OGCO-E27 Management of endometrial hyperplasia

Question 1

What is done at first dx of endometrial hyperplasia without atypia?

Answer 1

• Early hysteroscopy and D+C should be arranged for patients who opt for conservative Mx to rule out endometrial carcinoma and other pathology such as polyp. There is still a chance of missing carcinoma or focal pathology with a pipelle biopsy.
• Slide reviw of both the endometrial biopsy and the D&C specimen should be arranged to rule out atypia and carcinoma after D&C.
• if cytological atypia is present, hysterectomy should be discussed

Question 2

What treatment options can be offered for endometrial hyperplasia without atypia?

Answer 2

• Mirena intrauterine system (Mirena IUS): optimal treatment for endometrial hyperplasia without atypia with >90% regression rates. AE: irregular spotting in the first 6 months and 20% will have amenorrhea after 1 year with the Mirena IUS
• Norethisterone (Primolut N): 10-15mg daily for 6 months
• Medroxyprogesterone acetate (MPA) 10-20mg daily for 6 months: to be given if patient cannot tolerate norethisterone

AE of oral progestogens: nausea, bloating. breast tenderness, headahce, change in vaginal discharge, mood swings, blurred ivsion, dizziness, weight gain/loss

Endometrial hyperplasia with atypia will be offered hysteroscopy (prevent progression)

Question 3

What is FU after initial Tx for endometrial hyperplasia?

Answer 3

1. Follow-up 4 months after commencement of treatment to review symptoms and at 1 month
   after cessation of treatment to perform endometrial aspiration with Pipelle.
2. The first endometrial aspiration should be performed 7 months after commencement of treatment because treatment for 4 months is needed to assess clinical response and treatment
   of at least 6 months is needed to assess histological response.

Question 4

If after initial tx for endometrial hyperplasia it persists what is done?

Answer 4

• If endometrial hyperplasia persists after treatment with oral progestogen for 6 months, patient will be counselled on treatment with Mirena or to continue oral progestogen at a higher dose with Medroxyprogesterone acetate 40mg daily continuously for 3 months
• Endometrial aspiration should be repeated after 3 months of high dose progestogen treatment. If endometrial hyperplasia still persists, then hysterectomy should be discussed
• In patients treatedw ith Mirena, if endometrial hyperplasia persists after the first 6 months, treatment could be allowed to continue for 6 months further as the mean time of progression is 6 months for simple hyperplasia and 9 months complex hyperplasia on Mirena
• If endometrial hyperplasia persists after 1 year of treatment with Mirena, discuss hysterectomy.
• Endometrial aspirate can be performed after Mirena in-situ

Question 5

If after initial tx for endometrial hyperplasia it progresses what is done?

Answer 5

1. Hysterectomy should be discussed if endometrial hyperplasia progressed despite treatment.

Question 6

If after initial tx for endometrial hyperplasia it regresses what is done?

Answer 6

Question 7

What is Mx for atypical endometrial hyperplasia?

Answer 7

1. Hysterectomy should be recommended as risk of progression to carcinoma is 30-40% and risk of co-existing carcinoma can be up to 50%.
2. Patients who have fertility issues or decline hysterectomy or of a poor surgical candidate should
   be assessed individually and reason(s) for the final decision should be clearly documented.
3. Patients with atypical hyperplasia not undergoing hysterectomy should be followed up more intensively. For example, every 3 months until two consecutive negative biopsies and then long term FU with endometrial biopsy every 6-12 months till hysterectomy performed.

Question 8

What is the slide review for patients with endometrial hyperplasia??

Answer 8

Question 9

What is the treatment flowchart for endometrial hyperplasia without atypia?

Answer 9