Endometrial Hyperplasia - GT67 Flashcards
What are the WHO 2014 classifications of endometrial hyperplasia?
- Hyperplasia without atypia
- Atypical hyperplasia
When should direct visualisation and biopsy of the cavity be done with regards to endometrial hyperplasia?
When it has been diagnosed within a polyp or other discrete lesion
What is the risk of endometrial hyperplasia without atypia progressing to endometrial cancer?
<5% over 20 years
Most will regress during follow up
When is progestogen treatment for endometrial hyperplasia without atypia recommended?
- When fails to regress with observation alone (can be done - but much better regression rate with treatment)
- If symptomatic with abnormal uterine bleeding
What is the first line medical treatment for endometrial hyperplasia without atypia and why?
LNG-IUS > oral progestogens
- higher regression rate
- more favourable bleeding profile
- fewer adverse effects
What is the recommended treatment for endometrial hyperplasia without atypia in women who decline LNG-IUS?
Medroxyprogesterone 10-20mg/day
or norethisterone 10-15mg/day
NOT cyclical progesterones - less regression
What should the duration of treatment be for endometrial hyperplasia without atypia?
Minimum 6/12
If adverse effects OK and no wish for fertility - keep LNG-IUS for 5 years (less relapse)
What is the follow up for endometrial hyperplasia without atypia?
6 monthly biopsies
Need 2 negative consecutive biopsies to be discharged
In which women should annual biopsies be taken following 2 negative biopsies for endometrial hyperplasia?
Higher risk of relapse
BMI >35
Being treated with PO progestogens
When should hysterectomy be considered as a treatment for endometrial hyperplasia without atypia?
- Progession to atypia during follow up
- No histological regression despite 1 year Rx
- Relapse of EH after completing progestogen Rx
- Persistence of bleeding symptoms
- Declines surveillance/non-compliant with Rx
What special consideration is there for postmenopausal women having hysterectomy for EH?
Should have BSO at the same time
Consider in premenopausal - individualised
What is the management of atypical endometrial hyperplasia?
Total hysterectomy +/- BSO depending on menopausal status
No benefit of frozen section/lymphadenectomy
How should women with atypical hyperplasia who wish to preserve their fertility or who are not suitable for surgery be managed?
- Rule out underlying invasive Ca/concurrent ovarian Ca
- LNG-IUS (PO progesterones if not)
- Hysterectomy once fertility not required
- Biopsy every 3/12 until 2 consecutive negative; if regression every 6-12/12 until hysterectomy
How should endometrial hyperplasia be managed in women wishing to conceive?
- Need >=1 negative sample
(higher implantation and clinical pregnancy rate) - Refer to ACU to discuss ART
(higher live birth rate and less likely to get
regression)
What is the advice with HRT and endometrial hyperplasia?
- Systemic oestrogen only not used in women with a uterus
- Report unscheduled bleeding
- If on sequential advise to change P componenet to LNG-IUS or continuous combined
- Consider LNG-IUS in continuous combined if still need to continue HRT
Which breast cancer treatment(s) are associated with increased risk EH and endometrial cancer?
Tamoxifen
Not known to - aromatase inhibitors
What is the advice for women taking tamoxifen and LNG-IUS?
- LNG-IUS prevents polyp formation and incidence of EH
- However action on breast cancer unknown therefore cannot be recommended
- Treatment would need discussion with oncologist
How should endometrial hyperplasia confined to an endometrial polyp be managed?
Removal of polyp
Sample of background endometrium
How many new cases of endometrial hyperplasia were reported in 2012 in the UK?
8617
How much more common is endometrial hyperplasia than endometrial cancer?
x3
What is the prevalence of endometrial hyperplasia in granulosa cell tumours?
Up to 40%
What non-oestrogenic risk factors are there for endometrial hyperplasia?
2x in renal graft recipients - ?immunosuppression/infection
What % of women will have endometrial hyperplasia despite a negative biopsy result?
2%
What are the TVUS features that would give reason for endometrial sampling in a woman with abnormal uterine bleeding?
- ET of 3-4mm or more (?higher in tamoxifen or HRT)
- Irregularity of endometrial profile
- Double layer ET measurement
What is the cut off ET in women with PCOS and absent bleeds below which EH is unlikely?
7mm
What is the risk of endometrial cancer in atypical hyperplasia?
4 years - 8%
9 years - 12%
19 years - 28%
What % of women undergoing hysterectomy for atypical hyperplasia will have concomitant carcinoma?
Up to 43%
What is the incidence of atypical hyperplasia in an endometrial polyp in a 57 year old woman that was found incidentally?
1.2%
Risk factors for endometrial hyperplasia?
High bmi-peripheral conversion of androgen to eostrogen (E)
Anovulation- pcos or perimenopause
E producing rumours -granulosa cells -40%
Unopposed E eg HRT, tamoxifen
