Endometrial hyperplasia
Unopposed-oestrogen endometrial proliferation (± atypia)
Overview
Proliferation of the endometrium from unopposed oestrogen — a precursor to endometrial cancer, especially with atypia. A key cause of abnormal/postmenopausal bleeding and the reason oestrogen-only HRT is contraindicated with an intact uterus.
Recognise
- Abnormal uterine bleeding: heavy/irregular, intermenstrual, or POSTMENOPAUSAL bleeding
- Risk factors = unopposed oestrogen: obesity, PCOS, nulliparity, late menopause, tamoxifen, oestrogen-only HRT
- Hyperplasia WITH ATYPIA carries a high progression risk to cancer
Red flags
- Postmenopausal bleeding → 2-week-wait referral; atypical hyperplasia → high cancer risk/coexisting cancer
Differentials & how to tell them apart
Investigations
Transvaginal USS (endometrial thickness); endometrial biopsy (pipelle) ± hysteroscopy to diagnose and grade (with/without atypia).
Management
Without atypia: progestogen (LNG-IUS first-line) + address risk factors; WITH atypia: hysterectomy
- 1Hyperplasia WITHOUT atypia: LNG-IUS (first-line) or oral progestogen, weight loss / stop unopposed oestrogen; repeat biopsy to confirm regression.Gate: Hyperplasia WITH atypia → total hysterectomy (high progression/coexisting-cancer risk); fertility-sparing progestogen only in selected cases
- 2Postmenopausal: total hysterectomy ± BSO is often preferred even without atypia.
Key points
Unopposed oestrogen is the theme — which is why oestrogen-only HRT needs a progestogen (or LNG-IUS) with an intact uterus. Atypia is the pivot to surgery.
Monitor & prognosis
Repeat biopsy to confirm regression; surveillance.
Without atypia usually regresses on progestogen; with atypia carries significant cancer risk.
Source: RCOG/BSGE endometrial hyperplasia; NICE