Benefits, Harms, and/or Costs
- 1In addition to epidemiologic risk factors related to estrogen exposure, intermenstrual bleeding and postmenopausal bleeding are associated with increased risk of endometrial hyperplasia. Endometrial sampling should be carried out as per published algorithms with particular attention to women 40 years or older or with a body mass index of 30 kg/m2 or greater (moderate).
- 2Since the majority of cases of endometrial hyperplasia without atypia are successfully managed medically, hysterectomy is not considered first-line treatment and surgery is reserved for specific circumstances (moderate).
- 3A minimally invasive approach to hysterectomy is preferred for endometrial hyperplasia as it decreases perioperative morbidity and mortality (high).
- 4If hysterectomy is indicated for endometrial hyperplasia without atypia then postmenopausal women should also be offered bilateral salpingo-oophorectomy. This decision is individualized for premenopausal women due to increased mortality and morbidity associated with removal of the ovaries in young women with benign disease (moderate).
- 5Hysterectomy and bilateral salpingo-oophorectomy are the recommended treatment for atypical endometrial hyperplasia due to the underlying risk of malignancy or progression to endometrial cancer. Retention of the ovaries in premenopausal women may be considered (low).
- 6There is no evidence to support routine intraoperative frozen section analysis in cases of endometrial hyperplasia (low).
- 7There is no evidence to support routine lymphadenectomy for atypical endometrial hyperplasia (moderate).
- 8There is insufficient evidence to support endometrial ablation as first-line surgical treatment for endometrial hyperplasia without atypia (low).
- 9Endometrial hyperplasia found in endometrial polyps should be treated according to its histologic classification (low).
- 1Health care providers should use the 2014 World Health Organization histopathologic classification of endometrial hyperplasia (strong, low). If endometrial cancer is suspected, endometrial tissue sampling using a Pipelle device in an outpatient setting is the most appropriate first step for diagnosis (strong, high).
- 2Those with recurrent symptoms of abnormal uterine bleeding after initial observation or medical treatment should be reassessed with an endometrial biopsy (strong, high).
- 3Patients with endometrial hyperplasia should be assessed for reversible risk factors and receive education and support from their clinicians in order to treat and reverse those conditions (strong, high).
- 4Patients with endometrial hyperplasia without atypia can be observed. They can be offered hormonal treatment if hyperplasia does not resolve with observation or experience abnormal uterine bleeding (weak, low).
- 5The levonorgestrel intrauterine system should be used as the first-line treatment for endometrial hyperplasia without atypia due to its effectiveness and favourable side effect profile (strong, high) and due to the fact that it can be kept in place for 5 years in patients showing treatment response (strong, moderate).
- 6Low-dose oral and injectable progestins remain an acceptable treatment option for women with endometrial hyperplasia with and without atypia desiring an alternative treatment modality (strong, high). For patients on oral progestins, we suggest starting on a low dose for a minimum of 6 months. We suggest that assessment of the endometrium be done mid-therapy as well as 3 weeks after completion of treatment to ensure proper interpretation (strong, very low).
- 7Surgical treatment of endometrial hyperplasia without atypia should be reserved for patients who do not want to preserve their fertility and experience progression to atypical hyperplasia or carcinoma during follow-up, whose hyperplasia fails to regress after 12 months of medical treatment or relapses after completing treatment with progestins, who continue to experience abnormal uterine bleeding despite treatment, or who decline endometrial surveillance or medical treatment (strong, high).
- 8If surgery is indicated for endometrial hyperplasia without atypia, the procedure should include total hysterectomy with opportunistic salpingectomy, with or without bilateral oophorectomy depending on menopausal status (strong, moderate).
- 9Total hysterectomy with bilateral salpingo-oophorectomy is recommended for treatment of atypical hyperplasia in premenopausal and postmenopausal women (strong, moderate). In premenopausal women, ovarian preservation should be discussed (strong, moderate).
- 10We recommend that subtotal (supracervical) hysterectomy and morcellation be avoided in all cases of endometrial hyperplasia (strong, low).
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This document reflects clinical and scientific consensus on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well-documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the publisher.
All people have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order to facilitate informed choice, patients should be provided with information and support that is evidence-based, culturally appropriate, and tailored to their needs.
This guideline was written using language that places women at the centre of care. The SOGC is committed to respecting the rights of all people–including transgender, gender non-binary, and intersex people–for whom the guideline may apply. We encourage health care providers to engage in respectful conversation with patients regarding their gender identity and their preferred gender pronouns to be used as a critical part of providing safe and appropriate care. The values, beliefs, and individual needs of each patient and their family should be sought and the final decision about the care and treatment options chosen by the patient should be respected.