Irregular vaginal bleeding due to endometrial hyperplasia

Irregular vaginal bleeding or intermenstrual spotting is a very common problem. It is very often the result of a hormonal imbalance where there is excessive amounts of oestrogen, and will need to be investigated. In postmenopausal women there is the possibility that this is due to a cancer of the lining of the womb and should be investigated urgently. My latest patient was a peri-menopausal lady with heavy irregular bleeding for several months. An ultrasound scan showed that the lining of the womb was thickened to more than 15 mm. In addition there was an ovarian cyst measuring 4 cms in diameter. In view of the unusual thickening of the lining, I advised a minor procedure. Using a hysteroscope (fine telescope), I examined the lining and took a sample for examination. The histology turned out to be simple endometrial hyperplasia.
Endometrial hyperplasia can be simple, complex, with or without atypia. The risk of cancer developing is highest in complex endometrial hyperplasia with atypia and lowest in simple endometrial hyperplasia without atypia.
My patient had the best prognosis. However I advised her to have treatment in the form of low dose progesterone and regular follow-up. The risk of progression to a cancer is less than 5% for her. The risk of progression in simple or complex with atypia is around 30%.
The take home message is that all abnormal bleeding needs to be investigated without delay particularly when it is around the time of menopause.