What this guide covers — this short guide explains how to recognise hyperplasia symptoms, what they might mean and practical next steps in the UK. It focuses mainly on endometrial hyperplasia, the thickening of the womb lining.
Abnormal vaginal bleeding is the commonest presenting issue. Tests — especially biopsy — are needed to confirm the cause, so findings from bleeding alone cannot establish a diagnosis.
Types matter: there are forms without atypia and forms with atypical cells. This distinction affects treatment choices and the chance of progression to cancer.
The article then walks through symptoms to watch for, who is most at risk, medicines and hormones that can trigger changes, diagnosis pathways, management options and follow-up. Most cases are treatable, but any unusual bleeding — particularly after the menopause — should be checked promptly.
Key Takeaways
- Endometrial hyperplasia means a thicker womb lining and needs assessment.
- Abnormal bleeding is the most common sign; tests confirm the cause.
- Two main pathological types influence risk and treatment choice.
- Many cases respond well to hormone treatments and monitoring.
- Post‑menopausal bleeding always warrants urgent review by a clinician.
Understanding endometrial hyperplasia and why it happens
“The lining of the womb can thicken when the normal balance of reproductive hormones shifts.”
Endometrial hyperplasia means the endometrium — the inner lining of the uterus — becomes excessively thick because cells multiply and crowd together.
Normally the endometrium grows after ovulation and then sheds at the period if pregnancy does not occur. Regular cycles limit build-up before the menopause.
The core mechanism is a hormone imbalance: oestrogen drives growth while progesterone calms it. If there is too much oestrogen or too little progesterone, the lining can overgrow.
Real-life causes include infrequent ovulation, perimenopausal cycle changes and some medicines that reduce progesterone exposure. These scenarios raise the chance of lining overgrowth.
“An excess of oestrogen without enough progesterone is central to most cases.”
This condition is not the same as cancer, but some forms can progress to endometrial cancer over time. Risk depends on age and menopause status, as well as modifiable factors such as weight, certain medicines and diabetes control.
Hyperplasia symptoms to watch for
Patterns of vaginal bleeding often point clinicians towards further investigation. Abnormal vaginal bleeding is the key change that usually leads to assessment for endometrial hyperplasia.
Heavier or longer periods
Heavier or longer periods can mean flooding, soaking a pad or tampon very quickly, or bleeding that lasts several days more than usual. Women may notice large clots or the need to change protection overnight.
Bleeding between periods
Spotting or bleeding between cycles — including after sex or mid‑cycle — should be recorded. Even light, unpredictable bleeding matters because it helps clinicians judge urgency.
Unexpected bleeding after the menopause
Any bleeding after 12 months without periods is a red flag. Postmenopausal bleeding needs prompt review to exclude endometrial hyperplasia or cancer causes.
When signs are easy to miss
Small changes — light spotting, irregular flow in the perimenopause, or blaming stress — can delay diagnosis. Keep a simple diary of dates, volume, clots, pain and possible triggers to help the GP triage and choose tests.
Who is most likely to develop endometrial hyperplasia
Certain groups of women carry a higher chance of developing changes in the womb lining. Clinicians use these factors to judge who needs quicker tests or closer follow-up.
Perimenopause and postmenopause changes
Irregular ovulation around the menopause means less progesterone and more unopposed oestrogen. This makes the lining more likely to develop endometrial over time and raises the risk developing lining problems after the menopause.
Weight, metabolic health and PCOS
Obesity increases oestrogen because fat tissue converts androgens to oestrogen. That higher hormone exposure can drive lining thickening in women with long-term weight issues.
Polycystic ovarian syndrome (PCOS) causes infrequent ovulation. Fewer progesterone ‘reset’ cycles mean the endometrium may be stimulated persistently, increasing the chance to develop endometrial hyperplasia.
Reproductive history, diabetes and family concerns
Early first periods, a late menopause or never having children raise lifetime oestrogen exposure. Diabetes and metabolic conditions also add to the overall risk profile clinicians consider.
A close family history of womb, bowel or ovarian cancer can change assessment and referral thresholds. Rarely, an oestrogen‑producing tumour of the ovary (for example a granulosa cell tumour) will explain unexplained hormonal change and prompt specialist review.
Hormones and medicines that can trigger endometrial overgrowth
Certain medicines and hormone treatments can change how the lining of the uterus responds to normal cycles. Clinicians look for situations where oestrogen drives growth without enough opposing influence from progesterone.
Oestrogen‑progesterone balance and the lining
Oestrogen stimulates the lining uterus to thicken. Progesterone limits that growth and promotes orderly shedding. When oestrogen acts alone — called unopposed oestrogen — the risk of endometrial hyperplasia rises.
Hormone replacement therapy and practical UK advice
If a person still has a uterus, hormone replacement therapy usually combines oestrogen with progesterone to protect the lining uterus. Different regimens (continuous combined or sequential) change bleeding patterns, so unexpected bleeding on HRT should be assessed by a GP or menopause clinic.
Tamoxifen and other oestrogen-like effects
Tamoxifen can act like oestrogen in the womb and is linked with higher rates of endometrial change. People taking tamoxifen must report any unusual bleeding promptly so that investigation can exclude serious causes.
Always tell clinicians about current medicines — include HRT type, dose, start date and any missed doses. Medicines can increase risk, but testing is still needed to confirm whether endometrial hyperplasia is present.
| Medicine or therapy | How it acts on the lining | Practical advice |
|---|---|---|
| Oestrogen-only HRT | Raises lining uterus growth if uterus present | Usually avoided; add progesterone if uterus remains |
| Combined HRT (continuous) | Steady hormone levels, less monthly bleeding | Still report unexpected bleeding |
| Tamoxifen | Oestrogen-like effects in womb tissue | Urgent review for any new bleeding |
| Other oestrogenic medicines | Can increase lining thickness | Disclose all drugs at appointments |
Types of endometrial hyperplasia and what they mean
Pathology reports sort endometrial change into two main groups that guide care.
Endometrial change without atypia
Endometrial hyperplasia without atypia describes a thickened lining where cells remain regular in shape and organisation.
Under the microscope, cells appear crowded but normal. The long‑term risk of progression to cancer is low — under 5 in 100 over 20 years. Management often uses progesterone therapy and monitoring rather than immediate surgery.
Abnormal cell changes (atypical)
Atypical endometrial hyperplasia means cells show abnormal features (called atypia) when examined microscopically.
This atypical endometrial change carries a much higher chance of developing cancer. Around 43% of people with atypical endometrial hyperplasia may already have cancerous cells elsewhere in the uterus at diagnosis.
How type affects treatment and cancer risk
- Without atypia: conservative hormone treatment and follow‑up are common.
- With atypia: discussion about surgery is usually recommended because of the higher risk.
- Type cannot be determined from bleeding alone — a biopsy and microscopic assessment are needed for confirmation.
“Cell appearance under the microscope decides the pathway—treatment and urgency depend on whether atypia is present.”
When to contact a GP or seek urgent advice in the UK
Any unexpected bleeding after the menopause needs prompt medical review. If someone has gone 12 months without periods, even a small spot should be checked by a GP because it can be linked with endometrial hyperplasia and, occasionally, cancer.
Bleeding after menopause is always worth checking
Book a same‑day or urgent GP appointment if possible. For heavy bleeding, fainting, dizziness or severe pain, contact NHS 111 or attend urgent care straight away.
How to describe bleeding patterns clearly at an appointment
Give concise details: when the bleeding started, how often it occurs and how heavy it is. Note clots, whether it followed sex, and any recent changes in cycles.
Bring a list of medicines including HRT, tamoxifen and any new drugs. Also state risk factors such as PCOS, diabetes, BMI concerns or a family history of cancer.
Clear answers help clinicians decide tests and urgency. Common investigations include ultrasound, biopsy or hysteroscopy, and good descriptions speed up appropriate referral.
| What to tell the clinician | Why it matters | Immediate action |
|---|---|---|
| When bleeding started and pattern | Helps judge urgency and likely cause | GP triage; possible urgent referral |
| How heavy and presence of clots | Indicates severity and need for same‑day care | Call NHS 111 if heavy or with fainting |
| Medicines and HRT/tamoxifen | Some drugs raise lining risk or alter tests | Bring medication list to appointment |
| Relevant medical risks (PCOS, diabetes, BMI, family history) | Affects referral threshold and test choice | May prompt faster ultrasound or biopsy |
Preparing for a medical appointment about symptoms
Being ready with dates, drugs and risks helps clinicians choose the right tests. Bring a short symptom diary noting when bleeding started, the number of days between periods and any change in flow. If cycles are irregular, record the last period date and whether the person is perimenopausal or post‑menopausal.
Key history to share: pregnancy history, previous episodes of bleeding, and any other gynaecological issues. Give a full medicines list — include brand names, HRT regimen (oestrogen‑only or combined), missed doses and any past tamoxifen use.
Note personal risk factors: PCOS, diabetes, recent weight change, and family history of womb, bowel or ovarian cancer. Include age at first period and menopause if known.
- Ask clear questions: which tests are recommended — ultrasound, biopsy or hysteroscopy?
- Ask what results could mean and how long results take to return.
- Confirm who to contact if bleeding worsens while waiting.
Practical tips: bring the diary and medicines, ask about pain relief for a biopsy, and request written advice or a follow‑up plan before leaving.
How endometrial hyperplasia is diagnosed
A clear pathway helps clinicians find the cause of abnormal bleeding. In the UK this usually starts with a GP assessment and, if needed, referral to gynaecology for imaging and tissue sampling.
Transvaginal ultrasound and a thickened endometrium
Ultrasound uses a small probe placed in the vagina to image the uterus and endometrium. A report may describe a thickened endometrium, which flags the need for further tests.
Ultrasound is quick and painless for most people, but it cannot confirm a diagnosis on its own. It guides whether an endometrial biopsy is required.
Endometrial biopsy as the definitive test
An endometrial biopsy samples the lining of the womb. Clinicians usually pass a thin plastic tube through the cervix in an outpatient clinic to collect tissue.
The procedure commonly causes brief cramping. The sample is sent to pathology because the biopsy is the test that confirms whether endometrial hyperplasia is diagnosed.
Hysteroscopy for visual assessment and targeted sampling
Hysteroscopy uses a slim telescope to view inside the uterus and take targeted biopsies. Most are done as outpatient procedures.
Some people need a hysteroscopy under anaesthetic to remove polypoid tissue or to obtain better samples.
What the microscope looks for: crowded glands and cell appearance
Pathologists examine the biopsy to see if glands are crowded and whether cells look normal or show atypical features. This microscopic review decides the final diagnosis.
Results then guide management — from monitoring to progesterone treatment or surgery — and set the schedule for follow‑up biopsies.
| Step | What it shows | Typical setting |
|---|---|---|
| GP assessment | History and initial examination; triage urgency | Primary care |
| Transvaginal ultrasound | Thickness of the endometrium; structural changes in uterus | Gynaecology clinic or imaging centre |
| Endometrial biopsy | Definitive tissue sample to confirm diagnosis | Outpatient clinic; sometimes theatre |
| Hysteroscopy | Direct visual assessment and targeted sampling | Outpatient or operating theatre with anaesthetic if required |
What test results can show and how clinicians interpret them
A final diagnosis depends on the whole clinical picture — what was seen, what was sampled and how cells look under the microscope.
Confirming endometrial change versus other causes
Clinicians combine the bleeding history, ultrasound findings and biopsy pathology to decide whether endometrial hyperplasia is present.
Abnormal bleeding can come from polyps, fibroids, infection or HRT‑related changes, so tissue sampling is essential to confirm the cause.
Understanding results described as without atypia
Hyperplasia without atypia means the lining is thicker but cells look normal under the microscope.
This carries a lower long‑term cancer risk (under 5% over 20 years) and is often managed with progesterone treatment and close follow‑up.
Understanding atypical results and the chance of cancer already present
When pathology finds atypical cells the report raises concern because abnormal cell features increase the risk of cancer.
Data show roughly a 43% chance that cancer is already present elsewhere in the uterus when atypical change is found. That figure explains why urgent specialist discussion is common.
Ask clinicians to explain the exact wording of the pathology report, the planned follow‑up, and which signs should trigger re‑contacting services.
How to manage endometrial hyperplasia without atypia
Many people with a non‑atypical diagnosis can be managed without immediate surgery. The goal is to reverse overgrowth, reduce future cancer risk and improve bleeding and quality of life.
Watchful waiting and when it is appropriate
Observation is an option when risk factors can be changed — for example stopping unopposed oestrogen HRT or attempting weight loss. Clinicians will usually arrange a follow‑up biopsy to check the lining.
Progesterone tablets and typical treatment duration
Oral progesterone such as norethisterone or medroxyprogesterone is commonly used. Tablets are often prescribed for around six months to encourage regression and control bleeding.
Mirena® (IUS) progesterone coil and why it often works best
Mirena® (IUS) releases local progesterone directly inside the uterus. It often gives the best regression rates, fewer systemic effects and protects for up to five years.
Expected success rates with and without treatment
Approximately 75% of cases regress with observation alone. Progesterone treatment raises regression chances to about 89–96%, with the IUS generally producing the best outcomes.
Managing troublesome bleeding during treatment
Progesterone commonly reduces heavy or irregular bleeding. Patients should be told what to expect and advised to seek urgent review for very heavy bleeding, dizziness or fainting.
| Approach | When used | Usual duration | Approximate regression rate |
|---|---|---|---|
| Observation | Reversible risks present; low clinical urgency | Clinical review with biopsy at 3–6 months | ~75% |
| Oral progesterone | Preferred when medical therapy wanted or bleeding needs control | Typically 6 months | ~89–96% |
| Mirena® (IUS) | Best for ongoing local therapy and fewer side effects | Up to 5 years (reviewed earlier) | Highest within progesterone options |
“Follow-up biopsy is essential even if bleeding settles, to confirm the lining has returned to normal.”
How atypical endometrial hyperplasia is managed to reduce cancer risk
Atypical cell changes prompt a different clinical pathway because they increase the chance that endometrial cancer is already present or may develop. Pathology data show a notably higher rate of concurrent cancer, so clinicians usually plan definitive risk‑reduction rather than simple observation.
Why atypia carries a higher risk of endometrial cancer
Abnormal cell features under the microscope reflect disordered growth. This raises progression risk and explains why urgent specialist assessment is common.
When hysterectomy is usually recommended
Removal of the uterus by hysterectomy is commonly offered once childbearing is complete. This approach both treats confirmed disease and reduces future cancer risk.
Referral, pre‑operative assessment and a discussion of surgical approaches (laparoscopic, vaginal or open) are routine before any operation.
Considerations about removing the ovaries at the same time
Removing ovaries may be discussed depending on age, menopausal status, family history and overall risk. The choice is individualised and weighs surgical risks, hormonal effects and cancer prevention benefits.
What happens if hysterectomy is not possible
If surgery is unsuitable or declined, specialist‑led treatment with intensive progesterone therapy and close surveillance is an alternative. Regular repeat biopsies and imaging are required to monitor response.
Shared decision‑making matters: clinicians balance cancer risk, fitness for surgery, fertility wishes and personal preference when agreeing a plan.
Follow-up and monitoring after diagnosis or treatment
Careful follow-up after treatment helps ensure the lining has truly returned to normal. Bleeding may settle before tissue normalises, so planned checks reduce the chance of missed relapse.
Repeat biopsy at six months and beyond
Most pathways include a repeat biopsy at around six months after starting treatment. Clinicians may repeat the biopsy again at 12 months depending on the earlier result and clinical judgement.
Who may need yearly biopsies
People with ongoing risk factors — for example a BMI over 35 — or those treated with oral progesterone tablets rather than an IUS often face a higher relapse risk.
These women may be offered yearly biopsies until the lining remains stable.
What relapse means and next steps
Relapse means the lining shows renewed overgrowth on microscopy or bleeding returns. Underlying drivers such as weight, diabetes control or continued oestrogen exposure explain why relapse risk rises.
If abnormal bleeding returns after discharge the patient should contact their GP promptly. A repeat biopsy is commonly the next step to check for recurrence and to guide further treatment.
- Why follow-up matters: biopsy confirmation reduces missed ongoing disease.
- Typical timeline: repeat biopsy at ~6 months; sometimes again at 12 months.
- Personalised plans: monitoring depends on type of endometrial hyperplasia, response to treatment and individual risk.
| Action | When | Who |
|---|---|---|
| Repeat biopsy | 6 months (±12 months if needed) | Most patients |
| Yearly biopsy offer | Annual | BMI >35 or on oral progesterone |
| GP review | Any return of bleeding | All patients after discharge |
Lowering future risk and preventing recurrence
Addressing reversible drivers of endometrial overgrowth helps protect against future episodes. Small, sustainable changes can support medical treatment and reduce the chance of return.
Weight management and reducing reversible risk factors
Reducing excess body fat lowers oestrogen produced in adipose tissue and improves metabolic health. Weight loss can increase the chance of regression in people who are overweight.
- Ask a GP about NHS weight management services or local referral programmes.
- Focus on steady changes: balanced eating, regular activity and behavioural support.
- Work with practice nurses or dietitians for tailored plans and long‑term follow up.
Reviewing HRT and ensuring progesterone protection
If the uterus remains in place, combined regimens that include progesterone alongside oestrogen usually protect the lining. Patients should not stop or change HRT without medical advice; instead request a review to confirm the most suitable formulation.
Ongoing medication reviews, including tamoxifen
Drugs with oestrogen‑like effects can influence recurrence. A medication review helps clinicians weigh benefits and risks and arrange closer surveillance if needed.
Report any new bleeding promptly and ensure tamoxifen exposure is discussed at each review so clinicians can plan appropriate monitoring.
Prevention is part of long‑term care: addressing weight, medicines and HRT, and keeping scheduled checks, lowers the chance of recurrence.
Conclusion
Conclusion
When bleeding differs from a person’s normal pattern, it is sensible to seek prompt assessment. Abnormal bleeding is the key change that usually leads to investigation for endometrial hyperplasia.
The practical pathway is simple: recognise changes, contact a GP, attend tests and use biopsy results to guide next steps. This approach helps clinicians decide between medical care and surgery.
Endometrial hyperplasia is not the same as cancer, but the type found matters. Non‑atypical change often responds well to progesterone‑based treatment such as Mirena®, while atypical findings need earlier specialist planning.
Follow-up checks confirm the lining has returned to normal and catch any return early. Most people have effective options and clear next steps, so if unusual bleeding returns they should seek medical review rather than self‑manage.
