Hyperplasia without atypia

Question 1

Initial management of hyperplasia without atypia

Answer 1

• Risk of to endometrial cancer is less than 5% over 20 years
  The majority of cases of endometrial hyperplasia without atypia will regress spontaneously during follow-up
• Progestogen treatment is indicated in women who fail to regress following observation alone and in
  symptomatic women with abnormal uterine bleeding

Question 2

First line medical tx for hyperplasia without atypia

Answer 2

• The LNG-IUS first-line medical treatment because it
  has a higher disease regression rate with a more favourable bleeding profile and it is associated with
  fewer adverse effects.
• Continuous progestogens (medroxyprogesterone 10–20 mg/day or norethisterone 10–15 mg/day) for women who decline the LNG-IUS.
• Cyclical progestogens should not be used because they are less effective in inducing regression.

Question 3

Duration of tx and f/up in hyperplasia without atypia

Answer 3

• Oral progestogens or the LNG-IUS should be for a minimum of 6 months.
• If adverse effects are tolerable and fertility is not desired, women should retain the LNG-IUS for up to 5 years.
• Endometrial surveillance with outpatient endometrial biopsy is recommended.
• Endometrial surveillance at a minimum of 6-monthly intervals, but should be individualised and responsive to changes in a woman’s clinical condition.
• At least two consecutive 6-monthly negative biopsies should be obtained prior to discharge.
• Consider annual endometrial biposy in high risk women

Question 4

Surgical management of hyperplasia without atypia

Answer 4

Hysterectomy is indicated only if:
- Progression to Atypical hyperplasia occurs during follow-up,
- There is no histological regression of hyperplasia
despite 12 months of treatment
- There is relapse of endometrial hyperplasia after completing progestogen treatment
- There is persistence of bleeding symptoms
- The woman declines to undergo endometrial surveillance or comply with medical treatment.