Atypical hyperplasia

Question 1

Initial management of atypical hyperplasia

Answer 1

Hysterectomy

• with BSO in postmenopausal women
• with salpingectomy if conservation of ovaries
• laparoscopically if possible, but NO morcellation and no supracervical hysterectomy
• do not offer ablation
• no lymph-nodes

Question 2

Risk of endometrial Ca in atypical hyperplasia

Answer 2

• 8% after 4 years
• 12.4% after 9 years
• 27.5% after 19 years
• 43% cases of atypical hyperplasia are associated with carcinoma on histology

Question 3

Tx of atypical hyperplasia in women who want to retain fertility or surgery is contraindicated

Answer 3

• Pretreatment investigations should aim to rule out invasive endometrial cancer or co-existing ovarian
  cancer.
• Histology, imaging and tumour marker results should be reviewed in MDT and a plan for management and ongoing endometrial surveillance formulated.
• First-line treatment with the LNG-IUS, with oral progestogens as a second-best alternative.
  Once fertility is no longer required, hysterectomy should be offered in view of the high risk of disease
  relapse.
• 1/4 women will achieve live birth
• Length of f/up is uncertain, therefore f/p until hysterectomy is recommended 3-6 monthly
• . Review intervals should be every 3 months until two consecutive negative biopsies are obtained
• If not regression after 12 months, then further progesterone cycle can be considered