SHBG and Hyperinsulinemia: The similar association observed with diabetes (77% of diabetic women had ET >4 mm, χ2=4.56, p=0.033) is often intertwined with obesity, as insulin resistance and hyperinsulinemia can further promote endometrial proliferation through both direct mitogenic effects and by influencing sex hormone-binding globulin (SHBG) levels, thereby increasing bioavailable estrogen [18].