Atrophic endometrium

by Adnan Karavelic, MD FRCPC
September 5, 2025

Atrophic endometrium is a term used to describe endometrial tissue (the lining of the uterus) that is smaller, thinner, and less active than normal. This is a benign change, meaning it is not cancer. Atrophy is a natural process that occurs when the endometrium is no longer stimulated by estrogen and progesterone, the hormones that control the menstrual cycle.

Pathologists sometimes also use the term inactive endometrium to describe the same finding. Atrophic endometrium is very common in women after menopause and may also be seen in younger women in certain situations.

What causes atrophic endometrium?

Atrophic endometrium is a normal finding in the following situations:

  • Postmenopausal women, when estrogen and progesterone levels fall.

  • Prepubertal girls, before the menstrual cycle begins.

  • Perimenopausal women, as hormone levels naturally decline.

Atrophy may also be seen in younger women of reproductive age who are still menstruating but have changes that reduce hormone stimulation to the endometrium.

Examples include:

  • Use of oral contraceptive pills.

  • Use of an intrauterine device (IUD) that releases hormones, such as Mirena, Kyleena, Skyla, or Liletta.

Because some precancerous or cancerous conditions can also cause the endometrium to appear atrophic, your doctor may recommend a biopsy if there are concerning symptoms, such as abnormal vaginal bleeding.

How do pathologists make the diagnosis of atrophic endometrium?

The diagnosis is usually made after a sample of endometrial tissue is removed in a procedure called an endometrial biopsy or dilation and curettage (D&C). The tissue is sent to a pathologist who examines it under the microscope and describes what is seen in a pathology report.

Information about hormone use or contraception, such as an IUD, is important for both your doctor and the pathologist. This information should always be recorded in the clinical notes and included on the pathology requisition form.

How is atrophic endometrium different from normal endometrium?

When examined under the microscope, atrophic endometrium looks different from normal endometrium.

Pathologists often describe the following features:

  • The cells in the epithelium are small and may appear flattened or cuboidal in shape.

  • Very few dividing cells, called mitotic figures, are seen.

  • The glands become rounder and sometimes cystic, meaning they look larger and filled with fluid.

  • The tissue between the glands, called the stroma, appears inactive and less cellular than usual.

These features confirm that the endometrium is not actively responding to hormonal stimulation.

Is atrophic endometrium a concern?

For most women, atrophic endometrium is a normal, age-related finding and does not require treatment. However, if you are experiencing abnormal vaginal bleeding, especially after menopause, your doctor may recommend a biopsy to rule out other conditions, including precancerous changes or cancer.

Questions to ask your doctor

  • Was my biopsy result completely consistent with atrophic endometrium?

  • Could my symptoms be related to atrophy, or do they require further testing?

  • Do I need follow-up or repeat testing?

  • Could my medications, birth control, or IUD explain the atrophic changes?

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