Menopause & perimenopause
Endometrial hyperplasia of the uterus
by Marcy Holmes, NP, Certified Menopause Clinician
Topics covered in this article:
Endometrial hyperplasia is the medical term for unusual or excessive cell growth in the inner glandular lining of the uterus, also called the endometrium. Most of the time, endometrial hyperplasia is uncomplicated and easily treated by your ob/gyn provider, with minimal intervention.
Women in menopause or experiencing menopausal symptoms can be more at risk for developing endometrial hyperplasia. Understanding hyperplasia and how it relates to women’s health and balance of hormones is what Women to Women is here to explain. Imbalance of hormones or hormonal changes can happen around the time of menopause, and contribute to the development of hyperplasia in some women. Endometrial hyperplasia of the uterus, by itself, is not cancerous, but it does require treatment and monitoring to prevent the risk of cancer.
However, there are times when uterine hyperplasia can get worse, leading to atypical and precancerous cellular changes. This is why any woman with hyperplasia is considered to be at a higher risk for cancer than one without. And even though this sounds scary, especially if you’ve just been diagnosed with a thickened endometrium, you should know that there are many steps between hyperplasia and full-blown uterine cancer — and early identification and intervention for uterine abnormalities is highly successful.
As practitioners there is so much we can do to evaluate and treat women with endometrial hyperplasia, but the more we know and the earlier, the better. This is why we tell all of our patients who experience heavy vaginal bleeding, irregular bleeding, or bleeding after menopause to come in and get a thorough evaluation.
What happens during a uterine exam for women?
Your healthcare practitioner will first want to rule out pregnancy and infection. He or she will also perform a Pap test to identify any cellular changes of the cervix, and will then proceed to evaluate the uterus and endometrium.
The evaluation process generally begins with a speculum and bimanual exam (internal exam and external palpation of the pelvic organs). An ultrasound and tissue sampling with endometrial biopsy, hysteroscopy and/or D&C may then take place, depending on any previous findings.
The lab pathologist will examine the tissue sample obtained from biopsy or D&C under a microscope, then grade the findings and issue a report. Pathological grades span a wide range and set into motion certain standards of care. The grade should help guide the decision-making process between you and your healthcare provider. You may be recommended for further testing, or to wait a certain period of time before returning for repeat evaluation, or to consider otherwise appropriate medical or surgical treatments for your particular situation.
Interpreting your pathology report after an endometrial biopsy
Your provider may use the language of a standard pathology grading system when they give you the results of your endometrial biopsy. At the milder end of the grading system, tests may indicate benign uncomplicated forms of hyperplasia. With each increasing gradation, the findings move toward identifying more concerning cellular features, increasing potential for malignancy, and ultimately cancer of the uterus.
Grades of endometrial hyperplasia
| Relatively benign, rarely progressing to endometrial cancer |
- Proliferative endometrium
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| Probably benign, hormone-stimulated proliferation, yet requiring medical treatment and follow-up tissue sampling to ensure regression |
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- Glandular hyperplasia without atypia
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- Complex hyperplasia without atypia
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| More concerning types of precancerous changes suggesting more aggressive medical treatment, close monitoring, or option for surgical intervention, especially if the abnormality persists |
- Complex hyperplasia with atypia
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- Any type of cytologic atypia features
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| Cancerous, definitely requiring surgical treatment and oncology management |
- Atypical adenomatous hyperplasia
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- Endometrial adenocarcinoma (various subtypes)
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- Endometrial intraepithelial neoplasia
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A word about uterine cancer and endometrial abnormalities
There are two major paths by which uterine cancers tend to develop, one slower than the other, occurring over time as a result of overstimulation of the endometrium by unopposed estrogen. Another rarer type of uterine cancer develops more aggressively, and in most cases has multifactorial roots that go beyond estrogen stimulation alone. If you have received abnormal findings from your endometrial biopsy or D&C, take heart. Nowadays we are fortunate to be able to say there is a high success rate in treating nearly all stages of uterine or endometrial abnormalities, even cancer of the uterus. Again, the key is timely identification and treatment.
Special considerations for women using tamoxifen for breast cancer
Tamoxifen is a selective estrogen receptor modulator (SERM). SERM drugs are designed to selectively block many estrogen receptors in the body, and can thereby prevent stimulation of breast cancer cells driven by estrogen. The hope is that the cancer won’t reoccur or metastasize if its estrogen supply is cut off or reduced. Tamoxifen is often prescribed to women after breast cancer surgery/chemo/radiation when the tumor is shown to be estrogen receptor-positive, as well as to women who are at high risk as a preventative.
Conversely, tamoxifen tends to exaggerate rather than block estrogen activity on the part of the uterus. So a potential side effect of tamoxifen use is uterine thickening, or development of hyperplasia, and an increased risk for uterine cancer over time. Because of this increased risk, women on tamoxifen are watched closely for bleeding events, and their healthcare providers typically follow a plan to monitor the uterus regularly.
Management of endometrial hyperplasia of the uterus —
medical and surgical options
In cases of hyperplasia without atypia, the general routine is to use prescription-strength progesterone/progestin therapy for three months, then to retest the endometrium. In milder cases this usually works well. Many healthcare providers use Provera for this purpose, but at Women to Women we use Prometrium, a brand of micronized natural progesterone (at high doses) that the body seems to handle effectively when used properly. Compounded bioidentical progesterone can also be used with great success. We prefer this treatment to Provera because we question how well the body is able to break down and clear synthetic compounds.
When atypia is present, a standard option for women who want to wait or avoid surgery altogether is Megace (megestrol acetate), a very potent, orally administered hormonal agent. This can be a good choice for a woman who would like to get pregnant in the future. Very attentive monitoring is required when undergoing this treatment.
In Europe the Mirena IUS is often used to treat just the uterus. This is an estrogen-free contraceptive intrauterine device that steadily delivers small doses of a synthetic progestin directly onto the inner lining of the uterus, which decreases its thickness. Although it has not been FDA-approved for this purpose in the US, some doctors may choose this “off-label use,” and it may be worth discussing.
At Women to Women we refer most cases beyond complex hyperplasia without atypia to an expert in gynecological cancers. Women with persistent or recurrent bleeding issues despite benign test results may also want to see a specialist and consider specific tissue sampling with hysteroscope-guided D&C, a procedure done under anesthesia.
In certain circumstances, removal of the uterus may be unavoidable to safeguard your long-term health. If this is something you are considering, we encourage you to read our articles on hysterectomy to learn more about indications and alternatives.
Since each woman’s situation is unique, a treatment plan for uterine hyperplasia should always be tailored to her individual needs. Because ongoing follow-up is critical to ensure resolution, be sure to schedule and keep follow-up appointments as recommended by your healthcare provider. Ask questions and seek a second opinion if you feel you aren’t getting answers. And don’t let your fear of the worst keep you from exploring all of your options. You should be confident regarding your short-term and long-term plan and know that you have all the support and information you need.
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