Endometrial Hyperplasia — Diagnosis & Management
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
| 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 |
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)
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)
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
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
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: 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
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
