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Endometrial hyperplasia

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Updated 2024 SOGC guidelines for the evaluation and management of asymptomatic endometrial thickening in postmenopausal patients.

Background

Overview

Definition
Endometrial hyperplasia is an abnormal growth of endometrial glands and stroma due to excessive estrogen exposure and can be a precursor to endometrial cancer.
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Pathophysiology
The pathophysiology of endometrial hyperplasia is primarily driven by chronic exposure to unopposed estrogen, which stimulates the proliferation of endometrial cells, and a deficiency in progesterone, which normally counteracts the effects of estrogen by inducing cell differentiation and apoptosis.
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Epidemiology
The incidence of endometrial hyperplasia is estimated at 133 per 100,000 woman-years, peaking at ages 50-60. The peak incidences of simple, complex, and atypical endometrial hyperplasia are estimated at 142, 213, and 56 per 100,000 woman-years, respectively.
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Risk factors
Risk factors for endometrial hyperplasia include obesity, diabetes, PCOS, and postmenopausal status, all of which can lead to an excess of estrogen. Certain medications, such as tamoxifen and selective estrogen-receptor modulators, can also increase the risk of endometrial hyperplasia.
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Disease course
Clinically, endometrial hyperplasia most commonly presents with abnormal uterine bleeding, which can manifest as heavy menstrual bleeding or postmenopausal bleeding.
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Prognosis and risk of recurrence
The prognosis of endometrial hyperplasia varies based on the type of hyperplasia and the presence of atypical cells. While most cases of endometrial hyperplasia are benign, there is a potential for progression to endometrial cancer. The cumulative 20-year progression risk is < 5% for non-atypical endometrial hyperplasia but increases to 28% for atypical hyperplasia.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of endometrial hyperplasia are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2024,2019), the American College of Obstetricians and Gynecologists (ACOG 2023), the Royal College of Obstetricians and Gynaecologists (RCOG 2017,2014), the British Society for Gynaecological Endoscopy (BSGE/RCOG 2016), and the ...
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Diagnostic investigations

Diagnostic imaging
As per BSGE/RCOG 2016 guidelines:
Consider obtaining a transvaginal ultrasound for the diagnosis of endometrial hyperplasia in premenopausal and postmenopausal patients.
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Do not obtain CT or diffusion-weighted MRI routinely in the management of endometrial hyperplasia.
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  • Biomarkers

Diagnostic procedures

Diagnostic hysteroscopy
As per BSGE/RCOG 2016 guidelines:
Consider performing diagnostic hysteroscopy to facilitate or obtain an endometrial sample, especially where outpatient sampling fails or is nondiagnostic.
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Perform direct visualization and biopsy of the uterine cavity during hysteroscopy where endometrial hyperplasia has been diagnosed within a polyp or other discrete focal lesion.
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  • Endometrial biopsy

Medical management

Addressing reversible factors: as per SOGC 2019 guidelines, assess for reversible risk factors of endometrial hyperplasia and provide education and support to treat and reverse those conditions.
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  • Expectant management

  • Progestin therapy

Therapeutic procedures

Endometrial ablation: as per BSGE/RCOG 2016 guidelines, do not perform endometrial ablation for the treatment of endometrial hyperplasia, as complete and persistent endometrial destruction cannot be ensured and intrauterine adhesion formation may preclude future endometrial histological surveillance.
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Surgical interventions

Hysterectomy and salpingo-oophorectomy: as per SOGC 2019 guidelines, reserve surgical treatment of endometrial hyperplasia without atypia for patients not wishing to preserve their fertility and having any of the following:
progressing to atypical hyperplasia or carcinoma during follow-up
failing to regress after 12 months of medical treatment or relapsing after completing treatment with progestins
continuing to have abnormal uterine bleeding despite treatment
declining endometrial surveillance or medical treatment.
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Specific circumstances

Patients with asymptomatic endometrial thickening, tissue sampling: as per SOGC 2024 guidelines, do not extrapolate indications for endometrial tissue sampling in patients with postmenopausal bleeding to asymptomatic patients.
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  • Patients with asymptomatic endometrial thickening (further evaluation)

  • Patients with asymptomatic endometrial thickening (ultrasound surveillance)

  • Patients with atypical endometrial hyperplasia (evaluation)

  • Patients with atypical endometrial hyperplasia (general counseling)

  • Patients with atypical endometrial hyperplasia (hysterectomy and salpingo-oophorectomy)

  • Patients with atypical endometrial hyperplasia (endometrial ablation)

  • Patients with atypical endometrial hyperplasia (progestin therapy)

  • Patients with atypical endometrial hyperplasia (endometrial surveillance)

  • Patients contemplating pregnancy

  • Patients receiving hormonal replacement therapy

  • Patients receiving tamoxifen

  • Patients receiving aromatase inhibitors

  • Patients with PCOS

  • Patients with endometrial polyps

Preventative measures

Primary prevention: as per ACOG 2023 guidelines, advise lifestyle modifications resulting in weight loss and glycemic control to improve overall health and potentially decrease the risk of endometrial intraepithelial neoplasia-atypical endometrial hyperplasia and endometrial cancer.
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Follow-up and surveillance

Endometrial surveillance: as per BSGE/RCOG 2016 guidelines, obtain endometrial surveillance incorporating outpatient endometrial biopsy after a diagnosis of endometrial hyperplasia without atypia.
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