Endometrial hyperplasia

Disease Description (Causes and Symptoms)

• Definition: A condition in which endometrial tissue proliferates abnormally and becomes thickened (Endometrial hyperplasia).
• Causes and pathophysiology: Mainly caused by ovulatory dysfunction or relative excess estrogen (insufficient progesterone). Risk factors include obesity, polycystic ovary syndrome (PCOS), estrogen-only hormone therapy, tamoxifen use, and metabolic diseases such as diabetes and hypertension. Histologically, epithelial cell proliferation increases, and when atypia is present, the risk of progression to endometrial cancer increases.
• Main symptoms: Often asymptomatic. Common symptoms include abnormal vaginal bleeding (bleeding outside of menstruation), heavy menstrual bleeding (menorrhagia), irregular menstruation, lower abdominal discomfort, and bleeding after a prolonged period of amenorrhea. Postmenopausal bleeding is particularly important (as it may indicate a serious lesion).

Treatment Methods

• Diagnostic principles: The definitive diagnosis is made by endometrial tissue examination (endometrial biopsy or curettage/collection of lesions identified by hysteroscopy). Transvaginal ultrasound (for assessing endometrial thickness) and hysteroscopy may be used as supplementary tests.
• Non-atypical endometrial hyperplasia
  • First-line: Progestin therapy (oral progestin or a levonorgestrel intrauterine device [LNG-IUD, e.g., 52 mg]) — an LNG-IUD is commonly recommended because of its high effectiveness and local effect.
  • Treatment duration: Generally administered for at least 3–6 months, followed by tissue examination to assess the response.
  • With conservative treatment, regular tissue examinations and ultrasound follow-up are necessary.
• Atypical endometrial hyperplasia
  • Standard treatment: Hysterectomy is recommended for those who are postmenopausal or have completed childbearing (whether to include the ovaries is determined based on the patient’s condition).
  • If fertility preservation is desired: Treatment may be attempted with high-dose progestin (oral or LNG-IUD) and very strict monitoring (repeat endometrial examinations and imaging tests), but careful consultation with a specialist is necessary because of the risk of progression to cancer.
• Additional management
  • Control of anemia and bleeding, correction of metabolic factors (obesity and diabetes), ovulation-induction treatment (if necessary), and adjustment of causative medications (e.g., estrogen-only therapy).
  • Surgical treatment (hysterectomy) is considered when there is a high concern for recurrence or progression, or when medication treatment fails.
• Follow-up: Repeat tissue examination is recommended at 3- to 6-month intervals after starting treatment (more frequently in cases of atypia). After menopause, immediate evaluation is needed if clinical symptoms occur.

Checklist Before an Outpatient Visit (Items to Bring and Tests/Records)

• Items to bring and materials to submit
  • List of currently taken medications (including hormone medications), including dosage and duration of use
  • Previous gynecological examination and pathology results (particularly those related to the endometrium), preferably as electronic files or printouts
  • Menstrual history record (for the past 3–6 months): timing and duration of bleeding, amount (based on pads/tampons), and intervals
  • Onset and changes in symptoms (e.g., the date postmenopausal bleeding began)
  • Underlying conditions (diabetes, hypertension, obesity, PCOS, etc.) and changes in weight
  • Whether pregnancy is possible (testing is necessary if pregnancy is not desired)
• Main items the healthcare provider may ask about during the outpatient visit (examples)
  • The onset and pattern of bleeding and whether pain is present
  • Whether you are taking hormone medications (contraceptive pills, HRT, or therapeutic medications)
  • History of endometrial biopsy or uterine surgery
  • Whether you plan to become pregnant and whether you wish to preserve fertility

Examples of General Questions to Ask the Doctor

• "How should my tissue examination results be interpreted—non-atypical or atypical?"
• "Is a hysterectomy absolutely necessary in my case? Is conservative treatment possible?"
• "What are the side effects and expected effects of the progestin treatment (medication or IUD) you recommend?"
• "After treatment, how often will I need tissue examinations or ultrasound follow-up?"
• "What lifestyle changes should I make to reduce the risk of recurrence?"

Examples of Condition-Specific Questions

• When fertility preservation is desired: "Can I be treated with a levonorgestrel IUD or high-dose progestin to preserve fertility? What are the success rate and necessary follow-up examinations?"
• When atypia is present: "There are findings of atypia. If I choose conservative hormone treatment instead of surgery, please explain specifically how high the risk of progression to cancer is and how follow-up will be conducted."

(Note: If bleeding has newly started or if there is postmenopausal bleeding, immediate gynecological evaluation is necessary. This material provides general information; individual diagnosis and treatment should be determined in consultation with your healthcare provider.)