Endometrial hyperplasia Prof. Dr - PowerPoint Presentation

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Endometrial hyperplasia

Prof. Dr Esraa AL-Maini 2019-2020

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Endometrial thickness guidelines

premenopausal women :Endometrial thickness in normal endometrial vary according to day of cycle≤ 4 mm on day 4 of the menstrual cycle ≤ 8 mm by day 8.

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Persistent

endometrial thickness, independent of cycle day, measuring =>12 mm should be further evaluated especially for women those with risk factors for endometrial carcinoma .

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Etiology for endometrial hyperplasia

. A-Endogenous estrogen. The most common cause Chronic anovulation is associated with _The polycystic ovary syndrome(PCOS) _ Ovarian tumor (eg,

granulosa

cell tumor

_ Obese women

B- Exogenous estrogen.

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Classification endometrial hyperplasia

The World Health Organization classification of endometrial hyperplasia is based upon two factors:1. Simple or complex glandular/stromal architectural pattern

2.

The presence or absence of nuclear

atypia

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. Endometrial carcinoma is more than 10-fold more likely in

atypical hyperplasia (simple or complex).

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Risk factors

1-Increasing age2-Unopposed estrogen therapy3-Late menopause (after age 55)4-Nulliparity5-Polycystic ovary syndrome (Chronic anovulation)

6-Obesity

7-Diabetes

8-Hereditary

nonpolyposis

colorectal cancer

9-Tamoxifen

10-Early menarche

11-Estrogen secreting tumor

12-Family history of endometrial, ovarian, breast, or colon cancer

 

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Clinical manifestations.

Endometrial hyperplasia should be suspected in:1- Women with heavy, prolonged, frequent (ie, less than 21 days).2- Irregular uterine bleeding. Abnormal uterine bleeding

in

perimenopausal

or postmenopausal women is the most common clinical symptom of endometrial

neoplasia

, although such (PMB)bleeding is usually (80%) due to a benign condition.

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Diagnostic and surveillance methods for endometrial

hyperplesia

1-Transvaginal

sonography

; may have a

role in diagnosing endometrial hyperplasia in pre- and postmenopausal women

2-Endometrial biopsy

:diagnosis of endometrial hyperplasia requires histological examination of the endometrial tissue.

1-Office biopsy(out patients)

2-D/C biopsy.

3-Hysteroscopic guided biopsy

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Indication for evaluation of the

endometrium 1-Abnormal -uterine bleeding with risk factors 2-Failure to respond to medical treatment for abnormal uterine bleeding

3-unopposed estrogen replacement therapy

4- Asymptomatic women

presence of endometrial cells on Pap smear if they are at increased risk of endometrial cancer

5-Women with hereditary

nonpolyposis

colorectal cancer

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B. Indications for additional diagnostic evaluation by hysteroscopy/directed biopsy

1-Endometrial hyperplasia with atypia by office biopsy, further evaluation by Dilation and curettage (D&C) is needed to exclude a coexistent endometrial adenocarcinoma(% 25)

2.

Non diagnostic office biopsy.

Endometrial hyperplasia/cancer needs to be excluded in women with a non diagnostic office biopsy. hysteroscopy/directed biopsy

3

. Persistent bleeding

. After

benign endometrial biopsy or treatment of endometrial pathology. hysteroscopy/directed biopsy

4. Postmenopausal women.

hysteroscopy/directed biopsy

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Management of hyperplasia without atypia

1- Observation alone The risk of progressing to endometrial cancer is less than 5% over 20 years .The majority o will regress spontaneously during follow-up. Observation alone with follow-up endometrial biopsies to ensure disease regression can be

considerd

, especially when identifiable

risk factors

such as obesity and the use of (HRT) can be reversed.

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2-Treatment with progestogens

Higher disease regression rate than observation alone.  indications:1-In women who fail to regress following observation alone 2- In symptomatic women with abnormal uterine bleeding.

Types of progesterone;

1-

Local progesterone ([LNG-IUS])

should be the first-line medical treatment because compared with 2:

It has a higher disease regression rate

More

favourable

bleeding profile

It is associated with fewer adverse effects.

2-

Continuous oral progesterone

should be used (

medroxyprogesterone

10–20 mg/day or

norethisterone

10–15 mg/day) for women who decline the LNG-IUS.

Cyclical

progestogens

should not be used

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The duration of treatment and follow-up of hyperplasia without

atypia - Treatment with oral progestogens or the LNG-IUS should be for a minimum of 6 months in order to induce histological regression ,women should be encouraged to retain the LNG-IUS for 5 YEARS

this reduces the risk of relapse

1-If adverse effects are tolerable

2-fertility is not desired

3-If it alleviates abnormal uterine bleeding symptoms.

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FOLLOW UP ;

-Endometrial surveillance with outpatient endometrial biopsy should be arranged at a minimum of 6-monthly intervals. -At least two consecutive 6-monthly negative biopsies should be obtained .

-Women should be advised to seek a further advice if abnormal vaginal bleeding recurs after completion of treatment because this may indicate disease relapse.

In women at higher risk of relapse;

-As body mass index (BMI) of 35 or greater Those treated with oral

progestogens

6-monthly and endometrial biopsies

are recommended

Once two

consecutive negative endometrial biopsies have been obtained

long-term follow-up should be considered

with annual endometrial biopsies

.

 

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3-Surgical management( Hysterectomy

) should not first-line treatment because progestogen induces remission in the majority avoids the morbidity Hysterectomy is indicated in women not wanting to preserve their fertility when

1-Progression to atypical hyperplasia during follow-up,

2- No histological regression after 12 months of treatment

3- Relapse of endometrial hyperplasia after completing

progestogen

4- Persistence of bleeding symptoms

5-The woman declines to undergo endometrial surveillance or comply with medical treatment

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Types of surgery

1- Postmenopausal women should be offered a bilateral salpingo-oophorectomy together with the total hysterectomy. 2- premenopausal women, the decision to remove the ovaries should be individualised; reduce the risk of a future ovarian malignancy. 

3- A laparoscopic approach is preferable .

4- Endometrial ablation is not recommended .

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Management of atypical hyperplasia

1- Total Hysterectomy because of- The risk of underlying malignancy25%, Progression to cancer 25-50% laparoscopic approach Postmenopausal

should be offered

bilateral

salpingo-oophorectomy

-

premenopausal women

,

the decision to remove the ovaries

individualised

; but removal will reduce the risk of a future ovarian malignancy.

Endometrial ablation

is not recommended

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2--

Women with atypical hyperplasia who wish to preserve their fertility or who are not suitable for surgery Women wishing to retain their fertility should be counselled about the risks Pretreatment investigations should aim to rule out invasive endometrial cancer or co-existing ovarian cancer by TVUS and endometrial biopsy First-line treatment with the LNG-IUS should be recommended, with oral

progestogens

as a second-best alternative

Once fertility is no longer required, hysterectomy should be offered because high risk of disease relapse

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followed upTVUS and endometrial biopsy : at 3 months interval until minimum two consecutive negative biopsies are obtainedSo two negative and asymptomatic women long-term follow-up with endometrial biopsy every 6–12 months is recommended until a hysterectomy is performed.

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In women wishing to conceive

Disease regression should be achieved on at least one endometrial sample before women attempt to conceive. Assisted reproduction may be considered as the live birth rate is higher and it may prevent relapse.

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HRT and endometrial hyperplasia

1- Systemic estrogen-only HRT should not be used in women with a uterus.2- All women taking HRT should be encouraged to report any unscheduled vaginal bleeding promptly. 3- advised to change to continuous progestogen intake using the LNG-IUS or a continuous combined HRT preparation.  

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THANK YOU