Factors associated with interobserver variation amongst pathologists in the diagnosis of endometrial hyperplasia: a systematic review

Chloe A. McCoy*, Helen G. Coleman, Charlene M. McShane, W. Glenn McCluggage, James Wylie, Declan Quinn, Úna C. McMenamin

*Corresponding author for this work

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Reproducible diagnoses of endometrial hyperplasia (EH) remains challenging and has potential implications for patient management. This systematic review aimed to identify pathologist-specific factors associated with interobserver variation in the diagnosis and reporting of EH.

Three electronic databases, namely MEDLINE, Embase and Web of Science, were searched from 1st January 2000 to 25th March 2023, using relevant key words and subject headings. Eligible studies reported on pathologist-specific factors or working practices influencing interobserver variation in the diagnosis of EH, using either the World Health Organisation (WHO) 2014 or 2020 classification or the endometrioid intraepithelial neoplasia (EIN) classification system. Quality assessment was undertaken using the QUADAS-2 tool, and findings were narratively synthesised.

Eight studies were identified. Interobserver variation was shown to be significant even amongst specialist gynaecological pathologists in most studies. Few studies investigated pathologist-specific characteristics, but pathologists were shown to have different diagnostic styles, with some more likely to under-diagnose and others likely to over-diagnose EH. Some novel working practices were identified, such as grading the “degree” of nuclear atypia and the incorporation of objective methods of diagnosis such as semi-automated quantitative image analysis/deep learning models.

This review highlighted the impact of pathologist-specific factors and working practices in the accurate diagnosis of EH, although few studies have been conducted. Further research is warranted in the development of more objective criteria that could improve reproducibility in EH diagnostic reporting, as well as determining the applicability of novel methods such as grading the degree of nuclear atypia in clinical settings.

Original languageEnglish
Article number0302252
Number of pages19
JournalPLoS One
Issue number4
Publication statusPublished - 29 Apr 2024


  • Endometrial Hyperplasia - diagnosis - pathology
  • Endometrial Neoplasms - diagnosis - pathology
  • Female
  • Humans
  • Observer Variation
  • Pathologists


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