Decoding Menopause

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Menopause — Diagnosis, HRT & Care

Menopause is a natural stage that brings symptoms and long-term health risks. This sheet gives how to stage and diagnose it, how to choose hormone therapy, the options when hormones are unsuitable, and follow-up.

🎯 AT A GLANCE — MENOPAUSE

Menopause is the permanent end of menstruation, diagnosed after 12 months without a period (when she is not on hormonal contraception)

The transition (perimenopause) can last several years, with irregular periods and symptoms such as hot flushes, night sweats, poor sleep, low mood and vaginal dryness

In women over 45, diagnose perimenopause from the symptoms and the irregular periods; blood tests are not needed

Hormone therapy (HT or HRT) is the most effective treatment for hot flushes and night sweats, and for vaginal symptoms and bone loss

For most healthy symptomatic women under 60 or within 10 years of menopause, the benefits of HT outweigh the risks

Offer every woman information on symptoms, options, bone and heart health, and contraception, so that she can choose.

🚨 DO NOT ASSUME MENOPAUSE IF…

She is under 40 with no or infrequent periods — think of premature ovarian insufficiency; check FSH twice, 4–6 weeks apart, and refer

Bleeding after the menopause, or irregular heavy bleeding that does not fit the pattern — needs endometrial assessment; it can be hyperplasia or cancer

Unexplained weight loss, a breast lump, or pelvic mass or pain — examine and investigate; do not blame the menopause (from memory)

She has had breast cancer, active liver disease, undiagnosed vaginal bleeding or a past blood clot or stroke — do not start HT without specialist advice (from memory)

Mood symptoms with thoughts of self-harm, or severe depression — assess and refer; treat as depression, not only as menopause (from memory)

STEP 1 · RECOGNISE IT — stages, symptoms and diagnosis

🕰️ STAGES OF THE TRANSITION

Women over 45: diagnose perimenopause clinically from vasomotor symptoms and irregular periods; do not use AMH, inhibin, oestradiol or ovarian scans

Women aged 40–45 with symptoms, or under 40 where menopause is suspected: consider an FSH test

Do not use FSH when she is on a combined hormonal contraceptive or high-dose progestogen; hormonal treatment can mask the picture

After hysterectomy without removal of the ovaries, diagnose from symptoms, since periods cannot be used

Premature ovarian insufficiency (under 40): symptoms with a raised FSH on two samples 4–6 weeks apart; offer hormone replacement until at least the natural age of menopause unless contraindicated

🩺 SYMPTOMS TO ASK ABOUT

Vasomotor

Hot flushes

Night sweats

Palpitations

Genitourinary (GSM)

Vaginal dryness and soreness

Pain with sex

Urinary urgency and recurrent infections

Mind and sleep

Low mood and anxiety

Poor sleep and tiredness

Poor concentration (“brain fog”)

Body

Joint and muscle pain

Low sexual desire

Bone loss, later fractures

Symptoms vary a lot between women; ask about the effect on work, sleep and relationships.

STEP 2 · BEFORE YOU TREAT — check the woman first

📋 ASSESS AND COUNSEL

History: symptoms, last period, bleeding pattern, personal and family history of breast cancer, clots, stroke, heart disease, liver disease (from memory)

Examine: blood pressure, weight (BMI), breasts and pelvis as due, and check cervical screening is up to date (from memory)

Contraception: she can still conceive in perimenopause; offer advice on contraception until the menopause is confirmed

Bone health: calcium, vitamin D, weight-bearing exercise, no smoking, little alcohol; consider a bone scan when risk factors are present (from memory)

Lifestyle for symptoms: regular exercise, cool clothing, avoiding triggers such as spicy food, alcohol and caffeine (from memory)

Explain the benefits and risks of each option, then let her decide.

STEP 3 · TREAT — hormone and other options

💊 HORMONE THERAPY: CHOOSING THE REGIMEN

Situation	What to offer	Points to remember
Has a uterus	Oestrogen plus a progestogen (sequential if still having periods, continuous when postmenopausal)	The progestogen protects the endometrium; oestrogen alone is not given
No uterus	Oestrogen alone	No progestogen needed after hysterectomy (unless she had endometriosis, from memory)
Vaginal symptoms only	Vaginal oestrogen; moisturisers and lubricants	Safe to use alongside systemic HT; symptoms return when it stops; routine endometrial thickness checks are not advised
Raised risk of blood clots (for example BMI over 30)	Transdermal (patch or gel) rather than oral	Standard-dose transdermal HT carries no greater risk than baseline; refer high-risk women for haematology advice
Premature ovarian insufficiency	HT or a combined hormonal contraceptive until at least the age of natural menopause	Protects bone, heart and mood
Low sexual desire despite HT	Consider testosterone	Specialist-led; unlicensed in many places

Doses and products differ by country; use the lowest dose that controls symptoms and follow your local formulary. Compounded “bioidentical” hormones are unregulated and are not advised.

⚖️ BENEFITS AND RISKS OF HT

Outcome	What the guidance says
Hot flushes and night sweats	HT is the most effective treatment
Bone	Lowers the risk of fracture while taken; the benefit fades after stopping
Heart disease	Does not raise the risk when started under 60; heart risk factors are not a bar when well managed
Stroke	Oral oestrogen gives a small increase; transdermal does not
Blood clots (VTE)	Oral HT raises the risk; standard-dose transdermal does not
Breast cancer	Oestrogen alone: little or no effect. Oestrogen with a progestogen: the risk may rise with duration and falls after stopping
Dementia	The effect is unknown
Diabetes	Does not raise the risk of type 2 diabetes

🌿 WHEN SHE CANNOT OR WILL NOT USE HORMONES

Cognitive behavioural therapy can help hot flushes, low mood and sleep

Drugs such as SSRIs, SNRIs (for example venlafaxine) and clonidine are not first-line for flushes alone, but are options when hormones are unsuitable; do not give paroxetine or fluoxetine with tamoxifen

Newer non-hormonal drugs and gabapentin exist for hot flushes; follow your local guidance (from memory)

Herbal products such as isoflavones and black cohosh may help, but their safety is uncertain and they can interact with other medicines; St John’s wort has interaction risks

Vaginal symptoms: moisturisers and lubricants; local oestrogen may be used after specialist advice even in women who cannot take systemic HT

After breast cancer: give information on all options and refer to a menopause specialist

STEP 4 · FOLLOW-UP — review, stop and stay healthy

📅 REVIEW AND STOPPING

Review at 3 months for effect and side effects, then every year

Irregular bleeding is common in the first 3 months of HT; tell her to report it at the review, or promptly if it starts later

Refer if symptoms do not improve, side effects persist, or the choice is uncertain

She need not stop HT at age 60 or 65; review the risks and benefits regularly and continue while the benefit is clear

Stopping: she can stop gradually or at once; gradual stopping may limit a short-term return of symptoms

Keep up cervical and breast screening as for her age, and check blood pressure, weight and bone health (from memory)

⚠️ COMMON PITFALLS

Sending blood tests to diagnose menopause in a woman over 45

Giving oestrogen alone to a woman with a uterus

Forgetting contraception during the transition

Missing premature ovarian insufficiency in a young woman with irregular periods

Using oral HT in a woman at high clot risk, when a patch or gel would do

Not offering vaginal oestrogen, or stopping it when she has improved

Labelling every symptom as menopause without looking for other causes

Memory Aid

CHANGE

Six reminders for the woman in menopause.

C

Clinical diagnosis — symptoms and periods, no blood tests over 45

H

HT is the most effective — for flushes, vaginal symptoms and bone

A

Add a progestogen — whenever she has a uterus

N

Non-hormonal options — CBT and others when HT is unsuitable

G

GSM: vaginal oestrogen — safe alongside systemic HT

E

Evaluate yearly — benefits, risks, bleeding and bone health

Remember: menopause is a normal stage of life; treat the symptoms that trouble her, protect her bones and heart, and decide together.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against: the NICE NG23 menopause guideline (diagnosis, FSH use, premature ovarian insufficiency, HT choice and route, vaginal oestrogen, risks and benefits, non-hormonal and herbal options, review and stopping, contraception) and a report of the 2022 NAMS hormone therapy position statement (who benefits, duration beyond 60 or 65, genitourinary syndrome, unregulated compounded hormones). Items marked “from memory” (early menopause age, history and examination points, bone and lifestyle advice, contraindications, newer non-hormonal drugs) were not checked. Guidance differs between countries and is updated: follow your local protocol and refer complex cases to a menopause specialist.

FIBROID UTERUS (LEIOMYOMA) Revised

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Fibroid Uterus — FIGO Classification & Treatment

Uterine fibroids are very common benign tumours that cause heavy bleeding and pressure symptoms in some women. This sheet gives how to assess them, the FIGO classification, the medical options, the procedures and surgery, and care when she wants to conceive.

🎯 AT A GLANCE — FIBROID UTERUS (LEIOMYOMA)

Fibroids are benign smooth-muscle tumours of the uterus, and the commonest solid pelvic tumour in women; at least 70% of women develop them by late reproductive age

Many cause no symptoms and need no treatment

When they do cause symptoms: heavy or prolonged periods and anaemia, and bulk symptoms such as pelvic pressure, frequent urination and constipation

Treatment depends on symptoms, size and position of the fibroids, and whether she wants to keep her fertility and her uterus

Medicines control bleeding but do not remove large fibroids; surgery or embolisation is needed for bulk

Ask before choosing: what bothers her most, does she want children, and does she want to keep her uterus.

🚨 URGENT REVIEW OR SPECIALIST REFERRAL IF…

She is severely anaemic or has heavy bleeding with dizziness or fainting — admit, resuscitate and treat as for acute heavy bleeding

Rapid growth of a “fibroid”, or growth after menopause — think of a sarcoma; image with MRI and refer; avoid morcellation

Sudden severe pain in a woman with a fibroid — think of torsion of a pedunculated fibroid or red degeneration, mostly in pregnancy; check for other causes

Retention of urine, hydronephrosis or severe pressure symptoms — refer for surgery /span>

She wants to conceive and has a submucosal or large fibroid, or repeated miscarriage — refer to a fertility or gynaecology service before treatment

STEP 1 · RECOGNISE IT — presentation and assessment

🧬 THE FIGO CLASSIFICATION OF FIBROIDS

Type	Position	Description
0	Submucosal: pedunculated intracavitary	Attached by a stalk and lying inside the cavity
1	Submucosal: less than 50% intramural	Mostly in the cavity; less than half is inside the muscle
2	Submucosal: 50% or more intramural	Mostly in the muscle wall, but touching the endometrium
3	Contacts the endometrium, 100% intramural	Entirely in the muscle, touching the endometrium; does not distort the cavity
4	Intramural	Entirely in the muscle, away from both the endometrium and the outer surface
5	Subserosal: 50% or more intramural	Mostly in the muscle, reaching the outer surface
6	Subserosal: less than 50% intramural	Mostly outside the muscle, less than half inside
7	Subserosal: pedunculated	Attached by a stalk to the outer surface
8	Other	Elsewhere, for example the cervix or a parasitic fibroid; state the site

Types 0–3 touch the endometrium (submucosal); types 4–8 are the rest. A hybrid fibroid touching both surfaces is written with two numbers, the endometrial side first (for example 2-5).

🧭 WHY THE TYPE MATTERS

Types 0, 1 and 2 can usually be removed through the hysteroscope (hysteroscopic myomectomy is highly effective for these types)

Submucosal fibroids (0–3) are the ones that most often cause heavy bleeding and affect fertility

Type 3 does not distort the cavity but touches the lining; it may still cause bleeding

Types 4–7 give bulk symptoms and need laparoscopic or open surgery, or embolisation, when treatment is required

Type 7 can twist, and type 8 (cervical or parasitic) needs a specialist plan

Write the type in the notes and the scan report so the whole team plans the same operation

🔬 TYPES AND SYMPTOMS

Fibroids are classified by position: submucosal (inside the cavity), intramural (in the muscle) and subserosal (on the outer surface); the FIGO types 0 to 8 are shown above

Submucosal fibroids cause the most bleeding and affect fertility most

Heavy menstrual bleeding and anaemia: tiredness, breathlessness and pallor are the main complaints

Bulk symptoms: pelvic pressure or heaviness, frequent urination, constipation, and a lump felt in the lower abdomen

Other effects: pain, pain with sex, and sometimes infertility or pregnancy complications

Women of African descent develop clinically significant fibroids earlier, with larger uteri

🩺 INVESTIGATION

Examination: a firm, irregular, enlarged uterus, usually non-tender

Pelvic ultrasound (transvaginal and abdominal) shows size, number and position; use MRI when more detail is needed, for example before embolisation or myomectomy

Hysteroscopy for submucosal fibroids, and when the cavity needs to be seen

Full blood count and ferritin to look for anaemia and iron deficiency

Pregnancy test, and endometrial sampling if she is over 45 or has risk factors for hyperplasia (from memory)

STEP 2 · TREAT THE BLEEDING AND BULK — medical treatment first

💊 MEDICAL OPTIONS

Option	Dose and use	Points to remember
Tranexamic acid	1.3 g three times a day, at least 6 hours apart, for up to 5 days a cycle, started when heavy bleeding begins (trial dose, maximum 3.9 g a day)	Non-hormonal; reduces bleeding but not size. Avoid with a history of thrombosis (last point
NSAIDs	Taken during the period	Help pain; can be offered while investigations or treatment are arranged
LNG-IUS 52 mg	One device, up to 5 years (duration	Treats the bleeding; expulsion is more frequent with fibroids, and it may not suit a distorted cavity
Combined hormonal contraceptives or progestogens	As for heavy menstrual bleeding	May help bleeding; evidence is limited
Oral GnRH antagonist with add-back (relugolix 40 mg, estradiol 1 mg, norethindrone acetate 0.5 mg once daily; elagolix combination also exists)	Up to 24 months (FDA limit)	Reduce bleeding and may shrink fibroids; bone loss risk, hence the limit. Availability varies by country
GnRH agonist (for example leuprolide)	Short-term, up to 6 months without add-back, or 12 months with add-back (oestrogen with norethindrone)	Shrinks fibroids and raises haemoglobin before surgery; fibroids regrow within 6–9 months of stopping; menopausal side effects
Ulipristal acetate (and mifepristone)	Short courses only where available	Not approved for daily use in the USA; use limited in Europe because of rare serious liver injury

Doses are from the ACOG summary and the NICE pathway; check the local product label. Treat iron deficiency anaemia with iron, and correct it before surgery.

STEP 3 · PROCEDURES AND SURGERY — choose by what she wants

📊 HOW OFTEN IS A SECOND PROCEDURE NEEDED?

🔪 PROCEDURES AT A GLANCE

Option	For whom	Points to remember
Hysteroscopic myomectomy	Submucosal fibroids (types 0, 1 and 2)	Highly effective; complications 1–3%; re-intervention about 7% at 60 months
Myomectomy (laparoscopic, robotic or open)	Wants to keep the uterus or conceive	Recommended when future pregnancy is wanted; recurrence about 25% by 40 months; transfusion risk 0–5%
Uterine artery embolisation	Wants to keep the uterus and is not planning pregnancy	Similar satisfaction at 2–5 years; more repeat procedures (15–38%); little data on later pregnancy
Radiofrequency ablation	Uterus-sparing, where available	Shrinks fibroids by 50–75%; access is limited; little pregnancy data
Hysterectomy	Family complete or other treatment failed or declined	Definitive; use the least invasive route, with vaginal preferred where possible

Endometrial ablation has too little evidence for fibroid bleeding. Consider a GnRH agonist before surgery if it helps (to raise haemoglobin or shrink the uterus for a minimally invasive route).

🤰 FERTILITY AND PREGNANCY

Most women with fibroids conceive and deliver normally (from memory)

Submucosal fibroids lower the chance of pregnancy and raise the risk of miscarriage; removal by hysteroscopy is advised when she is trying to conceive (from memory)

If she wants a pregnancy and the uterus kept, myomectomy is recommended, ideally minimally invasive

Fibroids in pregnancy can cause pain (red degeneration), malpresentation, and bleeding after birth; the obstetric team should plan the delivery (from memory)

Medicines that suppress ovulation are not used when she is trying to conceive

⚠️ COMMON PITFALLS

Treating asymptomatic fibroids because they look large on a scan

Missing anaemia and not giving iron

Offering hormonal treatment when she is trying to conceive

Using a GnRH agonist for months without add-back and without a plan for the next step

Choosing embolisation for a woman who wants a pregnancy

Morcellating a uterus without excluding a sarcoma (from memory)

Ignoring a fast-growing fibroid

Memory Aid

FIBROID

Six reminders for a woman with a fibroid uterus.

F

FIGO type — note it in every report

I

Image — ultrasound, MRI if surgery is planned

B

Bleeding and blood count — treat anaemia

R

Rapid growth is a red flag — think of sarcoma

O

Options match the goal — medicine, embolisation, myomectomy, hysterectomy

D

Decide together — and review often

Remember: fibroids are common and benign; treat the symptoms and the woman’s goals, not the scan.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against: a summary of ACOG Practice Bulletin 228 (2021) on managing fibroids (prevalence, symptoms, tranexamic acid, GnRH agonist and antagonist regimens, LNG-IUS, ulipristal, embolisation, radiofrequency ablation, myomectomy, hysterectomy, re-intervention rates, fertility) the FIGO leiomyoma subclassification (types 0–8 and hybrid notation, from a published table), and the NICE NG88 heavy menstrual bleeding care pathway (investigation, options by fibroid size, GnRH agonist before surgery). Items marked “from memory” (red-flag situations, examination findings, blood tests, pregnancy effects, sarcoma and morcellation caution, LNG-IUS duration) were not checked. Availability of drugs differs between countries: follow your local protocol and involve a senior gynaecologist.

Menorrhagia — PALM-COEIN

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Menorrhagia — PALM-COEIN, Work-up & Treatment

Heavy menstrual bleeding (menorrhagia) is a common reason for women to see a gynaecologist and a leading cause of iron deficiency. This sheet gives the FIGO PALM-COEIN classification, how to assess, medical and surgical treatment, and the red flags.

🎯 AT A GLANCE — HEAVY MENSTRUAL BLEEDING (MENORRHAGIA)

Heavy menstrual bleeding (HMB) is excessive menstrual blood loss that interferes with a woman’s physical, social, emotional or material quality of life

The word “menorrhagia” is now replaced by “heavy menstrual bleeding”; the old term “dysfunctional uterine bleeding” has been dropped

Normal cycle: every 24–38 days, lasting up to 8 days; there is no fixed volume, so ask how the bleeding affects her life

Always classify the cause with PALM-COEIN: structural causes (P, A, L, M) and non-structural causes (C, O, E, I, N)

Many women with HMB have iron deficiency, so check haemoglobin and ferritin in every case

Treat the cause if there is one, and offer treatment that suits her wishes about fertility and contraception.

🚨 ADMIT, SCAN OR REFER IF…

Heavy bleeding with dizziness, fainting, a fast pulse or low blood pressure — treat as an emergency: resuscitate, check the haemoglobin, and call the gynaecologist

She is pregnant, or the pregnancy test is positive — think of miscarriage or ectopic pregnancy before anything else

Bleeding after menopause, or bleeding between periods or after sex — needs an endometrial and cervical assessment

She is over 45, or younger with risk factors (obesity, PCOS, tamoxifen), or treatment has failed — sample the endometrium (from memory)

Bleeding since the first period, or with easy bruising, nosebleeds, or bleeding after delivery or dental work — screen for a bleeding disorder, and refer to haematology

STEP 1 · CLASSIFY THE BLEEDING — normal values and the PALM-COEIN system

📏 WHAT IS NORMAL?

Parameter	Normal range (FIGO)	Abnormal terms
Frequency	Every 24–38 days	Frequent (under 24 days) or infrequent (over 38 days)
Regularity	Cycle length varies by 7–9 days at most, depending on age	Irregular if the variation is more
Duration	Up to 8 days	Prolonged: more than 8 days
Volume	No fixed number; judged by the woman	Heavy menstrual bleeding: interferes with her life
Other	Bleeding between periods (intermenstrual) can be cyclical or random	Always ask about it

🧩 THE PALM-COEIN CLASSIFICATION

Letter	Cause	Definition and clues
P	Polyp	Endometrial or endocervical polyp, found at hysteroscopy or sonohysterography
A	Adenomyosis	Diagnosed by imaging criteria on transvaginal ultrasound (MUSA); two or more criteria are strongly associated
L	Leiomyoma	Submucosal (types 0–3) or other (types 4–8, not distorting the cavity)
M	Malignancy and hyperplasia	Endometrial carcinoma, leiomyosarcoma, or atypical hyperplasia (EIN)
C	Coagulopathy	Systemic bleeding disorders such as von Willebrand disease
O	Ovulatory dysfunction	Unpredictable cycles; includes PCOS, thyroid disease, hyperprolactinaemia, adolescence and perimenopause (examples from memory)
E	Endometrial	A primary disorder of the endometrium, such as chronic endometritis; diagnosed by exclusion
I	Iatrogenic	Hormonal drugs, intrauterine devices and drugs that affect ovulation; anticoagulants were moved here in 2018
N	Not otherwise classified	Rare causes such as an arteriovenous malformation or a caesarean scar defect (niche)

STEP 2 · ASSESS — history, examination and tests

🩺 HISTORY AND EXAMINATION

Ask about the bleeding pattern: cycle length, duration, clots and flooding, bleeding between periods or after sex, and the effect on work and life

Ask how often she changes pads, whether blood leaks through at night, and about clots and flooding; these suggest heavy loss, but they are only rough guides (from memory)

Screen for a bleeding disorder: heavy periods since menarche, bleeding after delivery, surgery or dental work, bruising or nosebleeds once or twice a month, bleeding gums, or a family history. A positive screen needs haematology tests (von Willebrand factor and clotting)

Check the drugs: hormones, IUD, tamoxifen, anticoagulants, and aspirin (from memory)

Examine: pallor, thyroid, blood pressure, abdomen, speculum for the cervix, and bimanual examination for uterine size and tenderness (from memory)

🧪 INVESTIGATIONS

Urine or serum β-hCG to exclude pregnancy

Full blood count with platelets, and serum ferritin for anaemia and iron stores

Ovulation: predictable cycles usually mean ovulation; if unsure, a mid-luteal progesterone; TSH when thyroid disease is suspected (from memory)

Transvaginal ultrasound when the uterus is enlarged or a mass is felt, bleeding is persistent, or treatment fails; add sonohysterography or hysteroscopy for polyps and submucosal fibroids

Endometrial sampling when risk of hyperplasia or cancer is present

Clotting tests only when the bleeding disorder screen is positive

STEP 3 · TREAT — medical first, then procedures

💊 MEDICAL TREATMENT: WHAT TO OFFER

Line	Option	Dose and notes
First	LNG-IUS 52 mg	More effective than oral treatment; keep for at least 12 months; warn about spotting in the first 6 months and persevere for 6 cycles
Second	Tranexamic acid	1 g three times a day for up to 4 days, started when the period begins (maximum 4 g a day). Check for a history of thrombosis (last point from memory)
Second	NSAIDs (mefenamic acid, ibuprofen, diclofenac)	Ibuprofen 200–400 mg three or four times a day, or diclofenac 75–150 mg a day in divided doses; preferred when there is period pain; take with food
Second	Combined oral contraceptive	Also gives contraception and cycle control; check the contraindications
Third	Cyclical progestogen (norethisterone 5 mg three times a day, day 5 to 26) or injectable medroxyprogesterone every 12 weeks	Less effective than the options above; low-dose luteal norethisterone is not effective
Add-on	GnRH analogue for a few months before surgery	To shrink an enlarged uterus or fibroids, or before endometrial ablation

Give NSAIDs or tranexamic acid for at least three cycles and continue if they help. If the first treatment fails, try another medical option before surgery. Treat the underlying cause (for example thyroid disease or a bleeding disorder).

🔪 PROCEDURES AND SURGERY

Surgery is mainly for proven pathology such as fibroids, or when medical treatment has failed or been refused

Uterus under about 10 weeks’ size: endometrial ablation (second-generation) is first line; she should not want a pregnancy

Larger uterus, wants to keep it: uterine artery embolisation or hysteroscopic myomectomy

Does not want to keep the uterus: hysterectomy, vaginal if possible; healthy ovaries should not be removed

Polyps: remove at hysteroscopy and send for histology (from memory)

Atypical hyperplasia or cancer: refer to a gynaecologist or gynaecological oncology team

🚑 ACUTE HEAVY BLEEDING

Assess airway, breathing, circulation; check pulse, blood pressure and haemoglobin; insert an intravenous line (from memory)

Tranexamic acid by mouth or slow intravenous injection, and consider a high-dose progestogen or oestrogen as per local protocol (from memory)

Transfuse for severe anaemia or shock; exclude pregnancy first (from memory)

If bleeding does not settle, call the gynaecologist for procedures such as curettage or hysteroscopy, or balloon or surgical measures (from memory)

🩸 TREAT THE ANAEMIA

Check haemoglobin and ferritin; start iron if she is iron deficient

Treat the anaemia as well as the bleeding; women may feel tired and breathless long before they seek help (from memory)

Give iron by mouth on alternate days or daily, and use intravenous iron if she cannot take or absorb tablets, or when a rapid rise is needed before surgery (from memory)

Recheck the blood count after a few weeks (from memory)

⚠️ COMMON PITFALLS

Starting treatment without a pregnancy test and a blood count

Missing a bleeding disorder in a girl with heavy bleeding since her first period

Treating with tablets when the uterus is large or a mass is felt, without a scan

Missing endometrial hyperplasia or cancer in an older or obese woman

Stopping the LNG-IUS too early because of spotting

Using cyclical low-dose norethisterone, which does not work

Treating the bleeding but not the anaemia

Memory Aid

PALM-COEIN

Nine causes of abnormal uterine bleeding.

S

Structural: PALM — Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia

N

Non-structural: COEIN — Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise classified

1

First tests — pregnancy test, blood count, ferritin

2

First treatment — LNG-IUS; then tranexamic acid, NSAID or the pill

Remember: classify the cause, treat the anaemia, and match the treatment to what she wants.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against: the FIGO 2018 systems for normal and abnormal uterine bleeding (Munro et al: PALM-COEIN categories, normal menstrual parameters, definition of heavy menstrual bleeding, initial investigations, bleeding disorder screen); a primary care summary of the NICE NG88 heavy menstrual bleeding guidance (order of medical treatment, LNG-IUS, cyclical progestogen, GnRH analogue, surgical options by uterine size); and an NHS formulary page (tranexamic acid, ibuprofen and diclofenac doses, notes on the LNG-IUS and low-dose norethisterone). Items marked “from memory” (how to estimate blood loss, examples of ovulatory causes, red-flag situations, acute management, iron regimens, thyroid and other tests) were not checked. Regimens differ between countries: follow your local protocol and involve a senior gynaecologist.

Endometrial Hyperplasia

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Endometrial Hyperplasia — Diagnosis & Management

Endometrial hyperplasia is a precursor of endometrial cancer, driven by unopposed oestrogen. This sheet gives the classification and cancer risk, how to investigate abnormal bleeding, treatment with and without atypia, fertility-sparing care, and follow-up.

🎯 AT A GLANCE — ENDOMETRIAL HYPERPLASIA

Endometrial hyperplasia is an overgrowth of the endometrial glands, most often from oestrogen that is not balanced by progesterone

The WHO 2014 system has two groups: hyperplasia without atypia (benign) and atypical hyperplasia, also called EIN (premalignant)

Without atypia, progression to cancer is under 5% over 20 years; with atypia the risk is much higher, and cancer is already present in up to 43% of hysterectomy specimens

It usually shows as abnormal uterine bleeding, and it is diagnosed only by histology

Treatment: the LNG-IUS for hyperplasia without atypia, and hysterectomy for atypical hyperplasia when fertility is complete

Any woman with postmenopausal bleeding, or persistent abnormal bleeding with risk factors, needs an endometrial assessment.

🚨 ESCALATE OR DO NOT ASSUME BENIGN IF…

The biopsy shows atypical hyperplasia — refer to a gynaecologist; cancer may already be present, so do not treat in the primary care clinic

Bleeding after menopause — assess with transvaginal ultrasound and sampling; a thickness of 3–4 mm or less makes cancer very unlikely

Bleeding continues despite a negative biopsy — about 2% of negative biopsies miss hyperplasia; do hysteroscopy

A polyp contains hyperplasia, or a focal lesion is seen — remove it fully with hysteroscopy and sample the surrounding endometrium

There is no regression after 12 months of treatment, or the hyperplasia relapses or progresses to atypia — offer hysterectomy if she has completed her family

STEP 1 · UNDERSTAND IT — what it is and who is at risk

🔬 CLASSIFICATION AND RISK

Older WHO 1994 term	WHO 2014 group	Meaning
Simple or complex hyperplasia (no atypia)	Hyperplasia without atypia	Benign; gland pattern no longer part of the grading; usually regresses with treatment or with the cause removed
Simple or complex hyperplasia with atypia	Atypical hyperplasia (EIN)	Premalignant; the guideline treats EIN and atypical hyperplasia as interchangeable

📋 RISK FACTORS AND CAUSES

Obesity: fat cells convert androgens to oestrogen

Anovulation: perimenopause and polycystic ovary syndrome leave oestrogen unopposed by progesterone

Oestrogen-secreting ovarian tumours, such as granulosa cell tumours

Oestrogen-only HRT in a woman with a uterus, and long-term tamoxifen

Also: nulliparity, diabetes and a family history of endometrial or colorectal cancer (from memory)

Ask every woman with abnormal bleeding: weight, cycle pattern, HRT, tamoxifen, and family history of cancer.

STEP 2 · DIAGNOSE — history, scan and sampling

🩺 INVESTIGATION

Histology is required for the diagnosis; the scan only suggests it

Outpatient endometrial biopsy is the first test; it detects hyperplasia well (positive likelihood ratio 12), but about 2% of negative biopsies still hide it

Hysteroscopy when sampling fails or is inadequate, when hyperplasia is in a polyp or focal lesion, or when bleeding persists

Transvaginal ultrasound, postmenopausal bleeding: 3–4 mm or less rules out cancer in over 99% of cases; use a higher cut-off on HRT or tamoxifen

Premenopausal women with PCOS: no hyperplasia was found when the endometrium was under 7 mm

Do not use CT, MRI or blood biomarkers routinely

Women under 45 with persistent abnormal bleeding, or any age with risk factors, deserve sampling (from memory)

STEP 3 · MANAGE — by histology and by what she wants

🌿 HYPERPLASIA WITHOUT ATYPIA

Counsel her, correct reversible causes (weight loss if BMI is over 30; stop or change oestrogen-only HRT), and offer observation with repeat biopsies when she has no heavy bleeding

Regression with progestogens is about 89–96%, and with observation alone about 74–81%

First choice: the levonorgestrel IUS (better regression, better bleeding control and fewer side effects than tablets)

If she declines the IUS: continuous oral progestogen: medroxyprogesterone 10–20 mg a day or norethisterone 10–15 mg a day. Cyclical progestogens are not recommended

Treat for at least 6 months; the LNG-IUS can stay up to 5 years if tolerated and fertility is not wanted

Biopsy every 6 months; discharge after two consecutive negative biopsies. Women with a BMI of 35 or more, or on oral progestogen, need annual follow-up afterwards

Hysterectomy is not first line; offer it for progression to atypia, no regression at 12 months, relapse, persistent bleeding, or when she declines surveillance

Endometrial ablation is not recommended

⚠️ ATYPICAL HYPERPLASIA (EIN)

Standard treatment: total hysterectomy, laparoscopic if possible; do not use supracervical hysterectomy

Postmenopausal: remove both tubes and ovaries. Premenopausal: decide about the ovaries together with her; consider removing the tubes

Avoid morcellation; frozen section is not reliable; routine lymph node removal is not needed

Imaging and CA-125 beforehand when needed, to exclude cancer

Ablation or resection is not recommended

Cancer may already be there: send the uterus for full histology and review the result with a gynaecological oncology team.

🤰 FERTILITY-SPARING CARE FOR ATYPICAL HYPERPLASIA

Counsel about the cancer risk and get a multidisciplinary review; first exclude invasive or ovarian cancer with CA-125 and ultrasound or MRI

First line: the LNG-IUS; oral progestogens are second best

Regression is about 86%, relapse about 26%, and live birth about 26% in observational data

Biopsy every 3 months until two negative results, then every 6–12 months

If there is no regression by 12 months, or cancer is found, hysterectomy is strongly recommended

Confirm regression before she tries to conceive; offer hysterectomy once the family is complete

💊 HRT, TAMOXIFEN AND OTHER SITUATIONS

HRT: never give oestrogen alone to a woman with a uterus; on sequential HRT switch to a continuous progestogen or the LNG-IUS, and stopping may be enough to induce regression

Tamoxifen: raises the risk of hyperplasia and cancer; review with the oncologist if hyperplasia develops

Polyps: remove completely and sample the endometrium around it; background hyperplasia is found in about half

Obesity: advise weight loss, because a BMI of 35 or more raises the chance of relapse on the LNG-IUS; for conception aim for a BMI under 30

Bleeding after treatment: tell her to come back at once; relapse needs a new biopsy

⚠️ COMMON PITFALLS

Treating abnormal bleeding with tablets without a biopsy in a woman at risk

Treating atypical hyperplasia with progestogens alone when she has finished her family

Giving cyclical progestogen, which is not recommended

Stopping surveillance after one negative biopsy

Using endometrial ablation, which hides the problem and blocks later sampling

Missing HRT or tamoxifen as the cause

Forgetting to deal with weight, which drives recurrence

Memory Aid

GLAND

Five reminders for endometrial hyperplasia.

G

Get a biopsy — histology makes the diagnosis

L

LNG-IUS first — for hyperplasia without atypia

A

Atypia means hysterectomy — when the family is complete

N

No oestrogen alone — and no cyclical progestogen

D

Do follow-up — repeat biopsy at 6 months, weight loss, and report bleeding

Remember: most hyperplasia without atypia can be reversed; atypia needs a gynaecologist because cancer may already be present.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against: RCOG/BSGE Green-top Guideline No. 67 on the management of endometrial hyperplasia (classification, cancer risk, investigation, progestogen doses, surveillance, hysterectomy, fertility-sparing care, HRT, tamoxifen, polyps, obesity) and a review of the WHO 2014 classification (EIN criteria, coexisting carcinoma). Items marked “from memory” (extra risk factors, the age threshold for sampling) were not checked. Guidelines are updated and differ between countries: follow your local protocol and involve a gynaecologist, and a gynaecological oncology team when cancer is possible.