Endometrial Hyperplasia

Question 1

Specific history?

Answer 1

C – cycle – LMP, menarche, cycle length, abnormal bleeding (IMB/PMB)
M – menopause – age, sx, HRT/other meds
MSPF (for medical, surgical, psych, family hx incl genetic)
- previous Pipelle/hysteroscopy
Meds
- HRT/Tamoxifen use

Question 2

Specific exam?

Answer 2

BMI
Urine bHCG
Abdo – mass/tender/organomeg
Nodes
Spec (Chap/consent) (VVCx)
- bivalve
Bimanual size/mass/mobility/nodularity

Question 3

Aetiology

Answer 3

Unopposed oestrogen (oestrogen effect \> progesterone effect) e.g. obesity (aromatase in fat coverts androgens to oestrogen), oestrogen-only HRT in presence of uterus, anovulation associated with the perimenopause or PCOS, oestrogen-secreting tumours e.g. granulosa cell tumours, Tamoxifen. 
- stimulates endometrial cell growth 

Lynch Syndrome

Question 4

DDx

Answer 4

For AUB:

PALM COEIN

• polyp
• adenomyosis
• leiomyoma
• malignancy and hyperplasia
• coagulopathy
• ovulatory dysfunction
• iatrogenic
• not otherwise classified

Pregnancy 
Malignancy (endometrial Ca, Granulosa cell tumour of ovary)

Question 5

Specific Ix?

Answer 5

Urine bHCG
USS pelvis (TV)
Endometrial sampling:
- Pipelle
- Diagnostic hysteroscopy if outpatient sampling fails or is non-diagnostic. Direct visualisation and biopsy of the uterine cavity also recommended where EH as been diagnosed within a polyp or other discrete focal lesion

FBC

Question 6

Mx of endometrial hyperplasia without atypia?

Answer 6

Conservative
Medical
- hormonal - LNG-IUS or oral progestogens
Surgical - hysterectomy not considered first line, as major surgical morbidity and progestogens induce regression in the majority of women

Inform patient that the risk of EH without atypia progressing to endometrial cancer is <5% over 20 years, and that the majority of cases of EH without atypia will regress spontaneously.

Address reversible risk factors - obesity, HRT

Observation with follow-up endometrial biopsies to ensure regression can be considered however, inform the woman that Rx with progesterone has a higher disease regression rate.

Progestogen Rx is indicated in women who fail to regress following observation alone and in symptomatic women with AUB.

First line medical Rx:

• LNG-IUS - compared with oral progestogens has a higher disease regression rate
• if LNG-IUS declined, continuous progestogens (do not use cyclical) include MPA 10-20mg/day or NET 10-15mg/day
• Rx duration = minimum 6 months to induce histological regression. Encourage the woman to retain the LNG-IUS for up to 5 years - reduces risk of relapse

Surveillance during Rx:

• endometrial surveillance at minimum Q6monthly
• at least two consecutive 6-monthly negative biopsies before discharge

Follow-up:

• advise patient to seek further referral if AUB recurs after completion of Rx
• if high risk (BMI >/= 35 or treated with oral progestogens), 6-monthly endometrial biopsies recommended. Once two negative 6-monthly bx, consider long-term follow-up with annual Pipelle.

Hysterectomy indicated if not wishing fertility preservation and :

• progression to atypia
• no regression of hyperplasia despite 12 months of Rx
• relapse of EH after completed progestogen Rx
• persistence of bleeding symptoms
• declines endometrial surveillance of to comply with medical Rx

Question 7

Outline mx of women with atypical endometrial hyperplasia who wish fertility preservation

Answer 7

Counsel re: risk of underlying malignancy and subsequent progression to cancer.

Pretreatment Ix should aim to rule out invasive endometrial cancer or co-existing ovarian cancer (as not embarking upon surgery in the first instance).

MDT - review histo, imaging, tumour markers and make a plan for mx and ongoing endometrial surveillance.

Recommend LNG-IUS as first-line Rx, oral progestogens as second-best alternative.

Follow-up:

• Q3monthly endometrial surveillance (biopsy) until two consecutive negative bx obtained
• if asymptomatic and two negative biopsies as above (regression), long-term follow-up with bx every 6 -12 months until hysterectomy performed

If wishing to conceive:

• disease regression should be achieved on at least one endometrial biopsy before attempting to conceive
• refer to fertility specialist to discuss options (live birth rate higher with ART)

Once fertility no longer required, offer hysterectomy given high risk of disease relapse.

Question 8

Management of atypical hyperplasia?

Answer 8

Total hysterectomy + BSO due to the risk of underlying malignancy (40%) or progression to cancer (30%). Risk also of concurrent ovarian cancer (endometrioid).

Laparoscopic approach preferred - shorter hospital stay, less post-op pain, faster recovery.

Note: recommend hysterectomy + BSO if post-menopausal (i.e. TLH + BSO)
- consider BSO if pre-menopausal (remove tubes at minimum to reduce ovarian cancer risk)