Endometrial Hyperplasia

Question 1

Definition Endometrial Hyperplasia

Answer 1

A precancerous proliferation of the endometrial lining

Question 2

Risk factors to identify in history

Answer 2

Age
White race
Obesity
PCOS
Early menarche/late menopause
Nulliparity/infertility
Unopposed systemic oestrogen
Tamoxifen
HNPCC
Medical disease

Protective factors
- Long term cOCP use
- Smoking

Question 3

Clinical evaluation

Answer 3

Most often present with postmenopausal bleeding

Take history with notes re risk factors above

Symptoms of metastatic disease
- Weight loss
- Pain
- Neurological/respiratory symptoms
- Bladder/bowel disturbance

Examination
o General appearance, BMI
o Cardiorespiratory examination (pre-operative and evidence of mets)
o Abdominal examination
- Bimanual examination (uterine size, cervical involvement)
o Speculum/pap smear/?pipelle

Investigations
Preoperative workup
- Bloods – FBE/UEC/LFTs/Coags/Group and Hold
- ECG
- CXR
o Imaging
- Pelvic ultrasound if not previously performed to assess ET
- CT abdo/pelvis if concern about metastatic disease

Question 4

Diagnosis

Answer 4

Diagnosis
* Tissue diagnosis based on office pipelle, dilation and curettage or hysterectomy

Question 5

Counselling

Answer 5

• Endometrial hyperplasia is an abnormal thickening of the lining of the uterus
• It may progress to cancer or co-exist with endometrial cancer, so further treatment is required
• Risk of progression
  o Complex hyperplasia without atypia – 3% risk of malignant progression
  o Complex hyperplasia with atypia – 30% risk of malignant progression
• Additionally, >30% of women with this diagnosis on pipelle/curettage will have endometrial cancer on histopathology at hysterectomy

Question 6

Management

Answer 6

• Depends on age, symptoms and desire for fertility
• All patients should be advised to modify risk factors
  o Especially weight loss
• Hyperplasia without atypia
  o Reasonable to treat medically
• Provera po 10mg daily for >=14 days/month
• 100% regression at 6/12
• Mirena IUD
• 90% regression at 6/12
• Depo-Provera
  o Repeat sampling after 6/12 to ensure resolution (regression occurs in 80%)
• Hyperplasia with atypia
  o Mainstay of treatment is TAH/BSO
  o If surgery is medically contraindicated or declined (ie for fertility reasons) can treat with progesterone as above
• Recommend repeat endometrial sampling after 3 months
  Recommend at least 1 negative sample before attempting to achieve pregnancy
  Consider ART which may prevent recurrence