Endometrial Hyperplasia on Your Biopsy: What "With" or "Without Atypia" Means

You had a biopsy for heavy, irregular or post-menopause bleeding, and the result says “endometrial hyperplasia.” It means the lining of the uterus has thickened, with changes in its glands and tissue.¹ It isn’t cancer, but one type carries a much higher cancer risk than the other, so the details matter.

The key word: atypia

Pathologists now usually sort hyperplasia into two groups:¹

• Hyperplasia without atypia (also called benign hyperplasia)
• Atypical hyperplasia, also called endometrial intraepithelial neoplasia (EIN)

Atypical hyperplasia is the bigger concern because it can be a precursor of endometrial cancer.¹ Ask for your result in writing so you can see which one you have.

What causes it

Hyperplasia usually comes from estrogen that isn’t balanced by progesterone. That can happen during perimenopause when you skip ovulation, with polycystic ovary syndrome, with tamoxifen, or with hormone therapy that’s estrogen only.² Our guide to bleeding on hormone therapy covers that situation.

What the cancer numbers show

A 2020 review pooled the available studies:³

• About one in three women diagnosed with atypical hyperplasia already had endometrial cancer somewhere in the uterus.
• Among women with atypical hyperplasia, progression to cancer averaged about 8% per year.
• Only one study looked at hyperplasia without atypia, with a rate of about 2.6% per year.

The authors noted the number of studies is small, so these are rough estimates.³

Common treatments

Hormone treatment with a progestin is the usual approach for hyperplasia without atypia, and hysterectomy is the main option for atypical hyperplasia.² Standard treatments are still not fully settled.²

A Norwegian trial in 170 women aged 30 to 70 with lower-risk hyperplasia compared three six-month treatments:⁴

• Hormonal IUD: all 53 women had a normal lining afterward.
• Daily progestin pills: 96% responded.
• Progestin pills for 10 days a month: only 69% responded.

Side effects were fairly common in all three groups.⁴ Our articles on hormonal IUD bleeding patterns and endometrial biopsy results explain more.

Questions to ask

1. Is my hyperplasia with or without atypia?
2. What likely caused it, and can we change that?
3. Which treatment do you recommend, and why?
4. When will you repeat the biopsy to check it worked?
5. Should I see a gynecologic oncologist?

Try: “My biopsy says hyperplasia. Can you show me whether there’s atypia, and walk me through the treatment options and the follow-up plan?”

Period, Handled includes a Period Scorecard and a visit script. Use them to record bleeding patterns, test dates and your treatment plan. See the book.