This protocol covers the management of endometrial hyperplasia without atypia in women where initial conservative measures have not resulted in confirmed histological regression to normal endometrium.
The diagnosis is endometrial hyperplasia without atypia — one of two groups in the 2014 revised WHO classification, which categorises endometrial hyperplasia based solely on the presence or absence of cytological atypia, independent of architectural complexity.
The first-line approach — identifying and addressing reversible risk factors (such as obesity and hormone replacement therapy use) and observation with follow-up endometrial biopsies — did not achieve the goal of histological regression to normal endometrium. Active medical treatment is now indicated.
Structured progestogen-based medical therapy is the mainstay of treatment at this stage. One delivery method is recommended as first-line over alternatives on the basis of regression rates and tolerability profile. Treatment is maintained for a defined minimum duration, with response assessed by endometrial biopsy.
The 2014 revised WHO classification simply separates endometrial hyperplasia into two 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 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 fewer adverse effects.
Continuous progestogens should be used (medroxyprogesterone 10–20 mg/day or norethisterone 10–15 mg/day) for women who decline the LNG-IUS.
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.
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