Endometrial hyperplasia Flashcards
Types of endometrial hyperplasia
- With atypia
- Without atypia
Symptoms of endometrial hyperplasia (EH)
Abnormal uterine bleeding
- IMB
- PMB
- Unscheduled bleeding on HRT
- Irregular bleeding
RF of EH
Unopposed estrogen
- Obesity
- Nulliparity
- PCOS due to anovulation
- Estrogen screting tumours (granulosa cell tumours)
- Early menarche and late menopause
- Drug induced: Tamoxifen
ALWAYS scan to rule out ovarian tumours
Uterine sampling methods
- Pipelle - risk of 2% of hyperplasia if negative
- OP or GA hysteroscopy
When is hysteroscopy a must
- If hyperplasia is diagnosed
- Polyps or other abnormality on scan
- Bleeding persists
- Insufficient sample on pipelle
Risk of cancer with normal ET on scan
<1%
TV US cut offs
- PMB >4mm needs sampling
- On cont HRT >5mm needs sampling
- On seq HRT >7mm
Role of CT/MRI
- If staging is needed
- Not routinely used to monitor EH
Risk of EH without atypia progressing to cancer
<5% in 20 years
Treatment for EH without atypia - Expectant
- Wt loss
- Adjust HRT
- Ask about other meds- black cohosh, etc
- Review tamoxifen
Treatment of EH - progesterone
- Mirena, best form
- Others- Norethisterone 10-15mg/day
Or Medroxyprogesterone 10-20mg/day - Dont use cyclical
Benefit of progesterone
- Higher regression rate compared to no treatment
- 89-96% vs 74-80%
F/u and surveillance
- Resample every 6 months
- 2 negative biopsies before d/c
- If other RF like obesity or treated with oral prog - F/u yearly
When to offer Hysterectomy
- NOT FIRST LINE!
- If bleeding or hyperplasia persists for 12months
- Becomes atypical
- Declines f/u
- Relapse
Hysterectomy- BSO and TLH Vs TAH
- If post-menopause- BSO
- If pre-menopause- Leave ovaries
TLH better than TAH
Pathways
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If fertility is required
- Advise oral prog and 2 negative biopsies before trying for preg
Mx of EH w atypia
Laparoscopic Hysterectomy + BSO or BS (premenopause)
What not to do during hysterectomy
- Do not perform lymphadenectomy
- Do not morcelate- risk of spreading cancer
- Do not do subtotal hysterectomy
Cancer risk of EH w atypia
30% in 20y
If fertility wanted
- Council about risk of cancer
- Take biopsy, do tumour markers, MRI and discuss in MDT
- Consider IVF
Rx if fertility wanted
- Offer Mirena or progesterone.
- Wt loss, stop smoking etc
- Repeat biopsy in 3 months till 2 negative.
- Long term f/u w 6 monthly biopsy till TLH.
- Hysterectomy once fertility is not needed.
Mx of EH with HRT
- Biopsy
- Change to cont HRT
- Use Mirena as progesterone
- Avoid estrogen only if uterus insitu
Tamoxifen risks
- Endometrial estrogen agonist
- Notify doctor ASAP if abnormal bleeding
- Higher risk in those >49
Mx of EH on tamoxifen
- Consider changing to aromatase inhibitor
- Mirena- reduces EH but effect on breast CA unknown
