Endometrial Hyperplasia Part 2 and An Added Bonus, “Vitamin D and Covid“ Lecture Video!

January 14, 2021

The blog on December 16, 2020, discussed a scenario posed to me by a patient on Bio-Identical Hormone Replacement Therapy (BHRT) having an ultrasound showing Endometrial Hyperplasia.  The biopsy report came back as “endometrial hyperplasia without atypia’ meaning no abnormal cells that could become precancerous. Her long-standing OB-GYN told her if she wanted to continue BHRT he would only condone it if she got a complete hysterectomy.   How does endometrial hyperplasia occur?  What is the real risk in this situation? Should she have a complete hysterectomy?

Mechanism of Increasing and Decreasing Endometrial Lining

Estrogen increases or proliferates the endometrial lining getting it ready for fertilization.   If there is no fertilization, progesterone thins the endometrial lining.  There should always be a balance of estrogen and progesterone to protect the endometrial lining whether you are on Hormone Replacement Therapy (HRT) or not on HRT.  When you have too much estrogen or too little progesterone you can develop endometrial hyperplasia.  Endometrial hyperplasia is defined as an endometrial lining >4-5 mm and is diagnosed by pelvic ultrasound.  As an aside, this same scenario can lead to fibroid formation and growth of fibroids.   When endometrial hyperplasia is diagnosed, a biopsy needs to be done to determine if the lining contains atypical cells/cancerous cells, or cells without atypia/normal cells.

Treatment of Endometrial Hyperplasia

First line treatment in women on HRT who have endometrial hyperplasia without atypia is simply to decrease the amount of estrogen they are using and/or increase the amount of progesterone they are using.  This is one reason women on HRT with an intact uterus should always be on progesterone to oppose estrogenic effects.  Women who have hysterectomies do not have this problem!  This reasoning is why my patient’s doctor told her she should have a hysterectomy.  His wanting her to have an ovariectomy follows the same line of thinking.  Is it necessary to do surgery?  Absolutely not.  Surgery is not the first line therapy in this case of endometrial hyperplasia without atypia.   Manipulation of progesterone and estrogen is the first line therapy.  If by chance the endometrial lining does not decrease, then a D&C should be done.  Sometimes a D&C is done along with an adjustment of hormone therapy.

Endometrial Hyperplasia and Endometrial Cancer Risk

The main reason my patient’s OB_GYN said to have a hysterectomy and ovariectomy, a complete hysterectomy, is to avoid endometrial cancer and/or ovarian cancer.  What is the risk of endometrial cancer in this situation?

“The risk of endometrial hyperplasia without atypia, or no abnormal cells, progressing to endometrial cancer is less than 5% over 20 years.” * 

“In the majority of cases of endometrial hyperplasia without atypia, they will regress spontaneously during follow-up as reversible risk factors such as obesity and the use of HRT are identified and addressed.”*

The decision to have a complete hysterectomy is truly up to the individual in this case, knowing the risks involved and different treatments offered.  In this case, the patient decided on conservative treatment stopping the estrogen all together, continue progesterone, and get a repeat pelvic ultrasound in 3-6 months to see if the endometrial hyperplasia has regressed.  If she does not feel well on progesterone alone, we will discuss adding a little estrogen after another Ultrasound is obtained.  Will keep you posted!

Have an awesome day.   Dr D

As a really big deviation from today’s topic, I am also including a YouTube lecture on Vitamin D and Covid.  I found this lecture the other day while researching endometrial hyperplasia!  It is an hour long.  You may have to watch it in shorter segments, but I found it to be excellent.  Hope you enjoy and thank you to the people who put it together.  Dr D

Posted in Covid19, Vitamin D