A 45-year-old woman with abnormal uterine bleeding undergoes endometrial biopsy showing complex hyperplasia without atypia. She has no family history of malignancy. What is the most appropriate management?

• A Total abdominal hysterectomy with bilateral salpingo-oophorectomy
• B Progestin therapy with follow-up endometrial sampling ✓
• C Continuous combined hormone replacement therapy
• D GnRH agonist therapy for 6 months

Explanation

Endometrial hyperplasia without atypia is managed conservatively with progestin therapy (oral medroxyprogesterone acetate, levonorgestrel-releasing IUD, or cyclic progestins) with repeat endometrial sampling at 3-6 months. Progression to cancer is low (1-3%). Hysterectomy is reserved for hyperplasia with atypia or progression despite progestin therapy. HRT would worsen hyperplasia. GnRH agonists are second-line options. (FIGO AUB guidelines; ACOG Practice Bulletin on Endometrial Hyperplasia).

Reference: Comprehensive Gynecology, 8th ed.

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