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Observation alone with follow-up endometrial biopsies to ensure disease regression can be considered, C especially when identifiable risk factors can be reversed. However, women should be informed that treatment with progestogens has a higher disease regression rate compared with observation alone. Progestogen treatment is indicated in women who fail to regress following observation alone and in P symptomatic women with abnormal uterine bleeding. There are two cohort studies and a case–control study describing the natural history of hyperplasia without atypia and its risk for progression to cancer. Two cohort studies have followed up women diagnosed with endometrial hyperplasia who had no treatment. The first study was a multicentre prospective study where 35 women with simple hyperplasia and four women with complex hyperplasia were followed up for 24 weeks without any treatment. Regression to normal endometrium occurred in 81% of women (74/93) with simple Evidence hyperplasia, while 18% (17/93) had persistent disease and 1% (1/93) progressed to level 2+ endometrial cancer. The slow progression of endometrial hyperplasia without atypia to cancer offers a window of opportunity to address these factors. Obesity is a major risk factor and advising obese women to lose weight is recommended, but there is no evidence on weight loss strategies and their impact on progression or relapse outcomes during follow-up. Observational studies have demonstrated that up to 10% of severely obese women could harbour asymptomatic endometrial hyperplasia and bariatric surgery may reduce this risk. Clinicians should be aware that nonprescribed estrogen intake may take level 2++ various forms. This is particularly important for postmenopausal women as they have a higher risk of developing endometrial hyperplasia and cancer because of unopposed extraovarian estrogenic stimulation. Ongoing tamoxifen treatment should be reviewed in conjunction with the woman’s oncologist. If not, this should be arranged to exclude the possibility of an estrogen- secreting granulosa cell tumour of the ovary. In view of a high spontaneous regression rate and uncommon progression to more severe disease, it is uncertain whether medical management is appropriate for all women. Many women are diagnosed with endometrial hyperplasia while undergoing investigation of abnormal uterine bleeding. Because of the risk of progression to cancer, women who fail to regress with observation alone should be treated and followed up to ensure regression.

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Rocaltrol
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