North America, or northern Europe. Sweden, Norway, Denmark, Iceland, there may be some confounding factors.
5. Abnormal uterine bleeding is the most common presentation of endometrial hyperplasia.
6. Premenopausal women: Menorrhagia, intermenstrual spotting.
7. Postmenopausal women: Any bleeding.
8. A detailed history is useful in determining the patient’s risk for endometrial hyperplasia and carcinoma.
9. Use of postmenopausal estrogen supplements.

Treatment

The treatment is going to depend upon the woman’s age, and it is going to depend whether or not there is atypia and then it is also going to depend on whether or not she wants to remain fertile, because in some cases if there is atypia the most preferable treatment is hysterectomy. So, if she is postmenopausal or if she does not care to get pregnant in the future, then a hysterectomy in those cases is most suitable. Most cases will present without atypia. So if there is no atypia then it should be determined whether or not she is menopausal. The treatment is the same as far as the drug use, so if there is no atypia, the patient can be treated medically, and most commonly MDPA (medroxyprogesterone acetate) or megestrol is the choice.