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.