If you or someone you care about has PCOS and is facing concerns about endometrial hyperplasia, it’s natural to have questions. Why does this happen? How serious is it? And most importantly, what can be done about it? For many, receiving a diagnosis of hyperplasia, or even suspecting it can feel overwhelming, especially when paired with the challenges of managing PCOS. For more about PCOS, you might wish to look at our article PCO vs PCOS.
PCOS, or polycystic ovary syndrome, is already known for causing hormonal imbalances, but one of its lesser-discussed consequences is the increased risk of endometrial hyperplasia. This condition occurs when the uterine lining, or endometrium, becomes unusually thick due to prolonged exposure to unopposed oestrogen. If left untreated, hyperplasia can lead to more serious concerns, including endometrial cancer, so having an early understanding and intervention is crucial. If you are concerned that your hyperplasia may be progressing, please refer to our page on Precancer Diagnostics.
In this article, we’ll explore the connection between PCOS and endometrial hyperplasia, the risks involved, and the treatment options available to manage and reduce those risks. Whether you’re seeking to understand your diagnosis or looking for reassurance about what comes next, we’re here to guide you through it.
How does PCOS increase the risk of endometrial hyperplasia?
Polycystic ovary syndrome (PCOS) is a hormonal condition that disrupts the balance of key reproductive hormones, and this imbalance can significantly increase the risk of developing endometrial hyperplasia. At the heart of this connection lies the relationship between oestrogen and progesterone, two hormones that regulate the growth and shedding of the uterine lining.
The hormonal imbalance in PCOS
In individuals with PCOS, the ovaries often produce insufficient progesterone due to irregular ovulation or anovulation (the absence of ovulation). Progesterone is crucial for balancing the effects of oestrogen, which stimulates the growth of the endometrial lining.
Can PCOS cause a thickened endometrium?
Yes, PCOS can directly contribute to a thickened endometrium. Without regular ovulation to trigger progesterone production, oestrogen levels remain unchecked, leading to the continuous thickening of the uterine lining (endometrium). This prolonged exposure to unopposed oestrogen creates an environment where the endometrial lining grows excessively, increasing the risk of hyperplasia. If untreated, this can potentially progress to more serious complications, including atypical hyperplasia (where abnormal or precancerous cells are present in the uterine lining) or, in rare cases, endometrial cancer.
What does it mean when the lining of the uterus is thick?
If detected on an ultrasound, a thickened uterine lining typically suggests the endometrium has not been adequately shed due to hormonal imbalance. In the context of PCOS, this is often the result of unopposed oestrogen causing the lining to build up month after month. Persistent thickening may require treatment to prevent hyperplasia from advancing to more severe forms, such as atypical hyperplasia.
Symptoms of endometrial hyperplasia in PCOS
Polycystic ovary syndrome (PCOS) and endometrial hyperplasia share some overlapping symptoms, which can make it challenging to differentiate between the two. However, recognising the distinct signs of hyperplasia alongside PCOS can help guide diagnosis and treatment.
Distinguishing between PCOS and PCOS with hyperplasia symptoms
Standard symptoms of PCOS
These symptoms are primarily caused by hormonal imbalances and irregular ovulation:
Irregular menstrual cycles
Periods may be infrequent, absent, or irregular.
Excess androgen levels
Symptoms include acne, excessive body or facial hair (hirsutism), and thinning hair or hair loss on the scalp.
Ovarian cysts
Multiple small cysts on the ovaries, detected through ultrasound, are a hallmark of PCOS.
Weight gain or difficulty losing weight
Many individuals with PCOS struggle with insulin resistance, leading to weight challenges.
Difficulty conceiving
Infertility or reduced fertility due to irregular ovulation.
Fatigue and mood changes
Hormonal fluctuations can lead to fatigue, depression, or anxiety.
Symptoms that indicate PCOS with endometrial hyperplasia
Hyperplasia occurs when the uterine lining becomes abnormally thick due to prolonged exposure to unopposed oestrogen, a common issue in PCOS. Signs to watch for include:
Abnormal uterine bleeding
Heavy, prolonged, or irregular bleeding between periods.
Spotting in the absence of a regular menstrual cycle.
Pelvic pain or discomfort
A thickened endometrium can cause pressure or mild cramping in the lower abdomen.
Prolonged absence of periods (Amenorrhoea)
Without a period, the uterine lining may continue to build up, increasing the risk of hyperplasia.
Postmenopausal bleeding (if applicable)
In women with PCOS background who are postmenopausal, any bleeding is a potential sign of hyperplasia or other uterine conditions.
Thickened uterine lining on ultrasound
An ultrasound may reveal a lining exceeding normal thickness (i.e. >10mm).
Unresolved symptoms despite PCOS management
Persistent irregular bleeding or pain, even with PCOS treatment, could indicate underlying hyperplasia.
Key differences
To summarise these key differences in symptoms, the table below provides an at a glance summary of how symptoms differ in PCOS vs cases where PCOS and hyperplasia occur together.
Symptom | PCOS | PCOS with Hyperplasia |
Menstrual irregularity | Common, light to moderate flow | Irregular but often heavier or prolonged |
Pelvic pain | Occasionally due to ovarian cysts | Often due to thickened uterine lining |
Bleeding patterns | Infrequent or absent periods | Abnormal bleeding or spotting between periods |
Fertility concerns | Due to anovulation | May be compounded by uterine abnormalities |
Endometrial thickness | Usually normal | Typically thickened |
Additional insights into symptoms
In addition to the core symptoms of endometrial hyperplasia already covered, here are some nuanced details that may help you better understand and identify this condition if you have PCOS:
Changes in period flow pattern
While abnormal bleeding is a hallmark symptom, pay attention to subtle shifts in the pattern, such as periods becoming heavier over time or the duration of bleeding increasing with each cycle. This gradual change can be an early indicator of hyperplasia.
Prolonged spotting post-menstrual cycle
Spotting that persists for several days after your regular period may also indicate an overgrowth of the uterine lining.
Anaemia-like symptoms
For individuals with prolonged heavy bleeding, symptoms such as fatigue, dizziness, or shortness of breath might develop due to iron deficiency anaemia.
Pelvic discomfort related to pressure
Beyond mild pain, some individuals report a sensation of fullness or pressure in the lower abdomen, which can be linked to a thickened endometrial lining.
Impact of delayed treatment
The longer hyperplasia goes untreated, the more likely it is to cause progressively severe bleeding episodes or chronic pelvic pain, making early evaluation critical.
If you or a loved one are experiencing any of these symptoms or suspect an issue with the uterine lining, it’s essential to seek medical advice promptly to explore potential causes and treatment options. Early diagnosis of comorbid hyperplasia can prevent further complications and ensure appropriate treatment.
What are the risks of endometrial hyperplasia in PCOS?
Endometrial hyperplasia is a significant concern for individuals with PCOS due to the hormonal imbalance that contributes to prolonged thickening of the uterine lining. If left untreated, hyperplasia can progress to more severe conditions, such as atypical hyperplasia or even endometrial cancer in some cases.
Progression to atypia or cancer
Atypical hyperplasia is a more advanced form of endometrial hyperplasia, where abnormal or precancerous cells are present in the uterine lining. This condition carries a higher risk of progressing to endometrial cancer if left untreated and typically requires more intensive treatment, such as hormonal therapy or surgical intervention, to prevent complications.
Hyperplasia without atypia, the most common form, typically has a low risk of progression to cancer, particularly when treated early [1]. However, if the condition evolves into atypical hyperplasia, where abnormal (precancerous) cells are present, the risk increases significantly. Research suggests that about 8–29% of cases of atypical hyperplasia may progress to endometrial cancer over time if untreated [1].
This makes monitoring and timely intervention critical, especially for individuals with PCOS, who are already at heightened risk due to chronic anovulation and prolonged exposure to unopposed oestrogen.
How long before endometrial hyperplasia turns into cancer?
The timeline for progression from hyperplasia to cancer varies widely and depends on several factors, including the presence of atypia and whether treatment is initiated. Hyperplasia without atypia typically progresses slowly, with studies estimating that the risk of progression is less than 5% over 20 years for untreated cases [2]. However, for atypical hyperplasia, the risk of progression has been demonstrated to be within 1-5 years following diagnosis [3].
These timelines underscore the importance of early diagnosis, regular monitoring, and effective treatment, particularly for individuals with PCOS, whose hormonal imbalance puts them at ongoing risk.
Reducing the risks
The good news is that with appropriate treatment, such as progesterone therapy, lifestyle changes, and regular follow-ups, the risk of progression can be dramatically reduced. Addressing PCOS through weight management, dietary adjustments, and medical therapies can also help regulate hormonal levels, lowering the likelihood of hyperplasia development or recurrence.
If you or a loved one has PCOS and is concerned about hyperplasia, seeking timely medical advice is key to preventing complications and safeguarding long-term health.
Can hyperplasia go away on its own with PCOS?
Endometrial hyperplasia, especially in individuals with PCOS, rarely resolves entirely on its own without some form of intervention. However, in mild cases, particularly hyperplasia without atypia, certain lifestyle changes and weight management strategies can play a significant role in improving the condition and supporting overall uterine health.
Why hyperplasia doesn’t usually resolve without help
In PCOS, the underlying hormonal imbalance, manifested as too much oestrogen and not enough progesterone, drives the thickening of the uterine lining. Without addressing this imbalance, the endometrium continues to grow unchecked, making it unlikely to improve on its own. This is why medical treatments, such as progesterone therapy, are often essential to actively reverse hyperplasia.
The role of lifestyle changes
For mild cases, lifestyle adjustments can sometimes help slow the progression of hyperplasia and may complement medical treatments. These include:
Weight management
Excess weight can increase oestrogen levels, exacerbating hyperplasia. Weight loss can positively impact hormone levels and potentially reduce related health risks.
Healthy diet
A diet rich in whole foods, fibre, and healthy fats can help regulate insulin levels, which in turn supports hormonal balance. Reducing sugar and processed foods is particularly beneficial for individuals with PCOS.
Regular exercise
Physical activity helps lower insulin resistance, a common issue in PCOS, and can support weight loss and overall hormonal regulation.
Stress reduction
Chronic stress can worsen hormonal imbalances. Practices like mindfulness, yoga, or other stress-relieving activities may indirectly help in managing hyperplasia.
When medical treatment is necessary
Although hyperplasia rarely resolves completely on its own, adopting a healthier lifestyle can be a powerful tool in managing mild cases and preventing recurrence. When combined with medical treatment, these changes can support better outcomes and improve overall health for individuals with PCOS. Always consult with a healthcare provider to determine the best course of action for your unique situation.
While lifestyle changes can have a positive impact, they’re usually not enough to fully resolve hyperplasia caused by PCOS. Most cases require hormonal therapy, such as progesterone, to counteract the effects of unopposed oestrogen and thin the uterine lining. If lifestyle changes are used alone, it’s crucial to monitor the condition closely with regular ultrasounds and doctor consultations to ensure it isn’t progressing.
How is endometrial hyperplasia treated in PCOS?
The treatment for endometrial hyperplasia in individuals with PCOS follows many of the same principles as in those without PCOS. However, there are key differences tailored to address the underlying hormonal imbalance caused by PCOS. This dual approach not only targets the hyperplasia but also addresses the root cause to reduce the risk of recurrence.
Treatment options for endometrial hyperplasia in PCOS
Progesterone therapy
Progesterone therapy is the cornerstone of treatment for endometrial hyperplasia in both PCOS and non-PCOS individuals. However, in PCOS, the hormonal imbalance caused by anovulation (the lack of ovulation) makes progesterone even more critical. By counteracting the effects of unopposed oestrogen, progesterone helps thin the uterine lining and restore balance.
Common forms of progesterone therapy include:
Oral Progesterone Pills: Taken daily or cyclically.
Hormonal intrauterine device (IUD): Delivers progesterone directly to the uterine lining with fewer systemic side effects, often preferred for individuals with PCOS.
Injections or implants: Occasionally used in cases requiring more sustained delivery.
Key difference for PCOS:
For individuals with PCOS, long-term progesterone therapy is often needed due to chronic anovulation, whereas non-PCOS patients may only require short-term treatment.
Lifestyle changes to manage hormonal imbalance
Lifestyle modifications are particularly effective for PCOS-related hyperplasia, as they address the hormonal drivers of the condition.
Weight loss: Even a small reduction in weight can lower oestrogen levels and improve progesterone effectiveness, particularly in individuals with PCOS who may experience higher oestrogen production from adipose tissue.
Dietary adjustments: A diet low in refined carbs and sugars can help manage insulin resistance, a common issue in PCOS, which indirectly improves hormonal balance.
Exercise: Regular physical activity helps lower insulin resistance and can also reduce excess weight, further balancing hormone levels.
Key difference for PCOS:
Lifestyle changes are often more emphasised in PCOS treatment compared to those without PCOS, as metabolic factors like insulin resistance play a larger role in driving hormonal imbalances.
Ovulation induction
For individuals with PCOS who are trying to conceive, treatments that promote ovulation, such as clomiphene or letrozole, may be recommended. Ovulation induction can help restore the natural hormonal cycle, reducing the risk of hyperplasia over time.
Key difference for PCOS:
Ovulation induction is rarely a consideration in non-PCOS patients but is a valuable option for managing hyperplasia and improving fertility in PCOS.
Surgical options (in rare cases)
In severe or persistent cases, such as hyperplasia with atypia, surgical intervention may be required. Options include dilation and curettage (D&C) to remove the excess uterine lining or, in extreme cases, a hysterectomy if childbearing is not a consideration.
How does treatment differ for those with PCOS?
The main difference in treating hyperplasia in individuals with PCOS lies in addressing the broader hormonal and metabolic issues unique to PCOS. While progesterone therapy is central for all patients, the additional emphasis on managing insulin resistance, promoting ovulation, and implementing lifestyle changes sets PCOS treatment apart. This tailored approach not only resolves hyperplasia but also helps mitigate the long-term risks associated with PCOS, such as infertility, diabetes, and cardiovascular issues.
By combining targeted medical treatment with lifestyle adjustments, individuals with PCOS can achieve better outcomes and reduce the likelihood of recurrence. Regular follow-ups and personalised care remain essential to ensure successful management.
What is the most common treatment for hyperplasia in PCOS?
The most common and effective treatment for endometrial hyperplasia in individuals with PCOS is progesterone therapy. This hormone-based treatment addresses the root cause of hyperplasia: unopposed oestrogen, which causes the uterine lining to thicken excessively.
By reintroducing progesterone into the hormonal balance, the therapy helps thin the endometrial lining, reduce symptoms, and prevent progression to more serious conditions.
Why progesterone is the standard treatment for PCOS-related hyperplasia
In PCOS, the lack of regular ovulation (anovulation) means the body doesn’t produce enough natural progesterone to balance the effects of oestrogen. Without this balance, the uterine lining continues to grow unchecked, leading to hyperplasia. Progesterone therapy works by:
Thinning the uterine lining: Encouraging the shedding of excess tissue to restore a healthy endometrium.
Regulating hormonal cycles: Mimicking the effects of natural progesterone to rebalance the hormonal environment.
Reducing long-term risks: Preventing the progression of hyperplasia to atypia or endometrial cancer.
Forms of progesterone treatment
Progesterone can be delivered in various forms, depending on the patient’s needs and preferences:
Oral pills: Taken daily or in cycles, these are convenient but may cause systemic side effects.
Hormonal IUDs (e.g. Mirena coil): A localised treatment device that delivers progesterone directly to the uterus with fewer systemic side effects.
Injections or implants: Used for sustained release of progesterone in more severe cases.
For individuals with PCOS, the choice of progesterone delivery often depends on the severity of hyperplasia and the patient’s reproductive goals.
Side effects of progesterone treatment
While progesterone therapy is effective, it can come with side effects as the body adjusts to the hormonal changes. These may include:
Mood changes: Feelings of irritability or emotional sensitivity are common but often improve with time.
Bloating or breast tenderness: These symptoms are usually mild and can be managed with hydration and supportive clothing.
Irregular spotting or bleeding: This is a normal part of the uterine lining shedding process, indicating that the treatment is working.
Nausea or fatigue: Temporary discomfort that can be mitigated by eating smaller, frequent meals and prioritising rest.
Most of these side effects subside as the body acclimatises to the therapy. Patients should communicate with their healthcare provider if side effects persist or become disruptive, as adjustments to the treatment plan can often resolve these issues.
Why regular monitoring is essential
Progesterone therapy is highly effective when combined with regular follow-ups, such as ultrasounds or biopsies, to track the thickness of the uterine lining and ensure the treatment is working. For individuals with PCOS, who are at an ongoing risk of hyperplasia recurrence, long-term management is crucial to maintaining endometrial health.
Progesterone therapy remains the cornerstone of treatment for PCOS-related hyperplasia, offering a safe and reliable option for most patients. Addressing both the symptoms and underlying causes paves the way for better health outcomes and reduced long-term risks.
Preventing hyperplasia recurrence in PCOS
Endometrial hyperplasia can be successfully treated, but for individuals with PCOS, managing the long-term risk of recurrence is essential. The hormonal imbalances characteristic of PCOS, particularly the lack of ovulation and unopposed oestrogen, mean the uterine lining can continue to thicken over time if proactive measures aren’t taken. Preventing recurrence requires a combination of medical treatments, lifestyle adjustments, and regular monitoring.
Hormonal balance is a cornerstone of prevention. Long-term or cyclical progesterone therapy is often recommended to prevent excessive thickening of the uterine lining. For some, a hormonal intrauterine device (IUD) may be the preferred option, delivering targeted progesterone with minimal systemic side effects. For individuals looking to conceive, ovulation induction medications like clomiphene or letrozole may help restore a natural hormonal rhythm, reducing the risks associated with prolonged unopposed oestrogen. Such an approach can be considered once satisfactory regression of the hyperplasia is achieved.
Lifestyle changes also play a significant role in preventing recurrence. Weight management is particularly important for individuals with PCOS, as excess weight increases oestrogen production, exacerbating hyperplasia risks. Regular physical activity, such as 30 minutes of moderate exercise most days, also supports weight control and improves metabolic function, benefiting overall health.
Regular monitoring and personalised care are essential components of long-term management. Routine ultrasounds or endometrial biopsies ensure the uterine lining remains healthy, while follow-ups with a healthcare provider allow for timely adjustments to treatment plans. For individuals with PCOS, a tailored approach to prevention can significantly lower the risk of hyperplasia recurrence, supporting both uterine and overall health in the years to come.
Conclusion
For individuals with PCOS, the risk of developing endometrial hyperplasia can feel overwhelming, but the good news is that effective treatment options are readily available. From progesterone therapy to lifestyle adjustments, timely intervention can successfully resolve hyperplasia and significantly reduce the risk of recurrence. Early care not only leads to better outcomes but also provides reassurance and peace of mind.
Follow-up care is especially vital for managing hyperplasia in PCOS, ensuring the uterine lining remains healthy over time. Private healthcare offers a seamless way to maintain this essential continuity of care. With prompt appointments, regular check-ups, and a focus on personalised treatment plans, private care simplifies the process and ensures your health is consistently monitored without delays.
At Rylon Clinic, we understand the complexities of managing PCOS and endometrial health. Our expert team is here to guide you every step of the way, providing tailored solutions and ongoing support. If you’re ready to take the next step in managing your health, contact Rylon Clinic today to schedule a consultation.
References
Kurman et al. (1985) The behavior of endometrial hyperplasia. A long-term study of "untreated" hyperplasia in 170 patients. Cancer. https://pubmed.ncbi.nlm.nih.gov/4005805/
Singh and Puckett (2023) Endometrial Hyperplasia. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/n/statpearls/article-21104/
Lacey et al. (2008) Endometrial carcinoma risk among women diagnosed with endometrial hyperplasia: the 34-year experience in a large health plan. British journal of cancer. https://pubmed.ncbi.nlm.nih.gov/18026193/
Author: Mr Osama Naji
Mr Naji offers a “one-stop” gynaecology clinic for instant detection of various gynaecological cancers as well as providing all the diagnostic and treatment services needed under one roof.
Mr Naji provides advanced gynaecology scanning which is essential when conducting any gynaecology consultation, he is bilingual in English and Arabic and has an NHS base at the highly reputable Guy's and St Thomas' Hospital in London.
He is passionate about raising awareness of various subtle signs and symptoms of gynaecological conditions that are often overlooked by patients.
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