Management of Endometrial Hyperplasia

Background

Endometrial hyperplasia is irregular proliferation of endometrial glands with an increased gland-to-stroma ratio, driven by unopposed oestrogen. It is the recognised precursor of endometrial cancer, with an estimated incidence at least three times that of endometrial cancer, and typically presents with abnormal uterine bleeding (heavy, intermenstrual, irregular, unscheduled-on-HRT, or postmenopausal bleeding). Key risk factors: obesity, PCOS/anovulation, oestrogen-secreting ovarian tumours (e.g. granulosa cell tumours), unopposed HRT, and tamoxifen.

Classification

The guideline recommends the revised 2014 WHO classification, which replaces the older four-tier (simple/complex, with/without atypia) system with two groups based purely on cytological atypia:

• Hyperplasia without atypia
• Atypical hyperplasia (regarded as interchangeable with endometrial intraepithelial neoplasia, EIN)

Management of Hyperplasia Without Atypia

Risk of progression to cancer is <5% over 20 years, and most cases regress spontaneously, so observation alone (with reversal of risk factors such as obesity or unopposed HRT) is reasonable in some women.

• First-line medical treatment: the LNG-IUS (Mirena) — higher regression rate, better bleeding profile, and fewer adverse effects than oral progestogens.
• Second-line: continuous oral progestogens — medroxyprogesterone acetate 10–20 mg/day or norethisterone 10–15 mg/day — for women declining the LNG-IUS. Cyclical progestogens should not be used (inferior regression rates).
• Minimum treatment duration: 6 months.
• Hysterectomy is not first-line, but is indicated if: progression to atypia occurs, no histological regression after 12 months, relapse after completing treatment, persistent bleeding, or the woman declines surveillance/compliance.

Management of Atypical Hyperplasia

Because of the high risk of underlying malignancy (concomitant carcinoma found at hysterectomy in up to 43% of cases), total hysterectomy is recommended as initial management, laparoscopic approach preferred. Bilateral salpingo-oophorectomy is offered to postmenopausal women; in premenopausal women, oophorectomy is individualised (bilateral salpingectomy alone may be considered). Frozen section and routine lymphadenectomy are not recommended. For women wishing to preserve fertility (after MDT-guided pretreatment workup excluding invasive cancer/co-existing ovarian cancer): LNG-IUS first-line, oral progestogens as second-best alternative. Hysterectomy should follow once fertility is no longer desired, given the high relapse risk.

Follow-up and Surveillance

• Without atypia: endometrial biopsy at a minimum of 6-monthly intervals; at least 2 consecutive negative biopsies before discharge. Higher-risk women (BMI ≥35, or those on oral progestogens) should continue 6-monthly biopsies for at least 2 years, then move to annual biopsies long-term.
• Atypical hyperplasia not undergoing hysterectomy: biopsy every 3 months until 2 consecutive negative biopsies are obtained, then long-term surveillance with biopsy every 6–12 months until hysterectomy is eventually performed.

High-Yield Exam Points

• WHO 2014 classification: only two categories — with vs without atypia (complexity/architecture no longer classified).
• LNG-IUS is first-line medical therapy for both hyperplasia without atypia and (in fertility-sparing atypical hyperplasia) with atypia.
• Progression risk without atypia: <5% over 20 years — mostly regresses spontaneously.
• Atypical hyperplasia: up to 43% have concurrent endometrial cancer at hysterectomy — total hysterectomy is the default management.
• Endometrial ablation is not recommended for any grade of hyperplasia.
• Surveillance biopsy interval: 6-monthly (without atypia) vs 3-monthly (with atypia) until two consecutive negative results.

Source: RCOG Green-top Guideline No. 67 (First edition, published February 2016 (joint RCOG/British Society for Gynaecological Endoscopy [BSGE] guideline). No later revision or reaffirmation notice was found on the current RCOG guidance page as of this write-up — verify on RCOG's site before relying on this for a date-sensitive answer.)

Read the original on rcog.org.uk

Clinically reviewed by NHS obstetricians and gynaecologists · Source last updated First edition, published February 2016 (joint RCOG/British Society for Gynaecological Endoscopy [BSGE] guideline). No later revision or reaffirmation notice was found on the current RCOG guidance page as of this write-up — verify on RCOG's site before relying on this for a date-sensitive answer.

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