RCOG | Endometrial hyperplasia

This is a new guideline from RCOG on diagnosing and managing endometrial hyperplasia. This is a very common condition, so highly relevant for us and I had no idea on some of the management options. I am therefore doing a general summary.


  • Endometrial Hyperplasia without atypia - fewer than 5% will progress to cancer over 20 yrs and most regress spontaneously.
  • Endometrial Hyperplasia with atypia - there is a much high risk of cancer (8% at 4 yrs, 12% at 9 yrs and 27% at 19 yrs and concomitant cancer is found in 43% of women at hysterectomy).

Risk Factors

Oestrogen exposure, whether exogenous (tamoxifen / oestrogen only HRT) or endogenous (obesity, PCOS or perimenopause with anovulation or estrogen secreting tumours).

[Tweet "Obesity and PCOS are both risk factors for endometrial hyperplasia"]By Nephron (Own work) [CC BY-SA 3.0 ) or GFDL , via Wikimedia Commons


  • Heavy menstrual bleeding (beware the over 45s)
  • IMB
  • Irregular bleeding
  • Unscheduled bleeding on HRT
  • Postmenopausal bleeding


  • Endometrial biopsy
  • Hysteroscopic Biopsy (if above undiagnostic or if hyperplasia is found on a polyp)
  • USS transvaginal

- Postmenopausal - an endometrial thickness of < 3 or 4mm gives < 1% risk of CA. If there are endometrial irregularities or double layer thickness, hysteroscopy is needed.

- Premenopausal - In women with PCOS with amenorrhoea or abnormal bleeds, a cut-off of 7mm can be used (with no CA found in studies at this thickness).

- All women diagnosed with hyperplasia who haven't already had one, to check for ovarian tumours (which can secrete oestrogen).

Management in women without atypia

  • Risk factors - manage (eg obesity or HRT or tamoxifen)
  • Observation with regular biopsies - as many regress spontaneously. This is often the preferred initial management.
  • Progestogen treatment - if they fail to regress spontaneously or are symptomatic with abnormal bleeding. Mirena or other LNG-IUS is the first-line treatment, then oral progestogens.
  • Hysterectomy - failure of above treatments (generally after 12m), or if relapse after successful treatment.

Management in women with atypia

  • Hysterectomy - because of the high risk of cancer.
  • Progestogen treatment - this should only be considered in premenopausal women who wish to maintain their fertility. Hysterectomy is advised as soon as fertility is no longer required because of the high cancer risk.

HRT and endometrial hyperplasia

  • Sequential HRT - if endometrial hyperplasia is diagnosed,  swapping to continuous progestogen seems to resolve most cases. This can be done either with continuous combined HRT, or by using a Mirena.
  • Continuous HRT - consider the need to continue it. There isn't good evidence on the best options for treatment, but current advice is to consider using a Mirena to provide the progestogen.


Image by Nephron (Own work) [CC BY-SA 3.0 or GFDL], via Wikimedia Commons

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