How is endometrial hyperplasia classified and managed?

Endometrial hyperplasia is classified as hyperplasia without atypia, or atypical hyperplasia (endometrioid intraepithelial neoplasia).

Without atypia - low cancer risk; managed with progestogens (e.g. the levonorgestrel IUS) and treating the cause (e.g. weight loss). Atypical hyperplasia - high risk of coexisting/progression to cancer, so hysterectomy is usually recommended (progestogens if fertility-sparing).

Clinical relevance. Knowing endometrial hyperplasia classification (atypia or not) and management (progestogens vs hysterectomy) addresses this endometrial cancer precursor.

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Classification and management of endometrial hyperplasia

Endometrial hyperplasia is a precursor to endometrial cancer, classified by atypia.

Classification

• Hyperplasia without atypia - low risk of progression to cancer (<5% over years).
• Atypical hyperplasia (endometrioid intraepithelial neoplasia, EIN) - high risk of coexisting cancer or progression (a significant proportion harbour or progress to cancer).

Management - without atypia

• Treat the underlying cause (e.g. weight loss, stop unopposed oestrogen).
• Progestogen therapy - the levonorgestrel intrauterine system (first-line) or oral progestogens, with follow-up endometrial sampling to confirm regression.

Management - with atypia

• Total hysterectomy (with bilateral salpingo-oophorectomy in postmenopausal women) is usually recommended (because of the high risk of coexisting/subsequent cancer).
• Fertility-sparing - high-dose progestogens (e.g. LNG-IUS) with close surveillance for women wishing to conceive.