Postmenopausal Vaginal Bleeding with Endometrial Hyperplasia Without Atypia When Progestogen Therapy Has Not Achieved Regression
This protocol addresses postmenopausal women with vaginal bleeding in the context of endometrial hyperplasia without atypia — a finding associated with unopposed oestrogen exposure. While endometrial hyperplasia without atypia carries a low risk of progression to endometrial cancer, persistent bleeding and failure to achieve histological regression require escalation of management.
Active management with progestogens was carried out for a minimum of 6 months. First-line treatment was the levonorgestrel-releasing intrauterine system; where this was declined or contraindicated, continuous oral progestogen was used instead. The treatment goal — regression of endometrial hyperplasia confirmed by endometrial biopsy at 6-monthly intervals — was not achieved.
When progestogen-based management has not delivered histological regression, this protocol outlines a surgical management approach for eligible women. The complete structured regimen is available via the link below.
References
endometrial hyperplasia (EH) commonly presents with postmenopausal bleeding and develops in association with unopposed oestrogen exposure e.g. obesity, granulosa cell tumours, HRT and SERM use.
EH without atypia has a low risk of progressing to endometrial cancer at less than 5% over 20 years.
Hysterectomy should be discussed in women who progress to atypical hyperplasia, have no regression after a year of treatment, have recurrence of EH, have persistent postmenopausal bleeding or women who decline or are unable to attend follow up.
DOI: 10.1016/j.ogrm.2025.09.009
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