2016 67 Endometrial Hyperplasia Flashcards
How should endometrial hyperplasia be classified?
WHO classification
Hyperplasia without atypia
Atypical hyperplasia
How is endometrial hyperplasia diagnosed & monitored?
- Histology from endometrial biopsy
- Hysteroscopy if Pipelle sample fails or nondiagnostic, also for focal lesions like polyps
- TVUS has a role pre & post-menopausally
- NOT CT, MRI or biomarkers
What is the initial management of hyperplasia without atypia?
- Address reversible risk factors like obesity & HRT use
- Consider observation alone with follow-up biopsies
- Progestogens if symptomatic or if fails to regress alone
What is the risk of endometrial hyperplasia without atypia progressing to cancer?
<5% over 20 years
Majority regress spontaneously
What is the first line medical treatment of endometrial hyperplasia without atypia?
- Mirena or continuous oral progestogens
- Mirena has higher regression rate, more favourable bleeding profile & fewer side effects
- Oral: medroxyprogesterone 10-20mg/day, or norethisterone 10-15mg/day
- Do not use cyclical progestogens, as less effective
What should the duration of treatment & follow-up of endometrial without atypia be?
- Progestogens inc Mirena: 6/12 min
- Encourage to keep coil for 5 years
- Surveillance at minimum 6-monthly intervals until at least 2 consecutive -ve biopsies
- Further referral if abnormal PVB
- Consider annual if BMI >35 or oral
When is surgical management appropriate for endometrial hyperplasia without atypia?
Hysterectomy not 1st line due to high remission rates
Consider if not needing fertility &
1. progression to atypical
2. no regression in 12 months
3. relapse after completing treatment
4. persistence of bleeding
5. declines surveillance or medical Tx
If surgical Mx chosen for endometrial hyperplasia without atypia, how should it be done?
- Postmenopausal: total + BSO
- Premenopausal: consider BS
- Lap preferable to abdominal
- Endometrial ablation not recommended; often incomplete & prevents histological surveillance
What should the management of atypical hyperplasia be?
- Total hysterectomy due to risk of progression to cancer?
- Lap preferable to abdominal
- No benefit to intraoperative frozen section analysis or routine lymphadenectomy
- BSO postmenopausal, consider BS pre
- Not endometrial ablation
How can atypical hyperplasia be treated if wishing to preserve fertility or unsuitable for surgery?
- Counsel about risks of progression
- Rule out invasive Ca or coexisting ovarian Ca
- MDT review of histology, imaging & tumour markers to formulate plan
- 1st line Mirena, 2nd line oral prog
- Hysterectomy if/when possible
How should women with atypical hyperplasia & no surgery be followed up?
- Routine endometrial biopsies
- Every 3 months unless 2 consecutive -ve biopsies
- Long-term follow-up every 6-12 months after this until hysterectomy
How should endometrial hyperplasia be managed whilst trying to conceive?
- At least 1 -ve sample before TTC
- Referral to fertility specialist
- Consider assisted reproduction for higher live birth rate
- Regression associated with higher implantation & ongoing pregnancy rates
How should HRT be managed with endometrial hyperplasia?
- No systemic oestrogen with a uterus
- Report unscheduled bleeding promptly
- Change sequential to continuous progesterone, ideally Mirena
- Review if really need HRT
How should endometrial hyperplasia be managed in women on adjuvant treatment for breast cancer?
- Tamoxifen: inform about risks & actions
- Aromatise inhibitors anastrozole, exemestane & letrozole not known to increase risk
- Mirena reduces incidence but uncertainty about impact on breast
- Balance need for tamoxifen against hyperplasia management
How should endometrial hyperplasia confined to a polyp be managed?
- Complete polypectomy
- Subsequent Mx dependent on histology
