Hyperplastic processes in the uterus are common gynecological lesions. What is atypical endometrial hyperplasia? This is a pathological proliferation of the internal uterine membrane with a change in the properties of its cells.
This type of change is distinguished along with simple hyperplasia and endometrial polyps. In Russia, the term "adenomatosis" is often used to refer to this condition.
Pathology is often associated with several risk factors that need to be timely and targeted to identify with each woman's visit to a gynecologist.
Atypical hyperplasia of the endometrium of the uterus occurs when the imbalance of female sex hormones is disturbed: an increase in the estrogen content and a decrease in the level of gestagens.
- the persistence or atresia of the follicles, leading to the absence of ovulation,
- ovarian tumors that synthesize hormones (granulosa cell tumor, tekomatoz, and others),
- enhancing the function of the pituitary gland by producing gonadotropic hormone,
- excessive function of the adrenal cortex, for example, Itsenko-Cushing's disease,
- disorders in the treatment of hormonal drugs, in particular, tamoxifen.
Endometrial adenomatous hyperplasia often occurs on the background of other hormonal disorders:
- liver diseases (hepatitis, cirrhosis), in which estrogen utilization is delayed,
- thyroid disease.
Other risk factors:
- age after 35 years
- absence of pregnancies
- early onset and late cessation of menstruation,
- cases of cancer of the ovary, uterus or intestines in the family.
In addition to neurohumoral changes, endometrial damage due to abortion, curettage, and endometritis is also involved in the development of hyperplasia.
Can atypical endometrial hyperplasia go to cancer?
This condition at any age is considered precancerous, the probability of its malignant transformation depends on the degree of atypia and ranges from 3 to 30%.
Endometrium changes during the menstrual cycle under the influence of hormones. In the first phase, estrogens produced in the ovaries cause the cells of the mucous membrane in the uterus to grow and prepare for pregnancy. In the middle of the cycle, an egg cell leaves the ovary - ovulation occurs, after which the level of another hormone, progesterone, increases. He prepares the endometrium for the reception and development of a fertilized egg.
If the pregnancy does not develop, the level of all hormones is reduced, and menstruation occurs - rejection of the upper layer of the endometrium.
Hyperplasia of the uterine lining is caused by an excess of estrogen against the background of a decrease in progesterone levels. This condition occurs in the absence of ovulation. Endometrium does not decrease, but continues to thicken under the constant influence of estrogen. Its cells change shape and may become pathological, which further leads to cancer.
Hyperplasia usually occurs after menopause, when egg production stops and progesterone levels fall. It can appear during menopause with irregular ovulation, as well as under the influence of other causes.
Classification of atypical hyperplasia
Any hyperplastic processes in the endometrium according to the WHO 2004 classification are divided into hyperplasia without atypia and atypical.
Atypical hyperplasia can be mild, moderate or severe. It refers to precancerous conditions. According to modern classification, it is characterized by the proliferation of endometrial glands with a change in the structure of cells.
There are two forms of pathology: simple and complex.
- Simple atypical endometrial hyperplasia is characterized by an overgrowth of the endometrial glands with a normal structure of cells and their nuclei. This form turns into cancer in 8% of cases.
- Complex atypical hyperplasia of the endometrium, or adenomatosis with atypia, is accompanied by disorganization, disruption of the normal structure of the glandular cells, a change in their shape and nuclei. This form often turns into cancer - in 29% of patients.
Atypical hyperplasia of the endometrium is very different from the early stage of cancer in that it does not penetrate the plate separating the surface layer (epithelium) from the underlying tissue (stroma). Therefore, atypical cells grow and multiply in the upper layer of the endometrium, not falling into the blood and lymph nodes.
There are focal and diffuse forms of the lesion:
- Focal atypical endometrial hyperplasia develops in a restricted area, often in the area of corners or the bottom of the uterus. It manifests itself later and is worse diagnosed.
- Diffuse captures the entire inner surface of the uterus and early causes the symptoms of the disease.
Such a form as atypical glandular hyperplasia of the endometrium is not distinguished in modern classification. Glandular hyperplasia refers to forms without atypia, in many cases it is not a precancer.
The main signs of atypical endometrial hyperplasia do not differ from other forms of hyperplastic processes:
- irregular uterine bleeding,
- disruption of the menstrual rhythm
- copious menstruation,
- excretion of blood through sexual contact
- spotting in postmenopausal women.
Abdominal pain for this pathology is not typical. In young women, endometrial hyperplasia is often accompanied by infertility.
It is impossible to make a diagnosis on the basis of only patient complaints. Therefore, in violation of the menstrual cycle, it is necessary to undergo additional methods of examination.
Transvaginal Ultrasound of the Uterus
The method provides a lot of information about the state of the endometrium and can be used for rapid diagnosis in all groups of women.
If hyperplasia is suspected, the endometrial thickness (M-echo) is evaluated. In young women in the 2nd half of the cycle, it should not exceed 15 mm. In postmenopausal women who take hormone replacement therapy, the endometrium should be no thicker than 8 mm. If hormone replacement therapy is not carried out, the thickness of the M-echo after the cessation of menstruation should not exceed 5 mm. If this value is greater, the risk of atypia and endometrial cancer is 7%.
Transvaginal Ultrasound of the Uterus
Ultrasound can detect hyperplasia in 60-93% of cases, but with its help it is impossible to distinguish the glandular form from the atypical one. The method has the greatest diagnostic value in women in pre- and postmenopause, whereas at a young age the thickness of the endometrium depends strongly on the phase of the cycle.
The method gives the most information about the state of the uterus. On examination, the doctor discovers the pathology of the pathology, assesses its location and size, and, if necessary, takes a biopsy of the endometrium. Hysteroscopy is carried out before and after scraping. It allows you to make a diagnosis in 63-97% of cases. The study is conducted under local anesthesia, less common anesthesia is required.
Simple and complex atypical endometrial hyperplasia have the same endoscopic signs as glandular: thickening and swelling of the endometrium, a large number of points — glands of discharge, pale pink color.
Analysis of endometrial tissue under a microscope helps to finally make a diagnosis. It gives a description of the structure of the epithelial layer, the structure of cells and nuclei, reveals their atypia. This study is performed using a pipe biopsy or during hysteroscopy. However, the sensitivity of the biopsy to detect atypia and cancer does not reach 100%.
When receiving aspirate from the uterus, it is also examined under a microscope, but the information content of such an analysis is lower than that of histology. The method is used as a screening during follow-up, as well as to assess the effectiveness of treatment.
With insufficient information and the presence of other diseases of the uterus, computed or diffusion-weighted magnetic resonance imaging is indicated.
When endometrial hyperplasia is necessary to exclude cancer of the uterus and ovaries.
The goal of therapy is to stop uterine bleeding and prevent the development of endometrial cancer.
In women in pre - and postmenopause, extirpation (removal) of the uterus is indicated. The issue of removal of the ovaries is solved individually, although it is desirable to ovariectomy, especially in elderly patients. This significantly reduces the risk of ovarian cancer later on.
Surgical intervention is necessary because of the high risk of uterine cancer. Preferably the laparoscopic method, in which there is no large incision, the surrounding tissue is injured a little, the recovery period is much shorter than during normal surgery. Removal of lymph nodes is not carried out.
In young patients, bleeding is stopped by curettage, and then hormone therapy is prescribed. In this case, the woman should be aware of the high risk of uterine cancer in her, even when all the recommendations for drug treatment. If the birth of the child is no longer planned, it is best to conduct a hysterectomy.
Hormonal treatment of atypical endometrial hyperplasia is carried out using three groups of drugs:
- progestins (medroxyprogesterone),
- antigonadotropins (gestrinon),
- agonists of gonadotropin-releasing factor (goserelin, buserelin).
For the introduction of progesterone into the body the most effective intrauterine device "Mirena". You can also use these drugs in the form of tablets.
If atypical hyperplasia is combined with uterine myoma or ovarian pathology, hormone therapy is practically ineffective.
2 months after the start of taking hormones, curettage is prescribed under the control of hysteroscopy. The same procedure is carried out after completion of treatment. The course duration is 6 months, and when using depot-forms of Buserelin, Goserelin or Triptorelin, only 3 injections are necessary with an interval of 28 days. The purpose of the reception and the criterion of the effectiveness of hormonal drugs is the atrophy (thinning) of the endometrium and its glandular layer.
Recurrences of hyperplasia after hormonal therapy occur quite often: in 14% of patients with the Mirena system installed and in 30% of patients taking gestagens in tablets. Therefore, such patients need long-term monitoring.
Intrauterine device "Mirena"
After the effect is achieved, the second stage of treatment is started - rehabilitation to restore the menstrual cycle and childbearing function. To do this, within six months, the woman prescribed combined contraceptives. After this, separate curettage with hysteroscopy is again necessary.
After completion of hormone therapy, you must constantly monitor ovulation. With anovulatory cycles, the risk of disease recurrence is very high. Ovulation can be determined using special tests, as well as a simple method of measuring rectal temperature. When anovulation in young women, its stimulation with Clomiphene is recommended, and if this drug is ineffective against the background of polycystic ovary syndrome, surgical intervention is necessary.
After full completion of all treatment steps, monitoring is carried out after 3 and 6 months. Cytological examination of the aspirate from the uterus and ultrasound, and after 6 months - also curettage under the control of hysteroscopy.
Complete cessation of menstruation after hormonal treatment in women of premenopausal age is a good sign. Clinical surveillance is carried out for another 1-2 years, regularly doing ultrasound and exploring the aspirate from the uterus. When returning irregular bleeding, a woman should immediately consult a doctor, as this is a sign of a relapse of the disease.
Relapse of atypical hyperplasia in young women requires removal (extirpation) of the uterus. If the disease has returned to the patient in pre - or postmenopausal, the scope of the operation is expanded to panhysterectomy (removal of the uterus and appendages).
One of the modern methods of treatment that can be used is the transcervical resection of the endometrium, that is, the removal of the inner layer of the uterus through the cervical canal.
In extremely rare cases, instead of removing the uterus, ablation of the endometrium is performed. This is only possible at the risk of major surgery for life. Even an experienced endoscopist cannot guarantee complete removal of atypical tissue from the uterus, which can cause endometrial cancer.
In addition, after such an operation, commissures are formed in the uterus, which prevent further observation of the patient. Conception and gestation after ablation of the endometrium is extremely problematic. Therefore, leading gynecologists in Russia and foreign countries do not recommend such intervention.
If a woman decides to become pregnant after treating hyperplasia, it is necessary to obtain at least one biopsy specimen confirming the regression of the disease. Then she should consult a fertility specialist to plan conception and plan for observation. In vitro fertilization is optimal for such patients.
Atypical endometrial hyperplasia of the uterus is otherwise called adenomatous. This is a pathology in which there is an active growth of various endometrial cells. Cells actively divide, as a result, the endometrial layer thickens, and the total tissue volume increases.
In general, ordinary typical cells undergo division. What is the difference between atypical hyperplasia of the uterus? When it grows cells with impaired structure. They can be enlarged, distorted in shape, without nuclei or with two or more nuclei, etc. Such cells are called atypical.
Patients who are in the process of a hormonal failure or burst are most affected by such changes. For this reason, the disease often develops in women before or immediately after menopause. In adolescents, atypical uterine hyperplasia is rarely observed, although typical is periodically diagnosed in this group.
Severe cell atypia develops not too often from typical hyperplasia. If the typical is found in about 20% of all patients, then atypical - in 10-15% (although according to some data this indicator is much higher). Situations where typical hyperplasia develops into atypical, rare, they are observed only in 10% of cases.
Adenomatous hyperplasia of the endometrium is manifested mainly by violations of the menstrual cycle, like any other. These are abnormalities such as:
- A significant amount of discharge, large blood loss during menstruation,
- Failures of the menstrual cycle, shortening it, but more often, delay,
- Longer periods compared to their normal course (7 days or more),
- Acyclic hemorrhages in the middle of the cycle or before the start, immediately, menstruation.
Since atypical hyperplasia of the uterus has uncharacteristic symptoms, a timely visit to a doctor, as well as a thorough differential diagnosis, plays a big role.
The causes of simple and complex atypical endometrial hyperplasia lie in hormonal disruptions. A significant increase in the level of estrogen on the background of the usual content of progesterone leads to the activation of proliferative processes. And these processes and cause accelerated cell division. Any malfunctions in the cell copying program lead to atypical phenomena.
There are a number of factors that increase the likelihood of such symptoms:
- Frequent abortions or diagnostic curettage, other endometrial damage,
- Refusal to use oral contraceptives
- Numerous childbirth or, on the contrary, lack of pregnancy and childbirth,
- Endometriosis, endometritis and other diseases of the endometrium,
- The presence of other structures associated with accelerated cell division - myomas, polyps, etc.,
- Polycystic processes
- Improper nutrition, use of preservatives and dyes with tumor activity,
But even the exclusion of these factors does not guarantee complete protection against this disease. Since its main cause, in any case, is hormonal failure.
Go to cancer
It is known that atypical pathology often turns into cancer than typical. This occurs in about 30% of cases, whereas in the case of typical cells - in 10%. In itself, the presence of a large number of atypical cells is already considered a precancer. But, like any precancer, the actual oncological process such a phenomenon goes relatively infrequently. Especially with timely and adequate treatment.
Types and types
Hyperplasia is a generic name for a group of diseases associated with tissue growth and pathologically accelerated cell division. Because there are many varieties of this pathology. Types are determined depending on the nature of the changes, the involvement of certain tissues in the process, the severity of the pathology.
More often than other types, simple non-atypical pathology occurs. What it is? In this condition, only one type of epithelial cells changes. For example, only ferruginous, or only connecting. In an atypical course, only these cells undergo mutations. When non-atypical - they just grow in a normal form.
Other characteristics have complex atypical endometrial hyperplasia. With this course of the disease, there is a proliferation of cells of several types. To a greater or lesser extent, proliferate, for example, connective, integumentary and / or glandular cells. In this case, atypical mutations can have only one type of cells or all at once.
Focal hyperplasia of the epithelium is diagnosed when growth is observed in a specific area. It can be several sections or only one. But not the entire inner surface of the uterus. The severity of changes at different sites may not be the same. Some of them may have atypical changes, others may not.
Concentrated focal pathology, mainly in the lower part of the uterus. This disease gives almost no symptoms. It is usually more difficult and later diagnosed than diffuse changes.
Diffuse hyperplasia of the epithelium - the process of tissue growth, which develops on the entire inner surface of the uterus. In varying degrees, a thickening of the endometrium is observed in each of its parts. At the same time, atypical changes can develop as well as on the entire surface, and only on some of its parts.
Such a course of the disease gives pronounced symptoms of the menstrual cycle. For this reason, it is faster diagnosed and treated more promptly.
Where to turn?
Although the opinion that endometrial hyperplasia of the uterus is cancer is very common, it is still not the case. Therefore, the gynecologist-therapist treats such a disease. But if there are large numbers of atypical cells or actively progressing, the patient can be redirected to an oncologist gynecologist. In case of need of surgical intervention, the gynecologist-surgeon is connected to the course of treatment.
Can endometrial hyperplasia pass by itself? Theoretically, degradation can occur with the normalization of hormone levels or after menopause. But in fact, this rarely happens. Therefore, the disease must be promptly treated. This is done with the help of hormonal drugs, the main purpose of which is the normalization of the hormonal balance of the patient.
For a period of 3 to 6 months, the following groups of drugs may be prescribed:
- Combined oral contraceptives (Janine, Regulon, Ioannina),
- Antagonists of gonadotropin-releasing factor (Buserelin, etc.).
Sometimes surgery is performed. This may be cauterization of the endometrium with a laser or electric current, or complete removal of the uterus. How to treat the pathology in a particular case is decided by a specialist.
Simple or complex atypical endometrial hyperplasia is a contraindication to pregnancy. Conception is rather difficult, the embryo does not attach. Also, at almost any stage there is a threat of miscarriage or premature birth, the birth process is complicated.
Moreover, if during treatment the uterus was not removed, then pregnancy can be planned after it. Theoretically, as soon as the endometrium has returned to normal, conception can be carried out. After cauterization, it is recommended to wait about six months.
If you do not treat this pathology, then complications of three types can develop:
- Anemia due to significant blood loss,
- Oncological process, endometrial cancer,
With timely treatment, the prognosis is quite good. Oncology is often avoided.
Atypical hyperplasia is a precancerous condition that is best treated surgically. Reception only phytopreparations in this case is completely ineffective and can lead to the rapid progression of the disease.
Medicinal plants can only be used as an adjunct to hormone therapy:
- Borovaya uterus - take 1 tbsp. spoonful of leaves in 500 ml of water, heat in a water bath for 15 minutes, cool, strain and drink in several doses on an empty stomach,
- raw beets - take 50-100 ml of juice per day,
- viburnum bark - 1 tbsp. spoon a glass of water, brew and drink during the day,
- nettle leaves - brew in a water bath (2 spoons per cup of water), take during the day.
To reduce the risk of endometrial hyperplasia, you must follow these rules:
- use for hormone replacement therapy after menopause is not estrogen in its pure form, but their combination with gestagens,
- in case of irregular menstruation, take combined oral contraceptives as prescribed by a doctor,
- reduce weight
- if irregular bleeding occurs after the age of 35, immediately contact a gynecologist.
With the right choice of treatment, the prognosis of atypical hyperplasia is favorable: in most patients, it is possible to prevent the development of uterine cancer. The best long-term results are recorded after removal of the uterus.
Causes of endometrial hyperplasia
In most cases, endometrial hyperplasia occurs in women in premenopause (40-50 years) with chronic anovulation — single-phase cycles without maturation of the egg. Less commonly, pathology develops in young women, as well as in adolescents with irregular menstrual cycles. In reproductive age, women with polycystic ovary (Stein-Leventhal syndrome) are particularly prone to developing hyperplasia. All possible causes of endometrial hyperplasia are listed below:
Endometrial hyperplasia in menopause
As menopause approaches, the number of anovulatory cycles increases. Normally, slow synchronous extinction of hormones leads to a decrease in the activity of the endometrium and its subsequent atrophy. However, various disruptions in the hormonal system due to obesity, diabetes mellitus or other pathologies lead to a relative increase in estrogen levels against the background of a relative decrease in progesterone. Hormone replacement therapy and late menopause also stimulate the development of the disease. Endometrial hyperplasia in menopause is a serious condition that is a precursor of uterine cancer, so finding out the causes and treatment should be prompt.
Symptoms of atypical endometrial hyperplasia
- Bloody spotting: spontaneous, contact.
- Uterine bleeding: acyclic, cyclic.
- Ultrasound signs:
- childbearing period: ≥20-30 mm
- postmenopause: ≥4-5 mm
The symptoms of typical and atypical endometrial hyperplasia are the same. At the beginning of the development of the disease proceeds without clinical manifestations.
1. Conservative preservative treatment
Today, the tactics of treatment of atypical endometrial hyperplasia with oral progestin hormones is considered to be ineffective.
Indications for hormone therapy:
- Contraindications to surgical treatment due to somatic pathology of the patient.
- Refusal of the patient from surgical treatment: the desire to preserve the ability to bear children - a reproductive plan.
Atypical endometrial hyperplasia - symptoms
Atypical endometrial hyperplasia, mainly manifested through uterine bleeding, occurring, in many cases, against the background of postponement of the menstrual cycle for up to 90 days. Such long pauses, as a rule, end with bleeding, the duration and intensity of which is different and is accompanied by painful sensations.
In 8–20% of women, an atypical form of endometrial hyperplasia develops into a malignant form of the disease.
The regularity of the cycle is rarely observed in various pathologies of the endocrine glands and the absence of obesity, prolonged heavy bleeding, more than seven days. Anovulatory uterine bleeding with an atypical form of endometrial hyperplasia occurs in 25% of people. 5-10% of patients suffering from atypical form of hyperplasia, revealed bleeding in the uterus (metrorrhagia). Also not permanent small bleeding, in the absence of regul in the period of the menstrual cycle or in the period of menopause. Atypical endometrial hyperplasia is often accompanied by metabolic dysfunctions.
In 50% of cases, overweight and virilization symptoms are observed:
- Alopecia, excess hair,
- lower tone of voice
- clitoral enlargement, etc.
If body weight is normal, virilization occurs in a third of patients with atypical endometrial hyperplasia.
As a rule, in patients with atypical form, inflammations of a chronic nature are additionally present in the reproductive system of the female body, chronic miscarriage, mastopathy, adenomyosis, and endometriosis are observed. These pathologies are detected in patients with no signs of obesity more often, about two times.
Atypical form of endometrial hyperplasia, in fact, the uterus mucous membrane, it is very difficult to identify only by clinical manifestations. In addition to the above-mentioned signs, there are other, similar to other forms of hyperplasia, manifestations of the disease:
- pain in the lumbar region and lower abdomen,
- decreased performance and
- fatigue and weakness.
Often, women over 45 take the symptoms of an atypical form of endometrial hyperplasia for the symptoms of uterine fibroids and do not go to the doctor, resorting to “folk remedies”. However, we should not forget that uterine myoma is also a disease that provokes the development of oncology, and timely clinical diagnosis, even with such "suspicions" is necessary - once every six months is enough.
Atypical endometrial hyperplasia - diagnosis
Sources of information to confirm the diagnosis are patient survey data, the results of the examination and laboratory tests. During the medical history, the doctor determines the age of the menarche and the characteristics of the cycle. After that, the patient is prescribed transvaginal ultrasound (hereinafter ultrasound examination), the results of which assess endometrial quality indicators, such as uniformity, thickness, and its structure, and signs of tumors, polycystic ovary syndrome (further PCOS) are detected.
Diagnostics ultrasound uniquely recognize precisely the atypical form of endometrial hyperplasia can not. In reproductive age, the normal thickness of the endometrium can be up to 7 mm. During postmenopausal thickness of the endometrium is reduced to 5 mm, and with its duration and more than five years, the thickness of the layer should not exceed 4 mm. Any increase in mucosal thickness relative to the above norms is only a basis to suspect the presence of endometrial hyperplasia.
but most informative (over 90% of diagnosis confirmations) Atypical endometrial hyperplasia is a hysteroscopy in combination with diagnostic curettage as a diagnostic test for compliance with the diagnosis.
Further diagnosis is prescribed for signs of polycystic ovary syndrome and metabolic changes. Additionally, mammography is prescribed. In addition, in the event of recurrence of the disease, atypical endometrial hyperplasia, an extensive analysis of biopsy, histology, and hormonal studies of the number of male and female sex hormones are conducted. In any case, complaints of prolonged bleeding or purulent discharge are indications for the start of a surgical course of treatment.
Treatment of atypical endometrial hyperplasia
During surgical treatment, procedures are performed to stop metrorrhagia, make up for blood loss, and in emergency cases blood transfusions are performed. After scraping the endometrium, iron preparations are prescribed. Atypical hyperplasia of the endometrium in the treatment by the method of infusion therapy involves the use of drugs that improve blood parameters: aqueous solutions, gelatinol or reopoliglyukin.
The next stage of treatment is hormone therapy for half a year. To obtain an effective result during this period, it is recommended to take vitamins and drugs that suppress allergic reactions.
If the patient has contraindications for hormone therapy and the lack of a positive effect during conservative therapy, they resort to surgical intervention. As a result, the entire thickness of the uterine mucosa is completely removed. Today, this electrosurgical operation in our country is performed by safe bipolar resectoscopes. A prerequisite is the observation of the patient with a diagnosis of atypical endometrial hyperplasia in the dispensary for six months after the operation.
With the complete ineffectiveness of all types of treatment or the occurrence of recurrent atypical forms of endometrial hyperplasia, they resort to the most radical method of treating the disease - this is the complete removal of the uterus.
Means of traditional medicine are used after surgery, during rehabilitation. To increase the level of hemoglobin in the blood is recommended infusions of nettle. It has tonic properties. But traditional medicine does not affect the treatment of the disease itself. In the event of symptoms of the disease, you must contact the medical institution.
What is atypical hyperplasia
Endometrial hyperplasia with atypia is considered a consequence of mutation of the epithelial cells lining the uterus. Growth cells are different from the tissue from which they began to develop. The result of the rapid cell division was the thickening of the endometrial layer. A characteristic feature of the atypical form of pathology is the fact that mutated cells divide.
Manifestations of endometrial hyperplasia (its atypical type) do not have definite differences from the symptoms of the other forms of the known hyperplastic processes. They are presented:
- disruptions of the rhythm of menstruation,
- uterine bleeding (usually irregular),
- bloating secretions at the time of postmenopause,
- profusion of menstruation,
- release of blood during sex.
With the disease under consideration, abdominal pain does not occur.
Attention: in young girls, the pathological proliferation of the “lining of the uterus” is often accompanied by sterility.
The risk factors that can provoke an abnormal proliferation of the tissues of the reproductive organ, doctors include:
- age. Patients over 35 are more likely to suffer,
- oncology of the ovary, intestine, uterus, diagnosed in someone of family members,
- early periods, their late termination,
- lack of pregnancy.
Not only neurohumoral changes take part in the development of the pathology under consideration. To become a provocateur of the appearance of atypical endometrial hyperplasia can injure him for the following reasons:
Doctors associate the occurrence of the disease with several risk factors. They must be promptly detected at each examination by the gynecologist. There is atypical endometrial hyperplasia in the presence of a disruption in the balance of hormones (gestagens decrease, the level of estrogen increases). The causes of this phenomenon are:
- swelling of the ovaries responsible for the production of hormones
- atresia of follicles. This condition provokes the absence of ovulation,
- hyperactivity of the adrenal cortex (Itsenko-Cushing disease),
- disruptions caused by hormone therapy. "Tamoxifen" is particularly negative,
- increased activity of the pituitary gland due to the production of gonadotropic hormone.
Doctors often fix adenomatous hyperplasia on the background of certain hormonal disruptions:
- thyroid disease,
- liver damage, accompanied by delayed estrogen utilization (cirrhosis, hepatitis).
This method is considered the most informative. Examination is performed under local anesthesia. Only occasionally there is a need for general anesthesia. Having examined the uterus, the specialist establishes the center of growth, determines its size, localization. He can take an endometrial biopsy. The specified research method can be carried out before scraping. It is also possible after this procedure. He helps to diagnose abnormal changes in 63 - 97% of cases.
The doctor sees in the examination of the swelling, thickening of the endometrial layer, a characteristic color (pale pink), many points that are the outlets of the glands.
Carrying out diagnostics under a microscope guarantees an accurate diagnosis. The doctor receives a description of the structure of the epithelium, the structure of the nuclei, cells, sees their deviations.
Carry out the procedure can with hysteroscopy, by means of a pipe biopsy. The sensitivity of the biopsy to the definition of cell anomalies, oncology does not give 100% accuracy of the result.
This diagnostic method provides an assessment of the endometrium and is considered the fastest. If the doctor is suspected of a hyperplastic process, he estimates the thickness of the endometrial layer:
- The indicator for young women for a period of 2 half cycles is no more than 15 mm.
- Postmenopausal patients who are receiving hormone replacement medication should have a figure not higher than 8 mm.
- In postmenopausal women (without hormonal treatment), the thickness cannot exceed 5 mm.
Excess of these normal indicators indicates a high risk of abnormal cell development, endometrial cancer process (about 7%).
Hyperplasia on ultrasound is found in 60-93% of cases. The downside is that this research method is not able to distinguish between glandular, atypical pathologies.
First stop uterine bleeding, prevent oncology. Then restore the cycle, the fertility ability. Treatment is prescribed based on the patient's age, the severity of the abnormal process.
Can atypical endometrial hyperplasia recur in cancer
A feature of atypical endometrial hyperplasia from oncology (early stage) is the lack of penetration of growth through the facets of the plate, separating the surface and stroma. Mutant cells multiply in the zone of the upper layer of the endometrium. They do not penetrate to the blood nodes, lymph nodes.
Atypical hyperplasia in gynecology is considered as the beginning of a malignant process (called its endometrial precancer). There is a risk of developing into cancer in the absence of adequate therapy.
Forms of pathology
The degree of damage to the mucosa affects the rate of hormones. Absolute or relative growth of estrogen causes endometrial adenomatosis. In turn, hyperestrogenism develops as a result of age-related fluctuations in the background of hormones, with progesterone deficiency, polycystic ovary syndrome, adrenal dysfunction, after frequent scraping.
The disease is characterized by slow or fast growths, hyperplasia on the inner layer of the uterine mucosa. Pathology is divided into types according to the type of localization, progression of the process, the structure and the presence of atypical cells, as well as additional symptoms, such as the presence or absence of menstruation.
Simple adenomatous hyperplasia is characterized by the following clinical manifestations:
- the appearance of stromal and glandular cells, a decrease in the number of normal structures of the endometrium,
- uniform localization of vessels in the stroma,
- increase and swelling of the endometrial layer up to cystic enlargement,
- the acquisition of cells round shape, the violation of their order.
The risk of transformation of this form of pathology into a malignant neoplasm is 8–20%.
In addition, possible violation of the menstrual rhythm, the emergence of those or other non-standard discharge. In the early stages of endometrial damage, the symptoms are almost absent, the pathology does not manifest itself.
Complex atypical hyperplasia manifests itself in the growth of the endometrial layer, a change in its structure and the disorganization of cells. It is this type of pathology that is considered the most dangerous, since in almost 30% of cases it degenerates into cancer.
In the glandular tissues of the mucous in case of a complex type of pathology, structures appear that should not normally exist, for example, individual clusters (foci), and glandular tissue may cover the entire endometrium (diffuse type). Glands not only acquire an irregular shape, but also significantly differ from each other.
According to some reports, this pathology leads to the development of uterine cancer in almost 57% of cases. Always diagnosed with a diagnosis of "precancer (non-invasive)". Treatment is usually longer, no herbal remedies or folk remedies in this case are not used.
The focal form is characterized by finger-like growths of the glands, which visually resemble a polyp. Normally, a change in the structure of cells is not observed, they have a rounded shape.
Endometrial adenomatosis occurs exclusively from the functional layer, while the polyp affects only the basal layer. At the same time, polyps are not hormone-dependent pathologies, and hyperplasia always responds to fluctuations in hormonal levels.
Hyperplasia is divided into several types, each of which is the result of a mutation of cells. It is a focal type of pathology that is found in the overwhelming majority of cases - atypical cell damage almost always has a focus. The peak incidence is observed more often at the age of 40 years.
It must be remembered that this pathology is a precancerous condition of the body of the uterus. At the beginning of its development, atypical cells are similar in structure to healthy ones, but when examining the process of histology, one can see a transformation - nuclear polymorphism, an uncontrolled process of division.
Bleeding in this phase is rare. However, this condition of the endometrium is already considered non-invasive cancer and requires careful observation. Progressive genetic division and mutation of cells are difficult to treat.
Somatic diseases such as diabetes, obesity, hypertension, further increase the risk of developing full-fledged cancer.
Symptoms of a focal type of pathology are damage to the ovary, uterus, profusion of menstruation, infertility, anemia in the blood test, spotting intermenstrual discharge.
Atypical hyperplasia refers to the diffuse type when the damage process covers the entire surface of the tissue. Growths are localized in almost any part of the endometrium, the entire area is damaged.
Pathology is divided into several types - adenomatous, glandular-cystic type of hyperplasia.
When adenomatous atypical variant of the growth transformed into a tumor. Hyperplasia can border the myometrium, damage the muscular uterus, causing the precancerous state of cells that have already undergone transformation.
Perhaps not only the development of oncology, fibroids, increases the risk of other pathologies, most often endocrine, as well as liver diseases. Overgrowth affects the bottom of the uterus and its walls. May be uniform on all parts of the layer or erratic.
Atypical diffuse variant leads to uncontrolled, often progressive, cell and nucleus division. In the absence of treatment and elimination of comorbidities, invasive cancer develops in 1–13 years in 40–50% of cases.
Cytological studies allow with the highest accuracy to determine the presence of atypical cells, as well as carry out differential diagnostics, screening for cancer in women in risk groups and monitoring therapy to rule out relapses and metastasis.
For examination, mucosal cells from the uterus are usually taken on the 6–9th day of the cycle or no later than 5 days before the beginning of the month. If the material is withdrawn during or immediately before the onset of menstruation, an erroneous diagnosis is possible.
Tissues are extracted in various ways - swabs, scraping, aspiration. Most often, cells are removed with a syringe, the capacity of which is 20 ml.
When adenomatous hyperplasia during the cytological examination, together with areas of unchanged cells, epithelial layers are detected, in which there are signs of atypia. The nuclei of these cells are large, polymorphic, with a pale color, homogeneous chromatin. The contours of the cytoplasm are fuzzy, can merge with the general background, the color is light.
Cytology only suggests cancer. If cell malignancy is suspected, the material is sent for histology.
Also, cytological examination is carried out to differentiate hyperplasia with uterine myoma, polyps, fibroids. In addition to this method applies tomography, ultrasound.
The most adequate, especially at childbearing age and, if the woman desires, to preserve reproductive capacity, the treatment is the use of hormone-containing agents. Adenomatous hyperplasia responds well to treatment with various drugs containing estrogen and progesterone. Progestin treatment is aimed at preventing the pathology from degenerating into a classic cancer. Also, this therapy improves cellular structural differentiation, reduces the risk of atrophic changes in the endometrium.
Hormone therapy takes place in several stages:
- For the first six months, progestin is administered at least three times a week (medroxyprogesterone acetate or oxyprogesterone capronate is chosen). Drugs combined with tamoxifen. These tools allow you to eliminate atypical changes in the epithelium, reduce cell proliferation, prevent the transition of the endometrium to the atrophy phase. The clinical picture at this stage is persistent amenorrhea, cessation of bleeding. Scraping of the affected tissues is performed after 2 months of therapy. While maintaining atypical hyperplasia in the material, the possibility of surgical treatment is discussed.
- Further, if a woman is interested in the future conception, ovulation is stimulated, clomiphene citrate is most often used. This drug reduces the risk of recurrence and allows you to cancel progestins. At this stage, in the presence of polycystic ovarian resection is performed to restore the ovulatory cycle. Its duration is from 10 to 12 months.
On average, hormonal treatment takes up to one year, but if there is no effect or at least regression of the disease after 3–6 months, surgical methods come to the fore. The main is the extirpation of the uterus (together with the appendages or with their preservation in women under the age of 35 years).
Therapy with folk remedies for EH is used only as an aid in the symptomatic treatment. Not only herbs are used, such as nettle, celandine, boron uterus, burdock and plantain, but also hirudotherapy and homeopathic chemist's.
Drugs based on folk recipes do not affect the structure of the endometrial glands, but they can reduce bleeding, stabilize the cycle, improve reproductive function and balance the hormonal levels.
Causes of atypical endometrial hyperplasia
The causes of atypical endometrial hyperplasia are closely related to disorders of the hypothalamus, the part of the cerebral cortex responsible for the functioning of the endocrine system. This causes adverse changes in the hormonal background during menstruation. On the other hand, malfunctions in the functioning of the pituitary gland, which is the main endocrine gland, affect the normal activity of the ovaries.
As a result of such violations in the optimal balance of endocrine-metabolic processes changes occur with a tendency to increase the amount of estrogen required in the first half of the monthly cycle, and in the second half, in which the hormones are provided with progesterone, this female sex hormone is not sufficiently produced.
The causes of atypical endometrial hyperplasia are also due to the fact that the hypertrophied endometrium leads to the absence of a secretion phase, during which the uterine mucosa is prepared for embryo acceptance. At the same time, when the secretion phase does not occur, and the growth of the mucous membrane continues, after a decrease in the level of estrogen, its gradual rejection occurs. This is accompanied by prolonged and heavy menstrual bleeding, which can also occur in the intermenstrual period.
As the pathological changes progress, the properties of the uterine mucosa become different, which now significantly contribute to the appearance of atypical cells, which may be a sign of the development of a malignant disease.
Atypical glandular hyperplasia of the endometrium
Atypical glandular hyperplasia of the endometrium is a process of proliferation of the glands, characterized by high intensity and significant pathological transformation at the structural level.
In addition to activating the processes of their growth and reproduction, endometrial cells are subject to changes in the structure of nuclei, which, with a certain combination of factors, can be a sign of incipient malignant processes.
The foci of appearance may become either functional or basal layer of the mucous membrane of the uterus, or both of them may be involved in the development of pathology. In the event that both of these layers are affected at the same time, the likelihood of a new formation of cancer properties and qualities is especially high.
Atypical glandular hyperplasia of the endometrium can occur not only due to the hyperplastic endometrial layer, but also in the case of its thinning and with atrophic changes.
There are two types of this disease - cellular and structural hyperplasia of the endometrium.
In the first case, pathological processes take place in epithelial cells and in the stroma, while the second type causes changes in the location and shape of the glands.
Complicated atypical endometrial hyperplasia
Complicated atypical endometrial hyperplasia is characterized by a large consolidation of the location of endometrial glands or their individual foci.
This lesion of the endometrium of the uterus has a significant degree of severity of proliferation of the glands. In the glands affected by this process, pathological changes in structure and shape are noted. There is a violation of the optimal ratio in the growth of glands and stroma. There is also a pronounced phenomenon of epithelial multi-core. Atypicality in the change of nuclei with this disease is not observed.
Complicated atypical endometrial hyperplasia is one of the most dangerous forms of endometroiodic lesions in women. With a high degree of risk, it can be transformed into a cancer of the uterus. The likelihood of such a transformation into a malignant neoplasm is 22-57% of cases.
Distinctive features are the presence of pronounced epithelial proliferation with the appearance of atypia in cells and tissues.
With the development of this pathology in the mucous membrane of the uterus, the glands acquire irregular shapes and can be significantly different in size from each other, and the polymorphic nuclei are elongated or round.
Focal atypical endometrial hyperplasia
Focal atypical endometrial hyperplasia may develop in one of the following scenarios.
In many cases, the cause of focal proliferation lies in fragments for some reason not rejected tissue of the mucous membrane of the uterus. Often this is caused by all sorts of endocrine disorders and hormonal imbalances.
Under normal conditions, the endometrial layer of the uterus thickens during the menstrual cycle and, if fertilization does not occur, it goes out piecemeal with menstrual blood. Not separated residues of the endometrial layer are causes of intermenstrual uterine bleeding, and may also subsequently cause focal growth of the endometrium and provoke the formation of a polyp in the inner cavity of the uterus.
Another mechanism for the appearance of foci of endometriotic lesions is triggered by the insufficient amount of estrogen produced in the body. Because of this, there is no maturation of the egg, which leads to prolonged irregular production of this female hormone. In the end, an immature egg cannot leave the ovary, and menstrual bleeding continues for a long time. In this case, rejection of the uterine mucosa occurs gradually, and some of its particles may linger inside.
Such fragments remaining in the uterine cavity become the reasons for the appearance of focal atypical endometrial hyperplasia.
The emergence of foci of endometrial neoplasms can be triggered by the consequences of inflammatory diseases of the uterus, traumatic factors, difficult labor, abortions, endocrine disruption, stress, overweight problems, etc.
Simple atypical endometrial hyperplasia
Simple atypical endometrial hyperplasia has a number of specific characteristic features.
Among them is the presence of a slight predominance of ferrous and stromal structures over the normal ones.
There is an increase in the endometrium in the volume, as well as a change in its structure, which manifests itself in the following. Stroma and glands are active, the location of the glands is uneven, some of them are subject to cystic expansion.
As for the stroma, then it is necessary to note the uniform location of the vessels in it.
Simple atypical endometrial hyperplasia also has its manifestations of a violation of the normal order of the cells, which are distinguished by their unusual, in many cases round, shape. This disease is also characterized by significant polymorphism of cell nuclei, without a tendency to atypia.
In addition, the features are the presence of cell dispolarity, anacitosis, hyperchromatism and an increase in nucleus size. Of the number of cellular changes, there are also phenomena of vacuole expansion and cytoplasmic eosinophilia.
The degree of risk of transformation into a malignant neoplasm is determined with a probability from 8 to 20 cases out of 100.
Causes of disease
The proliferation of uterine mucous membrane cells (hyperplasia) occurs when the ratio of estrogen and progesterone, which are produced in the ovaries, is disturbed. During the period of maturation of the egg under the action of estrogen, the cells of the mucous membrane grow, the development of the vascular system. Именно сюда попадает оплодотворенная яйцеклетка, здесь закрепляется и растет, превращаясь в плод.
Прогестерон необходим для того чтобы приостановить дальнейшее разбухание эндометрия. Its role is to provide the conditions for successful consolidation and development of a fertilized egg. Progesterone is produced by the corpus luteum, which forms in its place in the ovary. If it is not enough, then due to the predominance of estrogen, there is a further growth of the membranes (hyperplasia), which is a pathology.
Hormonal disorders are one of the main causes of endometrial hyperplasia. The treatment takes into account that violations can be caused by internal and external causes. Internal causes are:
- the premenopausal period in a woman, when progesterone levels decrease due to the extinction of the activity of the corpus luteum,
- puberty, during which the level of estrogen rises sharply,
- inflammatory and neoplastic diseases of the ovaries associated with enhanced estrogen production,
- endocrine disorders, obesity, metabolic disorders, diabetes and other diseases associated with the production of hormones in the body,
- inflammatory diseases of various parts of the uterus, genitals.
External causes of hormonal imbalance include the treatment of various diseases with the use of hormonal drugs, the use of contraceptive oral hormonal agents, protection from pregnancy by installing an IUD. At risk are women 45-50 years old, suffering from hypertension, diabetes, obesity.
Symptoms and effects of hyperplasia
The usual symptoms of endometrial hyperplasia are irregular periods: abundant after a long delay or scanty, occurring in the middle of the menstrual cycle. Abundant menstruation can last more than 10 days, accompanied by pain in the lower abdomen, general weakness, fainting.
The result of the disease is infertility. In some cases, it is possible the degeneration of endometrial cells, the occurrence of a malignant tumor of the uterus.
Therefore, for any violations of the menstrual cycle, changes in the nature of bleeding, the appearance of cramping abdominal pain, you should consult a doctor. Endometrial hyperplasia also appears in postmenopausal women, when menstruation is normally absent. Bleeding during this period is a pathology.
Types of hyperplasia
Distinguish simple (typical) form of the disease and difficult (atypical). Simple hyperplasia is characterized only by an abnormal increase in the number of cells, and the atypical form is associated with changes occurring in the nuclei of cells. Rebirth of nuclei in this case can lead to the development of a cancer. Therefore, atypical rebirth is more dangerous.
Depending on the changes in the tissues, the following types of hyperplasia exist:
- glandular (curvature of the glands due to cell proliferation),
- glandular cystic (voids develop in overgrown cells),
- adenomatosis (atypical form, in which there are changes in the structure of the tissue of the type "iron in iron").
In some cases, the growths have the form of polyps (thickenings with a leg). This condition usually occurs when focal hyperplasia that develops in certain areas. If the endometrium is completely affected, then such hyperplasia is called diffuse.
In the treatment of endometrial hyperplasia, the type of disease is of great importance.
It is used mainly in the treatment of typical forms of hyperplasia. Complicated atypical form is usually treated surgically (the uterus is removed), since the probability of degeneration into a malignant tumor is high.
Hormonal remedies are used in drug treatment to eliminate abnormal bleeding and to prevent the transformation of hyperplasia into cancer. Hormonal drugs are selected individually after blood tests. Hormonal background is normalized, which prevents further growth of the endometrium.
Oral contraceptives combined action. Appointed, as a rule, to girls and women who have not given birth. Means are used within six months. Scraping is done only in emergency cases, if there is a dangerous bleeding.
Analogs of progesterone. By increasing the level of progesterone in the body, endometrial tissues stop growing. Such treatment of endometrial hyperplasia is carried out within 3-6 months. They can be prescribed for any form of the disease, regardless of the age of the patient. The drug is taken according to a specific scheme. When treating a woman, there may be a discharge of blood between menstruation.
Drugs that weaken the effect of estrogen. It is also taken for a long time to suppress the growth of endometrial cells and eliminate pathological bleeding.
Intrauterine device. It has a gestagennoe effect (similar to progesterone). The spiral is a means of protection from pregnancy, effective for 5 years, prevents the proliferation of the uterine mucosa.
Drugs that block the production of sex hormones. At the same time, the endometrium is atrophied, the growth of its cells and tissues stops. The advantages of such drugs are the absence of the need for daily medication (such drugs are taken 1 time per month), as well as the ability to treat infertility.
Note: There is a chance that after the end of drug treatment, the disease may return. Therefore, in the period of menopause, the most effective is the operational method of treatment.
With extensive lesions of the endometrium, especially in the case of atypical hyperplasia, complete or partial surgical removal of the affected endometrium is performed.
Scraping the uterus. In this case, both complete and partial removal of the endometrium or its individual layers is possible. This method eliminates severe uterine bleeding. The removed tissues are necessarily examined by the histological method in order to establish what danger this lesion represents, whether it is atypical, and whether there is no malignant cell degeneration.
Ablation of the endometrium. The method of complete removal of the endometrium. This applies intravenous anesthesia. This method has advantages over scraping, as there is no injury to the walls of the uterus. The operation is faster, its effectiveness is higher. The entire layer of the endometrium is destroyed, and then it is completely removed. The following methods are used:
- laser ablation - removal of damaged layers of the uterus with a laser pulse,
- radiofrequency ablation - the destruction of tissue under the influence of high temperature using radiofrequency radiation,
- balloon thermoablation - the endometrium is destroyed by cauterization, for which a balloon with glycerin heated to 75 ° C is introduced into the uterus,
- diathermocoagulation - endometrial destruction by alternating high-frequency electric current,
- cryodestruction - freezing of damaged endometrium with liquid nitrogen,
- microwave effect on endometrial tissue, leading to their destruction.
After the operation performed by all these methods, there is no scar left on the wall of the uterus, epithelial tissue is quickly restored. Within a few weeks after such exposure, a woman appears with copious mucous discharge between the periods, which subsequently disappear. Ablation can save a woman's womb.
Hysterectomy - uterus removal. It is performed in the presence of complex atypical endometrial hyperplasia. Treatment in this way involves 2 options:
- Only the uterus is removed, the ovaries are preserved. It is used for women at the age of premenopause, if the ovaries are not affected by a tumor.
- Complicated surgery involves the complete removal of the uterus and ovaries. It is performed when women have hyperplasia in the postmenopausal period when oncology or adenomatosis is detected.
Surgical treatment of hyperplasia is combined with hormonal therapy. Sometimes drugs are prescribed before the operation. This reduces the area of damage to the endometrium. In some cases, this way it is possible to influence hard-to-reach areas. After the operation, restorative and prophylactic treatment with hormonal preparations is carried out.