GTG 67 Endometrial Hyperplasia

Management of Endometrial
Hyperplasia
Green-top Guideline No. 67

RCOG/BSGE Joint Guideline | February 2016
Management of Endometrial Hyperplasia
This is the first edition of this guideline.This is a joint guideline between the Royal College of Obstetricians
and Gynaecologists (RCOG) and the British Society for Gynaecological Endoscopy (BSGE).
Executive summary of recommendations
What are the risk factors for endometrial hyperplasia?
P
Endometrial hyperplasia is often associated with multiple identifiable risk factors and assessment
should aim to identify and monitor these factors.
How should endometrial hyperplasia be classified?
The revised 2014 World Health Organization (WHO) classification is recommended. This separates
endometrial hyperplasia into two groups based upon the presence of cytological atypia: i.e. (i)
D
hyperplasia without atypia and (ii) atypical hyperplasia.
What diagnostic and surveillance methods are available for endometrial hyperplasia?
Diagnosis of endometrial hyperplasia requires histological examination of the endometrial tissue.

Endometrial surveillance should include endometrial sampling by outpatient endometrial biopsy.
B
P
Diagnostic hysteroscopy should be considered to facilitate or obtain an endometrial sample, especially
where outpatient sampling fails or is nondiagnostic.
P
Transvaginal ultrasound may have a role in diagnosing endometrial hyperplasia in pre- and
postmenopausal women.
P
Direct visualisation and biopsy of the uterine cavity using hysteroscopy should be undertaken where
endometrial hyperplasia has been diagnosed within a polyp or other discrete focal lesion.
There is insufficient evidence evaluating computerised tomography (CT), diffusion-weighted magnetic

resonance imaging (MRI) or biomarkers as aids in the management of endometrial hyperplasia and
B
their use is not routinely recommended.
How should endometrial hyperplasia without atypia be managed?
What should the initial management of hyperplasia without atypia be?
Women should be informed that the risk of endometrial hyperplasia without atypia progressing to
endometrial cancer is less than 5% over 20 years and that the majority of cases of endometrial
B
hyperplasia without atypia will regress spontaneously during follow-up.
P
Reversible risk factors such as obesity and the use of hormone replacement therapy (HRT) should be
identified and addressed if possible.
Observation alone with follow-up endometrial biopsies to ensure disease regression can be considered,
especially when identifiable risk factors can be reversed. However, women should be informed that
C
treatment with progestogens has a higher disease regression rate compared with observation alone.
P
Progestogen treatment is indicated in women who fail to regress following observation alone and in
symptomatic women with abnormal uterine bleeding.
RCOG/BSGE Green-top Guideline No. 67 2 of 30 Royal College of Obstetricians and Gynaecologists

What should the first-line medical treatment of hyperplasia without atypia be?
Both continuous oral and local intrauterine (levonorgestrel-releasing intrauterine system [LNG-IUS])
progestogens are effective in achieving regression of endometrial hyperplasia without atypia.
A
The LNG-IUS should be the first-line medical treatment because compared with oral progestogens it
has a higher disease regression rate with a more favourable bleeding profile and it is associated with
A
fewer adverse effects.
Continuous progestogens should be used (medroxyprogesterone 1020 mg/day or norethisterone

1015 mg/day) for women who decline the LNG-IUS.
B
Cyclical progestogens should not be used because they are less effective in inducing regression of
endometrial hyperplasia without atypia compared with continuous oral progestogens or the LNG-IUS.
A
What should the duration of treatment and follow-up of hyperplasia without atypia be?
Treatment with oral progestogens or the LNG-IUS should be for a minimum of 6 months in order to
induce histological regression of endometrial hyperplasia without atypia.
B
P
If adverse effects are tolerable and fertility is not desired, women should be encouraged to retain the
LNG-IUS for up to 5 years as this reduces the risk of relapse, especially if it alleviates abnormal uterine
bleeding symptoms.
Endometrial surveillance incorporating outpatient endometrial biopsy is recommended after a

diagnosis of hyperplasia without atypia.
C
Endometrial surveillance should be arranged at a minimum of 6-monthly intervals, although review

schedules should be individualised and responsive to changes in a womans clinical condition.
D
At least two consecutive 6-monthly negative biopsies should be obtained prior to discharge.
P
Women should be advised to seek a further referral if abnormal vaginal bleeding recurs after
completion of treatment because this may indicate disease relapse.
In women at higher risk of relapse, such as women with a body mass index (BMI) of 35 or greater or
those treated with oral progestogens, 6-monthly endometrial biopsies are recommended. Once two
D
consecutive negative endometrial biopsies have been obtained then long-term follow-up should be
considered with annual endometrial biopsies.
When is surgical management appropriate for women with endometrial hyperplasia without atypia?
Hysterectomy should not be considered as a first-line treatment for hyperplasia without atypia because
progestogen therapy induces histological and symptomatic remission in the majority of women and
C
avoids the morbidity associated with major surgery.
Hysterectomy is indicated in women not wanting to preserve their fertility when (i) progression to
atypical hyperplasia occurs during follow-up, or (ii) there is no histological regression of hyperplasia
C
despite 12 months of treatment, or (iii) there is relapse of endometrial hyperplasia after completing
progestogen treatment, or (iv) there is persistence of bleeding symptoms, or (v) the woman declines
to undergo endometrial surveillance or comply with medical treatment.

P
Postmenopausal women requiring surgical management for endometrial hyperplasia without atypia
should be offered a bilateral salpingo-oophorectomy together with the total hysterectomy.
For premenopausal women, the decision to remove the ovaries should be individualised; however,
bilateral salpingectomy should be considered as this may reduce the risk of a future ovarian
D
malignancy.
A laparoscopic approach to total hysterectomy is preferable to an abdominal approach as it is

B
associated with a shorter hospital stay, less postoperative pain and quicker recovery.
Endometrial ablation is not recommended for the treatment of endometrial hyperplasia because
complete and persistent endometrial destruction cannot be ensured and intrauterine adhesion
D
formation may preclude future endometrial histological surveillance.
How should atypical hyperplasia be managed?
What should the initial management of atypical hyperplasia be?
Women with atypical hyperplasia should undergo a total hysterectomy because of the risk of
B
underlying malignancy or progression to cancer.

B
There is no benefit from intraoperative frozen section analysis of the endometrium or routine
C
lymphadenectomy.
P
Postmenopausal women with atypical hyperplasia should be offered bilateral salpingo-oophorectomy
together with the total hysterectomy.
D
malignancy.
Endometrial ablation is not recommended because complete and persistent endometrial destruction
cannot be ensured and intrauterine adhesion formation may preclude endometrial histological
C
surveillance.
How should women with atypical hyperplasia who wish to preserve their fertility or who are not
suitable for surgery be managed?
P
Women wishing to retain their fertility should be counselled about the risks of underlying malignancy
and subsequent progression to endometrial cancer.
P
Pretreatment investigations should aim to rule out invasive endometrial cancer or co-existing ovarian
cancer.
P
Histology, imaging and tumour marker results should be reviewed in a multidisciplinary meeting and
a plan for management and ongoing endometrial surveillance formulated.
First-line treatment with the LNG-IUS should be recommended, with oral progestogens as a
second-best alternative (see section 7.2).
B

Once fertility is no longer required, hysterectomy should be offered in view of the high risk of disease
relapse.
B
How should women with atypical hyperplasia not undergoing hysterectomy be followed up?
Routine endometrial surveillance should include endometrial biopsy. Review schedules should be
individualised and be responsive to changes in a womans clinical condition. Review intervals should
D
be every 3 months until two consecutive negative biopsies are obtained.
P
In asymptomatic women with a uterus and evidence of histological disease regression, based upon a
minimum of two consecutive negative endometrial biopsies, long-term follow-up with endometrial
biopsy every 612 months is recommended until a hysterectomy is performed.
How should endometrial hyperplasia be managed in women wishing to conceive?
P
Disease regression should be achieved on at least one endometrial sample before women attempt to
conceive.
Women with endometrial hyperplasia who wish to conceive should be referred to a fertility specialist
D
to discuss the options for attempting conception, further assessment and appropriate treatment.
Assisted reproduction may be considered as the live birth rate is higher and it may prevent relapse
C
compared with women who attempt natural conception.
Prior to assisted reproduction, regression of endometrial hyperplasia should be achieved as this is

B
associated with higher implantation and clinical pregnancy rates.
HRT and endometrial hyperplasia
Systemic estrogen-only HRT should not be used in women with a uterus.

A
P
All women taking HRT should be encouraged to report any unscheduled vaginal bleeding promptly.
Women with endometrial hyperplasia taking a sequential HRT preparation who wish to continue HRT
should be advised to change to continuous progestogen intake using the LNG-IUS or a continuous
B
combined HRT preparation. Subsequent management should be as described in the preceding sections
of the guideline.
P
Women with endometrial hyperplasia taking a continuous combined preparation who wish to continue
HRT should have their need to continue HRT reviewed. Discuss the limitations of the available evidence
regarding the optimal progestogen regimen in this context. Consider using the LNG-IUS as a source of
progestogen replacement. Subsequent management should be as described in the preceding sections
of the guideline.
How should endometrial hyperplasia be managed in women on adjuvant treatment for breast cancer?
What is the risk of developing endometrial hyperplasia on adjuvant treatment for breast cancer?
Women taking tamoxifen should be informed about the increased risks of developing endometrial
D
hyperplasia and cancer. They should be encouraged to report any abnormal vaginal bleeding or
discharge promptly.

P
Women taking aromatase inhibitors (such as anastrozole, exemestane and letrozole) should be
informed that these medications are not known to increase the risk of endometrial hyperplasia and
cancer.
Should women on tamoxifen be treated with prophylactic progestogen therapy?
There is evidence that the LNG-IUS prevents polyp formation and that it reduces the incidence of
A
endometrial hyperplasia in women on tamoxifen. The effect of the LNG-IUS on breast cancer recurrence
risk remains uncertain so its routine use cannot be recommended.
How should women who develop endometrial hyperplasia while on tamoxifen treatment for breast
cancer be managed?
P
The need for tamoxifen should be reassessed and management should be according to the histological
classification of endometrial hyperplasia and in conjunction with the womans oncologist.
How should endometrial hyperplasia confined to an endometrial polyp be managed?
Complete removal of the uterine polyp(s) is recommended and an endometrial biopsy should be
D
obtained to sample the background endometrium.
P
Subsequent management should be according to the histological classification of endometrial
hyperplasia.
1. Purpose and scope
The aim of this guideline is to provide clinicians with up-to-date evidence-based information regarding
the management of endometrial hyperplasia.
2. Introduction and background epidemiology
Endometrial hyperplasia is defined as irregular proliferation of the endometrial glands with an increase
in the gland to stroma ratio when compared with proliferative endometrium.1
Endometrial cancer is the most common gynaecological malignancy in the Western world and
endometrial hyperplasia is its precursor.2 In the UK, 8617 new cases of endometrial cancer were
registered in 2012.3 The incidence of endometrial hyperplasia is estimated to be at least three times
higher than endometrial cancer and if left untreated it can progress to cancer.2,4
The most common presentation of endometrial hyperplasia is abnormal uterine bleeding. This
includes heavy menstrual bleeding, intermenstrual bleeding, irregular bleeding, unscheduled bleeding
on hormone replacement therapy (HRT) and postmenopausal bleeding.2
3. Identification and assessment of evidence
This guideline was developed using standard methodology for developing RCOG Green-top
Guidelines. The Cochrane Library (including the Cochrane Database of Systematic Reviews, the
Database of Abstracts of Reviews of Effects [DARE] and the Cochrane Central Register of Controlled
Trials [CENTRAL]), EMBASE, MEDLINE and CINAHL were searched for relevant papers. The search was
inclusive of all relevant articles published until June 2015. The databases were searched using the
relevant Medical Subject Headings (MeSH) terms, including all subheadings and synonyms, and this
was combined with a keyword search. The search included the following terms: (endometr*

hyperplas* or premalignant endometr* or precancer* endometr* or endometrial neoplasms or
endometr* cancer) AND (intrauterine devices or mirena or progest* or LNG-IU* or gestag* or fertility-
sparing therapy or conservative therapy or hormon* therapy or estrogen replacement therapy or
hormone replacement therapy or tamoxifen or progestins or hysterectomy or ultrasound or magnetic
resonance imaging or computed tomography or endometr* biopsy or hysteroscopy or infertility or
endometrial ablation). The search was limited to humans and papers in the English language. Relevant
guidelines were also searched for using the same criteria in the National Guideline Clearinghouse,
National Institute for Health and Care Excellence (NICE) Evidence Search and the Canadian Medical
Association (CMA) Infobase.
Where possible, recommendations are based on available evidence. Areas lacking evidence are
highlighted and annotated as good practice points. Further information about the assessment of
evidence and the grading of recommendations may be found in Appendix I.
4. What are the risk factors for endometrial hyperplasia?
P
Endometrial hyperplasia is often associated with multiple identifiable risk factors and assessment
should aim to identify and monitor these factors.
Endometrial hyperplasia develops when estrogen, unopposed by progesterone, stimulates

endometrial cell growth by binding to estrogen receptors in the nuclei of endometrial cells.
Known risk factors for endometrial hyperplasia reflect this aetiology: increased body mass
index (BMI) with excessive peripheral conversion of androgens in adipose tissue to Evidence
estrogen; anovulation associated with the perimenopause or polycystic ovary syndrome level 2+
(PCOS); estrogen-secreting ovarian tumours, e.g. granulosa cell tumours (with up to 40%
prevalence of endometrial hyperplasia); and drug-induced endometrial stimulation, e.g. the
use of systemic estrogen replacement therapy or long-term tamoxifen.510
A Cochrane meta-analysis found that unopposed estrogen replacement therapy is associated

Evidence
with an increased incidence of hyperplasia at all doses and is not recommended for use in level 1++
women with a uterus.9
While estrogenic stimulation of the endometrium is believed to be the main aetiological

risk factor for developing the condition, other elements such as immunosuppression and
Evidence
infection may also be involved.10 A retrospective analysis of 45 renal graft recipients with level 3
abnormal bleeding found a two-fold increased incidence of endometrial hyperplasia (69%
versus 33%) compared with nontransplanted controls.10
5. How should endometrial hyperplasia be classified?
The revised 2014 World Health Organization (WHO) classification is recommended. This separates
endometrial hyperplasia into two groups based upon the presence of cytological atypia: i.e. (i)
D
hyperplasia without atypia and (ii) atypical hyperplasia.
Classification systems for endometrial hyperplasia were developed based upon histological
characteristics and oncogenic potential.
The widely adopted 1994 WHO classification of endometrial hyperplasia was based upon
both the complexity of the glandular architecture and the presence of nuclear atypia.1 It
Evidence
comprised four categories: (i) simple hyperplasia, (ii) complex hyperplasia, (iii) simple
level 4
hyperplasia with atypia and (iv) complex hyperplasia with atypia. The association of
cytological atypia with an increased risk of endometrial cancer has been known since 1985.2

The endometrial intraepithelial neoplasia (EIN) classification is an alternative system of
nomenclature proposed in 2003,11 the purpose of which was to improve prediction of
clinical outcomes, improve inter-observer reproducibility and reduce subjective bias
inherent to the 1994 WHO classification. The EIN diagnostic schema comprises three
categories benign (endometrial hyperplasia), premalignant (a diagnosis of EIN based upon
five subjective histological criteria) and malignant (endometrial cancer) but this
classification is not extensively used in the UK.
Evidence
1
The 2014 revised WHO classification simply separates endometrial hyperplasia into two level 4
groups based upon the presence or absence of cytological atypia, i.e. (i) hyperplasia without
atypia and (ii) atypical hyperplasia; the complexity of architecture is no longer part of the
classification. The diagnosis of EIN in the new WHO classification is considered
interchangeable with atypical hyperplasia. This guideline has adopted the new 2014 WHO
classification of endometrial hyperplasia, although much of the supporting evidence
identified has used the 1994 WHO nomenclature categorising hyperplasia morphologically
as simple or complex.
6. What diagnostic and surveillance methods are available for endometrial hyperplasia?
Diagnosis of endometrial hyperplasia requires histological examination of the endometrial tissue.

Endometrial surveillance should include endometrial sampling by outpatient endometrial biopsy.
B
P
Diagnostic hysteroscopy should be considered to facilitate or obtain an endometrial sample, especially
where outpatient sampling fails or is nondiagnostic.
P
Transvaginal ultrasound may have a role in diagnosing endometrial hyperplasia in pre- and
postmenopausal women.
P
Direct visualisation and biopsy of the uterine cavity using hysteroscopy should be undertaken where
endometrial hyperplasia has been diagnosed within a polyp or other discrete focal lesion.
There is insufficient evidence evaluating computerised tomography (CT), diffusion-weighted magnetic

resonance imaging (MRI) or biomarkers as aids in the management of endometrial hyperplasia and
B
their use is not routinely recommended.
Endometrial hyperplasia is often suspected in women presenting with abnormal uterine bleeding.
However, confirmation of diagnosis requires histological analysis of endometrial tissue specimens
obtained either by using miniature outpatient suction devices designed to blindly abrade and/or
aspirate endometrial tissue from the uterine cavity or by inpatient endometrial sampling, such as
dilatation and curettage performed under general anaesthesia. Endometrial sampling is also
fundamental in monitoring regression, persistence or progression.
Outpatient endometrial biopsy is convenient and has high overall accuracy for diagnosing
endometrial cancer.12 The accuracy for hyperplasia is more modest, with a systematic review
reporting a pooled likelihood ratio (LR) of 12.0 (95% CI 7.818.6) for a positive test and 0.2
(95% CI 0.10.3) for a negative test result.13 Despite a negative biopsy result, 2% of women
will still have endometrial hyperplasia.13 Evidence
level 2++
A transvaginal ultrasound scan (TVS) that detects an irregularity of the endometrial profile
or an abnormal double layer endometrial thickness measurement would give further reason
to perform an endometrial biopsy in women with postmenopausal bleeding.14,15 Systematic
reviews have suggested a cut-off of 3 mm or 4 mm for ruling out endometrial cancer and

have shown that the probability of cancer is reduced to less than 1% when the endometrial
thickness is less than the cut-off.14,1618 However, a larger cut-off value has been suggested for Evidence
women taking HRT or tamoxifen, whether presenting with abnormal uterine bleeding or level 2++
asymptomatic.15,19
The role of ultrasound in premenopausal women is restricted to identifying structural

abnormalities, as there seems to be an overlap between normal endometrial thickness and
that caused by endometrial disease.20 However, for women with PCOS and absent
withdrawal bleeds or abnormal uterine bleeding, a TVS should be considered, as advised by Evidence
RCOG guidance.21 A prospective study of 56 women with PCOS found that no woman with level 2+
an endometrial thickness of less than 7 mm had endometrial hyperplasia.22 As a result, the
RCOG guidance supports the conclusion that below this cut-off endometrial hyperplasia is
unlikely.21
Hysteroscopy with additional endometrial assessment may be necessary if abnormal

bleeding persists or if intrauterine structural abnormalities such as polyps are suspected on
TVS or endometrial biopsy. A small cohort study has shown that up to 10% of endometrial Evidence
pathology can be missed even with inpatient endometrial sampling.23 However, in level 2
premenopausal women who wish to preserve their fertility, repeated curettage should be
minimised to reduce the incidence of Ashermans syndrome.
Hysteroscopy can detect focal lesions such as polyps that may be missed by blind sampling.24
A population-based cross-sectional study diagnosed focal endometrial pathology in
Evidence
approximately 10% (64/684) of women who volunteered to undergo a saline contrast level 2++
sonohysterography as part of the research; two of these were found to have hyperplasia
without atypia.25
In addition, hysteroscopy can be used to facilitate or complement the endometrial biopsy,

especially where sampling is not possible or is nondiagnostic. Directed biopsies can be Evidence
taken through the operating channel of a continuous flow operating hysteroscope24,26 or level 1
blindly through the outer sheath after removing the telescope.27
Diagnostic hysteroscopy can be conducted in the outpatient setting using miniature

hysteroscopes and without the need for anaesthesia or vaginal instrumentation.28 The
accuracy of hysteroscopy in diagnosing cancer and hyperplasia in women with abnormal
bleeding has been evaluated in a systematic quantitative review of data from 26 346 women.29
A positive hysteroscopy result (positive LR 60.9) increased the probability of cancer to 71.8%
from a pretest probability of 3.9%, whereas a negative hysteroscopy result (negative LR 0.15)
reduced the probability of cancer to 0.6%.29 A hysteroscopy suggestive of endometrial disease
(i.e. cancer or endometrial hyperplasia of any type) increased the probability of disease from
a pretest probability of 10.6% to 55.2% (positive LR 10.4). A negative or normal hysteroscopy
reduced the probability of endometrial disease from 10.6% to 2.8% (negative LR 0.24).29 Evidence
Hence, hysteroscopy is more accurate in detecting than excluding endometrial disease and level 2++
has a higher accuracy for endometrial cancer than endometrial hyperplasia.29
CT or MRI to aid the diagnosis of hyperplasia is not commonly used. It is reported that a
preoperative CT scan of women who have atypical endometrial hyperplasia or grade 1
endometrial cancer could alter management in 4.3% of cases.30 However, there are no
studies evaluating its use for following up women with endometrial hyperplasia when
treated conservatively. It is an expensive test and because of the radiation associated with
its application it should not be routinely recommended. Diffusion-weighted MRI may help
in identifying women with invasive cancer and it has the future potential to diagnose

endometrial hyperplasia and other endometrial lesions.31 Thus, it could become a useful
technology in women undergoing surveillance for atypical endometrial hyperplasia as a
predictor for malignant change, but more evidence is needed.
Several biomarkers associated with endometrial hyperplasia have been investigated, but as Evidence
of yet none of them predicts disease or prognosis accurately enough to be clinically useful. level 2++
A systematic review evaluated 123 observational immunohistochemical studies and found
that the phosphatase and tensin homolog (PTEN), perhaps in combination with B-cell
lymphoma 2 (BCL-2) and BCL-2-like protein 4 (BAX), could be potentially useful, but more
research is needed before use.32
7. How should endometrial hyperplasia without atypia be managed?
7.1 What should the initial management of hyperplasia without atypia be?
Women should be informed that the risk of endometrial hyperplasia without atypia progressing to
endometrial cancer is less than 5% over 20 years and that the majority of cases of endometrial
B
hyperplasia without atypia will regress spontaneously during follow-up.
P
Reversible risk factors such as obesity and the use of HRT should be identified and addressed if
possible.
Observation alone with follow-up endometrial biopsies to ensure disease regression can be considered,
C
especially when identifiable risk factors can be reversed. However, women should be informed that
treatment with progestogens has a higher disease regression rate compared with observation alone.
P
Progestogen treatment is indicated in women who fail to regress following observation alone and in
symptomatic women with abnormal uterine bleeding.
There are two cohort studies and a casecontrol study describing the natural history of
hyperplasia without atypia and its risk for progression to cancer.2,33,34 A 20-year follow-up
study found that, among women with hyperplasia without atypia, previously known as
women with simple or complex hyperplasia, the cumulative long-term risk for progression
to cancer is less than 5%.33 An earlier study with a mean follow-up duration of 13.4 years
found that progression to cancer occurred in 1/93 (1%) women with simple hyperplasia
compared with 1/29 (3%) women with complex hyperplasia.2 A nested casecontrol study
of endometrial hyperplasia found a significant increase in risk of progression to endometrial
cancer for women with complex hyperplasia compared with matched controls with
disordered proliferative endometrium (rate ratio 2.8, 95% CI 17.9), although not for simple
hyperplasia (rate ratio 2.0, 95% CI 0.94.5).34 Evidence
level 2++
Spontaneous regression often occurs in women with hyperplasia without atypia. Two cohort
studies have followed up women diagnosed with endometrial hyperplasia who had no
treatment. The first study was a multicentre prospective study where 35 women with simple
hyperplasia and four women with complex hyperplasia were followed up for 24 weeks
without any treatment. They underwent endometrial sampling at 4, 8, 12 and 24 weeks of
follow-up.35 For women with simple hyperplasia, regression to normal endometrium
occurred in 74% of women (26/35), while 17% (6/35) had persistent hyperplasia and 9%
(3/35) progressed to atypical hyperplasia after 24 weeks of follow-up.35 For women with
complex hyperplasia, regression to normal endometrium was observed in 75% of women
(3/4) and one woman had persistent complex hyperplasia after 24 weeks.35

The second study was a retrospective cohort study, which followed up 93 women with
simple hyperplasia and 24 women with complex hyperplasia who were not treated for 12
years. Regression to normal endometrium occurred in 81% of women (74/93) with simple Evidence
hyperplasia, while 18% (17/93) had persistent disease and 1% (1/93) progressed to level 2+
endometrial cancer.2 For women with complex hyperplasia, 79% (19/24) regressed to
normal endometrium and the remaining 21% (5/24) had persistent complex hyperplasia.2
There are several reversible risk factors for endometrial hyperplasia. The slow progression of
endometrial hyperplasia without atypia to cancer offers a window of opportunity to address these
factors. Obesity is a major risk factor and advising obese women to lose weight is recommended, but
there is no evidence on weight loss strategies and their impact on progression or relapse outcomes
during follow-up.
Observational studies have demonstrated that up to 10% of severely obese women could
harbour asymptomatic endometrial hyperplasia and bariatric surgery may reduce this
risk.3638 Another observational study described the acceptability of bariatric referrals when Evidence
offered by gynaecological oncologists to 106 women and found that more than 90% would level 2
be happy to discuss weight loss and approximately half accepted a medical referral to a
bariatric specialist with or without surgical referral.39
Clinicians should take a detailed history of any use of exogenous hormones that includes
both prescribed HRT preparations and over-the-counter preparations that may contain high Evidence
potency estrogens. Clinicians should be aware that nonprescribed estrogen intake may take level 2++
various forms.40
The indication and type of combined HRT regimen should be reviewed, especially as regards the
relative dosages of estrogen and progestogen as well as the mode of administration of these hormones.
A manipulation of the combined HRT regimen alone is often sufficient in inducing regression of
endometrial hyperplasia without atypia. This is particularly important for postmenopausal women as
they have a higher risk of developing endometrial hyperplasia and cancer because of unopposed
extraovarian estrogenic stimulation.
Ongoing tamoxifen treatment should be reviewed in conjunction with the womans oncologist.
Anovulatory cycles are often causal of endometrial hyperplasia in women who have PCOS
or who are perimenopausal and they are likely to regress to normal once women with PCOS Evidence
resume ovulation or perimenopausal women reach the menopause.41 For further guidance level 2
on PCOS, please see RCOG Green-top Guideline No. 33.21
Many women with endometrial hyperplasia without atypia will present through
postmenopausal bleeding pathways and it is likely that they will have undergone a baseline
pelvic ultrasound. If not, this should be arranged to exclude the possibility of an estrogen-
secreting granulosa cell tumour of the ovary. If an ovarian cyst is detected on pelvic
ultrasound, then blood for ovarian tumour markers should be obtained as recommended
by the RCOG.42,43 In the absence of other identifiable risk factors for endometrial hyperplasia,
Evidence
a serum inhibin level together with an estradiol level may be considered if a granulosa cell level 2+
tumour is suspected.44,45
Progestogen treatment appears to have higher regression rates (8996%)46 compared with
observation only (74.281%)2,35 and it may reduce the risk of progression to cancer4 and
the need for hysterectomy.47 However, these estimates are derived from small observational
studies with varying completeness and lengths of follow-up.2,35,46

No comparative studies were identified that compared medical treatment with observation only for
women with endometrial hyperplasia without atypia. In view of a high spontaneous regression rate
and uncommon progression to more severe disease, it is uncertain whether medical management is
appropriate for all women.
Many women are diagnosed with endometrial hyperplasia while undergoing investigation of abnormal
uterine bleeding. Thus, treatment may be required on symptomatic grounds. Because of the risk of
progression to cancer, women who fail to regress with observation alone should be treated and
followed up to ensure regression. Observation alone is expected to fail where there is no identifiable
reversible risk factor causing the endometrial hyperplasia, but there is limited evidence.
7.2 What should the first-line medical treatment of hyperplasia without atypia be?
Both continuous oral and local intrauterine (levonorgestrel-releasing intrauterine system [LNG-IUS])
progestogens are effective in achieving regression of endometrial hyperplasia without atypia.
A
The LNG-IUS should be the first-line medical treatment because compared with oral progestogens it
has a higher disease regression rate with a more favourable bleeding profile and it is associated with
A
fewer adverse effects.
Continuous progestogens should be used (medroxyprogesterone 1020 mg/day or norethisterone

B
1015 mg/day) for women who decline the LNG-IUS.
Cyclical progestogens should not be used because they are less effective in inducing regression of
endometrial hyperplasia without atypia compared with continuous oral progestogens or the LNG-IUS.
A
Progestogens have been advocated to treat endometrial hyperplasia because they modify the
proliferative effects of estrogen on the endometrium. Treatment with progestogens was originally
limited to oral progestogens such as norethisterone, medroxyprogesterone acetate and megestrol
acetate.
Oral progestogens can have significant adverse effects and norethisterone at a high dose
has similar contraindications to combined contraceptive pills.48 More recently, intrauterine
delivery of progestogens via the LNG-IUS has been successfully used for this purpose.46
Evidence
The intrauterine release of the levonorgestrel minimises the systemic absorption of the level 4
hormone and aids compliance by reducing adverse effects. The LNG-IUS achieves a higher
concentration of levonorgestrel at the level of the endometrium compared with oral
progestogens.49
In women of reproductive age the LNG-IUS can also provide effective contraception and it
is recommended as first-line treatment for heavy menstrual bleeding.50
Evidence comparing use of the LNG-IUS and oral progestogens was identified from seven
randomised controlled trials, involving a total of 766 women, with a moderate risk of bias.5157
The available randomised controlled trials are summarised in a meta-analysis that found that Evidence
the LNG-IUS achieved a higher regression rate compared with oral progestogens after 3 level 1+
months (OR 2.30, 95% CI 1.393.82), 6 months (OR 3.16, 95% CI 1.845.45), 12 months
(OR 5.73, 95% CI 2.6712.33) and 24 months of treatment (OR 7.46, 95% CI 2.5521.78).
Women treated with a LNG-IUS compared with oral progestogens were less likely to need
hysterectomy during follow-up (OR 0.26, 95% CI 0.150.45). No difference was found in the
frequency of irregular vaginal bleeding in the two groups (OR 1.12, 95% CI 0.542.32).58

Only one randomised controlled trial was identified that compared different types, doses
and regimens for oral progestogens. This trial compared the efficacies of three different
10-day cyclical progestogens when used for 3 months for the treatment of simple hyperplasia Evidence
without atypia. The observed disease regression rates were similar for all drugs: 60% (18/30) level 1
for medroxyprogesterone (10 mg/day), 44% (11/25) for lynestrenol (15 mg/day) and 59%
(16/27) for norethisterone (15 mg/day).55
Meta-analyses of seven randomised controlled trials and 24 uncontrolled observational

Evidence
studies found that the most commonly used progestogens were medroxyprogesterone level 1+
(dose range 1020 mg/day) and norethisterone (dose range 1015 mg/day).46,57
7.3 What should the duration of treatment and follow-up of hyperplasia without atypia be?
Treatment with oral progestogens or the LNG-IUS should be for a minimum of 6 months in order to
B
induce histological regression of endometrial hyperplasia without atypia.
P
If adverse effects are tolerable and fertility is not desired, women should be encouraged to retain the
LNG-IUS for up to 5 years as this reduces the risk of relapse, especially if it alleviates abnormal uterine
bleeding symptoms.
Endometrial surveillance incorporating outpatient endometrial biopsy is recommended after a

diagnosis of hyperplasia without atypia.
C
Endometrial surveillance should be arranged at a minimum of 6-monthly intervals, although review

schedules should be individualised and responsive to changes in a womans clinical condition.
D
At least two consecutive 6-monthly negative biopsies should be obtained prior to discharge.
P
Women should be advised to seek a further referral if abnormal vaginal bleeding recurs after
completion of treatment because this may indicate disease relapse.
In women at higher risk of relapse, such as women with a BMI of 35 or greater or those treated with oral
progestogens, 6-monthly endometrial biopsies are recommended. Once two consecutive negative
D
endometrial biopsies have been obtained then long-term follow-up should be considered with annual
endometrial biopsies.
Higher regression rates have been shown from increasing the duration of medical treatment
from 3 to 6 months. One trial randomised women between the LNG-IUS and oral
continuous medroxyprogesterone and reported histological regression rates for endometrial Evidence
hyperplasia without atypia according to the duration of therapy. Between 3 and 6 months level 1
the regression rates improved for the LNG-IUS from 84% to 100% and for oral
medroxyprogesterone from 50% to 64%.53
In one trial women were randomised to LNG-IUS or two regimens of oral progestogens for
Evidence
6 months. The LNG-IUS was removed after 6 months. The authors found that relapse was level 1+
common (33%) and did not differ among the three groups.56
A meta-analysis of 11 observational uncontrolled studies found that oral progestogens were

Evidence
generally given for 36 months, whereas the LNG-IUS was usually used beyond this time and level 2++
for up to 5 years.46

Two long-term prospective cohort studies provide information about the duration of
follow-up and relapse rates following successful regression of endometrial hyperplasia.59,60
In the largest cohort, relapse of complex endometrial hyperplasia following initial regression
occurred in 12.7% (18/142) of women treated with the LNG-IUS compared with 28.3%
(17/60) of women treated with oral progestogens (hazard ratio 0.37, 95% CI 0.180.73).59
Women from the same cohort were stratified according to their BMI. For those women
treated with the LNG-IUS, only 3% of women with a BMI under 35 relapsed during follow-up
compared with 33% of women with a BMI of 35 or greater over a median follow-up of
67 months (hazard ratio 5.51, 95% CI 1.0528.87). In contrast, in women treated with oral
progestogens, a womans BMI was not found to be predictive of relapse.
Evidence
Another observational study of women treated with the LNG-IUS found that 26% (9/34) of level 2+
women underwent hysterectomy after evidence of regression of the hyperplastic process
and in more than half (5/9) of these women there was evidence of relapse of hyperplasia on
the final hysterectomy specimen. The authors recommended periodic endometrial sampling
for at least 2 years after stopping treatment.60 The optimal schedule for clinical follow-up is
uncertain because of the limited availability of published data, but the observational studies
available support endometrial biopsies every 6 months and at least two consecutive negative
biopsies to confirm disease regression to normality.59,60 In women at higher risk of disease
relapse, persistence or progression, such as those with a BMI of 35 or greater or treated
with short courses of oral progestogens, biopsies at 6-monthly intervals for at least 2 years
should be considered and long-term follow-up on an annual basis thereafter.
In view of the risk of relapse of endometrial hyperplasia, it is reasonable to continue with

LNG-IUS treatment despite a regression of the hyperplasia. In the absence of adverse effects,
the final decision to persist with treatment or remove the device should be made in
consultation with the woman and according to her preferences. If adverse effects are
tolerable and fertility is not desired, women should be encouraged to retain the LNG-IUS
for the 5-year duration, especially if it alleviates abnormal uterine bleeding symptoms. For
oral progestogens, there is evidence from randomised trials that 6 months of therapy is
more efficacious than 3 months, but there are no comparative data for longer therapy Evidence
durations.53 Data reporting longer term courses of continuous oral progestogens beyond level 2++
6 months to maintain disease remission are unavailable. Cessation of oral progestogens
after 36 months of therapy appears to be commonly practised46,59 and this may relate to
fears over potential adverse effects arising from chronic administration of high-dose
continuous oral progestogens and compliance issues. In the absence of safety and efficacy
data, the routine use of longer term oral regimens cannot be supported. Women
experiencing abnormal vaginal bleeding after the end of treatment should be advised to
seek a further referral as this may signify relapse.
In summary, there is evidence from randomised trials that treatment with progestogens should last for
at least 6 months. If endometrial hyperplasia persists for 12 months despite treatment, the risk of
underlying cancer is high and the chances of disease regression are low, such that hysterectomy is
advised. Observational evidence shows that a BMI of 35 or greater or treatment of endometrial
hyperplasia without atypia by oral progestogens carries a higher risk of relapse and long-term follow-
up may be warranted. Annual endometrial biopsies can be considered for these high-risk women, but
follow-up schedules should be individualised. They should take into account the baseline cancer risk,
medical comorbidities, presence of abnormal bleeding and treatment factors such as response,
tolerance and compliance, as well as the wishes of the patient.

7.4 When is surgical management appropriate for women with endometrial hyperplasia
without atypia?
Hysterectomy should not be considered as a first-line treatment for hyperplasia without atypia because
C
progestogen therapy induces histological and symptomatic remission in the majority of women and
avoids the morbidity associated with major surgery.
Hysterectomy is indicated in women not wanting to preserve their fertility when (i) progression to
C
atypical hyperplasia occurs during follow-up, or (ii) there is no histological regression of hyperplasia
despite 12 months of treatment, or (iii) there is relapse of endometrial hyperplasia after completing
progestogen treatment, or (iv) there is persistence of bleeding symptoms, or (v) the woman declines
to undergo endometrial surveillance or comply with medical treatment.
P
Postmenopausal women requiring surgical management for endometrial hyperplasia without atypia
should be offered a bilateral salpingo-oophorectomy together with the total hysterectomy.
D
malignancy.

B
Endometrial ablation is not recommended for the treatment of endometrial hyperplasia because
complete and persistent endometrial destruction cannot be ensured and intrauterine adhesion
D
formation may preclude future endometrial histological surveillance.
The majority of women will experience regression of their endometrial hyperplasia without
atypia following progestogen treatment.46 However, some cases will persist or may relapse
during follow-up. There is limited research on the best approach for those women. A
prospective cohort study followed up women treated with the LNG-IUS for complex
hyperplasia.47 The 16 women with complex hyperplasia who did not achieve regression in
this study were offered hysterectomy. This was performed in 13 of them and a diagnosis of
cancer was made in 23.1% of these women (3/13).47 Thus, the data from this cohort suggest
that after 12 months of progestogen treatment, if there is no evidence of regression of
endometrial hyperplasia then the risk of cancer is high and hysterectomy is warranted.61
The small increase in overall regression rates of endometrial hyperplasia observed in the
above cohort beyond 12 months of treatment has to be balanced against the risks of
histological undercall and thus endometrial cancer. While 39 of 68 (57%) refractory women
Evidence
subsequently regressed between 12 and 24 months in the above study, a decision to persist level 2+
with the LNG-IUS beyond 12 months should only be taken after careful consideration and
thorough discussion with the patient regarding the risks and benefits of prolonged medical
treatment compared with hysterectomy.47 It is advisable to obtain a multidisciplinary opinion
in such cases.
In the same cohort study of 219 women with mainly complex endometrial hyperplasia
(202/219) treated with either the LNG-IUS or oral progestogens, 19% (41/219) relapsed after
initial disease regression. Relapse occurred more often with the oral progestogens than with
the LNG-IUS (30% versus 14%; OR 0.34, 95% CI 0.170.7, P = 0.005). Of the 41 relapsed
women, only 17 underwent hysterectomy and two were diagnosed with cancer (11.7%).61
One woman initially diagnosed with complex endometrial hyperplasia and treated with the
LNG-IUS progressed to endometrioid cancer with a concomitant granulosa cell tumour of

the ovary, while the second woman who progressed to cancer was initially diagnosed with
atypical endometrial hyperplasia.61 These data further highlight the significant risk of Evidence
underlying endometrial cancer in persisting or relapsing endometrial hyperplasia without level 2+
atypia and a total hysterectomy should be recommended in these circumstances.
A first-line hysterectomy should also be considered in women diagnosed with endometrial hyperplasia
without atypia who have abnormal bleeding or who are not prepared to undergo endometrial
surveillance. Furthermore, a hysterectomy may be indicated in women not wishing or not suitable to
receive hormonal therapy where there are concerns over treatment or surveillance compliance.
However, these indications should be considered in the context of baseline cancer risk, co-existing
medical morbidities and patient preferences. In women in whom endometrial hyperplasia without
atypia fails to regress with progestogen treatment, a hysterectomy should be carried out.
The current surgical standard for endometrial hyperplasia without atypia is to perform a
total hysterectomy with bilateral salpingo-oophorectomy for postmenopausal women. For
premenopausal women, the decision to remove the ovaries depends on patient wishes and
Evidence
malignancy risk factors. However, a bilateral salpingectomy while preserving the ovaries can level 4
be considered as this may reduce the womans risk of a future ovarian malignancy.62
Supracervical hysterectomy should be avoided to ensure that all premalignant disease is
eliminated.63
We did not identify any specific evidence evaluating the different routes of hysterectomy for
hyperplasia without atypia. However, there is evidence that a laparoscopic approach may be
Evidence
preferable to the abdominal approach for women with atypical hyperplasia or stage I level 1+
endometrial cancer (see section 8.1) as it is associated with a shorter hospital stay, less
postoperative pain and quicker recovery.64
Endometrial ablation has been used as an alternative surgical approach to treat endometrial
hyperplasia without atypia and is also effective in reducing heavy menstrual loss.6466 In one
randomised controlled trial, women with endometrial hyperplasia without atypia (n = 34)
were randomised to either thermal balloon ablation or progestogen therapy. In the thermal
Evidence
balloon ablation group, 24% (4/17) failed to regress compared with 35% (6/17) in the oral level 1
progestogen group.67 However, complete endometrial destruction cannot be guaranteed
and regeneration of ablated endometrial tissue may occur.68 Subsequent endometrial
assessment with hysteroscopy or endometrial biopsy may be compromised because of
intrauterine adhesions. Hence, this method cannot be recommended routinely.
8. How should atypical hyperplasia be managed?
8.1 What should the initial management of atypical hyperplasia be?

Women with atypical hyperplasia should undergo a total hysterectomy because of the risk of
underlying malignancy or progression to cancer.
B

B
There is no benefit from intraoperative frozen section analysis of the endometrium or routine
C
lymphadenectomy.
P
Postmenopausal women with atypical hyperplasia should be offered bilateral salpingo-oophorectomy
together with the total hysterectomy.

D
malignancy.
Endometrial ablation is not recommended because complete and persistent endometrial destruction
C
cannot be ensured and intrauterine adhesion formation may preclude endometrial histological
surveillance.
The risk of developing endometrial cancer is highest in atypical hyperplasia. A casecontrol

study nested in a cohort of 7947 women diagnosed with atypical hyperplasia found that the
cumulative risk of cancer in 4 years was 8% (95% CI 1.3114.6), which increased to 12.4% Evidence
(95% CI 3.020.8) after 9 years and to 27.5% (95% CI 8.642.5) after 19 years.33 Atypical level 2++
hyperplasia has also been associated with a rate of concomitant carcinoma of up to 43% in
women undergoing hysterectomy.69
No comparative studies were identified that compared surgical with fertility-sparing

management for women with atypical hyperplasia. Due to the risk of underlying malignancy
or progression to cancer, a total hysterectomy is advised. The method chosen for
hysterectomy should allow assessment for further disease if necessary. Minimal access
techniques do allow staging and there is some evidence to suggest that they are beneficial
Evidence
when done by appropriately trained surgeons. A randomised trial comparing total level 1+
laparoscopic hysterectomy with total abdominal hysterectomy via a midline incision was
conducted in the Netherlands with 283 women with either stage I endometrial cancer or
atypical hyperplasia.64 There was no difference in major complications between laparoscopic
and abdominal approaches. However, laparoscopic hysterectomy was superior in terms of
a shorter hospital stay, less pain and quicker resumption of daily activities.64
Due to the risks of disseminating malignancy, morcellation of the uterus should be avoided. Evidence
Supracervical hysterectomy should not be performed.63 level 4
Intraoperative frozen analysis of the endometrium is not a reliable indicator of final

pathology in women with a preoperative diagnosis of atypical hyperplasia. Indermaur et al.
performed a retrospective review of frozen and final pathology in women with a
Evidence
preoperative diagnosis of atypical hyperplasia. In 61% (15/23) of the cases, the frozen and level 2+
final pathology reports disagreed.70 Eight of 14 women (57%) initially diagnosed with
atypical hyperplasia by frozen section were diagnosed with endometrial cancer on final
pathology.70
Lymphadenectomy should not be routinely performed in atypical hyperplasia because this

would result in unnecessary surgical risk for the majority of women. Although endometrial Evidence
cancer has been reported in 43% of cases during hysterectomy, the cancer was usually early level 2++
stage with low risk of lymphovascular disease.69
Furthermore, two randomised trials showed no benefit of routine lymphadenectomy in Evidence

early endometrial cancers.71,72 level 1+
Due to the risk of underlying malignancy, bilateral salpingo-oophorectomy should be performed in all
peri- and postmenopausal women undergoing hysterectomy for atypical hyperplasia.
However, the evidence is less clear about premenopausal women diagnosed with atypical
Evidence
hyperplasia and the risks of surgical menopause have to be balanced against the risk of level 2++
underlying cancer and the need for further surgery to remove the ovaries. The Nurses

Health Study did show that bilateral salpingo-oophorectomy is associated with increased
mortality in women aged less than 50 years who had hysterectomy for benign disease.73
Premenopausal women who undergo hysterectomy and bilateral salpingo-oophorectomy Evidence
for endometrial hyperplasia should consider the use of estrogen replacement, in the absence level 2++
of contraindications to its use, until the age of the natural menopause to minimise the risks
of surgical menopause. These considerations should be discussed with the woman.
As an alternative to hysterectomy, endometrial ablation and resection has also

been reported, although complete endometrial destruction cannot be guaranteed and
Evidence
regeneration of ablated endometrial tissue may occur.68,74 As with hysterectomy, this is not level 2+
a fertility-sparing procedure and intrauterine adhesion formation can render future
endometrial surveillance with hysteroscopy and/or endometrial biopsy problematic.
8.2 How should women with atypical hyperplasia who wish to preserve their fertility or who
are not suitable for surgery be managed?
P
Women wishing to retain their fertility should be counselled about the risks of underlying malignancy
and subsequent progression to endometrial cancer.
P
Pretreatment investigations should aim to rule out invasive endometrial cancer or co-existing ovarian
cancer.
P
Histology, imaging and tumour marker results should be reviewed in a multidisciplinary meeting and
a plan for management and ongoing endometrial surveillance formulated.
First-line treatment with the LNG-IUS should be recommended, with oral progestogens as a
B
second-best alternative (see section 7.2).
Once fertility is no longer required, hysterectomy should be offered in view of the high risk of disease
relapse.
B
Fertility-sparing therapy has been advocated for women who desire future fertility or who have medical
comorbidities precluding surgical management. However, women need careful counselling of the
risks involved with this option: co-existent or progression to endometrial cancer, co-existent ovarian
cancer, metastatic disease and death.
In a systematic review of uncontrolled observational studies of women with atypical

hyperplasia, the risk of co-existing ovarian cancer was up to 4%, the risk of progression to
higher than stage I endometrial cancer was about 2% and the risk of metastatic disease and
death was about 0.5%.75 Pretreatment investigations were proposed for identifying women Evidence
with undiagnosed advanced endometrial or ovarian cancer.75 The review authors separately level 2++
examined women who underwent pretreatment investigations (MRI, CT, TVS and serum
CA125) and those who did not.75 No significant difference was found in ovarian cancer or
advanced endometrial cancer diagnosis or prevalence of metastasis and death.75
However, in the absence of robust comparative evidence, investigations prior to fertility-sparing

treatment should be undertaken and these include tumour markers such as CA125 and imaging with
TVS and/or MRI scan to rule out co-existing ovarian cancer and invasive endometrial cancer.
Several hormonal therapies have been used to treat this group of women and these include oral
progestogens, the LNG-IUS, aromatase inhibitors and gonadotrophin-releasing hormone agonists.

In a large retrospective cohort study following up 242 women with atypical endometrial
hyperplasia, the risk of progression to cancer was reduced five-fold, from 101.4 to 20.5 per
1000 woman-years, with the use of progestogens.76 Interestingly, in this study there were Evidence
22 diagnoses of endometrial cancer and 21 were stage I (endometrioid grade 1 = 8, level 2++
grade 2 = 6, grade 3 = 1, unknown grade = 4; papillary serous = 2) and one woman was
diagnosed with stage II grade 1 endometrioid cancer.76
To date, there have been no randomised trials comparing different regimens of hormonal treatments.
Several observational studies have reported rates of regression, relapse and progression to
endometrial cancer together with reproductive outcomes following the use of hormonal
therapy. A meta-analysis of observational studies of fertility-sparing treatment for women
with atypical hyperplasia reported summary rates for disease regression of 85.6%, a relapse
rate of 26% and a live birth rate of 26.3%.75 Due to the high relapse rate and because the
Evidence
primary studies did not engage in long-term follow-up, the authors warn that true relapse level 2++
rates may be even higher and advise that once fertility is no longer required, a hysterectomy
should be performed. However, the review only reported on 151 women from 14 small
noncomparative studies of limited quality with diverse populations and interventions. As a
result, no comparison between treatments was possible, but oral progestogens and the
LNG-IUS were the most commonly used therapies.75
In summary, fertility-sparing management of atypical hyperplasia is possible, with one-quarter of

women achieving a live birth, but the evidence is weak and based almost exclusively on small studies.
The safety is uncertain as estimates of cancer diagnosis and stage during follow-up are imprecise. It is
essential that initial diagnosis is confirmed on formal hysteroscopy to minimise the chance of missing
cancer. The optimal treatment regimen is also ill-defined. In addition, the length of follow-up after
fertility-sparing treatment has been short, such that the risk of relapse in the longer term is uncertain.
Careful counselling about the risks of fertility-sparing treatment is of paramount importance, together
with pretreatment work-up to rule out advanced endometrial or ovarian cancer. Because of the rarity
and complexity of this clinical scenario, gynaecologists should seek gynaecological oncology
multidisciplinary advice, where the available histology, imaging and tumour markers are examined. The
advice should include a plan for endometrial biopsies and follow-up, together with a maximum
recommended duration of fertility-sparing treatment before a hysterectomy is performed.
8.3 How should women with atypical hyperplasia not undergoing hysterectomy be followed up?
Routine endometrial surveillance should include endometrial biopsy. Review schedules should be
individualised and be responsive to changes in a womans clinical condition. Review intervals should
D
be every 3 months until two consecutive negative biopsies are obtained.
P
In asymptomatic women with a uterus and evidence of histological disease regression, based upon a
minimum of two consecutive negative endometrial biopsies, long-term follow-up with endometrial
biopsy every 612 months is recommended until a hysterectomy is performed.
The follow-up should be customised to each woman, taking into account baseline risk
factors, associated symptoms and response to treatment. Obesity is associated with a
higher risk of failure to regress and relapse and should be taken into consideration when Evidence
arranging follow-up.59,77 This is best decided in the context of a gynaecological oncology level 2+
multidisciplinary meeting and women who decline or are unfit to undergo a hysterectomy
can be considered for discussion.

The minimum investigations required to monitor the endometrium during follow-up include a
detailed history for the presence of symptoms and signs suggestive of progressive disease, pelvic
examination and an endometrial biopsy. Hysteroscopy should be considered where an endometrial
biopsy cannot be satisfactorily obtained or where sampling is nondiagnostic. TVS has a role in ruling
out ovarian disease if this has not already been performed, although assessment of endometrial
thickness is unlikely to be useful in view of the absence of validated reference ranges and the difficulty
in obtaining accurate measurements with the LNG-IUS in place. There are no data to support the
routine use of MRI or CT during follow-up.
The optimal follow-up schedule is unknown, but in view of the risk of progression to
endometrial cancer and in the absence of research data, most clinicians would recommend Evidence
endometrial evaluation every 3 months initially,78 until two consecutive negative biopsies are level 4
obtained.47
Failure of atypical endometrial hyperplasia to regress is a worrying sign for underlying

endometrial cancer. If fertility-sparing therapy fails to induce regression of atypical
hyperplasia by 12 months or there is evidence of progression to cancer, women should be
Evidence
strongly recommended to undergo hysterectomy.75 The risk of relapse is especially high in level 2++
the first 2 years from diagnosis. If relapse occurs during follow-up, women should also be
advised to undergo hysterectomy as it is often associated with endometrial cancer at the
final hysterectomy specimen.75
If this is not possible or declined, a further cycle of progestogen treatment can be attempted.
In a study of 33 women with relapsed atypical hyperplasia, 85% (28/33) regressed following
Evidence
retreatment with oral medroxyprogesterone given for 6 months.79 Beyond 2 years, in level 2
asymptomatic women with a uterus and histologically regressed disease, recourse to annual
follow-up with endometrial biopsy was advised.79
9. How should endometrial hyperplasia be managed in women wishing to conceive?
P
Disease regression should be achieved on at least one endometrial sample before women attempt to
conceive.
Women with endometrial hyperplasia who wish to conceive should be referred to a fertility specialist
to discuss the options for attempting conception, further assessment and appropriate treatment.
D
Assisted reproduction may be considered as the live birth rate is higher and it may prevent relapse
compared with women who attempt natural conception.
C
Prior to assisted reproduction, regression of endometrial hyperplasia should be achieved as this is

B
associated with higher implantation and clinical pregnancy rates.
Women with endometrial hyperplasia who wish to conceive should be followed up to

ensure disease regression. Once regression of the endometrial hyperplasia is achieved,
women can be advised to attempt natural conception. However, as a hyperplastic Evidence
endometrium may predispose women to infertility, an early referral for fertility specialist level 4
consultation can be offered as per national recommendations.80 Obese women should aim
for a BMI of less than 30.80
A meta-analysis of observational studies has reported the live birth rates of 126 women who
Evidence
had fertility-sparing treatment for atypical hyperplasia. The study found that the live birth level 2++
rate was 26.3% (31/126).75 The live birth rate for women appeared to be higher with assisted

reproductive technology compared with natural conception following regression of atypical
hyperplasia or well-differentiated endometrial cancer.75 However, it was often not reported
in the primary studies exactly how many women were actively trying to conceive naturally.
Indirect comparison showed this difference between assisted reproduction and natural
Evidence
conception to be statistically significant (P = 0.001).75 Immediate assisted reproductive level 2++
technology avoids a prolonged interval of time without progestogen treatment, which could
cause women to relapse. A decision to initiate assisted reproduction immediately following
cessation of progestogen treatment should be made within a multidisciplinary team setting
taking into account risks of disease progression and fertility prospects.
Relevant to women with endometrial hyperplasia without atypia, a small randomised

controlled trial was performed in women with simple hyperplasia and PCOS undergoing
in vitro fertilisation (IVF). The trial compared LNG-IUS treatment with observation alone
and found that women treated with the LNG-IUS were more likely to achieve regression Evidence
(88% versus 15%) and also had higher implantation (29% versus 17%, P < 0.05) and clinical level 1
pregnancy rates (46% versus 28%, P < 0.05) following IVF treatment. None of the women
in the LNG-IUS group progressed to worsening hyperplasia but three women progressed in
the observation-alone group.81
A hysterectomy should be recommended to women with atypical endometrial hyperplasia

Evidence
once fertility is no longer required because of the high relapse rate of disease and the level 2++
potential for disease progression (see section 8.2).75
10. HRT and endometrial hyperplasia
Systemic estrogen-only HRT should not be used in women with a uterus.

A
P
All women taking HRT should be encouraged to report any unscheduled vaginal bleeding promptly.
Women with endometrial hyperplasia taking a sequential HRT preparation who wish to continue HRT
should be advised to change to continuous progestogen intake using the LNG-IUS or a continuous
B
combined HRT preparation. Subsequent management should be as described in the preceding sections
of the guideline.
P
Women with endometrial hyperplasia taking a continuous combined preparation who wish to continue
HRT should have their need to continue HRT reviewed. Discuss the limitations of the available evidence
regarding the optimal progestogen regimen in this context. Consider using the LNG-IUS as a source of
progestogen replacement. Subsequent management should be as described in the preceding sections
of the guideline.
A Cochrane review of randomised trials has shown a significantly increased risk of

hyperplasia with unopposed estrogen replacement therapy for 2 to 3 years, with evidence
of a doseresponse relationship.9 The addition of a progestogen (a minimum of 1 mg/day
norethisterone or 1.5 mg/day medroxyprogesterone) to the unopposed estrogen
replacement therapy resulted in fewer cases of endometrial hyperplasia when either
Evidence
sequential or continuous combined HRT regimens were adopted.9 level 1++
The Cochrane review pointed towards a reduced cumulative endometrial hyperplasia

prevalence at 3 years of follow-up with continuous combined HRT compared with sequential
regimens, but this difference did not reach statistical significance (Peto OR 0.23, 95% CI
0.051.02).9

All women taking HRT should report any unscheduled vaginal bleeding promptly and be referred for
further investigation.
In the Postmenopausal Estrogen/Progestin Interventions (PEPI) trial, 45 women were

Evidence
diagnosed with endometrial hyperplasia on sequential HRT. The HRT was stopped and most level 1+
women were treated with oral progestogens, from which 94% (34/36) achieved regression.82
In a large observational study, there were no cases of endometrial hyperplasia in 526 women
on continuous combined HRT. However, there were 21 cases of hyperplasia without atypia
among 360 women who had been taking sequential combined HRT. The hyperplasia
regressed to normal endometrium when women were changed to continuous combined
HRT preparations.83 An observational study included 2028 women who at entry point were
either taking sequential HRT or were not on HRT. All women were given or switched to Evidence
continuous combined HRT and endometrial response was assessed 9 months later. The level 2++
study showed no increase in the risk of endometrial hyperplasia with continuous combined
HRT and showed conversion of the endometrium back to normal in women who had
hyperplasia on sequential HRT at entry to the study.84 A further study showed similar findings
and included 22 women with hyperplasia with or without atypia at entry. All cases reverted
back to normal histology within 6 months of continuous combined HRT treatment.85
Stopping sequential combined HRT may be sufficient to induce regression of endometrial hyperplasia.
Subsequent management should be as described in the preceding sections of this guideline, in
accordance with the particular histological classification of hyperplasia. Further research is needed to
evaluate the effect on the hyperplastic process of changing or supplementing a combined HRT regimen
with local progestogens delivered via the LNG-IUS or whether combined HRT can be safely restarted
once hyperplasia has regressed.
11. How should endometrial hyperplasia be managed in women on adjuvant treatment for
breast cancer?
11.1 What is the risk of developing endometrial hyperplasia on adjuvant treatment for breast
cancer?
Women taking tamoxifen should be informed about the increased risks of developing endometrial
D
hyperplasia and cancer. They should be encouraged to report any abnormal vaginal bleeding or
discharge promptly.
P
Women taking aromatase inhibitors (such as anastrozole, exemestane and letrozole) should be
informed that these medications are not known to increase the risk of endometrial hyperplasia and
cancer.
Tamoxifen is a selective estrogen receptor modulator that inhibits proliferation of breast

cancer by competitive antagonism at estrogen receptors. However, it has a partial agonist
action on other tissues, including the vagina and the uterus. This estrogenic effect may
promote the development of fibroids, endometrial polyps and hyperplasia86,87 and increase
the risk of endometrial cancer.88,89 The risk increases with both dose and duration of
Evidence
treatment.88,89 Women taking tamoxifen should be informed of these risks and advised to level 1+
contact their doctor promptly if they experience abnormal vaginal bleeding or discharge.90
The ability of tamoxifen to induce endometrial cancer and other pathologies varies between
pre- and postmenopausal women. The National Surgical Adjuvant Breast and Bowel Project
Breast Cancer Prevention Trial (P-1), which compared tamoxifen with placebo in women at
high risk of breast cancer, reported that the risk of endometrial cancer in tamoxifen users

was not statistically significant in women aged 49 years or younger (risk ratio 1.42, 95% CI
Evidence
0.553.81), but that there was a statistically significant increase in risk in women aged 50 level 1+
years or older (risk ratio 5.33, 95% CI 2.4713.17).89
Aromatase inhibitors inhibit estrogen synthesis in the peripheral tissues and have a similar
tumour-regressing effect to tamoxifen. A Cochrane review has included randomised trials
Evidence
comparing aromatase inhibitors, such as anastrozole, exemestane and letrozole, used for level 1++
adjuvant therapy of early breast cancer with other endocrine therapies and found that they
do not increase the risk of endometrial pathology or vaginal bleeding.91
Aromatase inhibitors have also been explored as a treatment option for endometrial Evidence
hyperplasia in small observational studies with varied success.92,93 level 3
11.2 Should women on tamoxifen be treated with prophylactic progestogen therapy?

There is evidence that the LNG-IUS prevents polyp formation and that it reduces the incidence of
A
endometrial hyperplasia in women on tamoxifen. The effect of the LNG-IUS on breast cancer recurrence
risk remains uncertain so its routine use cannot be recommended.
A 2009 Cochrane review found that the LNG-IUS reduced the incidence of new endometrial
polyps in women on tamoxifen for breast cancer over a 1-year period (Peto OR 0.14, 95%
Evidence
CI 0.030.61).94 There was no clear evidence that the LNG-IUS prevented endometrial level 1++
hyperplasia or cancer in these women.94 An updated subgroup analysis has confirmed that
endometrial hyperplasia is reduced as well as endometrial polyp formation.95
A randomised controlled trial has compared the prophylactic use of the LNG-IUS to prevent
endometrial pathology with a control group in women prior to starting tamoxifen therapy
for breast cancer. Although use of the LNG-IUS significantly reduced de novo endometrial
polyp formation over a 5-year follow-up period, its impact on preventing endometrial Evidence
hyperplasia remained unclear because no cases were diagnosed in either group. There was level 1
no statistically significant increase in breast cancer recurrence rate for those treated with a
LNG-IUS compared with untreated controls (17.2% versus 10.0%) or cancer-related deaths
(10.3% versus 8.3%), but the study was underpowered.96
A small observational study did not find an increased risk of breast cancer recurrence Evidence
associated with use of the LNG-IUS.97 level 3
11.3 How should women who develop endometrial hyperplasia while on tamoxifen treatment
for breast cancer be managed?
P
The need for tamoxifen should be reassessed and management should be according to the histological
classification of endometrial hyperplasia and in conjunction with the womans oncologist.
The partial agonist action of tamoxifen in the genital tract is associated with an increased risk Evidence
of endometrial cancer.88,89 level 1++
In the presence of hyperplasia, it is presumed that this risk is even higher, although we found no
studies addressing this issue. Therefore, the use of tamoxifen should be reassessed in conjunction
with the womans oncologist and an alternative treatment sought if appropriate. In the absence of
evidence specific to this group of women, it is reasonable to treat them according to their histological
classification of hyperplasia.

12. How should endometrial hyperplasia confined to an endometrial polyp be managed?
Complete removal of the uterine polyp(s) is recommended and an endometrial biopsy should be
D
obtained to sample the background endometrium.
P
Subsequent management should be according to the histological classification of endometrial
hyperplasia.
Endometrial polyps are discrete overgrowths of endometrium and atypia may be restricted
to foci within the polyp. In the absence of background endometrial hyperplasia, it seems
reasonable to assume that removal of the polyp may be curative. However, there is very little
Evidence
evidence to help guide the management of these women. There has been only a small quasi- level 1
randomised trial of 21 women, which compared use of the LNG-IUS with no treatment after
removal of polyps with focal atypical hyperplasia.98 They found that after 5 years follow-up
there was no recurrence of atypia in either group.98
It is also important to ensure that histological analysis of the background endometrium is

performed even if the endometrium looks healthy on hysteroscopy. In a small observational
study, 52% (14/27) of women had endometrial hyperplasia concurrently in a polyp and the Evidence
background endometrium.99 Women with atypical hyperplasia in a polyp were slightly more level 3
likely to have hyperplasia in the surrounding endometrium than those with hyperplasia
without atypia.99
Following removal of the polyp, management should be according to the histological classification of
endometrial hyperplasia.
13. Recommendations for future research

The role of clinical factors and biomarkers in the diagnosis and follow-up of endometrial
hyperplasia.
The effect of weight loss, community-based obesity services, lifestyle programmes and bariatric
surgery on regression of endometrial hyperplasia.
The optimal duration of oral and local progestogen treatment for endometrial hyperplasia to
induce and maintain disease regression.
Evaluation of endometrial surveillance regimens.
Prospective long-term follow-up of women observed or treated for endometrial hyperplasia to
provide more precise estimates of the natural history of endometrial disease and to delineate risk
factors predictive of disease persistence, progression and relapse.
The role of the LNG-IUS in HRT-associated endometrial hyperplasia and whether it is safe to restart
HRT once hyperplasia has been successfully treated.
14. Auditable topics

100% of women with endometrial hyperplasia with a BMI greater than 30 should be advised to
lose weight.
100% of women with endometrial hyperplasia without atypia should have at least two negative
endometrial biopsies prior to discharge.
100% of postmenopausal women with atypical hyperplasia should undergo a total hysterectomy
and bilateral salpingo-oophorectomy if not medically contraindicated.

15. Useful links and support groups
Cancer Research UK. Endometrial hyperplasia http://www.cancerresearchuk.org/about-
cancer/cancers-in-general/cancer-questions/endometrial-hyperplasia.
Patient. Endometrial Hyperplasia http://patient.info/doctor/endometrial-hyperplasia.
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Appendix I: Explanation of guidelines and evidence levels
Clinical guidelines are: systematically developed statements which assist clinicians and patients in
making decisions about appropriate treatment for specific conditions. Each guideline is systematically
developed using a standardised methodology. Exact details of this process can be found in Clinical
Governance Advice No.1 Development of RCOG Green-top Guidelines (available on the RCOG website
at http://www.rcog.org.uk/green-top-development). These recommendations are not intended to dictate
an exclusive course of management or treatment. They must be evaluated with reference to individual
patient needs, resources and limitations unique to the institution and variations in local populations.
It is hoped that this process of local ownership will help to incorporate these guidelines into routine
practice. Attention is drawn to areas of clinical uncertainty where further research may be indicated.
The evidence used in this guideline was graded using the scheme below and the recommendations
formulated in a similar fashion with a standardised grading scheme.
Classification of evidence levels Grades of recommendations

1++ High-quality meta-analyses, systematic At least one meta-analysis, systematic review or
reviews of randomised controlled trials A randomised controlled trial rated as 1++, and
or randomised controlled trials with a directly applicable to the target population; or
very low risk of bias A systematic review of randomised controlled
1+ Well-conducted meta-analyses, systematic trials or a body of evidence consisting
reviews of randomised controlled trials principally of studies rated as 1+, directly
or randomised controlled trials with a applicable to the target population and
low risk of bias demonstrating overall consistency of results
1 Meta-analyses, systematic reviews of A body of evidence including studies rated as
randomised controlled trials or B 2++ directly applicable to the target
randomised controlled trials with a high population, and demonstrating overall
risk of bias consistency of results; or
2++ High-quality systematic reviews of case Extrapolated evidence from studies rated as
control or cohort studies or high-quality 1++ or 1+
casecontrol or cohort studies with a
A body of evidence including studies rated as
very low risk of confounding, bias or C 2+ directly applicable to the target population
chance and a high probability that the
and demonstrating overall consistency of
relationship is causal
results; or
2+ Well-conducted casecontrol or cohort Extrapolated evidence from studies rated as
studies with a low risk of confounding, 2++
bias or chance and a moderate
probability that the relationship is causal Evidence level 3 or 4; or
D Extrapolated evidence from studies rated as 2+
2 Casecontrol or cohort studies with a
high risk of confounding, bias or chance
and a significant risk that the
relationship is not causal Good practice point
P
3 Non-analytical studies, e.g. case reports, Recommended best practice based on the
case series clinical experience of the guideline
4 Expert opinion development group

Appendix II: Algorithm for the management of endometrial hyperplasia
Algorithm for the management of endometrial hyperplasia
Atypical hyperplasia (AH)

Endometrial hyperplasia
without atypia (EH)
Address risk factorsa Fertility required or surgery Total hysterectomy BSOb

Observation contraindicated
LNG-IUS (first line)
Oral progestogen (second line) Endometrial biopsy (EB)
to be taken:
EH at 6 months
AH at 3 monthsc
Regressiond Persistenced Progressiond
Review treatment Review treatment Review treatment

LNG-IUS continue for 5 yearse EH Start medical treatment if AH Total hysterectomy BSOb
Advise total hysterectomy

Oral progestogen stop after 6 observation failedf EC Manage according to local
months cancer guideline
Total hysterectomy BSOb if
BSOb if persistence after 12
months of medical treatment
AH Advise total hysterectomy
ongoing AUB
BSOb
Arrange follow-up (medical Arrange follow-up
management)
EH BMI < 35: two consecutive
No EC Review at 6 weeks and
discharge
negative EBs at 6-month EC Manage according to local
intervals, then dischargeg
BMI 35 or treated with oral
cancer guideline
progestogens: two
Notes:
a. Risk factors include obesity, HRT regimens, tamoxifen therapy and anovulation.
consecutive negative EBs at b. Consider ovarian conservation according to age, menopausal status and patient
6-month intervals, thereafter preferences. In addition to nonregression of EH or persistence of AUB symptoms
annual EB and reviewh following nonsurgical treatments, a total hysterectomy may be indicated where there are
AH two consecutive negative (i) adverse effects associated with medical treatment, (ii) concerns over compliance with
treatment or follow-up, or (iii) patient preferences e.g. high levels of anxiety.
EBs at 3-month intervals, c. The follow-up interval should be customised to each woman, taking into account baseline
thereafter 612-monthly EB risk factors, associated symptoms and response to treatment.
and reviewh d. Regression nonhyperplastic or nonmalignant endometrial sample or nondiagnostic
endometrial sample from an appropriately placed endometrial sampling device;
persistence no regression or progression of initial EH subtype after 3 or more months;
Relapsed progression development of AH or EC; relapse recurrence of EH or AH after one or
more negative EB result(s).
e. In general, advise continuation of the LNG-IUS for the duration of its 5-year use,
Advise total hysterectomy BSOb
especially if EH associated with AUB or other baseline risk factorsa and no adverse effects.
f. Start medical management if EH not treated initially. The decision to persist with medical
management should be taken after careful consideration and thorough discussion with
the woman regarding the risks and benefits of prolonged medical treatment compared
Abbreviations: with total hysterectomy with or without BSO. Persistence beyond 12 months is associated
AH atypical hyperplasia; with a significant risk of underlying malignancy and a high risk of failure to regress such
AUB abnormal uterine bleeding; that a total hysterectomy with or without BSO should be recommended.
BMI body mass index; g. At discharge, inform the woman of her estimated individual risk of recurrence, of the
BSO bilateral salpingo-oophorectomy; need to continue any risk-reducing strategies and to present for an urgent review if any
EB endometrial biopsy; further episodes of AUB.
EC endometrial cancer; h. Review the appropriateness of ongoing endometrial surveillance, continuation of medical
EH endometrial hyperplasia without atypia; management or total hysterectomy with or without BSO based on factors such as baseline
HRT hormone replacement therapy; risk factors including BMI, AUB symptoms, fertility requirements, compliance with
LNG-IUS levonorgestrel-releasing treatment and follow-up, medical comorbidities and riskbenefit ratio for total
intrauterine system. hysterectomy with or without BSO.

This guideline was produced on behalf of the Royal College of Obstetricians and Gynaecologists and the
British Society for Gynaecological Endoscopy by:
Mr ID Gallos1 MRCOG, Birmingham; Mr M Alazzam1 MRCOG, Dublin; Professor TJ Clark1 MRCOG,
Birmingham; Mr R Faraj1 MRCOG, Rotherham; Mr AN Rosenthal2 FRCOG, London; Dr PP Smith1 MB ChB,
Birmingham; and Professor JK Gupta1 FRCOG, Birmingham
1
on behalf of the BSGE 2 on behalf of the RCOG
and peer reviewed by:

Professor H Abu Hashim MRCOG, Mansoura, Egypt; Mr SO Ajayi MRCOG, Blackpool; Mr MTMS Bekhit FRCOG,
Liverpool; Mr PJ Bulmer MRCOG, London; Miss ME Connor FRCOG, Sheffield; Mr RAF Crawford FRCOG, Cambridge;
Mr KK Dhar FRCOG, Swansea; Professor M Fambrini, University of Florence, Italy; Mr PD Kaloo MRCOG, Cheltenham;
Mr B Kumar FRCOG, Wrexham; Professor WL Ledger FRCOG, Sydney, Australia; Dr RJ Luker MRCOG, Bath;
Dr GL Mutter, Brigham and Womens Hospital, Boston, USA; RCOG Womens Network; Dr GC Rieck MRCOG, Bangor;
Mr DJ Rowlands FRCOG, Wirral; Mr P Saha FRCOG, Birmingham; Dr F Sanaullah FRCOG,York; Dr F Scrimin, Institute for
Maternal and Child Health, IRCCS Burlo Garofolo,Trieste, Italy; Dr WH Tam,The Chinese University of Hong Kong,
Hong Kong, China; and Dr U Wiesenfeld, Institute for Maternal and Child Health, IRCCS Burlo Garofolo,Trieste, Italy.
Committee lead reviewers were: Dr PS Arunakumari FRCOG, Basildon; Mr DJ Cruickshank FRCOG, Middlesbrough;
Dr M Gupta MRCOG, London; Mrs G Kumar FRCOG, Wrexham; and Dr M Mehasseb MRCOG, Glasgow.
The chairs of the RCOG Guidelines Committee were: Dr M Gupta1 MRCOG, London; Dr P Owen2 FRCOG, Glasgow;
and Dr AJ Thomson1 MRCOG, Paisley.
1
co-chairs from June 2014 2until May 2014.
The developers acknowledge Dr S Khazali MRCOG, Surrey, and Dr E Cordle MRCOG, London.
All RCOG guidance developers are asked to declare any conflicts of interest. A statement summarising any
conflicts of interest for this guideline is available from: https://www.rcog.org.uk/en/guidelines-research-
services/guidelines/gtg67/.
The final version is the responsibility of the Guidelines Committee of the RCOG.
The review process will commence in 2019, unless otherwise indicated.
DISCLAIMER
The Royal College of Obstetricians and Gynaecologists produces guidelines as an educational aid to good clinical
practice. They present recognised methods and techniques of clinical practice, based on published evidence, for
consideration by obstetricians and gynaecologists and other relevant health professionals. The ultimate
judgement regarding a particular clinical procedure or treatment plan must be made by the doctor or other
attendant in the light of clinical data presented by the patient and the diagnostic and treatment options available.
This means that RCOG Guidelines are unlike protocols or guidelines issued by employers, as they are not
intended to be prescriptive directions defining a single course of management. Departure from the local
prescriptive protocols or guidelines should be fully documented in the patients case notes at the time the
relevant decision is taken.


GTG 67 Endometrial Hyperplasia

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GTG 67 Endometrial Hyperplasia

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Management of Endometrial

Green-top Guideline No. 67

Executive summary of recommendations

What are the risk factors for endometrial hyperplasia?

How should endometrial hyperplasia be classified?

Diagnosis of endometrial hyperplasia requires histological examination of the endometrial tissue.

There is insufficient evidence evaluating computerised tomography (CT), diffusion-weighted magnetic

How should endometrial hyperplasia without atypia be managed?

What should the initial management of hyperplasia without atypia be?

RCOG/BSGE Green-top Guideline No. 67 2 of 30 Royal College of Obstetricians and Gynaecologists

Continuous progestogens should be used (medroxyprogesterone 1020 mg/day or norethisterone

Endometrial surveillance incorporating outpatient endometrial biopsy is recommended after a

Endometrial surveillance should be arranged at a minimum of 6-monthly intervals, although review

RCOG/BSGE Green-top Guideline No. 67 3 of 30 Royal College of Obstetricians and Gynaecologists

A laparoscopic approach to total hysterectomy is preferable to an abdominal approach as it is

How should atypical hyperplasia be managed?

What should the initial management of atypical hyperplasia be?

A laparoscopic approach to total hysterectomy is preferable to an abdominal approach as it is

RCOG/BSGE Green-top Guideline No. 67 4 of 30 Royal College of Obstetricians and Gynaecologists

How should endometrial hyperplasia be managed in women wishing to conceive?

Prior to assisted reproduction, regression of endometrial hyperplasia should be achieved as this is

HRT and endometrial hyperplasia

Systemic estrogen-only HRT should not be used in women with a uterus.

RCOG/BSGE Green-top Guideline No. 67 5 of 30 Royal College of Obstetricians and Gynaecologists

Should women on tamoxifen be treated with prophylactic progestogen therapy?

How should endometrial hyperplasia confined to an endometrial polyp be managed?

1. Purpose and scope

2. Introduction and background epidemiology

3. Identification and assessment of evidence

RCOG/BSGE Green-top Guideline No. 67 6 of 30 Royal College of Obstetricians and Gynaecologists

4. What are the risk factors for endometrial hyperplasia?

Endometrial hyperplasia develops when estrogen, unopposed by progesterone, stimulates

A Cochrane meta-analysis found that unopposed estrogen replacement therapy is associated

While estrogenic stimulation of the endometrium is believed to be the main aetiological

5. How should endometrial hyperplasia be classified?

RCOG/BSGE Green-top Guideline No. 67 7 of 30 Royal College of Obstetricians and Gynaecologists

Diagnosis of endometrial hyperplasia requires histological examination of the endometrial tissue.

There is insufficient evidence evaluating computerised tomography (CT), diffusion-weighted magnetic

RCOG/BSGE Green-top Guideline No. 67 8 of 30 Royal College of Obstetricians and Gynaecologists

The role of ultrasound in premenopausal women is restricted to identifying structural

Hysteroscopy with additional endometrial assessment may be necessary if abnormal

In addition, hysteroscopy can be used to facilitate or complement the endometrial biopsy,

Diagnostic hysteroscopy can be conducted in the outpatient setting using miniature

RCOG/BSGE Green-top Guideline No. 67 9 of 30 Royal College of Obstetricians and Gynaecologists

7. How should endometrial hyperplasia without atypia be managed?

RCOG/BSGE Green-top Guideline No. 67 10 of 30 Royal College of Obstetricians and Gynaecologists

RCOG/BSGE Green-top Guideline No. 67 11 of 30 Royal College of Obstetricians and Gynaecologists

Continuous progestogens should be used (medroxyprogesterone 1020 mg/day or norethisterone

RCOG/BSGE Green-top Guideline No. 67 12 of 30 Royal College of Obstetricians and Gynaecologists

Meta-analyses of seven randomised controlled trials and 24 uncontrolled observational

Endometrial surveillance incorporating outpatient endometrial biopsy is recommended after a

Endometrial surveillance should be arranged at a minimum of 6-monthly intervals, although review

A meta-analysis of 11 observational uncontrolled studies found that oral progestogens were

RCOG/BSGE Green-top Guideline No. 67 13 of 30 Royal College of Obstetricians and Gynaecologists

In view of the risk of relapse of endometrial hyperplasia, it is reasonable to continue with

RCOG/BSGE Green-top Guideline No. 67 14 of 30 Royal College of Obstetricians and Gynaecologists

A laparoscopic approach to total hysterectomy is preferable to an abdominal approach as it is

RCOG/BSGE Green-top Guideline No. 67 15 of 30 Royal College of Obstetricians and Gynaecologists

8. How should atypical hyperplasia be managed?