WHAT IS ENDOMETRIAL HYPERPLASIA?
Endometrial hyperplasia is overgrowth of uterine lining (endometrium) that may progress to or coexist with endometrial (uterine) cancer.
WHAT CAUSES ENDOMETRIAL HYPERPLASIA?
Estrogen and progesterone are hormones secreted by the ovaries that control the growth and shedding of the uterine lining. Estrogen causes the growth of the uterine lining and progesterone counterbalances this growth. Long-term unopposed estrogen production causes overgrowth of the uterine lining and results in endometrial hyperplasia.
WHAT ARE RISK FACTORS FOR ENDOMETRIAL HYPERPLASIA?
- Polycystic Ovarian Syndrome
- Estrogen therapy without progesterone
- Estrogen-secreting ovarian tumors
WHAT ARE DIFFERENT TYPES OF ENDOMETRIAL HYPERPLASIA?
Types of hyperplasia differ based on the characteristics of the cells found in the biopsy sample. It is important to identify the type because some patients will have a significant risk of coexistent uterine cancer.
- Simple without atypia: One percent risk of uterine cancer.
- Complex without atypia: Three percent risk of uterine cancer.
- Simple with atypia: Eight percent risk of uterine cancer.
- Complex with atypia: The most significant type of endometrial hyperplasia. Twenty-nine percent of cases progress to uterine cancer and 17 to 59 percent of cases have coexistent uterine cancer.
Endometrial hyperplasia typically causes abnormal uterine bleeding and most commonly occurs in post-menopausal women.
Women with abnormal bleeding should be evaluated with a pelvic ultrasound. In post-menopausal women, the ultrasound is used to assess the thickness of the lining. Lining thickness of greater than four mm is suspicious for hyperplasia or malignancy. Biopsy of the uterine lining is the definitive test for diagnosis of hyperplasia. Biopsy can be performed in the office or in the operating room using anesthesia.
- Office biopsy without hysteroscopy: This is a blind biopsy. A thin plastic tube is inserted into the uterus, and a small sample of the lining is obtained. This procedure is performed without anesthesia and can cause significant discomfort. In some cases, an adequate amount of sample cannot be obtained, and a different procedure needs to be performed. The benefit of this procedure is that it is very fast and does not require preparation or special equipment.
- Office biopsy with hysteroscopy involves a thin camera being guided into the uterine cavity and a small biopsy obtained. Numbing injection to the cervix is used to decrease discomfort. The benefit of this procedure is that the entire cavity is visualized with the camera and the likelihood of insufficient sample is less than with the blind biopsy. This procedure does require special equipment and may require pre-medication to decrease the discomfort.
- Hysteroscopy, D&C is performed in the operating room under anesthesia. A scraping of the uterine lining (curettage) is performed with a special instrument. Since discomfort is not an issue, the majority of the thickened lining can be removed and a large sample of the lining obtained for analysis.
Treatment options for endometrial hyperplasia depend on the type of hyperplasia and whether the patient desires to preserve the uterus for fertility. Hysterectomy (removal of the uterus) is recommended for patients who are post-menopausal or patients who have completed childbearing.
WHAT IS THE NON-SURGICAL TREATMENT FOR HYPERPLASIA WITHOUT ATYPIA?
Progesterone therapy can be used to treat endometrial hyperplasia without atypia. Oral progesterone, Depo Provera (injection) or IUD (Intrauterine device) are all possible treatment options. Progesterone counteracts the effects of estrogen and thins the uterine lining. Endometrial sampling after the progesterone treatment should be used to assess resolution. Resolution of hyperplasia occurs in almost 80 percent of cases. If hyperplasia persists or atypia develops, hysterectomy should be the next step.
WHAT IS THE NON-SURGICAL TREATMENT FOR HYPERPLASIA WITH ATYPIA?
If the tissue biopsy was obtained in the office, a D&C should be performed to confirm the absence of cancer before considering non-surgical treatment. High-dose oral progesterone therapy (Megace) should only be offered to women who have not completed childbearing or women who cannot undergo surgery for medical reasons. Side effects of high dose progesterone include increased appetite and weight gain. Three months after the initiation of treatment, a D&C is performed to evaluate the response to treatment. If hyperplasia is still present, the dose of progesterone is increased and another D&C is performed in three months.
WHAT IF THE PROGESTERONE TREATMENT IS NOT EFFECTIVE?
Persistent hyperplasia after treatment for nine months is considered treatment failure and hysterectomy should be considered.
WHAT IF THE PROGESTERONE TREATMENT IS EFFECTIVE?
If hyperplasia resolves, the patient should proceed with childbearing as soon as possible. If childbearing is delayed, maintenance progesterone therapy and endometrial biopsy every six to 12 months is recommended.
WHAT IS THE SURGICAL TREATMENT FOR ENDOMETRIAL HYPERPLASIA WITH ATYPIA?
Total hysterectomy (removal of the uterus and cervix) is the treatment of choice for hyperplasia with atypia in patients who have completed childbearing. Supracervical hysterectomy should not be performed because the abnormal uterine cells can be present in the cervix.
Removal of bilateral tubes and ovaries should be performed in post-menopausal women. Five percent of post-menopausal women with uterine cancers have cancer cells in the ovaries. Since 17 to 59 percent of complex hyperplasia with atypia cases have coexistent cancer, removal of the ovaries is necessary.
In pre-menopausal women, the decision to remove the ovaries at the time of the hysterectomy is more difficult. Twenty-five percent of uterine cancers in pre-menopausal women have cancer cells in the ovaries. In some cases it is reasonable to remove the uterus only and wait for the final pathology to identify whether the uterus contains cancer. If cancer is found, a second surgery will be required to remove the ovaries.
WHAT IS THE POST-SURGERY FOLLOW UP?
If the pathology evaluation of the uterus confirms hyperplasia only and no uterine cancer, no further follow up is required. Estrogen replacement therapy is not contraindicated in women with hyperplasia after the removal of the uterus.
WHY CIGC FOR MY ENDOMETRIAL HYPERPLASIA TREATMENT?
Once diagnosed with endometrial hyperplasia, it is important to find a physician who will discuss all of the options available to you. Treatment options for endometrial hyperplasia depend on the type of hyperplasia and whether the patient desires to preserve her uterus for fertility.
CIGC physicians are specialists in minimally invasive GYN surgery. Patients diagnosed with hyperplasia without atypia who require non-surgical treatments are offered the best medical solutions available. They are handled with the same advanced and focused care as those patients diagnosed with hyperplasia with atypia who require surgery.
CIGC physicians are laparoscopic surgical specialists who have dedicated their careers to the performance of minimally invasive GYN care. Additionally, our commitment to surgery means that we have worked on a higher volume of cases, more difficult cases, and use advanced techniques and procedures learned in extensive training sessions. We strive to complete even the most complex surgeries with low complication rates.
If you do require a hysterectomy for endometrial hyperplasia, you should know that GYN care is the sole medicine practiced by CIGC surgical specialists. We partner with OB/GYNs to ensure patients have the best possible care. Increased surgical volume is important to develop and maintain surgical expertise.
CIGC surgeons do not perform open hysterectomies on patients with endometrial hyperplasia. Open surgeries are known to be painful, have a relatively high risk of complications, and have an extended recovery period. CIGC surgeons also do not perform robotic surgeries. Surgeries in which robotic technology performs the procedure is extremely expensive and has a high risk of complications.
Learn the benefits of CIGC procedures.
If required, at CIGC, we perform minimally invasive, advanced laparoscopic hysterectomies. This type of hysterectomy is far superior to open or robotic procedures. Using DualPortGYN, CIGC procedures leave you with minimal cosmetic scarring, you will have a shorter recovery period of only a few days, and there is a low risk of complications. Hear why our patients prefer our laparoscopic procedures.
Patients of laparoscopic procedures have a short hospital stay or none at all and minimal pain. Since recovery is so easy and fast, patients feel less sick afterward, which contributes greatly to an optimistic outlook. Feeling better physically and mentally makes the treatment and recovery process more tolerable. At the end of treatment, patients get to walk away with minimal scarring.
Know your options. Our surgeons assess endometrial hyperplasia patients on a case-by-case basis to choose the best treatment options. There are many different types of treatment options, and the type of procedure needed depends on the individual patient. We will offer you peace of mind by helping you understand your condition and options.
We know that our customers are picky when choosing their surgeons, and we think doing extensive research is important. When you are exploring your endometrial hyperplasia treatment options, get to know our surgical specialists and see why they are the best in the industry.
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