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ESSAY 188 - ENDOMETRIAL HYPERPLASIA

Posted by Sreekala S.
Management of this woman depends on her desire to retain her fertility. She should be counselled that there is a risk of co-existent endometrial malignancy in about 25-50% of cases with atypical endometrial hyperplasia and that about 22-33% of cases can progress to endometrial cancer. Total abdominal Hysterectomy with Bilateral salpingo oopherectomy should be recommended due to the high risk of co-existent cancer. It should be clear that TAH is a major surgery with significant morbidity and carries the risk of bowel/bladder injury, infection, DVT/PE. If she opts for TAH and BSO, then post operatively, HRT should be considered. Conservation of ovaries should be considered if she wishes but after careful counselling.

If she wishes to retain her fertility or refuses to undergo hysterectomy, she should be offered hormonal treatment. She should be counselled about the need for close long term follow up by repeated Endometrial biopsies. Progestogens, danazol, GnRH analogues and tamoxifen can be tried after discussing about the potential side effects. Medroxy Progesterone acetate 100mg/day can be given for 6 months with endometrial biopsy 3months after cessation of treatment to confirm regression of the abnormality.
Levonorgestrel Intra uterine system is an alternative form of delivering Progestogens which can be offered as it has the advantage of contraception as well and can be used for 5 years. It is known to be more useful in the absence of atypia.
Anemia should be excluded and treated if detected. Tranexemic acid and Mefenemic acid can be prescribed during periods to reduce the menstrual loss.There is no role for ablative techniques in the presence of atypical hyperplasia.
The woman\'s wishes should be respected and a plan made for her depending her wishes. The discussion should be well documented.Information leaflets should be provided and further appointments made if she she wishes.
Posted by Sarwa aldoori A.
Atypical hyperplasia is a premalignant condition that could lead to endometrial cancer in 22-80% ,also it may coexist with endometrial cancer in 20-50%.there is no place for expectant management in this case. management starts with history of exogenous estrogen in the form of HRT , tamoxifen use which result inendometrial hyperplasia. Thoruogh examination to rule out ovarian mass (cancer ) as a source of estrogen. Hysteroscopy and dilatation and curettage and thorough pelvic examination under anaesthesia to rule out assocaited ovarian mass. Ultrasound examination is important for detecting ovarian mass, also Ca 125 measurement which is abonrmally elevated in ovarian cancer.becuase of risk of progression to malignancy, the options available here are either surgery, progestogen systemic, or locla levenorgestrel IUD. Pteient need to be councelled at length .The best option should be total abdominal hysterectomy and bilateral salpingoophrectomy, this will provide removal of uterus as well as possiblr source for estrogen, this wil provide cure and remove occult carcinoma which might not be detected by endomterial biopsy.Also there is no need to follow up even in as it will remove the whole pathology.However this is major surgery , gnereal anesthetic required , associated with risk of thrombosis, hemorrhage , trauma to viscera, patient need to be fit, there is a high chance that she is anemic and this needs to be treated, also she might need control of associated medical condition.If she decline sugery then progestogen systemic can be given in high doses continuous, for three to six months,as there is agreed duration on the use of systemic steroids,this treatement need follow up for a long time as recurrence of atypicla hyperplasia and malignancy has been reported, als there is risk of irregular bleeding, this option is chosen if the patient is medically unfit for surgery.the other choice is leveorgestrl IUD which is basically local rather than systemic progestogen. it cuases irregular bleeding which could confuse the picture.
There are other option which are worht considering which is danazol, and intrauterind radiation, both of them are associated with serious side effect and are considered when patient is unfir medically, danazol is antiestrogen results in endometrial atrophy but is associate dwith androgenic side effect that may affect comliance, also radiation reults in vaginal stenosisand radiation complications.
Posted by Farzana N.
Endometrial hyperplasia is caused by unopposed stimulation of endometrium by excessive estrogens from endogenous or exogenous sources.Management would aim at identification of these sources of estrogens and their treatment.
Atypical hyperplasia is associated with underlying cancer in 10-20%cases and invasive cancer may develop in 50% cases.
H/o irregular periods, which is very common in the perimenopausal patients, would suggest anovulatory dysfunctional uterine bleeding. Unopposed prolonged estrogenic stimulation may result in endometrial hyperplasia. H/o ovarian tumors- causing endogenous estrogen secretion .H/o breast ca and use of tamoxifen, h/o vasomotor symptoms ?night sweats and hot flushes, for which she may be using HRT.These are exogenous causes of excessive estrogens
Examination ?general exam for degree pallor due to heavy periods,fitness for surgery should be assessed. Abdominal examination for any palpable abdominopelvic masses. Pelvic exam for size of uterus and any adnexal masses.
The main objectives of investigations in a pt found to have endometrial hyperplasia is to exclude invasive endometrial carcinoma,or ovarian ca ?source of endogenous estrogens.FBC for Hb,U&E ,LFTs,RFTs should be done as basic investigations to assess general fitness for surgery.USS should be done for ovarian masses .CA 125,and estradiol estimation .
EUA ,hyteroscopy and curettage are required to palpate adnexae and explore endometrial and endocervical cavities.
Treatment would include correction of anemia Estrogen treatment should be stopped .
Considering her age-45yrs and symptoms of heavy bleeding ,best treatment would be TAH and bilateral salpingo oophorectomy.She should be be counselled well and explained about the high risk of carcinoma. Her wishes should be respected .If she just refuses surgical treatment ,other option would be medical treatment with hormones.
Progestogens in modereately high doses such as MPA 100mg/day for six months or megestrol 20mg /day,for 8-12wks followed by endometrial biopsy three months later to confirm regression.Danazol ,tamoxifen and GnRH analogues have also been used with some success.In this case prolonged follow-up is required to detect recurrence.
Posted by Srivas  P.
Atypical endometrial hyperplasia is a premalignant condition of the uterus and in 10-20 % cases may be associated with underlying endometrial carcinoma and it may progress to invasive carcinoma in 50 % cases. It tends to occur around menarche and menopause because of unopposed estrogen in anovulatory cycles.

Risk factor for Endometrial Hyperplasia includes risk factors associated with endometrial carcinoma. Looking for these risk factors help assess her risk for getting endometrial cancer and helps plan management. The factors which increase this risk include Obesity, polycystic ovaries, nulliparity, unopposed estrogen---endogenous from estrogen secreting ovarian tumors or exogenous if is on HRT for likely perimenopausal complaints. Other risk factor is family history of endometrial cancer, breast, colon, or ovarian cancers.

In contrast, Cigarette smokers may have a decreased risk and also if she has been possibly using oral contraceptive pills to control her heavy periods. COCs decrease risk of endometrial cancer by 50 % and this effect is protective even after stopping the pill. History of taking sequential HRT for possible hot flushes or other menopausal complaints should be taken.

Investigation should include FBC to assess presence of anemia (to assess fitness for surgery), USG to look for polycystic ovaries and estradiol estimation and cervical smear if indicated. Ultrasound estimation of endometrial thickness is less reliable premenopausally compared to post menopausal estimation in suspecting endometrial cancer. Also it is less reliable when sequential HRT is being taken by the woman and the cut off for endometrial thickness to suspect endometrial cancer has to be higher. It is also important to enquire the endometrial biopsy was done by which method and if hysteroscopy was done. Plain D & C may miss 15 % of associated endometrial carcinoma while hysteroscopy misses only 3 % of the lesion. If hysteroscopy was not done it is preferable it is done now to improve the diagnosis.

With atypical hyperplasia with its high rate of progress to endometrial carcinoma, hysterectomy with bilateral salpingo-oopherectomy is the best option for this woman as hyperplasia with atypia does not respond as well to progestogens. Ovaries are the site for metastasis if underlying carcinoma is present and they are best removed. She would need HRT following oopherectomy. If she is unwilling for HRT, ovaries could be left behind after explaining to her the risk of subsequent development of ovarian cancer and need for follow up.

If she is reluctant for hysterectomy and wishes to preserve the uterus in spite of explaining the malignant potential of the lesion she may be put on high dose progestogens 20 mg /day of megesterol for 3-6 months with repeated endometrial sampling every 3 months under hysteroscopy. There is no role for endometrial ablation methods. GnRH analogues and Danazol have been tried with limited success. It is important to impress on her the necessity of very close follow up if she is on medical therapy for this high risk condition and she would need repeated endometrial assessments.
Posted by Aroosha B.
Endometrial hyperplasia is a premalignant condition of endometrium. Before management it is important to know the natural history of endometrial hyperplasia. The natural history of Endometrial hyperplasia is poorly understood but most important risk factor for progression is the presence of cytological atypia. A simple hyperplasia has 1 % chance of progression to cancer, adenomatus or complex hyperplasia has < 5 % chance, simple hyperplasia with atypia has 5 to 10% chance where as adenomatus or complex hyperplasia has 25 % risk of progression into cancer.
Management is started by taking a detailed history and explaining the condition to the patient. Endometrial hyperplasia is an Estrogen dependent condition so important conditions to be asked in history, are age of menarche, nulliparity, history of PCOS, exogenous source of estrogen like Tamoxifen all of which are associated with increased risk of progression. Her BMI should be determined as fats are an important endogenous source of estrogen. History of diabetes mellitus and hypertension should also be taken although both of which also not direct cause but usually associated with obesity.
The management options are medical and surgical and depend upon her wishes of further fertility. If she has completed her family then ideal treatment is hysterectomy because in presence of atypical endometrial hyperplasia, there is 25 % risk of progression to cancer and in many cases a cancer may be already present. The ovaries would normally be removed in women over age of 45 years while under 45 it depends upon degree of atypica and perceived risk of cancer being present. Hystrectomy may present an over treatment as 70 % of these patients will not progress to cancer, but it id difficult to categories which patient will develop cancer. In fact 30 % of patients having already well differentiated cancer being present. But if patient wishes to conserve her fertility the management options are as a medical treatment of menorrhagia. GnRH analague, Danazole or high dose progestron therapy all can be given.
Medroxy progesterone is given in high doses for six months and endometrial biopsy taken 3 months after cessation of therapy or earlier if the symptoms persist. LNG IUS has been used in cases of endometrial hyperplasia without atypia and good results have been obtained. Endometrial ablative techniques are an option but are associated with missing endometrial cancer in the buried zone at distal end of obliterated endometrial cavity. The woman should be counseled for long term surveillance if conservative management is undertaken. Whatever treatment method is used patient should be involved fully in decision making process, her wishes respected and discussion documented in notes. The patient should be given information leaflets.

Posted by QWER R.
I would take a history for risk factors for endometrial cancer - ie family hx of breast cancer, nulliparity; and risk factors for ovarian cancer - especially 1st degree relatives under 50, known BRCA mutation, no use of OCP. This may influence decision at time of surgery of potential prophlyactic BSO.

Hx of previous surgery, adhesions, pid and parity will influence planning and type of surgery.

Hx of nature of periods, how they impact on life, pts views on hysterectomy.

Review of cervical smear hx. Examination for ovarian mass on per abdominal and bimanual examination - ? granulosa cell tumour.

Further investigations, CBC, U/S for endometrial thickness and pelvic mass, formal hysteroscopy.

Directed hysteroscopic biopsy may demonstrate a lesion more advanced than endometrial hyperplasia that would alter further management. The patient would be counselled on the need for the procedure, the risks of GA, the possible risks of perforation and laparotomy. At hysteroscopy, cervical descent could also be assessed.

If further investigation confirms atypical hyperlasia, there is a 4% lifetime risk of endometrial cancer. The patient should be councelled that this is a pre malignant condition. Given that she is 44 yrs old, and is unlikely to have more children, a hysterectomy would cure her of menorrhagia and provide treatment.

If descent was present a VH could be performed, with faster recovery.
Discussion regarding prophylactic bilateral oopherectomy offered. BSO decreases but eliminate life time risk of ovarian cancer; but it causes an early menopause and HRT would be required for menopausal symptoms. There may be adverse effects of her lipid profile. Taking HRT for 6 years would bring her risk of breast cancer to that of a 50 yr old woman having menopause at the age of 50.

If VH is done, BSO may require laparoscopic assistance. If there is previous surgical scarring, TAH +- BSO may be the better option.

Discussion of risks of hysterectomy, (ie) infection, DVT, bladder, urinary tract infection. Pain and recovery time.

Other alternatives are progestagenic medication - ie medroxyprogesterone, mirena coil. Long term follow up would be required with rpt pipelle every 6months. Such an option would be more suitable for women with surgical/anaesthetic risk factors, a strong desire to retain the uterus or a wish for more children.

Information leaflets should be given and F/U appt arranged.
Posted by BAHAA-Uddin BOR B.
Atypical endometrial hyperplasia is representing premalignant lesion with the risk of the progression to frank malignancy reported to vary from 23 to 50%. In the management of this patient it is essential that if we are able to exclude co-existent carcinoma of the endometrium. Important causes of this diagnosis may be excluded from the history.This include unopposed oestrogen or tamoxifen therapy.History also, should be concentrated on a heavy periods ,menstrual flow(in perimenopausal women the abnormal flow is commonly anovulatory in nature .) and degree of disruption of daily lifestyle, history of symptoms suggesting anaemia like tirediness,breathlessness and dizziness ,also general obstetric and gynaecological history and when the last smear. Furthermore a contraceptive history with specific enquiry about use of hormonal preparations .General examination for signs of anaemia., body weight and height and BMI for obesity . Abdominal examination for palpable ovarian mass ,also pelvic examination should be performed for evaluation of the uterine size ,ovarian mass. FBC including Hb% is mandatory ,vaginal ultrasonography to measure endometrial thickness and hyperechogenicity,in which we received supplementary information for the whole pelvic pathology like ovarin tumour which may be the source of ,although the endometrial thichness in symptomatic woman does not reduce the need for endometrial sampling. A CA125 will be performed if there is suspected ovarian tumour or this has been confirmred on US Scan. Basic investigations in the form of chest X-ray,urea and electrolytes and creatinine and urine analysis should be done to ensure the optimal fitness if the treatment option is surgery. The standard method of treatment of atypical hyperplasia is hysterectomy as the estimated risk of development of endometrial carcinoma is up to 50%. Management of the patient will depend upon the severity of the hyperplasia , age of the woman as well as her desire to conserve her fertility. In woman 45 year old ,a hysterectomy alone can be advised ,though this will depend upon the degree and extent of the atypical hyperplasia ,and the risk of an invasion lesion being present.
If the woman wish to retain her fertility ,or refuse undergo hysterectomy , high dose progestogens such as medroxyprogesterone acetate in dose of 100mg daily should be given given for 6 months ,with a repeat endometrial biopsy 3 months after cessation of treatment . Long term close surveillance should continue,and the use of levonorgestrel intrauterine system may be useful in controlling the hyperplasia. More than 50% of atypical hyperplasia will revert to normal with MPA.,The latter group 25% will develop recurrent or resistant hyperplasia and 25% will develop cancer. Average time required for progression from hyperplasia to carcinoma is approximately 5 years.
However ,there is a high rate of coexisting endometrial carcinoma and an even higher risk of the subsequent development of cancer.Thus the best option will be a hysterectomy and bilateral salpingoophorectomy .This ensures that endometrial pathology is removed as well as possible source of oestrogens from the ovaries.
Multidisciplinary team approach including a gynae-oncologists, medical oncologist anaesthist ,nursing staff and her partner will assist in decision making.
Endometrial ablation or resection should not be used in the presence of atypical hyperplasia as underlying invasion can not be ruled out and follow-up may be impossible.
Radical hysterectomy with pelvic lymph node dissection would be over-treatment ,so is not an option. Danazol is an anti-oestrogen and will therefore counteract the effects of oestrogen on endometrium ,it is however , associated with severe side-effects .There may be a place for palliative radiotherapy ,especially for heavy bleeding.but it is associated with radiation complications and may induce vaginal stenosis.
Excessive counselling and all the options given in written information leaflet and the decision making is according to the patient\'s wishes.
Posted by adnan S.
Atypical endometrial hyperplasia is a premalignant condition of the endometriam.It progress to invasive cancer in 25-30% or there may be co-existing endometrial cancer .It is a oestrogen dependent condition.History is taken regarding any un oppose oestrogen therapy like HRT or tomoxifen for breast cancer .H/O diabetes and hypertension to be enquired as they are risk factors fpr endometrial carcinoma.On examination weight &height recorded to calculate BMI,obesity is also a risk factor for endometrial cancer.BP is also checked.Abdominal examination is done for any palpable masses.Bimanual vaginal examination is done to look for uterine size,mobility&any palpable adenexal messes.Investigations are aimed to r/o endometrial cancer and to identify internal source of oestrogen like ovarian oestrogen tumours like granulosa cell tumour.Pelvic ultra-sound is done to r/o ovarian masses but granulose cell tumours are un cmmon at this age,and assessment of endometrial thickness is also of no use as diagnosis of endometria atypical hyperplasia is already made.If TVS shows suspected ovarian tumours CA125 is done which might be the source of oestrogen.In this 45 year old woman the cause most likely to be premanopausal an ovulatory cycles.

In view of increased risk of progression to malignancy or the high co ?existance risk of endometrial carcinoma there is no place for expectant management.The standerd management would be total abdominal hysterectomy with bilateral salpingo-oophorectomy.This removes the cancer or potential to develop a cancer in the uterus.In this woman only atypical endometrial hyperplasia is diagnosed oophorectomy represent over treatment but if micro invasive cancer is co-existing oophorectomy should be done .If oophorectomy done to remove a site of possible metastesis ,HRT may be given to the woman if she wishes . oophorectomy done for co-existing invasive cancer there is theoretical risk of stimulation of pre-existing metastesis.the need of HRT is evaluvated with risk and benefits & menopausal symptoms on individual basis.After surgery there will be no need for follow-upthe patient even she had invasive cancer as it will be superficial invasion TAH&BSO is adequate treatment.
If she is un fit for surgery due to medical problems or if she refuse surgery non surgical management can be undertaken with LNG-IUS (merina) or medroxy progesterone acetate 100mg/day for six months.In either options further endometrial biopsy should be done around three months after cessation of treatment to confirm that hyperplasia has regressed.Long term follow-up is required .
Posted by Sarwat F.
Atypical hyperplasia is associated with endometrial carcinoma in 25 to 50 % cases. Management in this case will include certain investigations like full blood count and pelvic ultrasound and counselling woman regarding the need for total abdominal hysterectomy. Full blood count is important to exclude anaemia and pelvic ultrasound is done to assess ovaries. Any suspicious ovarian mass will require evaluation by doing serum CA125 and CT scan of abdomen..
She will be explained about the route of surgery, which will be abdominal hysterectomy, and it will involve a transverse pfannensteil incision. Informed consent will be taken explaining the risks associated with the procedure. Various complications associated with hysterectomy include anaesthetic complications, operative and postoperative complications. Operative risks include haemorrhage, damage to bladder that occurs in 1 in 500 cases, damage to ureter and far less common is the risk of damage to bowel. Postoperative complications include infection, haematoma formation, risk of thromboembolism and death.
If the woman is not willing for hysterectomy risks of association of malignancy are explained to her and alternative options are given. Progesterone can be given either in the form of MIRENA coil or oral megestrol acetate for 6 months and biopsy repeated to check for malignancy after that. Long-term followup will be needed in case conservative management is followed. Transcervical resection of endometrium is not advocated as a form of management as it has a high risk associated with remnant endometrium and hence the chances of malignancy. Danazol and gonadotrophin releasing hormone analogues can be used as they produce hypoestrogenic states but again these are not standard mangement.
Woman should be given written information regarding the risks and management of the condition and decision made in accordance with her consent.
Posted by SWATI M.
Atypical endometrial hyperplasia is a premalignant condition and may be coexistent with endometrial malignancy.Proper evaluation is important.If cystic hyperplasia with atypia, risk of progression to malignancy is 5-10% and in complex hyperplasia with atypia malignacy may be coexistent or progression occur in about 25-50% cases.
History about details of menstrual complaints to assess the amount of blood loss,clots alongwith symptoms of anaemia such as easy fatigue ability,feeling of tiredeness and palpitations should be enquired.
Assess risk factors for endometrial malignancy which includes early menarche, nulliparity, obesity.hypertension,diabetes,PCOS,family or personal history of breast cancer,use of tamoxifen or HRT .Cervical smear history should be taken into account.
Clinical examination includes measuring BMI, BP. Look for signs of anemia ,pallor and ejection systolic murmur.Assess uterine size,mobility and any adnexal mass by abdominal and pelvic examination.Granulosa cell tumour of ovary may be the cause of hyperplasia.
Investigations includes FBC for anaemia.Ultrasound for uterine size and adnexal mass as obesity may limit clinical findings.
Treat the anemia.Counsel her the risks ,depending upon whether cystic or complex type she has.
Hysterectomy with bilateral salpingo ?oopharectomy would eliminate the risk of malignancy in either case.If she is relunctant for surgery ,in cystic type use of progesterone can be recommended after appropriate counselling .Continuous high dose will be required for 3-6 months which later should be stopped and evaluated.As there is risk of recurrence or progression ,long term follow up will be needed with biopsy .
Side effects such as abdominal bloating , mastalgia, headache can be troublesome with systemic administration.Alternative is to use Mirena which will be associated with less progetogenic side effects.It induces ammenorrhea in most cases with use by 1 year.She will need evaluation if her symptoms recur .

Recommend TAH with BSO for complex hyperplasia as risk is high. BSO will be recoomedned as small risk of metastasis to ovaries even in early malignancies.Preop fitness and anasthetic review should be organized.
Procedure should be performed like staging laparotomy including peritoneal cytology and thorough examination of abdominal contents for metastasis.
Further management would depend upon histology but in most cases it will be early malignancy and may not need adjuvant treatment.Long term follow up will be
required.
Posted by Zaibunnisa khan K.
Management will depend on the risk of progression to endometrial cancer,severity of her symptoms affecting quality of
Life and her wishes preserving fertility .Detailed history to assess the risk of progression regarding prolonged unopposed use
Of estrogen ,temoxifen,personal history of breast or colon cancer,history of infertlilty ,nulliparity medical history of diabetes and
of diabetes and hypertension which need to be controlled ,her family history of breast ,endometrial and ovarian cancer should be
taken .Her general examination will include her body mass index ,as obesity is risk factor ,her blood pressure should be checked,her breast and abdomen should be examined for masses her perspeculm examination and bimanual p/v should performed to take papsmear if due and asses cervical status ,uterine size ,mobility ,adenaxae and per/ectum shoud be done
She should be full blood coun to asses for anaemia as prolong history of heavy periods and advised trans vaginal ultrasound to asses endometrial thickness and any adnexal pathology.
As endometrial hyperplasia is premalignant condition and the risk of progression to endometrial cancer in case of atypical hyperplasia is significant and insome cases ,there may be an invasive cancer already present and differentiation between the
Two may be difficult.The patient should be councelled regarding this risk. FIst step would be to discontinue estrogen and tmoxifen if patient is taking these drugs and to remove an estrogen secreting ovarian tumor.Hystrectomy would be recommended unless patient refuse for it .The removal of the ovaries should be discussed to avoid the risk of recurrence.
In case of history breast cancer ,familial ovarian ,breast or endometrial cancer ovaries should be removed.
.In case she refused to undergo hysterectomy then medical treatment in the form of high dose progesterone, Danazole,GNRHanalouges shoud be of .Progesterone in the form of Medroxyprogesteronacetat.Progesterone in the form of Medroxyprogesterone acetate, 100 mg/day ,6 month would be offered .Endometrial biopsy should be offered after 3 months cessation of treatment to confirm the regression of the condition.The levonorgestral intra uterine system may be useful in the management of endometrial hyperplasia particularly inpatient without cytological atypia.
Long term close surveillance should be continued as there is risk of recurrence even after many yeares.Subsequent need for HRT
Should be discussed considering the risk and benefits.
Posted by Zaibunnisa khan K.
Management will depend on the risk of progression to endometrial cancer,severity of her symptoms affecting quality of
Life and her wishes preserving fertility .Detailed history to assess the risk of progression regarding prolonged unopposed use
Of estrogen ,temoxifen,personal history of breast or colon cancer,history of infertlilty ,nulliparity medical history of diabetes and
of diabetes and hypertension which need to be controlled ,her family history of breast ,endometrial and ovarian cancer should be
taken .Her general examination will include her body mass index ,as obesity is risk factor ,her blood pressure should be checked,her breast and abdomen should be examined for masses her perspeculm examination and bimanual p/v should performed to take papsmear if due and asses cervical status ,uterine size ,mobility ,adenaxae and per/ectum shoud be done
She should be full blood coun to asses for anaemia as prolong history of heavy periods and advised trans vaginal ultrasound to asses endometrial thickness and any adnexal pathology.
As endometrial hyperplasia is premalignant condition and the risk of progression to endometrial cancer in case of atypical hyperplasia is significant and insome cases ,there may be an invasive cancer already present and differentiation between the
Two may be difficult.The patient should be councelled regarding this risk. FIst step would be to discontinue estrogen and tmoxifen if patient is taking these drugs and to remove an estrogen secreting ovarian tumor.Hystrectomy would be recommended unless patient refuse for it .The removal of the ovaries should be discussed to avoid the risk of recurrence.
In case of history breast cancer ,familial ovarian ,breast or endometrial cancer ovaries should be removed.
.In case she refused to undergo hysterectomy then medical treatment in the form of high dose progesterone, Danazole,GNRHanalouges shoud be of .Progesterone in the form of Medroxyprogesteronacetat.Progesterone in the form of Medroxyprogesterone acetate, 100 mg/day ,6 month would be offered .Endometrial biopsy should be offered after 3 months cessation of treatment to confirm the regression of the condition.The levonorgestral intra uterine system may be useful in the management of endometrial hyperplasia particularly inpatient without cytological atypia.
Long term close surveillance should be continued as there is risk of recurrence even after many yeares.Subsequent need for HRT
Should be discussed considering the risk and benefits.
Posted by Zaibunnisa khan K.
Management will depend on the risk of progression to endometrial cancer,severity of her symptoms affecting quality of
Life and her wishes preserving fertility .Detailed history to assess the risk of progression regarding prolonged unopposed use
Of estrogen ,temoxifen,personal history of breast or colon cancer,history of infertlilty ,nulliparity medical history of diabetes and
of diabetes and hypertension which need to be controlled ,her family history of breast ,endometrial and ovarian cancer should be
taken .Her general examination will include her body mass index ,as obesity is risk factor ,her blood pressure should be checked,her breast and abdomen should be examined for masses her perspeculm examination and bimanual p/v should performed to take papsmear if due and asses cervical status ,uterine size ,mobility ,adenaxae and per/ectum shoud be done
She should be full blood coun to asses for anaemia as prolong history of heavy periods and advised trans vaginal ultrasound to asses endometrial thickness and any adnexal pathology.
As endometrial hyperplasia is premalignant condition and the risk of progression to endometrial cancer in case of atypical hyperplasia is significant and insome cases ,there may be an invasive cancer already present and differentiation between the
Two may be difficult.The patient should be councelled regarding this risk. FIst step would be to discontinue estrogen and tmoxifen if patient is taking these drugs and to remove an estrogen secreting ovarian tumor.Hystrectomy would be recommended unless patient refuse for it .The removal of the ovaries should be discussed to avoid the risk of recurrence.
In case of history breast cancer ,familial ovarian ,breast or endometrial cancer ovaries should be removed.
.In case she refused to undergo hysterectomy then medical treatment in the form of high dose progesterone, Danazole,GNRHanalouges shoud be of .Progesterone in the form of Medroxyprogesteronacetat.Progesterone in the form of Medroxyprogesterone acetate, 100 mg/day ,6 month would be offered .Endometrial biopsy should be offered after 3 months cessation of treatment to confirm the regression of the condition.The levonorgestral intra uterine system may be useful in the management of endometrial hyperplasia particularly inpatient without cytological atypia.
Long term close surveillance should be continued as there is risk of recurrence even after many yeares.Subsequent need for HRT
Should be discussed considering the risk and benefits.
Posted by hala M.
Atypical endometrial hyperplasia is caused by the unopposed effect of oestrogen on the endometrium and is associated with high malignancy potential in addition to the possibility of the coexisting endometrial cancer. Therefore the patient needs to be informed of the diagnosis and its implication.

The source of excess oestrogen can be identified from the history of taking exogenous oestrogen (Tamoxifen,HRT and pheto-oestrogen) and the finding of oestrogen producing ovarian or adrenal tumour by the examination and pelvic USS/ abdominal CT scan. Poly cystic ovarian syndrome is associated with a status of unopposed oestrogen and this can be identified on the USS.

The patient weight, height, BMI and blood pressure need to be checked. GTT needs to be performed in cases with high risk possibility of DM. The patient?s fitness for surgery needs to be assessed.
The treatment of choice for the atypical endometrial hyperplasia is TAH&BSO, but giving the age of the patient the issue of conserving the ovaries after the exclusion of oestrogen secreting ovarian tumours needs to be considered and she can be managed by hysterectomy only. Early menopause might occur even in the case of ovarian preservation.

The patient needs to be told about the subsequent development of hypo estrogenic status and the risk of menopausal symptoms, osteoporosis and cardiovascular diseases.
The use of HRT would relieve the menopausal symptoms and prevent the development of osteoporosis when given in adequate dose, but this is on the expense of the increased risk of breast cancer associated with the long term use of HRT. Clonidin and SERM can be used in high risk cases.

If the source of oestrogen is adrenal tumour this needs to be excised with the help of general surgery colleagues.
There is no place for the expectant or medical treatment in atypical hyperplasia due to the risk of malignancy potential. If the patient refused the proposed surgical approach she needs to be informed that the risks with conserving the uterus outweigh the benefit. The management of such cases would be by giving high doses of Medroxy progesterone acetate/IUS and regular surveillance by USS/ hysteroscopy/biopsy.
Posted by M H.
Atypical endometrial hyperplasia has a 50% risk of progression to endometrial carcinoma and in 1-2% have existing underlying carcinoma. The management of this lady would depend largely upon whether she desires her fertility to be preserved. In women who have completed their family, the recommendation would be a hysterectomy with a bilateral oopherectomy in view of the risk of progression to carcinoma.

If she has yet to complete her family or unwilling to undergo a hysterectomy, she can be offered a trial of progetogen therapy, low dose progestogen initially for 3 months with a repeat biopsy and a further 3 month of high dose progestogen if the results have not changed. There have been a reported regression rate of about 50%. However, if there is still no change, she should be adviced to reconsider hysterectomy.

If she opts for hysterectomy, there should be discussion about iatrogenic menopause and the subsequent need for oestrogen replacement therapy (ERT). Family or personal history of 1st degree relative with breast cancer or thromboembolic disease, hypertension, cardiovascular disease are contraindications for ERT as there is associated increase in worsening or risk of the above conditions. The main concerns with early menopause is the risk of osteoporosis and vasomotor symptoms and this should be discussed with the lady. ERT is not contraindicated in atypical hyperplasia of endometrium.

Endometrial ablation therapy in this condition remains controversial. There have been reports of cure.

All information should be imparted in a non directed manner by an experienced gynaecologist so that she can make an informed choice based on evidence. She should be counselled with her partner if possible and be given opportunity to ask questions. A second appointment should be made. A referral for a second opinion and to appropriate support groups is appropriate. Written information should accompany all verbal information imparted.
Posted by Sreekala S.

\"Danazol ,tamoxifen and GnRH analogues have also been used with some success please let me know where you read this as it seems to have been written by other candidates ? tamoxifen CAUSES endometrial hyperplasia and is not effective treatment .In this case prolonged follow-up is required to detect recurrence. \"

Dear Paul,
The use of Tamoxifen,Danazol and GnRh analogues has been described in COG Vol-14/2, Page no-102
Best wishes,
Sreekala


Posted by Sreekala S.

\"Danazol ,tamoxifen and GnRH analogues have also been used with some success please let me know where you read this as it seems to have been written by other candidates ? tamoxifen CAUSES endometrial hyperplasia and is not effective treatment .In this case prolonged follow-up is required to detect recurrence. \"

Dear Paul,
The use of Tamoxifen,Danazol and GnRh analogues has been described in COG Vol-14/2, Page no-102
Best wishes,
Sreekala


Posted by QWER R.
busy4876
Regarding the need for further evaluation following an endometrial biopsy showing atypia. An endometrial biopsy does not mean that a D&C has been done as well.

If the lesion is purely atypical endometrial hyperplasia; there is the option of ovarian conservation.

A demonstration of endometrial ca would make oopherectomy clear cut.

A lesion greater than 1a low grade would require a gynae-oncologist to do the surgery; and preop MRI would be advantageous to see if need for radical approach/lympadenectomy warranted.

Granted, if ovarian conservation occurs with simple TAH and at histology, endometrial carcinoma was found, a formal staging laparotomy with oopherectomy could be performed- but the risk of such an event occuring would be minimised by ensuring the endometrium is sampled as well as possible by thorough curette.

Such has been my experience in waikato...

could you confirm that there is according to RCOG examiners .. not a justifiable benefit in formal D&C & hysteroscopy in this scenario; as this is not a universal position.... or perhaps this is what I needed to put in my essay?

http://www.emedicine.com/med/topic3334.htm


Dilatation and curettage

When the office endometrial biopsy or hysteroscopic-directed biopsy shows cytologic atypia, a formal D&C is indicated to increase the likelihood that the uterine cavity has been adequately sampled.

Even given this uncertainty, formal D&C helps distinguish patients who quite often have an adenocarcinoma along with EH with atypia and are therefore in need of the appropriate surgical intervention for endometrial adenocarcinoma.

Insufficient sampling of the endometrium can occur, even with D&C, and this possibility must factor into any decision made regarding a recommendation for conservative therapy.

Posted by SWATI M.
Dear Dr.Paul,
Thanks for the comments.I realised my mistake after checking the recent edition of Shaw\'s textbook.Better to do mistakes here than in the exam.
Posted by Vaani M.
Management of this woman would depend on her wishes to retain future fertility. Atypical endometrial hyperplasia is associated with endometrial carcinoma in one third of women and co-existent carcinoma is present in upto one half of women.

The ideal management for this woman would be hysterectomy with or without bilateral salpingo-oophorectomy. BSO would depend on her risk for further development of ovarian cancer especially if she has history of breast cancer, benign ovarian disease in the past, family history of breast or ovarian cancer. Her ovaries could be retained if she wishes and is not at high risk of development of ovarian cancer.

Hysterectomy could be done as abdominal, vaginal, laparoscopic or laparoscopic assisted vaginal hysterectomy. Appropriate pre-operative evaluation, investigations and preparation would be required. Prophylactic antibiotics and thromboprophylaxis would be required as this is a major surgery. Abdominal hysterectomy would be easier if BSO is planned, but post operative recovery would be a little longer. Vaginal hysterectomy would take lesser time to recover but associated adnexal pathology may be difficult to remove if required. Laparoscopic procedure has the advantage of having lesser blood loss, quick post operative recovery, and earlier return to normal daily activities. Hormone replacement therapy should be given if BSO has been done to protect bones. Appropriate information leaflets and support group support should be given. Informed consent should be taken after all information has been given.

If the woman refuses hysterectomy or wishes to retain fertility, she should be considered for conservative management with progesterone. Progesterone should be given in high doses as medroxy progesterone 100mg daily for 6 months or as local intrauterine progesterone mirena although she will need regular follow up with endometrial biopsies.

After appropriate counselling she should be given the choice to decide the most suitable and appropriate management for her.