GTG Endometrial Hyperplasia

Question 1

Which is the most common gynaecological cancer in western countries?

Answer 1

Endometrial cancer

Question 2

What is endometrial hyperplasia

Answer 2

Precancerous condition, irregular proliferation of the endometrial glands with increase in gland to stomal ratio.

Question 3

Most common Sx of endometrial hyperplasia

Answer 3

HMB
IMB
Irregular/unscheduled bleeding on HRT
PMB

Question 4

RF for endometrial hyperplasia

Answer 4

Unopposed oestrogen
- Increase BMI
- Anovulation
- Oestrogen secreting tumours (granulose cell tumour)
Drug induced endometrial stimulation (oestrogen replacement, tamoxifen)

+/- immunosuppression/infection

Question 5

What % of negative Bx from outpatient sampling will have EH

Answer 5

2%

Question 6

For PMB USS ET <4mm, what is the risk of cancer?

Answer 6

<1%

Question 7

For premenopausal, if PCOS what cut of endometrial thickness is used for low risk of cancer?

Answer 7

7mm

Question 8

Risk of endometrial hyperplasia without atypia progressing to endometrial cancer?

Answer 8

<5% over 20 years

Question 9

What % of endometrial hyperplasia without atypia will regress with and without progesterone

Answer 9

Without 74%
With 90-96%

Question 10

What is 1st line progesterone treatment for hyperplasia without atypia?

Answer 10

LNG-IUS - minimum 6 months, encourage to 5 years

If declines - medoxyprogesterone 10-20mg/day or
norethisterone 1–15mg/day - continuous

Question 11

Chance of replapse with IUS and progesterones

Answer 11

IUS 12%
Progesterone 28%

Question 12

For EH without atypia Tx with IUS, what FU is arranged?

Answer 12

Endometrial Bx every 6 months, must have 2 negatives in a row before discharge

Question 13

What is risk of relapse of EH with BMI < 35 and >35 with IUS

Answer 13

<35 3%
>35 33%

Question 14

If EH without atypia, treated with progesterones or BMI >35 what follow up should be arranged?

Answer 14

6 monthly Bx until 2 negative then every 12 month

Question 15

If after 12 months there is no regresstion, what is the risk of cancer and what treatment should be offered>

Answer 15

23% will have cancer
Offer hysterectomy

Question 16

With EH without atypia who should be offered hysterectomy?

Answer 16

Progression to atypia
No regression 12 months
Relapse of EH after completing progesterone
Persistent bleeding
Declines surveillance or not compliant with medical Tx

Question 17

What % of women with endometrial hyperplsia with atypia have carcinoma?

Answer 17

43%

Question 18

Should BSO be performed at hysterectomy?

Answer 18

Peri/Postmenopausal - yes
Premenopausal - consider risk of ovarian cancer vs surgical menopause

Question 19

Risk of ovarian cancer is endometrial hyperplasia?

Answer 19

4%

Question 20

If atypical hyperplasia and want to preserve fertility?

Answer 20

Pre-treatment Ix to rule out invasive endometrial cancer or ovarian cancer

MRI/CT/TVS/CA125

1st IUS
2nd PO progestone

Once fertility no longer required → hysterectomy

Question 21

If atypical hyperplasia and not undergoing hysterectomy, what follow up should be arranged?

Answer 21

Endometrial biopsy every 3 months until 2 neg bx

If regression, FU every 6-12 months until hysterectomy

If no regression at 12 months, strongly recommend hysterectomy

Question 22

For women who want to conceive, how many negative Bx before can try? What support?

Answer 22

1 negative Bx
Refer to fertility specialist, higer rates of hyperplasia

Question 23

What is the live birth rate for women with endometrial hyperplasia receiving fertility treatment?

Answer 23

25%

Question 24

What is the minimum amount of progesterone need for endometrial protection for women taking HRT with a uterus?

Answer 24

Norethisterone 1mg/day
Medroxyprogesterone 1.5mg/day

Question 25

If EH on HRT what should be done?

Answer 25

If want to continue, if sequential → continuous or LNG IUD
If continus → consider stopping HRT/LNG IUD

Question 26

What type of drugs is tamoifen

Answer 26

Selective oestrogen receptor modulator

Acts as partial agonist in vagina/uterus → fibroids, polyps, EH, cancer

Question 27

Progression to cancer for atypical hyperplasia

Answer 27

25-30%