Endometrial hyperplasia: when does the thickening of the lining become dangerous?

Development Mechanisms: How the Endometrium Works

The endometrium is the inner layer of the uterine cavity that contains numerous receptors for female sex hormones, estrogen and progesterone. During the first phase of the menstrual cycle, it develops through cellular proliferation, and then, during the second phase, the glands expand and accumulate secretions. In the absence of pregnancy, the endometrium is shed at the beginning of menstruation. At the end of the reproductive period, when the levels of sex hormones decrease, its growth stops.

What is Endometrial Hyperplasia?

Endometrial hyperplasia is a pathological condition in which the alternation of the phases of the menstrual cycle is disrupted and the cells of the endometrium begin to divide excessively. This results in a thickened mucous layer that does not regress despite the end of the cycle. The main clinical symptoms are irregular and heavy menstrual bleeding, as well as difficulties in conceiving.

Morphological forms of hyperplasia:

• Simple: the glands are hypertrophied, their structure is preserved;
• Complex: the glands are convoluted, cysts may form;
• Atypical: the cells acquire atypical characteristics, the risk of malignancy is increased.

Atypical hyperplasia is considered a precancerous state. Without treatment, 25 to 30% of women develop endometrial adenocarcinoma. In the case of focal hyperplasia, it is possible to combine hormonal treatment with hysteroscopic removal of the abnormal area.

Treatment Approaches

The choice of treatment depends on the type of hyperplasia, the woman's age, and her pregnancy plans. Simple hyperplasia is corrected with progestin treatment or the insertion of a levonorgestrel IUD for 6 to 12 months. Atypical forms in women who have completed their reproductive function are treated with hysterectomy. In young patients, organ-preserving hormonal treatment may be considered under medical supervision.

Causes and Risk Factors

The most common causes are:

• Endocrine disorders, particularly polycystic ovary syndrome (PCOS);
• Chronic anovulation;
• Consequences of abortions and intrauterine procedures;
• Chronic inflammatory processes of the uterine mucosa.

Role of Hormones: Estrogen Excess

Factors contributing to hormonal imbalance include:

• Thyroid function disorders;
• High androgen levels and progesterone deficiency;
• Use of glucocorticoids or dietary supplements for athletes;
• Hyperprolactinemia due to stress or medication use;
• Hormone-dependent tumors (fibroids, mastopathies).

It is precisely the imbalance between estrogen and progesterone that is responsible for most cases of hyperplasia.

Other Triggering Factors

• Obesity, particularly visceral obesity, increases aromatase production, leading to increased estrogen levels.
• Liver and gallbladder pathologies disrupt hormone elimination.
• A diet high in carbohydrates increases insulin levels and insulin resistance, thereby stimulating endometrial growth.
• Genetic mutations (e.g., MTHFR 677) promote disruption of cell division.
• Taking tamoxifen requires regular monitoring of the endometrium's condition.
• Smoking and Lynch syndrome also increase the risk of oncological complications.

Symptoms to Monitor

Often, the disease is asymptomatic and is detected during a routine ultrasound. Possible clinical manifestations include:

• Prolonged or heavy menstruation;
• Intermenstrual bleeding;
• Anemia symptoms: weakness, pallor, decreased hemoglobin levels;
• Any bleeding after menopause requires immediate medical consultation.

Diagnostic Methods

• Endometrial aspiration biopsy is performed during the second phase of the cycle. The sample is taken using a special catheter, followed by histological analysis.
• Hysteroscopy is a visual examination of the uterine cavity that allows for targeted biopsy and removal of pathological areas.

After the histological result, the doctor prescribes treatment. It is recommended that women with hyperplasia avoid heat-exposing practices such as saunas, hot baths, hammams, abdominal massages, wraps, and intentional sun exposure.

Role of Ultrasound

Pelvic organ ultrasound is performed during the second phase of the cycle (days 18-25). The normal thickness of the endometrium should not exceed 16 mm. During the first phase of the cycle (days 6 to 12), it is advisable to perform an ultrasound to exclude the presence of polyps.

Prevention of Endometrial Hyperplasia

• Annual examination by a gynecologist with ultrasound, hormonal screening, and cytological testing;
• Control of weight and lifestyle;
• A balanced diet, excluding excess sugar and hormonal products;
• Prompt treatment of pelvic organ inflammations;
• Genetic counseling in case of family predisposition;
• A responsible attitude towards medication intake, especially hormonal ones.

IVF and Hyperplasia: Is It Compatible?

Performing in vitro fertilization (IVF) in cases of hyperplasia requires prior preparation of the endometrium. The doctor's goal is to achieve normal thickness and structure of the mucosa, favorable for embryo implantation. The protocol includes hormonal treatment, regular ultrasounds, and, if necessary, a biopsy.

When endometrial hyperplasia is properly treated, the chances of successful pregnancy through IVF remain high.

We have discussed the issue of IVF for endometrial hyperplasia in a separate article.