Endometrial Hyperplasia · Progestin vs Hysterectomy

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

Full pathway

1. [Decision] Atypia + fertility wish + menopausal status
   Atypia (EIN/AEH)? Preserve fertility/uterus? Menopausal status? (Atypical hyperplasia (EIN/AEH) has ~35–40% concurrent endometrial cancer; before fertility-sparing, hysteroscopic targeted biopsy must exclude concurrent cancer.)
   • Without atypia → Without atypia → progestin (LNG-IUS preferred)
   • Atypical/EIN, completed childbearing/no fertility wish → Atypical/EIN completed childbearing → total hysterectomy
   • Atypical/EIN, wants fertility preservation or high surgical risk → Atypical/EIN fertility-sparing → high-dose progestin
2. [End] Without atypia → progestin (LNG-IUS preferred)
   Without atypia → progestin first-line, not first-line hysterectomy: LNG-IUS is better than oral (85–92% vs 72% resolution, lower recurrence), keep for 5 years; assess with 6-monthly ultrasound + endometrial biopsy to two consecutive negatives, 6-monthly biopsy follow-up if BMI ≥35 or on oral therapy. Failure/progression/recurrence/declining follow-up/symptomatic bleeding not wanting preservation → hysterectomy; add bilateral salpingo-oophorectomy if postmenopausal and surgery is needed.
3. [End] Atypical/EIN completed childbearing → total hysterectomy
   Atypical hyperplasia/EIN, completed childbearing → total hysterectomy is the definitive procedure: minimally invasive approach preferred, no subtotal hysterectomy, remove both fallopian tubes (add both ovaries if postmenopausal or high-risk); no endometrial ablation; preoperative hysteroscopic biopsy to exclude concurrent cancer.
4. [End] Atypical/EIN fertility-sparing → high-dose progestin
   Atypical hyperplasia/EIN, wants fertility preservation or high surgical risk → exclude concurrent cancer first, high-dose progestin (LNG-IUS preferred, or oral megestrol/MPA) + 3-monthly endometrial sampling; can pursue conception after complete resolution, hysterectomy advised after childbearing; young patients (<40) have higher resolution rates.

Source guidelines & references

• Endometrial hyperplasia management (ACOG EIN/AEH consensus 2023; RCOG/BSGE Green-top 67; exclude concurrent cancer before treatment)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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