Glandular endometrial hyperplasia is an excessive overgrowth of the glandular tissue of the endometrium, characterized by its thickening and increase in volume. Disease is manifested by copious menstruation, dysfunctional anovulatory bleeding, anemia, infertility. Ultrasound, hysteroscopy, Echo-HSG, endometrial biopsy, hormonal studies are performed to determine the hyperplastic transformation of the endometrium. Treatment includes curettage of the uterine cavity, hormone therapy, if necessary, resection or ablation of the endometrium.
N85.0 Glandular endometrial hyperplasia
The glandular hyperplasia of the endometrium is based on excessively active proliferative processes in the glandular tissue of the uterus. The main danger of hyperplastic endometrial changes is the possibility of their progression and malignant transformation. Therefore, the importance of diagnosis and treatment of glandular endometrial hyperplasia is dictated by the urgency of preserving a woman’s reproductive potential and preventing endometrial cancer. The diagnosis can only be made based on the results of histological examination of endometrial samples.
Hyperplastic transformation of the endometrium can occur in women of any age in the presence of risk factors, but it is more common in transitional periods associated with hormonal changes in the body (in adolescents and premenopausal patients).
Background genital processes accompanying the development are uterine fibroids, polycystic ovary syndrome, endometriosis, endometritis. The development is often preceded by gynecological operations, diagnostic endometrial curettage, abortions. Risk factors for hyperplastic processes of the uterus are the absence of a woman’s history of childbirth, refusal to use hormonal contraception, artificial termination of pregnancy, late menopause.
Extragenital concomitant diseases include diabetes mellitus, mastopathy, hypertension, obesity, diseases of the thyroid gland, liver and adrenal glands. The leading moment of the occurrence is hyperestrogenism or prolonged exposure to estrogens with a decrease in the inhibitory effect of progesterone.
According to the histological variant, there are several types of endometrial hyperplasia: glandular, glandular-cystic, atypical (adenomatosis) and focal (endometrial polyps). Glandular endometrial hyperplasia is characterized by the disappearance of the division of the endometrium into functional and basal layers. The border between the myometrium and the endometrium is clearly expressed, there is an increased number of glands, but their location is uneven, and the shape is not the same. In the glandular-cystic form of hyperplasia, part of the glands acquires a cystic-altered appearance.
Adenomatosis (atypical hyperplasia) is characterized by structural restructuring and more intensive proliferation of elements compared to glandular hyperplasia of the endometrium, polymorphism of the nuclei, a decrease in the number of stromal elements. With local hyperplasia, there is an overgrowth of the glandular and integumentary epithelium together with the underlying tissues, leading to the formation of endometrial polyps (glandular, fibrous, glandular-fibrous).
The greatest oncological alertness in gynecology is caused by atypical and polypous hyperplasia, which are regarded as a precancerous condition. The threat of the transition of adenomatosis to endometrial cancer is about 10%. Glandular and glandular-cystic endometrial hyperplasia are less prone to malignancy. This probability increases with their recurrent course after endometrial scraping and inadequate hormone therapy.
A characteristic symptom is a disorder of menstrual function, expressed by pathological uterine bleeding. Among the forms of menstrual dysfunction, there are menorrhagia (cyclic bleeding exceeding the usual monthly blood loss and duration) and metrorrhagia (acyclic bleeding of varying duration and profusion).
Bleeding occurs after a slight delay in menstruation or during the intermenstrual period. Juvenile bleeding that occurs with glandular endometrial hyperplasia in adolescents is characterized by a breakthrough character with the release of clots. Prolonged and copious bleeding eventually contributes to the development of anemia, weakness, malaise, dizziness. The anovulatory cycle, observed with glandular endometrial hyperplasia, is accompanied by infertility.
Since the manifestations are not specific only for this pathology, the issues of full and accurate diagnosis are of particular importance. When studying the anamnesis, the gynecologist asks about heredity, the peculiarities of the menstrual cycle, the state of childbearing function, the methods of contraception used, general and gynecological diseases suffered.
In addition to the general gynecological examination, the diagnosis includes transvaginal ultrasound, during which the thickness of the endometrium is determined, the presence of polypous growths. Ultrasound screening identifies a contingent of women who need histological confirmation of the diagnosis by means of an aspiration biopsy of the endometrium or separate diagnostic curettage.
Diagnostic curettage is performed on the eve of the expected menstruation or immediately after its onset under the control of hysteroscopy. Hysteroscopy ensures adequate curettage and complete removal of the pathologically altered endometrium. Endometrial scrapings are subjected to histological examination, which allows to determine the type of hyperplasia and establish a morphological diagnosis. In endometrial glandular hyperplasia, the informative value of diagnostic hysteroscopy is 94.5%, while transvaginal ultrasound is 68.6%.
With this disease, the patient’s progesterone and estrogen levels are examined, if necessary, adrenal and thyroid hormones. An auxiliary diagnostic role is played by hysterography or radioisotope scanning. Differential diagnosis of bleeding caused by glandular endometrial hyperplasia is carried out with ectopic pregnancy, trophoblastic disease, polyps or erosion of the cervix, uterine body cancer, uterine fibroids.
The procedure of separate diagnostic curettage of the uterine cavity serves as the first stage of treatment of glandular endometrial hyperplasia. In the future, taking into account the results of histology, a hormone therapy scheme is selected, aimed at suppressing further endometrial proliferation and eliminating hormonal imbalance.
With the glandular form of endometrial hyperplasia, COCs, progestogens for 3-6 months can be prescribed. With success in the treatment of glandular endometrial hyperplasia, the gestagen-containing intrauterine system “Mirena” is used, which has a local therapeutic effect on the endometrium. The use of gonadotropin releasing hormone agonists is effective in women over 35 years of age and perimenopausal period. These drugs cause a temporary reversible state of artificial menopause and amenorrhea.
In parallel with hormonal treatment, vitamin therapy, correction of anemia, acupuncture, physiotherapy (electrophoresis) is carried out. Control ultrasound during therapy is performed after three and six months of treatment; repeated endometrial biopsy – at the end of the course. In order to stimulate the ovulatory cycle, ovulation stimulators are used in the future.
In case of recurrence on the background of hormone therapy in patients interested in childbirth, endometrial ablation or resection can be performed using laser and electrosurgical techniques under hysteroscopic control. With glandular endometrial hyperplasia complicated by endometriosis, uterine fibroids, as well as during menopause, the method of choice may be removal of the uterus: supravaginal amputation, hysterectomy or pangisterectomy.
After completing the course of treatment of glandular endometrial hyperplasia, the issue of preventing its recurrence and endometrial cancer becomes of particular importance. For these purposes, regular gynecologist examinations, consultation of a gynecologist-endocrinologist and selection of contraception, professional training and management of pregnancy in patients are recommended. The prognosis of glandular endometrial hyperplasia largely depends on the woman herself, the timeliness of her treatment to a specialist and the fulfillment of the doctor’s prescriptions.