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OBGYN Royal College > Gynecology > Flashcards

Gynecology Flashcards

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1
Q

Incidence of endometrial hyperplasia

A

133 per 1000 women-years
Increases with age
Rarely seen < 30, peak 50-54
Same risk factors as for endometrioid endometrial carcinoma

SOGC 390

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2
Q

What percentage of endometrial hyperplasia without atypia progresses to carcinoma

A

1-3%

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3
Q

What percentage of endometrial hyperplasia with atypia already has, or progresses to, carcinoma?

A

Up to 60%

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4
Q

Genetic profile of endometrial hyperplasia with atypia (5)

A
  1. Microsatellite instability
  2. PAX2 inactivation
  3. PTEN mutation
  4. KRAS mutation
  5. CTNNB1 (beta-catenin) mutation

Hyperplasia with atypia shares a similar genetic profile with type I endometrial carcinomas as it is a precursor. However, hyperplasia without atypia does not share genetic mutations with hyperplasia with atypia

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5
Q

Risk factors for endometrial hyperplasia (12)

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A 
Menstrual
1- older age
2- postmenopausal status
3- nulliparity/infertility
4- early menarche/late menopause
5- anovulation/PCOS
6- menopausal transition
Iatrogenic
7- unopposed exogenous estrogen
8- tamoxifen
Comorbidities
9- obesity
10- diabetes mellitus
11- hypertension
12- Lynch syndrome
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6
Q

Risk of endometrial cancer in premenopausal woman with AUB or intermenstrual bleeding

A
  1. 11% AUB
  2. 52% intermenstrual bleeding

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7
Q

Indications for endometrial biopsy for AUB? (3)

A
  1. 40+ years
  2. < 40 years with risk factors
  3. Not responding to medical therapy

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8
Q

Sensitivity of Pipelle for detecting premenopausal endometrial cancer, postmenopausal endometrial cancer, and endometrial hyperplasia in general

A

91% premenopausal cancer
99.6% postmenopausal cancer
81% hyperplasia

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9
Q

Devices used for endometrial sampling (4)

A
  1. Pipelle
  2. Explora
  3. Accurette
  4. Novak

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10
Q

Indications for diagnostic hysteroscopy + directed endometrial sampling + curettage (5)

A
  1. Non-diagnostic or benign endometrial biopsy results with remaining high suspicion for hyperplasia or cancer
  2. Persistent bleeding
  3. Cervical stenosis
  4. Failed endometrial biopsy
  5. Excessive pain/anxiety

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11
Q

True/false: there is risk of tumour spillage through hysteroscopy or saline infusion

A

False

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12
Q

Medical options for management of endometrial hyperplasia without atypia (4)

A
  1. Oral progestins (MPA, MA, NETA, progesterone)
  2. Levonorgestrel intrauterine system
  3. Injection medroxyprogesterone acetate
  4. Aromatase inhibitors

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13
Q

Regression rate of endometrial hyperplasia without atypia after conservative management (i.e. observation)

A

75-100%

Patients with endometrial hyperplasia without atypia can be observed. They can be offered hormonal treatment if hyperplasia does not resolve with observation or experience AUB

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14
Q

Treatment of choice for endometrial hyperplasia without atypia

A

Levonorgestrel intrauterine system, due to its effectiveness and favourable side effect profile, and because it can be kept in place x 5 years

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15
Q

Regression rates for endometrial hyperplasia without atypia with different progestogen agents

A

67-72% oral progestins
81-94% LNG-IUS
92% DMPA

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16
Q

Minimum duration of treatment for endometrial hyperplasia without atypia

A

6 months

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17
Q

Medical treatment response follow-up for endometrial hyperplasia without atypia

A

Endometrial sampling q3-6 months (mid-therapy and 3 weeks after treatment completion)
Individualize decision to continue treatment > 6 months if no response
If no response after 12 months, consider changing treatment modality, as there is rarely response after this duration of time

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18
Q

Which populations have higher rate of relapse of endometrial hyperplasia without atypia (2)

A
  1. Those treated with progestins
  2. BMI > 35

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19
Q

Indications for surgical management of endometrial hyperplasia without atypia (4)

A
  1. Disease progresses to hyperplasia with atypia or cancer, and patient does not desire fertility preservation
  2. Hyperplasia fails to regress after 12 months of medical treatment, or relapses after completing treatment
  3. AUB continues despite medical therapy
  4. The patient declines endometrial surveillance or medical treatment

Surgical management may also be appropriate for patients who have contraindication or intolerance to medical therapy, or who have a high baseline risk for endometrial carcinoma

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20
Q

In patients with endometrial hyperplasia without atypia undergoing surgical management (total hysterectomy + bilateral salpingectomy), which patients should/should not have concomitant bilateral oophorectomy?

A

BSO if postmenopausal
Keep ovaries if premenopausal women < 45 years avoid risks of all-cause mortality/morbidity from BSO

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21
Q

Recommended management of endometrial hyperplasia with atypia

A

Surgical: total hysterectomy + bilateral salpingo-oophorectomy, for both pre/postmenopausal women. However, the increased risk of mortality and morbidity associated with oophorectomy in premenopausal women with benign disease should be discussed, and treatment tailored to each individual

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22
Q

What 2 groups of women may consider uterine preservation in the setting of endometrial hyperplasia with atypia

A
  1. Patient wishes to preserve her fertility
  2. Patient is medically unfit for surgery

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23
Q

What risks should the patient be counselled on if she opts for non-surgical management of endometrial hyperplasia with atypia (4)

A
  1. Up to 60% chance of underlying malignancy
  2. 2% chance of developing endometrial cancer > stage I
  3. 4% chance of having a coexisting ovarian cancer
  4. 0.5% chance of death

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24
Q

Goals of fertility preservation in the setting of endometrial hyperplasia with atypia (3)

A
  1. Complete reversal of disease
  2. Return of endometrium to its normal function
  3. Prevention of invasive disease

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25
Q

Goals of management of endometrial hyperplasia with atypia in patients that are poor surgical candidates (2)

A
  1. Disease stabilization
  2. Cancer prevention

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26
Q

Conservative management options for endometrial hyperplasia with atypia (3)

A
  1. Progestins (oral or local)
  2. Aromatase inhibitors
  3. GnRH agonists

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27
Q

Duration of medical management of endometrial hyperplasia with atypia

A

6 months minimum to see if there is a treatment response
Plateau around 12 months

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28
Q

Regression and recurrence rates of endometrial hyperplasia with atypia after conservative therapy

A

Regression 55-92% (lower rate if obesity present)
Recurrence 3-55%

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29
Q

What medication may increase the treatment effect of conservative therapy in the management of endometrial hyperplasia with atypia

A

Metformin, even in the absence of metabolic syndrome!

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30
Q

Recommended surveillance of endometrial hyperplasia with conservative management

A

Endometrial sampling q3 months until you have 2 negative specimens
Then, q6 months x 2 years (since the highest risk of recurrence is in the first 2 years after treatment cessation)
Then, q1 year thereafter until risk factors are corrected or hyst-BSO is performed

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31
Q

In patients who opted for conservative management of endometrial hyperplasia with atypia, what are indications for definitive surgical management (5)

A
  1. Progression to carcinoma
  2. Failure of disease to regress after 12 months of medical treatment
  3. Relapse of disease after having completed progestin treatment
  4. Patient continues to experience AUB despite treatment
  5. Patient declines medical treatment or to undergo endometrial surveillance

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32
Q

What to do if a poor surgical candidate has a recurrence of endometrial hyperplasia with atypia after a round of medical therapy

A

She may try a 2nd round, with 85% response rate
There is even possibility for a 3rd round

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33
Q

In patients with hyperplasia with atypia desiring fertility-sparing treatment, what options exist (3)

A
  1. Oocyte or embryo cryopreservation prior to total hysterectomy + BSO
  2. Medical treatment followed by ART
  3. Total hysterectomy with ovarian preservation and future use of a surrogate

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34
Q

What measures can a patient be counseled on regarding progression to cancer in the setting of conservative management of endometrial hyperplasia with atypia for fertility-sparing purposes (5)

A
  1. Encourage weight loss to BMI < 30, as relapse is much more common in obesity
  2. Cancer incidence is seemingly not increased when comparing primary total hysterectomy to delayed hysterectomy for fertility-sparing purposes
  3. Fertility treatments do not seem to increase the relapse rate of hyperplasia with atypia
  4. There is a 7-26% live birth rate, and pregnancy is associated with a lower chance of disease recurrence
  5. As risk of disease recurrence is high, total hysterectomy + BSO is recommended when childbearing is no longer desired

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35
Q

What approach should be used for hysterectomy in the setting of endometrial hyperplasia

A

Vaginal, laparoscopic, and open are all acceptable
However, fewer perioperative complications with vaginal and laparoscopic
Vaginal approach cannot guarantee BSO, so this approach should be avoided if planning to do BSO
Avoid subtotal (supracervical) hysterectomy and morcellation

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36
Q

Should intraoperative frozen section routinely be used in cases of endometrial hyperplasia

A

No
Limitations:
- potential for incongruent results between the frozen section and final pathology, resulting in under/overtreatment
- centres may not have a pathologist in-house to assess the frozen section, or an available skilled practitioner to perform lymphadenectomy if deemed necessary

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37
Q

Should the surgeon visually inspect the specimen intraoperatively to dictate further surgical management in cases of endometrial hyperplasia

A

No
There is sparse data
Inaccurate visual appreciation of the specimen could lead to incorrect surgical decisions

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38
Q

Is endometrial ablation a viable option for management of endometrial hyperplasia without atypia?

A

Insufficient evidence to support this as a first-line surgical treatment, though there are reports of success in this population, and may be considered in poor surgical patients
95.7% of patients in a prospective study had no further bleeding or pain
Limitations of this method:
- difficulty in confirming complete destruction of the endometrium
- ongoing surveillance can be challenging due to cavity obliteration

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39
Q

Is endometrial ablation a viable option for management of endometrial hyperplasia with atypia?

A

It should generally be avoided because it is a premalignant condition. It should be reserved for patients who are poor surgical candidates and in consultation with gynecologic oncology

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40
Q

How to manage endometrial hyperplasia found in an endometrial polyp

A

Sample the background endometrium, even when there is a normal hysteroscopic appearance (up to 52% have endometrial hyperplasia with/out atypia)
Treat according to its histologic classification

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41
Q

Risk of concurrent endometrial cancer in patients with an atypical endometrial polyp

A

5.6%

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42
Q

Histopathology of endometrial hyperplasia without atypia

A

Endometrium thickened with polypoid and cystic areas, but variable
Glands vary in size/shape, with irregular and cystic outlines with mitotic figures in the glandular epithelium
Variable amounts of stroma
Benign polyps can have irregular/dilated glands and be misinterpreted as hyperplasia without atypia
“Disordered proliferative endometrium” = where glandular irregularity exceeds normal proliferative endometrium but falls short of hyperplasia without atypia

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43
Q

Histopathology of hyperplasia with atypia

A

Endometrium thickened and polypoid, but variable
Complex glands are crowded leading to diminished stroma, with nuclear atypia (> 1 mm), distinctly different from adjacent unaffected glands
Must exclude benign metaplastic and artifactual glandular mimics
Lacks stromal desmoplasia and extensive glandular confluence of endometrioid adenocarcinoma

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44
Q

Histopathology of progestin-treated endometrial hyperplasia

A

Pseudo-decidualization appears to lessen glandular crowding and cytologic atypia

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45
Q

Should absence of hyperplasia on biopsy of a patient actively undergoing progestin treatment for endometrial hyperplasia be interpreted as clearance

A

No. Must have completed at least 6 months of therapy and have absence of hyperplasia AFTERWARDS on at least 2 consecutive samples

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46
Q

Odds ratios for having endometrial hyperplasia/carcinoma based on age or BMI

A

OR 3.85 for hyperplasia in women 45+
OR 4.03 for carcinoma in women 45+
OR 4.00 for hyperplasia/carcinoma in BMI 30+

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47
Q

Relative risk of progression to invasive endometrial carcinoma for hyperplasia with & without atypia

A

Without: RR 1.01-1.03
With: RR 14-45

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OBGYN Royal College (1 decks)

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