‘Endometrial hyperplasia’ refers to overgrown tissue in the uterus and the term is made up of the Greek endon meaning within; metra — uterus; hyper — more than normal; and the Latin plasia meaning a tendency to build up tissue.
Endometrial hyperplasia occurs for much the same reasons as dysfunctional uterine bleeding — there is prolonged or excessive stimulation of the endometrial cells by oestrogen — but in this case, the hormonal imbalance causes the cells to change and become overgrown (hyper-plastic). It can cause erratic bleeding in pre- or post-menopausal women. Other causes may include oestrogen therapy prescribed without progestogens, abnormal oestrogen metabolism or obesity.
The hyperplastic cells can progress through a range of changes from mildly overgrown and easily treated through to endometrial cancer. A provisional diagnosis is made with ultrasound, but a definitive diagnosis requires a biopsy during a hysteroscopy under general or local anaesthetic. The endometrial cells are examined and graded according to the degree of change from normal to abnormal, usually with a three-stage grading of mild, moderate and serious (often called simple, complex and atypical). Cystic hyperplasia is another term used for the least advanced (simple) form of endometrial hyperplasia.
Once the change in the endometrium has been graded, a treatment is decided upon which will take into account the severity of the endometrial change, the age of the woman and whether she expects to become pregnant or not.
It is important to identify the underlying causes of endometrial hyperplasia. These include ovulatory failure secondary to conditions like polycystic ovarian syndrome, thyroid disease, and ovarian and adrenal tumours. Relative oestrogen excess can occur as a result of obesity and diabetes. Other risk factors for developing endometrial hyperplasia include an early menarche, late menopause and never being pregnant.
The medical approach
The aim of treatment is to remove the abnormal tissue and then establish cyclic shedding of the endometrium — initially with drugs. The affected endometrium is removed with a D&C when the hysteroscopy is performed. This will not ‘cure’ the condition unless the hormonal causes of the endometrial hyperplasia are also dealt with.
To rectify the abnormal hormonal pattern, gynaecologists usually recommend synthetic hormones to simulate a hormonal pattern similar to the normal menstrual cycle. Usually, a progestogen is given by tablet for between ten and twenty days so that the endometrium develops the cells and structures similar to those of the luteal phase, then the drug is stopped to allow ‘menstruation’ to occur. Ovulation often starts spontaneously after a few cycles on progestogens. The reasons for this are not known.
Progestogens are not suitable for women who are actively trying to become pregnant at the time of treatment. When pregnancy is desired, ovulation is often stimulated by short courses of drugs like Clomid. Women taking this drug must be monitored closely because of the risk of hyperstimulation of the ovary and ovarian cysts.
Endometrial hyperplasia does not always become endometrial cancer, but the risk increases if the degree of cellular change is advanced. Between 1-4 per cent of women with the mildest form — simple or cystic hyperplasia — can develop endometrial cancer; but more than 20 per cent of women progress to cancer if they have the most advanced form.
About 10 per cent of all cases of post-menopausal bleeding are caused by endometrial hyperplasia (up to 20 per cent are caused by cancer). This figure increases when women are obese or are given oestrogen without progesterone. When oestrogen is given alone, cell changes occur because the endometrium is continually stimulated by oestrogen without the counterbalancing effect of progesterone.
The natural therapist’s approach
Endometrial hyperplasia is always diagnosed by a medical practitioner. Usually, the same doctor will administer medical treatment, but occasionally a woman will seek the advice of a natural therapist either because she is inclined towards natural treatments whenever possible, or because she fears the side-effects of the drugs her doctor has suggested. Endometrial hyperplasia presents specific difficulties in treatment because a pre-cancerous condition has already developed along with the failure to ovulate and shed the endometrium regularly. This condition should always be managed by herbalists and natural therapists with experience in the treatment of the complaint.
A natural therapist’s treatment will be similar to that for dysfunctional uterine bleeding, but with one major difference: regular cyclic menstruation must be reestablished, and with some speed. Even in the mildest forms (cystic hyperplasia), ovulation should be established within the first two cycles; sooner is always better than later.
This can be difficult. Most natural remedies are not capable of stimulating ovulation irrespective of the underlying cause. Some medicinal herbs can regulate the cycle by re-establishing ovulation, but will often fail unless the original cause for ovulatory failure has also been treated. For example, if a woman has developed endometrial hyperplasia because of an underactive thyroid, the treatment will need to be directed towards thyroid gland regulation. Often, ovulation will be delayed for too long (and hence menstruation), and the woman will be at risk in the interim.
A decision to treat with natural remedies should only be made after careful evaluation of all of the risks and benefits for that particular woman. Being over 40, being obese, or having the more severe type of endometrial hyperplasia should all be considered reasons for not using natural therapies. In many cases, the most practical suggestion is for the woman to follow her doctor’s advice.
When a decision has been made to treat endometrial hyperplasia, the regime is similar to that outlined for dysfunctional uterine bleeding with additional emphasis on:
• re-establishing ovulation and therefore menstruation
• protecting the endometrium with phyto-oestrogens which counter the effects of unopposed oestrogens, and anti-oxidants which minimise the risk of the hyperplastic changes becoming cancerous.
Sometimes, when regulating ovulatory patterns is not possible, or not possible quickly, herbs can be used which will cause menstruation to occur. These are chosen from the group of herbs called the emmenagogues.
All emmenagogues are abortifacients, and so due care is needed with their use. They are quite powerful and can cause some unpleasant effects in the wrong hands. They must be prescribed within a definite dose range, and it is necessary to make sure that pregnancy has not occurred prior to their administration. This group of herbs should only be prescribed by an experienced practitioner.
As is the experience of many traditional herbalists, Dr Weiss, a German herbalist and doctor, remarks on the use of the emmenagogues for restoring menstruation:
… medicinal plants get very good results in secondary amenorrhoea and in oligomenorrhoea (no periods or infrequent periods). Hormone therapy is much to the fore in this field, but there are considerable problems; hormone therapy calls for sophisticated techniques and in many cases fails to get results. Medicinal herbs therefore continue to have their place … Emmenagogues were very popular before hormone therapy. There remains the fact, based on experience, that emmenagogues will often restore normal menstrual flow and give very considerable subjective relief.
The popular and reliable emmenagogues are Ruta graveolens, Mentba pulegium and Artemesia vulgaris. They will usually need to be prescribed for several months until regular menstruation is established. Hormone-regulating herbs can be used at the same time.
Protecting the endometrium
The plant oestrogens occur naturally in foods and herbs, and when consumed as part of a normal diet have the potential to protect the tissues from over-stimulation by oestrogens. Medicinal herbs containing steroidal saponins can also be used. Trained herbalists follow traditional guidelines to treat this type of abnormal bleeding. They use specific herbs for the optimum period of time, and prescribe only those medicinal plants which have historically been used for menstrual disorders of this type. The most important of these is Alchemilla vulgaris.
Other herbs used include the anti-menorrhagic herbs Achillea millefolium and Capsella bursa-pastoris (which contains the same cancer-preventative agents as the cabbage family vegetables).
Numerous studies have been undertaken worldwide to evaluate the effectiveness of the anti-oxidants as protective agents against cancer, or as therapeutic substances in the treatment of cancer. Although there is no definitive evidence, a number of these studies have demonstrated a protective role for some of the anti-oxidants. Their effects on the endometrium may prevent endometrial hyperplasia from becoming a cancerous condition. Those shown to have a protective effect are the vitamins A, E, K and C, beta-carotene and the mineral selenium.
Selenium and vitamin E seem to work best when adequate levels of both are present in the body. When comparing the blood levels of these two nutrients, one study showed that women with endometrial tumours had 40 per cent less selenium and 23 per cent less vitamin E than their female relatives who lived in the same household. Selenium-containing foods are garlic, whole grains, meat, eggs, brewer’s yeast and fish.
Improving the regularity of ovulation may be necessary and the type of intervention will depend on the reason why ovulation has stopped. Stress and diet are often important factors. Excessive exercise; BMI below the recommended levels; many drugs (both prescribed or social); alcohol consumption, cocaine and other recreational drugs; and excessive amounts of coffee can all affect ovulation. These factors are discussed in ‘The usual suspects’.
Protective foods can be included in the diet as a means of reducing the risk of developing cancer. Healthy colonies of gut bacteria are needed to convert dietary phyto-oestrogens into the active forms needed for the competitive inhibition of oestrogen-binding sites. Yoghurt encourages healthy levels of gut bacteria and may improve conversion of inert lignans into the active forms.