Endometrial hyperplasia

Question 1

Types of endometrial hyperplasia

Answer 1

• With atypia
• Without atypia

Question 2

Symptoms of endometrial hyperplasia (EH)

Answer 2

Abnormal uterine bleeding
- IMB
- PMB
- Unscheduled bleeding on HRT
- Irregular bleeding

Question 3

RF of EH

Answer 3

Unopposed estrogen
- Obesity
- Nulliparity
- PCOS due to anovulation
- Estrogen screting tumours (granulosa cell tumours)
- Early menarche and late menopause

• Drug induced: Tamoxifen

ALWAYS scan to rule out ovarian tumours

Question 4

Uterine sampling methods

Answer 4

• Pipelle - risk of 2% of hyperplasia if negative
• OP or GA hysteroscopy

Question 5

When is hysteroscopy a must

Answer 5

• If hyperplasia is diagnosed
• Polyps or other abnormality on scan
• Bleeding persists
• Insufficient sample on pipelle

Question 6

Risk of cancer with normal ET on scan

Answer 6

<1%

Question 7

TV US cut offs

Answer 7

• PMB >4mm needs sampling
• On cont HRT >5mm needs sampling
• On seq HRT >7mm

Question 8

Role of CT/MRI

Answer 8

• If staging is needed
• Not routinely used to monitor EH

Question 9

Risk of EH without atypia progressing to cancer

Answer 9

<5% in 20 years

Question 10

Treatment for EH without atypia - Expectant

Answer 10

• Wt loss
• Adjust HRT
• Ask about other meds- black cohosh, etc
• Review tamoxifen

Question 11

Treatment of EH - progesterone

Answer 11

• Mirena, best form
• Others- Norethisterone 10-15mg/day
  Or Medroxyprogesterone 10-20mg/day
• Dont use cyclical

Question 12

Benefit of progesterone

Answer 12

• Higher regression rate compared to no treatment
• 89-96% vs 74-80%

Question 13

F/u and surveillance

Answer 13

• Resample every 6 months
• 2 negative biopsies before d/c
• If other RF like obesity or treated with oral prog - F/u yearly

Question 14

When to offer Hysterectomy

Answer 14

• NOT FIRST LINE!
• If bleeding or hyperplasia persists for 12months
• Becomes atypical
• Declines f/u
• Relapse

Question 15

Hysterectomy- BSO and TLH Vs TAH

Answer 15

• If post-menopause- BSO
• If pre-menopause- Leave ovaries

TLH better than TAH

Question 16

Pathways

Answer 16

insert image

Question 17

If fertility is required

Answer 17

• Advise oral prog and 2 negative biopsies before trying for preg

Question 18

Mx of EH w atypia

Answer 18

Laparoscopic Hysterectomy + BSO or BS (premenopause)

Question 19

What not to do during hysterectomy

Answer 19

• Do not perform lymphadenectomy
• Do not morcelate- risk of spreading cancer
• Do not do subtotal hysterectomy

Question 20

Cancer risk of EH w atypia

Answer 20

30% in 20y

Question 21

If fertility wanted

Answer 21

• Council about risk of cancer
• Take biopsy, do tumour markers, MRI and discuss in MDT
• Consider IVF

Question 22

Rx if fertility wanted

Answer 22

• Offer Mirena or progesterone.
• Wt loss, stop smoking etc
• Repeat biopsy in 3 months till 2 negative.
• Long term f/u w 6 monthly biopsy till TLH.
• Hysterectomy once fertility is not needed.

Question 23

Mx of EH with HRT

Answer 23

• Biopsy
• Change to cont HRT
• Use Mirena as progesterone
• Avoid estrogen only if uterus insitu

Question 24

Tamoxifen risks

Answer 24

• Endometrial estrogen agonist
• Notify doctor ASAP if abnormal bleeding
• Higher risk in those >49

Question 25

Mx of EH on tamoxifen

Answer 25

• Consider changing to aromatase inhibitor
• Mirena- reduces EH but effect on breast CA unknown