Management of Endometrial Hyperplasia: A Comparative Review of Guidelines

Endometrial hyperplasia, presenting without atypia (EH) or as atypical hyperplasia (AH), is considered a precursor of endometrial cancer and affects women of reproductive or perimenopausal age, posing a major public health concern. The aim of this study was to review and compare the most recently published influential guidelines providing recommendations on the management of endometrial hyperplasia. Thus, a comparative review of guidelines from the Royal College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynecologists of Canada, and the American College of Obstetricians and Gynecologists was conducted. There is a consensus regarding the optimal management strategies for EH, with observation and medical treatment being the first-line options and surgical treatment with total hysterectomy offering a second line in specific cases. Moreover, there is agreement regarding patients with AH, with surgical treatment being the recommended approach, while medical therapy is preferred for women who seek fertility preservation. Notably, close surveillance with endometrial biopsies every 3 or 6 months is suggested unanimously, as well as long-term follow-up in high-risk patients. Controversy exists regarding the initial diagnostic approach, with RCOG and SOGC suggesting outpatient endometrial biopsy, while ACOG recommends diagnostic hysteroscopy, as well as the therapeutic regimens for the oral treatment of EH. Surgical techniques such as endometrial ablation, intraoperative frozen section analysis, intraoperative visual inspection of the uterus, and morcellation constitute areas of controversy among the reviewed guidelines, and the surveillance protocols for women with EH are addressed differently between RCOG and SOGC. Notably, RCOG is the only medical society offering recommendations regarding women under HRT and those on therapy for breast cancer. The development of consistent international practice protocols for timely management strategies and surveillance protocols is of paramount importance to safely guide clinical practice and subsequently improve women's health.