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Endometrial hyperplasia has crucial clinical significance for its obvious association as a precursor lesion to endometrial adenocarcinoma. It almost always occurs in a setting of prolonged estrogen exposure unopposed by progesterone, and hence, the endometrium is mostly, if not always, proliferative in morphology, but rarely, the hyperplastic glands show secretory changes. Endometrial hyperplasia with secretory changes has diagnostic difficulties due to its benign and malignant mimickers. Benign mimickers such as Arias-Stella reaction can be ruled out by clinical signs of gestation, while malignant lesions can be ruled out by histological evidence of stromal or myometrial invasion. Diagnostic difficulty is more pronounced in cases with late secretory endometrium, endometrial polyps with secretory changes, mucinous metaplasia, and hormone-induced changes. In these cases, clinical history with histological workup will be of most value to establish the diagnosis.