Endometrial hyperplasia: symptoms, treatment and causes

The RCOG says the most common symptom is abnormal vaginal bleeding. Some women have no symptoms at all, and it is suspected when they have a scan for other reasons. If you are worried you may have it, speak to a healthcare professional. Depending on your symptoms, your GP may arrange further tests or refer you directly to a gynaecologist.

• Heavy bleeding or long periods.

• Bleeding between periods.

• Unexpected bleeding after the menopause.

• No symptoms at all, with the condition found on a scan done for another reason.

The NHS says that if you have postmenopausal bleeding you need to get it checked by a GP, even if it is only a small amount or has only happened once. It is not usually serious but can be a sign of cancer, and cancer may be easier to treat if found early. A GP should refer you to hospital or a postmenopausal bleeding clinic, and the NHS says you should not have to wait more than 2 weeks to see a specialist.

For heavy periods, the NHS says to see a GP if they are affecting your life, you have bleeding between periods or after sex, or severe pain, and that rarely heavy periods can be a sign of womb cancer.

Treatment depends on whether the cells show atypia (abnormal-looking cells). The RCOG says treatment with the hormone progesterone is the main option, and it can be given by tablet or by an intrauterine system (IUS) such as the Mirena, which it says is more likely to make the hyperplasia go away, may have fewer side effects and offers ongoing treatment for 5 years. If you are overweight, losing weight can increase the chance of it going away.

The endometrium is the lining of the womb. The RCOG says endometrial hyperplasia happens when it grows too thick or in a less ordered way than expected, and that it can lead to cancer of the womb over time, so follow-up or treatment is recommended to prevent cancer or pick it up early.

There are two types. Hyperplasia without atypia usually goes away, and carries a small risk of progressing to cancer over many years. Hyperplasia with atypia has a higher risk of progressing to cancer.

The RCOG says you are more likely to develop endometrial hyperplasia if you are overweight (BMI above 25) or obese (BMI above 30), are not ovulating regularly, which may happen with polycystic ovary syndrome (PCOS) or when approaching the menopause, or take medication that can stimulate growth of the womb lining, such as tamoxifen or oestrogen therapy without adequate protection from progesterone. The NHS adds that it can be caused by hormone replacement therapy (HRT), high levels of oestrogen or being overweight.

You can lower your risk of developing it, or of it progressing, by keeping your weight within a healthy range, according to the RCOG.

The RCOG says a transvaginal (internal) ultrasound scan can show if the womb lining is thickened, contains polyps or has changes in its blood supply. If the lining is thicker than expected, a biopsy (or removal of polyps) is recommended.

An endometrial biopsy is usually taken in an outpatient clinic using a speculum and a very thin tube passed through the cervix to remove a small sample. It can also be taken during hysteroscopy, in which a narrow telescope is passed into the womb. Some procedures cause mild pain and others find them more painful, and options for pain relief will be discussed. A specialist examines the sample under a microscope. Sometimes the first biopsy is not enough and it may be repeated.

The RCOG says you may wish to consider a hysterectomy, with or without removal of the ovaries, if hyperplasia without atypia does not go away or comes back, or bleeding problems continue. If you have hyperplasia with atypia and have completed your family, it is usually the recommended treatment and can often be done as a laparoscopic (keyhole) procedure. You can decline treatment or change your mind at any time.

If you have a hysterectomy you will no longer be able to get pregnant. If you cannot or do not want to have one, progesterone tablets or the IUS with regular biopsies, usually every three months, are recommended, though the RCOG says progesterone may lower the risk of cancer but may not prevent it.

The RCOG says that if you want to get pregnant you will be advised not to until a biopsy has confirmed that the hyperplasia has gone away. Fertility returns when progesterone stops, and you should be offered the chance to discuss fertility treatment with a specialist.

On HRT, the RCOG says it is not fully known how it affects endometrial hyperplasia, you should discuss it with your gynaecologist, and you may be advised to stop it to see if the hyperplasia goes away, or to take progesterone throughout the month or use the IUS. If you take tamoxifen after breast cancer, your healthcare professional may suggest seeking advice from the doctor who treated your breast cancer about the risks and benefits of stopping or continuing it.

On the NHS, a GP usually arranges initial assessment and refers you to a gynaecology or postmenopausal bleeding clinic for an ultrasound scan, biopsy or hysteroscopy, and follow-up biopsies are arranged by the gynaecology team.

Some people arrange a private scan and biopsy to be seen sooner. The tests and treatments are the same. Because follow-up biopsies are needed over many months, ask who will arrange them and how results will be shared with your GP.