2. DEFINITION
Endometrial hyperplasia is defined as irregular
proliferation of endometrial glands with an increase in
gland to stroma ratio when compared with
proliferative endometrium
It results from excessive or
unopposed action of estrogen on the endometrium.
3. EPIDEMIOLOGY
➢ Endometrial hyperplasia is the precursor of endometrial
cancer which is the most common gynaecological malignancy
in western world.
➢ INCIDENCE : Peak incidences among 40-55 yrs of age group.
● Endometrial hyperplasia estimated to be least three times
higher than endometrial cancer.
➢ PRESENTATION : Most common presentation of endometrial
hyperplasia is abnormal uterine bleeding ; includes-
-heavy menstrual bleeding,
-irregular bleeding,
-unscheduled bleeding,
-Postmenopausal bleeding.
4. ETIOLOGY AND
RISK FACTORS
➢ Endometrial hyperplasia develops when
estrogen, unopposed by progesterone,
stimulates endometrial cell growth by binding to
estrogen receptors in the nuclei of endometrial
cells.
➢ Other factors includes - Immunosuppression
- Infections
RISK FACTORS : associated with multiple
identifiable risk factors which includes :
-Chronic anovulation : perimenopause ,PCOS
-Increased BMI : obesity
-Estrogen secreting ovarian tumors
-Drug induced endometrial stimulation :
systemic ERT or Tamoxifen therapy
5. CLASSIFICATION
WHO 1994 :
i) simple hyperplasia without atypia - 1% malignant
potential (MP)
ii) complex hyperplasia without atypia - 3% MP
iii) simple hyperplasia with atypia and - 8% MP
iv) complex hyperplasia with atypia - 29% MP
THE 2014 REVISED WHO CLASSIFICATION : Simply
separates endometrial hyperplasia into 2 groups -
i) Hyperplasia without atypia and
ii) Atypical hyperplasia
6. DIAGNOSIS
➢ Histological examination via outpatient
endometrial sampling
➢ Diagnostic hysteroscopy should be considered
if biopsy has failed or is non diagnostic , or
endometrial hyperplasia has been diagnosed
within a polyp or other discrete focal lesion.
➢ Trans vaginal ultrasound may have role in
diagnosing endometrial hyperplasia in pre and
postmenopausal women.
★ There is insufficient evidence evaluating CT ,
MRI or biomarkers as aids in management of
endometrial hyperplasia and there use is not
routinely done.
8. ENDOMETRIAL
HYPERPLASIA
WITHOUT ATYPIA
1. Initial counseling :
➢ Women should explained that risk of EH without
atypia progressing to EC is less than 5% over 20
yrs and majority of cases will regress
spontaneously on follow up.
➢ Reversible risk factors such as obesity and use
of HRT should be identified and addressed.
➢ Observation alone with follow-up endometrial
biopsies to ensure disease regression can be
considered , especially when identifiable risk
factor is reversed.
➢ Progestogens use has higher disease regression
rate than observation alone.
9. ENDOMETRIAL
HYPERPLASIA
WITHOUT ATYPIA
2. MEDICAL TREATMENT :
Considered in women who failed to regress following
observation alone and in symptomatic women with
AUB.
➢ Progestogens- both continuous and oral and
local intrauterine [LNG-IUS] are effective in
regressing disease.
● LNG-IUS should be first line medical treatment
because compared to oral progestogens it has
higher disease regression rate with less side
effects.
● Continuous progestogens should be used
(medroxy-progesterone 10-20 mg/day or noret
histerone 10-15 mg/day) for women who
decline LNG-IUS.
● Cyclic Progestogens should not be used
because they are less effective in regressing EN
without atypia.
10. ENDOMETRIAL
HYPERPLASIA
WITHOUT ATYPIA
Duration of treatment and follow up :
➢ Treatment with oral progestogens or LNG-IUS
should be minimum for 6 months.
➢ If adverse effects are tolerable and fertility not
desired then women should encouraged to
retain LNG-IUS for upto 5 yrs as it reduces
relapse , especially if it alleviates AUB.
➢ Outpatient EBx is recommended after diagnosis
of EH without atypia.
➢ Endometrial surveillance should be arranged at
minimum of 6 months interval. Two consecutive
6- monthly negative biopsies should be obtained
prior to discharge.
➢ In women with high risk of relapse , two
consecutive negative 6 monthly biopsies
followed by long term follow up with annual
endometrial biopsies should be considered.
11. ENDOMETRIAL
HYPERPLASIA
WITHOUT ATYPIA
Surgical management :
➢ Hysterectomy should not be considered as first
line treatment. It is considered only in those who
don’t want to preserve fertility and when-
i) Progression to atypical hyperplasia
occurs during follow up
ii) no histological regression of hyperplasia
after 12 months
iii) there is relapse after treatment
iv) persistence of bleeding symptoms
v) women is not compliant to
progestogens
12. ENDOMETRIAL
HYPERPLASIA
WITHOUT ATYPIA
➢ Postmenopausal women should be offered BSO
together with total hysterectomy
➢ Premenopausal women should offered B/L
salpingectomy to avoid future risk of ovarian
cancer however removal of ovaries should be
individualised.
➢ Endometrial ablation not recommended in EH
as complete endometrial destruction not
ensured.
13. ENDOMETRIAL
HYPERPLASIA
WITH ATYPIA
➢ A laparoscopic approach to total hysterectomy
is preferable to abdominal approach as it is
associated with shorter hospital stay, less post
op pain and quicker recovery.
➢ Post menopausal women should offered BSO.
➢ In premenopausal women removal of ovaries
should be individualised however B/L
salpingectomy should be considered
14. Women with EH with atypia who wish to preserve
fertility or unsuitable for surgery
➢ Women should counseled about risks of
underlying malignancy and subsequent
progression to EC
➢ Pretreatment investigations should rule out
invasive EC or co-existing ovarian cancer
➢ MANAGEMENT :
❏ First line treatment is LNG-IUS should be
recommended, with oral progestogens as a
second best alternative.
❏ Once fertility is no longer required
hysterectomy should be offered i/v/o high
chances of relapse
15. EH WITH ATYPIA
(women not
undergoing
hysterectomy)
Follow up :
➢ Routine endometrial biopsy every 3 month
until 2 consecutive negative biopsy samples
should be obtained
➢ For asymptomatic women with 2 consecutive
negative biopsy samples - long term follow
up with 6-12 months biopsy until
hysterectomy done
16. EH and HRT
➢ Systemic estrogen only HRT should not be used
in women with uterus.
➢ All women with HRT should be encouraged to
report unscheduled vaginal bleeding
➢ Women on sequential HRT preparation and
wishing to continue HRT should be advised to
shift on to LNG-IUS.
17. EH in women on
adjuvant treatment
for breast cancer
➢ Women taking tamoxifen should explained
about increased risk of EH and cancer.
➢ Women taking aromatase inhibitor should be
informed that these medication do not increase
the risk of EH and EC.
➢ There is evidence that use of LNG-IUS prevents
polyp formation and it reduces incidence of EH
in women on tamoxifen therapy but the risk of
using LNG-IUS on breast cancer is uncertain
which limits its use routinely.
➢ EH confined to an endometrial polyp complete
removal of uterine polyp(s) should be
recommended and endometrial biopsy should
be obtained to sample the background
endometrium
18. ALGORITHM FOR MANAGEMENT OF EH
ATYPICAL ENDOMETRIAL
HYPERPLASIA
ENDOMETRIAL HYPERPLASIA WITHOUT
ATYPIA
ADDRESS RISK
FACTORS
OBSERVATION
LNG-IUD
ORAL
PROGESTINS
FERTILITY REQUIRED
OR
SURGERY C/I
TOTAL
HYSTERECTOMY +/-
BSO
EB TO BE TAKEN
EH AT 6 MONTHS
AH AT 3 MONTHS
REGRESSION PERSISTENCE PROGRESSION
19. REGRESSION
REVIEW TREATMENT :
LNG-IUS continue for 5 years
Oral progestogen stop after 6 months
Total hysterectomy +/- BSO if ongoing AUB
ARRANGE FOLLOW UP( MEDICAL MX)
EH- i) BMI< 35 , two consecutive EBs at 6 months intervals
negative - discharge
ii) BMI >35 , or treated with oral progestogens: > two
consecutive negative EBs at 6 months interval , thereafter
annual EB and review
AH- > 2 consecutive negative EBs at 6 months interval
thereafter 6-12 monthly EB and review.
If RELAPSE occurs : advice total hysterectomy +/- BSO
20. PERSISTENCE REVIEW TREATMENT :
EH- start medical management if observation failed
Advice Total hysterectomy +/- BSO if persistence after
12 months of medical treatment
AH- advice total hysterectomy +/- BSO
ARRANGE FOLLOW UP-:
No EC- review at 6 weeks and discharge
EC- manage according to guideline
21. PROGRESSION
REVIEW TREATMENT :
AH- total hysterectomy +/- BSO
EC- manage according to local guideline
ARRANGE FOLLOW UP :
No EC - review at 6 weeks and discharge
EC- manage according to local cancer guideline
22. Previous year
questions
1. a) What are the different types of endometrial hyperplasia? b)
Discuss briefly about the prognosis of each type c) how will you
manage different types of EH in a perimenopausal women?
[june 2018]
2. a) What is EH ? b) classify EH , indicating there malignant potential.
c) outline the principles of management of atypical hyperplasia. [ june
2016]
3. a) Classification of AUB. b) outline the workup plan for a 30 year old
women having AUB. c) How will you manage EH hyperplasia in such
women. [ Dec 12]
4. a) write briefly about management and prognosis of EH .b) Describe
the role of diagnostic and operative hysteroscopy in management of
uterine pathology. [ Dec 2011]
5. a) EH and its association .b) management of perimenopausal
women with simple cystic hyperplasia. [Dec 2019]
6. A 30 year old P1 L1 hs AUB . Histopathology report of endometrial
sample reveals hyperplasia with atypia . she desires to retain her
fertility a) list factors that predisposes to EH. b) management options
that you can offer her. c) outline her follow up protocol. [Dec 2018]
