Endometrial hyperplasia

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Introduction0:00–0:56

With endometrial hyperplasia, endometrial refers to the endometrium, which is the inner lining of the uterus, and hyperplasia means increased growth, so endometrial hyperplasia means excessive growth of the inner lining of the uterus.
The uterus consists of 3 layers, an outer thin layer called the perimetrium or the serosa, a middle smooth muscle layer called the myometrium, and the innermost layer, the endometrium.
The endometrium has two layers, an inner functional layer made up mainly of glands and supporting connective tissue, called stroma, and an outer thin basal layer which regenerates the overlying functional layer after each menstrual cycle.
Now, the growth of the functional layer is regulated by the hormones secreted by the ovaries. Each ovary is made up of a number of ovarian follicles.

Physiology0:56–2:22

Each follicle consists of an oocyte, which is the female germ cell, surrounded by an outer layer made up of theca cells, which secrete androgens, also known as the male hormones, and an inner layer made up of granulosa cells, which secrete estrogen.
Now estrogen stimulates the growth of endometrial glands and stroma. This effect of estrogen predominates during the first phase of the menstrual cycle.
This is also called the proliferative phase because it’s when the lining of the endometrium grows. At the end of this phase, ovulation occurs, where one ovarian follicle expels the oocyte into the fallopian tube and it travels to the uterus.
During the second phase of the menstrual cycle, also called the secretory phase, the remaining structure of the follicle, now called the luteal body, begins to secrete progesterone.
Progesterone counteracts the effect of estrogen on the endometrium by stopping its growth. At the same time, it causes the glands to produce secretions that acts as nutrients for any developing embryo.

Pathophysiology2:22–5:34

Endometrial hyperplasia most often results when the endometrium is exposed to high levels of estrogen for a prolonged time.
This leads to excessive growth of endometrial glands relative to stroma; meaning a high gland-to-stroma ratio. This is also accompanied by low levels of progesterone, which normally has an opposing effect to estrogen.
The excess of this hormone can be caused by a variety of conditions such as obesity, where the extra adipose tissue converts androgens to estrogen.
It could also be caused by estrogen-secreting tumors, such as granulosa cell tumors of the ovaries. People with polycystic ovarian syndrome are also at risk of endometrial hyperplasia.
In this condition, the ovary is full of cystic follicles all of which secrete estrogen. To make things even worse, these follicles don’t ovulate most of the time, a condition known as chronic anovulation, so there’s no luteal body to secrete progesterone.
So this disease will cause both high estrogen and low progesterone and both increases the risk of developing endometrial hyperplasia.
Now, a person could have normal estrogen production throughout their life, but the number of years the endometrium is exposed to estrogen is also a factor for developing endometrial hyperplasia.
Estrogen exposure is increased in people who have an early menarche, which is the age of the first menses, or those that have a late menopause.
This is because these people have experienced a greater number of menstrual cycles, where more follicles have grown, and more estrogen was secreted by these follicles.
The same goes for females who have never given birth, also called nulliparous, who are at a higher risk than those who have been pregnant.
This is because follicular growth and their estrogen secretion is inhibited during pregnancy. Thus people who have been pregnant will have fewer menstrual cycles in their lifetime compared to someone who hasn’t Also, we have drugs that can cause endometrial hyperplasia, such as estrogen-only hormone replacement therapy, usually taken by postmenopausal females to relieve menopause symptoms, such as hot flashes and vaginal dryness.
Endometrial hyperplasia can also be caused by tamoxifen, a breast cancer medication which blocks estrogen receptors on the breast, but at the same time, stimulating those on the endometrium.
Certain cases of endometrial hyperplasia can occur independent of estrogen and progesterone levels. These cases are often associated with mutations of a tumor suppressor gene, called PTEN, which normally acts like a brake on the cell cycle.
When this gene becomes defective, cells in the endometrium will grow and proliferate out of control, leading to hyperplasia.

Symptoms5:34–6:08

Alright, let’s talk about symptoms! The most common symptoms include menorrhagia, which means heavy or prolonged menstrual bleeding, metrorrhagia, bleeding between menstrual cycles, or a combination of both known as menometrorrhagia.
In some cases, there could also be amenorrhea which means missed menstrual periods. Keep in mind that any vaginal bleeding in a postmenapausal female could be a sign of endometrial hyperplasia!

Complications and diagnosis6:08–7:42

The most concerning problem with endometrial hyperplasia is that it increases the risk for endometrial cancer, which is the most common cancer arising from the female reproductive system.
The risk of developing endometrial cancer depends on the histological features of the cells undergoing hyperplasia, which means how they appear under the microscope.
So, zooming into a section of the endometrium, we can see simple hyperplasia where there’s a lot of dilated glands and stroma, but their ratio is similar to normal tissue.
In complex hyperplasia there are way more glands and less stroma and this type of hyperplasia is more at risk of progression to endometrial cancer.
If we zoom in even more, we can see the nuclei inside these glandular cells. The nucleus can be either a normal looking nucleus or it could appear larger and hyperchromatic, meaning it’s darker.
These abnormal nuclear features are called nuclear atypia, which is the most important factor in terms of progression to endometrial cancer.
In fact, simple hyperplasia alone has a risk of 1% to progress to endometrial cancer, but it goes up to 10% if it’s associated with atypia.
Similarly, complex hyperplasia alone has a risk of 5% but if it’s associated with atypia it increases up to 30%! Treatment for endometrial hyperplasia includes eliminating the underlying cause of excess estrogen, such as weight loss in cases of obesity, stopping unopposed estrogen therapy and correcting the problem of anovulation in cases of polycystic ovarian syndrome.

Treatment7:42–8:24

Also, progesterone-containing medications can be used, which help in counteracting the proliferative effect of estrogen.
In other cases, however, hysterectomy, where the uterus is surgically removed, might be the only treatment. This is especially true if there’s a high risk of progression to endometrial cancer.

Review8:24–9:08

All right, as a quick recap... Endometrial hyperplasia is the excessive growth of the endometrium.
In most cases, it’s caused by long-standing increased exposure to estrogen without the counteracting effect of progesterone.
Endometrial hyperplasia carries a risk of progression into endometrial cancer depending on the histological findings, where complex hyperplasia with nuclear atypia has the highest risk of progression to cancer.
Treatment of endometrial hyperplasia involves the removal of the underlying cause of excess estrogen, progesterone-containing medications and in some cases, hysterectomy.