Endometrial_Hyperplasia_Flashcards
What is endometrial hyperplasia?
Endometrial hyperplasia is an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle. A minority of patients with endometrial hyperplasia may develop endometrial cancer.
What are the types of endometrial hyperplasia?
Simple, complex, simple atypical, complex atypical.
What is a common feature of endometrial hyperplasia?
Abnormal vaginal bleeding, e.g., intermenstrual bleeding.
What is the management for simple endometrial hyperplasia without atypia?
High dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used.
What is the management for endometrial hyperplasia with atypia?
Hysterectomy is usually advised.
summarise
Endometrial hyperplasia
Endometrial hyperplasia may be defined as an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle. A minority of patients with endometrial hyperplasia may develop endometrial cancer
Types
simple
complex
simple atypical
complex atypical
Features
abnormal vaginal bleeding e.g. intermenstrual
Management
simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
atypia: hysterectomy is usually advised
You are a doctor working in gynaecology. One of your patients on the ward has endometrial hyperplasia. Which medication is associated with the development of this condition?
Cerelle (progesterone only pill)
Tamoxifen
Levothyroxine
Microgynon (combined oral contraceptive pill)
Orlistat
Tamoxifen
Tamoxifen is a risk factor for endometrial hyperplasia
Endometrial hyperplasia develops due to the presence of unopposed oestrogen. Oestrogen stimulates endometrial growth while progesterone stimulates shedding of this tissue.
Tamoxifen is used for oestrogen receptor-positive breast cancer, in the breast, it has anti-oestrogenic effects. However, on the endometrium, it has pro-oestrogenic effects. This effect, if unopposed by progesterone, can result in endometrial hyperplasia.
Combined oral contraceptive pills and progesterone only pills both contain progesterone and thus do not result in unopposed oestrogen stimulation.
While thyroid problems and obesity can be associated with the development of endometrial hyperplasia, taking levothyroxine or orlistat as a treatment for these conditions don’t increase the risk.
You are working in general practice, a 53-year-old female presents with 2 months of per-vaginal (PV) bleeding. She passed through the menopause at 49-years-old, her body mass index (BMI) is 34kg/m² and she drinks 18-units of alcohol a week. She has only had one sexual partner her whole life. She has no pain during sex or post-coital bleeding. Which diagnosis is most likely?
Vaginal atrophy
Cervical cancer
Chlamydia trachomatis infection
Ovarian cancer
Endometrial hyperplasia
Endometrial hyperplasia
Endometrial hyperplasia may present with intermenstrual bleeding, post-menopausal bleeding, menorrhagia or irregular bleeding
Endometrial hyperplasia may present with intermenstrual bleeding, post-menopausal bleeding, menorrhagia or irregular bleeding. In this presentation she has presented with post-menopausal bleeding, she also is overweight which is a risk factor for this development.
Typically vaginal atrophy will present in a post-menopausal patient with pain during sex and dryness, they may also have some postcoital bleeding. Cervical cancer is a less likely diagnosis in this presentation given that she has only had one sexual partner, this can present with intermenstrual and postcoital bleeding. Chlamydia trachomatis infection is also unlikely and will typically present with discharge and urethritis symptoms. Ovarian cancer has an ominous presentation with abdominal bloating, change in bowels or urinary symptoms, rarely post-menopausal bleeding.
You are working in general practice and see a 68-year-old female who has recently been diagnosed with endometrial hyperplasia. She asks you what could have cause this. Which of the following is associated with endometrial hyperplasia?
Tamoxifen
Aged 30 years or over
Alcohol intake
Combined oral contraceptive pill
Late menarche
Tamoxifen
Endometrial hyperplasia is caused by oestrogen which is unopposed by progesterone
Important for meLess important
Endometrial hyperplasia is associated with;
Taking oestrogen unopposed by progesterone
Obesity
Late menopause
Early menarche
Aged over 35-years-old
Being a current smoker
Nulliparity
Tamoxifen
Tamoxifen is a risk factor due to its pro-oestrogen effect on the uterus and bones. It does also have an anti-oestrogen effect on the breast.
A 57-year-old nulliparous female is seen in the gynaecology outpatient department with a 2-month history of postmenopausal bleeding. She has a past medical history of type 2 diabetes mellitus. Her last menstrual period was 4 years ago.
Transvaginal ultrasound shows an endometrial thickness of 8mm and the results of a pipelle biopsy are reported as follows:
‘There is evidence of increased gland-to-stroma ratio, with some evidence of nuclear atypia’.
What is the most appropriate management option?
Endometrial ablation
Hysterectomy alone
Hysterectomy with bilateral salpingo-oophorectomy
Mirena coil
Observation alone
Hysterectomy with bilateral salpingo-oophorectomy
A total hysterectomy with bilateral salpingo-oophorectomy, in addition, is advisable for all postmenopausal women with atypical endometrial hyperplasia, due to the risk of malignant progression
Hysterectomy with bilateral salpingo-oophorectomy is the recommended management for postmenopausal women with atypical endometrial hyperplasia due to increased risk of ovarian malignancy if bilateral salpingo-oophorectomy is not performed.
Endometrial ablation is not recommended in the management of endometrial hyperplasia due to the risk of intrauterine adhesion formation and irreversible destruction of the endometrium.
Hysterectomy alone may be considered in premenopausal patients with atypia, or those without atypia who fail to respond to medical management or have persistent bleeding. However, the royal college of obstetrics and gynaecology green-top guidelines state that bilateral salpingectomy should still be considered in these patients due to the risk of further ovarian malignancy.
A levonorgestrel-releasing intrauterine system such as the Mirena coil is the first-line treatment in hyperplasia without atypia.
Observation alone may be acceptable in patients without atypia, as in the majority of cases the disease will regress spontaneously. However, patients should be informed that the rate of disease regression is higher with progestogen treatment.
