All three conditions involve endometrial tissue and are driven by estrogen, but they differ in location and consequences.
| Feature | Endometrial hyperplasia | Endometriosis | Adenomyosis |
|---|
| What happens | Overgrowth of the endometrial lining inside the uterine cavity | Endometrial-like glands and stroma outside the uterus (ovaries, pelvic peritoneum, uterosacral ligaments, bowel, bladder) | Endometrial tissue within the myometrium (uterine muscle) |
| Mechanism | Unopposed estrogen — estrogen stimulation without enough progesterone | Retrograde menstruation, immune and inflammatory factors, genetics; implants bleed and inflame each cycle → adhesions and scarring | Invasion of the basal endometrium into muscle; uterus becomes diffusely enlarged and "boggy" |
| Typical client | Perimenopausal or postmenopausal; obesity, PCOS | Reproductive age (often teens to 30s) | Usually 35–50, multiparous, prior uterine surgery |
| Main symptoms | Abnormal uterine bleeding | Dysmenorrhea (progressive, secondary), dyspareunia, infertility | Heavy menstrual bleeding and dysmenorrhea |
| Cancer relation | Atypical hyperplasia is a precursor of endometrioid cancer | Small increase in certain ovarian cancers (clear cell, endometrioid) | Not premalignant |
Endometrial hyperplasia — classification (WHO 2014/2020)
- Hyperplasia without atypia — benign; low risk of progression (about 1–3%); most regress with progestin therapy
- Atypical hyperplasia / endometrial intraepithelial neoplasia (EIN) — precancerous; high risk of progression, and coexisting cancer is found in a substantial share (up to about 40%) at hysterectomy
- Older terms ("simple" and "complex") are still seen on exams.
Risk factors for hyperplasia — obesity, chronic anovulation (PCOS), estrogen-alone therapy with a uterus, tamoxifen, nulliparity, early menarche, late menopause, diabetes, estrogen-secreting tumors, Lynch syndrome. Early menopause is not a risk factor (less estrogen exposure).
Endometriosis — risk factors — early menarche, short cycles, heavy or long menses, nulliparity, outflow obstruction, family history; pregnancy and lactation tend to reduce symptoms. Endometriomas ("chocolate cysts") are ovarian cysts filled with old blood.
Infertility in endometriosis — pelvic adhesions and distorted tubal–ovarian anatomy that block oocyte pickup and transport, plus inflammation that impairs egg quality and implantation.
Endometrial hyperplasia
- Abnormal uterine bleeding — heavy or prolonged menses, intermenstrual bleeding, postmenopausal bleeding
- Signs of anemia; history of obesity, PCOS, diabetes, hormone therapy, tamoxifen
Endometriosis
- Secondary dysmenorrhea that worsens over time, often starting before menses
- Deep dyspareunia, chronic pelvic pain, dyschezia (painful bowel movements) or cyclic rectal bleeding, dysuria or cyclic hematuria
- Infertility
- Pelvic exam: tender nodules in the uterosacral ligaments or cul-de-sac, fixed retroverted uterus, adnexal mass (endometrioma); exam may be normal
- Symptom severity does not match disease extent
Adenomyosis
- Heavy menstrual bleeding and increasingly severe dysmenorrhea, chronic pelvic pain, dyspareunia
- Uniformly enlarged, soft, tender ("boggy") uterus
- Anemia
Endometrial hyperplasia
- Transvaginal ultrasound — in a postmenopausal woman with bleeding, an endometrial thickness ≤ 4 mm makes hyperplasia or cancer unlikely; a thicker lining (e.g., 8 mm) or persistent bleeding needs sampling
- Endometrial biopsy or hysteroscopy with D&C — histology is required for diagnosis
- Pregnancy test, CBC
Endometriosis
- Clinical diagnosis is now accepted: based on symptoms, exam, and imaging, treatment can start without surgery
- Transvaginal ultrasound (endometriomas, deep nodules) and MRI (deep disease)
- Laparoscopy with biopsy gives histologic confirmation and allows treatment — the historical "gold standard," now used mainly when imaging is negative and empiric therapy fails, or when surgery is planned
- CA-125 may be raised but is not a diagnostic test
Adenomyosis
- Transvaginal ultrasound — first-line: enlarged globular uterus, asymmetric myometrial thickening, poorly defined junctional zone, myometrial cysts
- MRI — most accurate imaging; ill-defined, diffuse borders distinguish it from well-circumscribed fibroids
- Definitive diagnosis traditionally by hysterectomy pathology
Endometrial hyperplasia
- Without atypia: progestin therapy — the levonorgestrel IUD is preferred (most effective, fewer systemic effects), or oral progestins (medroxyprogesterone acetate, megestrol, norethindrone), for at least 6 months, with repeat endometrial sampling (about every 6 months until two negative results); correct risk factors (weight loss, stop unopposed estrogen)
- Atypical hyperplasia/EIN: total hysterectomy (usually with bilateral salpingectomy; oophorectomy per age) — the preferred treatment, especially after menopause; high-dose progestin (LNG-IUD and/or oral) with sampling every 3–6 months for women who want fertility or cannot have surgery
- Endometrial ablation is not a treatment for hyperplasia
Endometriosis — goals: pain relief, fertility, prevention of progression
- First-line: NSAIDs plus hormonal suppression — combined hormonal contraceptives (cyclic or continuous) or progestins (norethindrone acetate, dienogest, depot medroxyprogesterone, levonorgestrel IUD)
- Second-line: GnRH agonists (leuprolide) with add-back therapy (low-dose hormone to prevent hot flashes and bone loss); oral GnRH antagonists (elagolix; relugolix combination)
- Estrogen alone worsens endometriosis and is not used
- Danazol (androgenic side effects, teratogenic) is rarely used now
- Surgery: laparoscopic excision or ablation of implants, cystectomy for endometriomas, adhesion removal; hysterectomy with or without oophorectomy for severe disease when childbearing is complete. Symptoms can recur
- Infertility: surgery, ovulation induction with insemination, or in vitro fertilization
- Radiation is not used for endometriosis
Adenomyosis
- NSAIDs, levonorgestrel IUD (thins and atrophies the endometrium, reducing bleeding and pain), combined hormonal contraceptives, progestins, GnRH analogues — relieve symptoms but do not cure
- Uterine artery embolization — a minimally invasive option
- Hysterectomy is the only definitive cure
Drug safety
| Drug | Key points |
|---|
| Progestins | Irregular bleeding or spotting, weight gain, bloating, mood changes, headache, breast tenderness; VTE risk with high doses; depot medroxyprogesterone → bone density loss (reversible), delayed return of fertility |
| Levonorgestrel IUD | Irregular spotting for 3–6 months, then light or absent periods; rare perforation or expulsion; check strings |
| Combined hormonal contraceptives | Contraindicated with smoking at 35 or older, VTE, migraine with aura, uncontrolled hypertension |
| GnRH agonists | Hot flashes, vaginal dryness, bone loss — add-back therapy, calcium, vitamin D; initial flare; not contraceptive — use nonhormonal contraception |
| Elagolix | Hot flashes, dose- and duration-dependent bone loss (use limited in time), mood changes and suicidal ideation, raised liver enzymes; contraindicated in pregnancy, known osteoporosis, severe hepatic impairment, and with strong OATP1B1 inhibitors (e.g., cyclosporine); may reduce effect of hormonal contraceptives |
| Relugolix–estradiol–norethindrone | Boxed warning: thromboembolic disorders — contraindicated with VTE history, smokers over 35, osteoporosis, known or suspected breast cancer or other hormone-sensitive cancer, liver disease, undiagnosed bleeding; bone loss — use limited to 24 months; mood changes |
| NSAIDs | GI bleeding, kidney injury; take with food |
Listed in priority order.
- Assess bleeding and anemia — vital signs, orthostatic changes, pad counts, hemoglobin; fall precautions when dizzy
- Ensure evaluation of postmenopausal bleeding — never attribute it to "normal" changes; confirm follow-up biopsy results
- Pain assessment and management — pain scale, pattern across the cycle, effect on daily life; scheduled NSAIDs as ordered, heat, rest, positioning
- Medication monitoring — contraindications before hormones (VTE, smoking, migraine with aura, liver disease, pregnancy); bone health with GnRH therapy; mood changes
- Postoperative care after laparoscopy or hysterectomy — bleeding, shoulder pain from CO₂ gas (expected; early ambulation helps), infection, VTE prevention, voiding, bowel function; laparoscopic excision near bowel or bladder → watch for fever and worsening abdominal pain (possible injury)
- Psychosocial support — chronic pain, infertility, sexual difficulties, delayed diagnosis; referral to counseling, pain specialists, fertility services, and support groups
- Promote activity — rest during severe pain, but complete bed rest is not needed; regular exercise can reduce pain
- Keep a pain and bleeding diary (timing, severity, triggers, medications, effect on activities) — it guides diagnosis and shows whether treatment works
- Take NSAIDs at the onset of pain or just before expected menses, with food
- Hormonal therapy: take continuously as prescribed; expect spotting at first; report calf pain, chest pain, sudden dyspnea, severe headache, vision changes
- GnRH therapy: hot flashes and vaginal dryness are expected; add-back therapy and calcium and vitamin D protect bone; use nonhormonal contraception
- Levonorgestrel IUD: irregular spotting for a few months is normal; periods usually become light
- Hyperplasia: return for repeat biopsies; report any new bleeding; weight loss and physical activity lower estrogen levels and recurrence risk; women with a uterus using estrogen must also take a progestogen
- Endometriosis and fertility: discuss family planning with the provider early; endometriosis is a common cause of infertility, but many women conceive with or without treatment
- After hysterectomy: no heavy lifting and no intercourse until cleared (about 6 weeks)
- Diet and lifestyle: balanced diet, regular exercise, stress management; heat packs and warm baths for cramps
- Seek care for heavy bleeding (soaking a pad every hour for 2 hours), fainting, fever after procedures, or pain not controlled by prescribed treatment
| Complication | Warning signs | Priority action |
|---|
| Endometrial cancer (from atypical hyperplasia) | Persistent or postmenopausal bleeding | Biopsy; hysterectomy |
| Severe anemia | Fatigue, tachycardia, dizziness, low hemoglobin | Iron or transfusion; treat bleeding |
| Ruptured or torsed endometrioma | Sudden severe pelvic pain, peritoneal signs | Emergency evaluation |
| Bowel or ureteral obstruction (deep endometriosis) | Constipation, cyclic rectal bleeding, flank pain, hydronephrosis | Imaging, surgical referral |
| Infertility | Inability to conceive | Fertility referral |
| VTE with hormonal therapy | Leg swelling, chest pain, dyspnea | Stop drug, emergency evaluation |
| Bone loss with GnRH therapy | Fracture, low bone density | Add-back therapy, limit duration |
| Postoperative injury (bowel, bladder, ureter) | Fever, increasing pain, leakage of urine | Notify surgeon |
- All three are estrogen-dependent
- Endometrial hyperplasia: unopposed estrogen; symptom = AUB; diagnosis = endometrial biopsy
- Without atypia → progestin (LNG-IUD preferred) with repeat sampling; atypical hyperplasia → hysterectomy (high cancer risk)
- Postmenopausal endometrium ≤ 4 mm is reassuring; thicker or persistent bleeding → biopsy
- Endometriosis = endometrial tissue outside the uterus; progressive dysmenorrhea, dyspareunia, dyschezia, infertility (adhesions, tubal distortion)
- Endometriosis can be diagnosed clinically and with imaging; laparoscopy with biopsy confirms
- Endometriosis treatment: NSAIDs + combined hormonal contraceptives or progestins; GnRH agonists with add-back; never estrogen alone
- Early menarche and heavy, long menses increase endometriosis risk
- Adenomyosis = endometrium within the myometrium; heavy bleeding + dysmenorrhea + boggy enlarged uterus; TVUS first, MRI best
- Adenomyosis: LNG-IUD relieves symptoms; hysterectomy is the only cure
- GnRH therapy → hot flashes and bone loss; elagolix is contraindicated with osteoporosis
Country Notes
United States
- Oral GnRH antagonists (elagolix, relugolix combination therapy) are FDA-approved for endometriosis pain with labeled limits on duration of use because of bone loss.
- ACOG and other professional bodies support empiric medical treatment of suspected endometriosis without requiring laparoscopic confirmation.
Philippines
- Access to MRI and specialized laparoscopic excision surgery is concentrated in larger urban centers; clinical diagnosis with ultrasound and first-line hormonal therapy is the usual starting approach.
- The Responsible Parenthood and Reproductive Health Act (RA 10354) supports access to modern contraceptive methods, including hormonal options used to manage these conditions.