OB/GYN
A 40-year-old woman presents with menorrhagia for the last 6 months.
She underwent an endometrial biopsy. Endometrial biopsy: Presence of simple endometrial hyperplasia without atypia. Which of the following is the most appropriate next step in management?
Explanation
Core Concept: Endometrial hyperplasia without atypia is an overgrowth of endometrial glands relative to the stroma, driven by unopposed estrogen exposure. It carries a low risk of progression to endometrial cancer (<5%).
Clinical Presentation:
- Abnormal uterine bleeding (menorrhagia, metrorrhagia, postmenopausal bleeding)
- Pelvic pain or cramping (less common)
- Complications: Chronic anemia due to heavy menstrual bleeding; small risk of progression to atypical hyperplasia or cancer.
Diagnosis:
- First-line: Transvaginal ultrasound to measure endometrial thickness.
- Gold Standard: Endometrial biopsy or hysteroscopy with directed biopsy showing crowded glands without cytologic atypia.
Management:
- Acute management: Control acute heavy bleeding with high-dose oral progestins, combined oral contraceptives, or tranexamic acid.
- Long-term/definitive: Progestin therapy (oral medroxyprogesterone acetate, megestrol, or the levonorgestrel-releasing intrauterine system [LNG-IUS]) to counteract estrogen effects and induce glandular regression. Follow-up biopsy is recommended after 6 months.