Endometrial hyperplasia (EH) refers to an increased proliferation of the endometrial glands relative to the stroma. One of the main concerns is the potential malignant transformation of the endometrial hyperplasia to the endometrial carcinoma.
It affects women of all age groups 12.
A great majority of patients present with abnormal uterine bleeding.
Hyperplasia with increased gland to stroma ratio; there is a spectrum of endometrial changes ranging from glandular atypia to frank neoplasia.
There are several types of endometrial hyperplasia, which include:
- simple hyperplasia without atypia also known as cystic endometrial hyperplasia
- simple hyperplasia with atypia
- complex hyperplasia without atypia
- complex hyperplasia with atypia
Hyperplasia can be also classified into two broad groups 5:
Unopposed oestrogen stimulation (either from an endogenous or exogenous source) is implicated in its pathogenesis; some of these conditions are:
- polycystic ovary syndrome
- pregnancy (and ectopic pregnancy)
- oestrogen secreting ovarian tumours
Imaging the endometrium on days 5-10 of a woman's cycle reduces the variability in endometrial thickness.
- normal endometrial thickness depends on the stage of the menstrual cycle, but a thickness of >15 mm is considered top normal in the secretory phase
- hyperplasia can be reliably excluded in patients only when the endometrium measures less than 6 mm 1
- a thickness of >5 mm is considered abnormal
The appearance can be non-specific and cannot reliably allow differentiation between hyperplasia and carcinoma 5. Usually, there is a homogeneous increase in endometrial thickness, but endometrial hyperplasia may also cause asymmetric/focal thickening with surface irregularity, an appearance that is suspicious for carcinoma.
- T2: hyperplasia is often isointense to hypointense to normal endometrium 7
Treatment and prognosis
Up to one-third of endometrial carcinoma is believed to be preceded by hyperplasia. A biopsy is required for a definitive diagnosis.
Because endometrial hyperplasia has a non-specific appearance, any focal abnormality should lead to biopsy if there is clinical suspicion for malignancy (e.g. vaginal bleeding).
On ultrasound, appearances can potentially simulate:
- normal thickening during the secretory phase: see endometrial thickness
- sessile endometrial polyp(s): may contain cystic spaces 4
- submucosal uterine fibroids
- endometrial cancer
- adherent intrauterine blood clot
- pregnancy (and ectopic pregnancy)
- 1. Nalaboff KM, Pellerito JS, Ben-levi E. Imaging the endometrium: disease and normal variants. Radiographics. 21 (6): 1409-24. Radiographics (full text) - Pubmed citation
- 2. Dubinsky TJ, Stroehlein K, Abu-ghazzeh Y et-al. Prediction of benign and malignant endometrial disease: hysterosonographic-pathologic correlation. Radiology. 1999;210 (2): 393-7. Radiology (full text) - Pubmed citation
- 3. Sheth S, Hamper UM, Kurman RJ. Thickened endometrium in the postmenopausal woman: sonographic-pathologic correlation. Radiology. 1993;187 (1): 135-9. Radiology (abstract) - Pubmed citation
- 4 . Hulka CA, Hall DA, Mccarthy K et-al. Endometrial polyps, hyperplasia, and carcinoma in postmenopausal women: differentiation with endovaginal sonography. Radiology. 1994;191 (3): 755-8. Radiology (abstract) - Pubmed citation
- 5. Jorizzo JR, Chen MY, Martin D et-al. Spectrum of endometrial hyperplasia and its mimics on saline hysterosonography. AJR Am J Roentgenol. 2002;179 (2): 385-9. AJR Am J Roentgenol (full text) - Pubmed citation
- 6. Bakour SH, Dwarakanath LS, Khan KS et-al. The diagnostic accuracy of ultrasound scan in predicting endometrial hyperplasia and cancer in postmenopausal bleeding. Acta Obstet Gynecol Scand. 1999;78 (5): 447-51. Acta Obstet Gynecol Scand (link) - Pubmed citation
- 7. Semelka RC. Abdominal-Pelvic MRI. Wiley-Blackwell. (2010) ISBN:0470487755. Read it at Google Books - Find it at Amazon
- 8. Montgomery BE, Daum GS, Dunton CJ. Endometrial hyperplasia: a review. Obstet Gynecol Surv. 2004;59 (5): 368-78. Pubmed citation
- 9. Armstrong AJ, Hurd WW, Elguero S et-al. Diagnosis and management of endometrial hyperplasia. J Minim Invasive Gynecol. 2012;19 (5): 562-71. doi:10.1016/j.jmig.2012.05.009 - Pubmed citation
- 10. Schmidt WO, Kurjak A. Color Doppler Sonography in Gynecology and Obstetrics. Thieme. ISBN:1588902560. Read it at Google Books - Find it at Amazon
- 11. Kumar V, Abbas AK, Aster JC et-al. Robbins and Cotran pathologic basis of disease. Saunders. ISBN:1416031219. Read it at Google Books - Find it at Amazon
- 12. Palmer J, Perunovic B, Tidy J. The Obstetrician & Gynaecologist. 2008;10 (4): . doi:10.1576/toag.10.4.211.27436
Ultrasound - gynaecology
- ultrasound (introduction)
- acute pelvic pain
- chronic pelvic pain
- Mullerian duct anomalies
- ovarian follicle
- ovarian torsion
- pelvic inflammatory disease
- ovarian cysts and masses
- ovarian cyst
- corpus luteum
- haemorrhagic ovarian cyst
- ruptured ovarian cyst
- ovarian epithelial tumours
- granulosa cell tumours of the ovary
- paraovarian cyst
- polycystic ovaries
- ovarian hyperstimulation syndrome
- post-hysterectomy ovary
- fallopian tube