Research out today (29th February) shows care improvements are needed to reduce the risk of developing cancer in patients diagnosed with endometrial hyperplasia.

Endometrial hyperplasia is a condition where the lining of the womb is thicker than normal and, in some cases, can lead to endometrial cancer (cancer of the womb lining). There are treatments available to stop the progression from endometrial hyperplasia to endometrial cancer once this condition has been diagnosed. Depending on the type of hyperplasia, the treatment may be hormone based or may be a hysterectomy (surgical removal of the womb).

Dr Naomi Black, one of the co-lead authors and a Clinical Research Fellow at the University of Warwick, said: “Follow up care needs to be better for women receiving hormone treatment. We hope that gynaecologists and hospital trusts will use the findings from our work to review how they manage women with this condition and that this will lead to a higher standard of care for all patients.

Dr Black and colleagues realised that no evaluation of the 2016 national guidance for the care of women diagnosed with both types of endometrial hyperplasia had taken place. Their study aimed to identify opportunities for quality improvement and to make care safer for patients.

Endometrial hyperplasia is grouped into two types; non-atypical, where the womb lining is thicker than normal but less likely to become cancerous, and atypical, where there is both the risk of an undetected womb cancer and a higher risk of cancer developing if the hyperplasia is left untreated.

The study looked at care pathways for 3,307 women who were diagnosed with endometrial hyperplasia between 2012 and 2020, comparing their actual care with the care recommended in the guidance. Of these, 1,655 had non-atypical endometrial hyperplasia and 1,652 had atypical endometrial hyperplasia. The 2016 national guidance for the care of women diagnosed with both types of endometrial recommends a trial of intra-uterine (given directly into the womb) hormonal treatment for women without atypia but a hysterectomy for those with atypia.

The research, out today in PLOS Medicine is the first to evaluate the care given to those with endometrial hyperplasia on a national scale. It is conducted by the UK Audit and Research Collaborative in Obstetrics and Gynaecology (UK ARCOG) and, led by researchers from the Universities of Warwick, Oxford, Edinburgh, Birmingham and UCL. It shows there are opportunities for further improvement, particularly for those with the condition who receive hormone-based treatment.

Key findings:

• The initial treatment of women without atypia changed following the introduction of national guidance. In 2012-15, 9% without atypia received no initial treatment, 31% received an initial intra-uterine hormone and 15% had an initial hysterectomy. In 2016-19, only 3% received no initial treatment, 48% received an initial intra-uterine hormone, and 12% had an initial hysterectomy;

• At two years from the initial diagnosis, the proportion of women without atypia who had successful treatment without requiring a hysterectomy increased from 38% to 52%;

• The initial treatment of women with atypia did not change, with 68% having an initial hysterectomy in 2012-15 and 67% in 2016-19;

• However, in 2020, coinciding with the COVID-19 pandemic, only 52% of women with atypia had an initial hysterectomy;

• For women who did not have a hysterectomy, only 27% without atypia and only 19% with atypia received the recommended schedule of follow up biopsies after the introduction of the guidance;

• Between 2016-19, 37% of the women who were diagnosed with atypical endometrial hyperplasia on a biopsy and who had an initial hysterectomy were found to actually have endometrial cancer on histological analysis of their womb after surgery, reinforcing the need for high quality counselling when deciding on treatment.

UK ARCOG is an organisation of doctors in specialty training in obstetrics and gynaecology in the UK that undertakes national audits to identify opportunities to improve the quality of care that patients receive.

ENDS