In simple words: Endometrial hyperplasia is a condition where the lining of the uterus (endometrium) becomes too thick.There are different types of endometrial hyperplasia, and some types are more likely to develop into cancer than others.It is a benign condition initially, but it needs to be monitored.

An abnormal overgrowth of the endometrium (the layer of cells that lines the uterus). There are four types of endometrial hyperplasia: simple endometrial hyperplasia, complex endometrial hyperplasia, simple endometrial hyperplasia with atypia, and complex endometrial hyperplasia with atypia. These differ in terms of how abnormal the cells are and how likely it is that the condition will become cancer.

Example 1: A 48-year-old woman experiences irregular and heavy menstrual bleeding. An endometrial biopsy reveals endometrial hyperplasia without atypia. The patient is treated with progestin therapy., A 60-year-old postmenopausal woman presents with vaginal bleeding. An ultrasound shows a thickened endometrium, and a biopsy confirms complex endometrial hyperplasia with atypia.A hysterectomy is recommended., A 55-year-old woman with a history of polycystic ovary syndrome (PCOS) undergoes an endometrial biopsy, which reveals simple endometrial hyperplasia. She is advised on lifestyle modifications and regular follow-up.

Documentation for endometrial hyperplasia should include details of the patient's presenting symptoms (e.g., abnormal bleeding), findings from physical examinations (e.g., pelvic exam), results of imaging studies (e.g., ultrasound), and pathology reports from endometrial biopsies. The type of hyperplasia (simple, complex, with or without atypia) should be clearly documented. Details about any treatment provided, such as hormonal therapy or surgery, should also be included in the medical record.

** The information provided is current as of December 1, 2024 and may be subject to change.Always refer to the most up-to-date coding guidelines and regulations.