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Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
Indonesia   Hyperplasia
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Indonesia Hyperplasia

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    • 1. Diagnostic & Operative Hysteroscopy in Endometrial Hyperplasia Franklin D. Loffer. M.D. Associate Clinical Professor – University of Arizona Executive Vice President/Medical Director American Association of Gynecological Laparoscopists
    • 2. Endometrial Hyperplasia <ul><li>An increase in the number of endometrial </li></ul><ul><li>glands </li></ul><ul><li>Usually associated with unopposed estrogen </li></ul><ul><li>Varying types - simple w/wo atypia </li></ul><ul><li>- complex w/wo atypia </li></ul>
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    • 6. Endometrial Hyperplasia <ul><li>An increase in the number of endometrial </li></ul><ul><li>glands </li></ul><ul><li>Usually associated with unopposed estrogen </li></ul><ul><li>Varying types - simple w/wo atypia </li></ul><ul><li>- complex w/wo atypia </li></ul>
    • 7. Endometrial Hyperplasia Related to Unopposed Estrogen Stimulation <ul><li>Annovulation (PCO) </li></ul><ul><li>Increasing age </li></ul><ul><li>Estrogen replacement therapy </li></ul><ul><li>Obesity </li></ul>
    • 8. Endometrial Hyperplasia <ul><li>An increase in the number of endometrial </li></ul><ul><li>glands </li></ul><ul><li>Usually associated with unopposed estrogen </li></ul><ul><li>Varying types - simple w/wo atypia </li></ul><ul><li>- complex w/wo atypia </li></ul>
    • 9. Types of Endometrial Hyperplasia <ul><li>Glands Stroma </li></ul><ul><li>Simple increased abundant </li></ul><ul><li>Complex increased little </li></ul>
    • 10. Risks of Hyperplasia Progressing to Endometrial Cancer <ul><li>Simple w/o atypia ~1% </li></ul><ul><li>Complex w/o atypia ~5% </li></ul><ul><li>Simple with atypia ~10% </li></ul><ul><li>Complex with atypia ~25% </li></ul>
    • 11. Endometrial Hyperplasia Presents As: <ul><li>Menorrhagia </li></ul><ul><li>Metorrhagia </li></ul><ul><li>Postmenopausal bleeding </li></ul><ul><li>Thickened Stripe </li></ul>
    • 12. Methods of Working Up Abnormal Uterine Bleeding
    • 13. Diagnostic Indications for Hysteroscopy <ul><li>Abnormal Bleeding </li></ul><ul><li>Questionable Ultrasound </li></ul><ul><li>Abnormal HSG </li></ul><ul><li>Infertility </li></ul><ul><li>Pregnancy wastage </li></ul>.
    • 14. Surgical Indications for Hysteroscopy <ul><li>Directed Biopsies </li></ul><ul><li>Polypectomy </li></ul><ul><li>Submucosal Myomectomy </li></ul><ul><li>Transection of Septum </li></ul><ul><li>Adhesiolysis </li></ul><ul><li>Endometrial Ablation </li></ul><ul><li>Sterilization </li></ul>.
    • 15. Other Methods of Endometrial Sampling <ul><li>Endometrial Biopsy </li></ul><ul><li>Aspiration Curettage </li></ul><ul><li>D & C </li></ul>
    • 16. Adequacy of Specimens From Pipelle Compared to Novak Endometrial Biopsies*
    • 17. Sensitivity of Pipelle Sampling in Detection of Known Endometrial Cancer*
    • 18. Comparison of Surface Area Sampled by Pipelle Biopsy vs Aspiration Curettage*
    • 19. Adequacy of D&C in Sampling Endometrium (60 pts)*
    • 20. Adequacy of D&C in Emptying the Uterine Cavity (124 pts)*
    • 21. Are Blind Biopsy Techniques Accurate Diagnostic Tools? <ul><li>Reason: </li></ul><ul><li>It misses large areas of endometrium </li></ul><ul><li>Does not give selected tissue to pathologist </li></ul><ul><li>Frequently misses polyps and fibroids </li></ul>Conclusion: No
    • 22. Is The D&C Therapeutic? Conclusion: No Reason: <ul><li>Fails to diagnose or remove polyps or fibroids </li></ul><ul><li>No proven decrease in blood loss* </li></ul>*Exception – incomplete AB’s and acute nonresponsive DUB
    • 23. Reduction in Blood Loss After D&C in 22 Patients Hayes, et al, B J ObGyn, 1977
    • 24. Reduction in Blood Flow After D&C MP After Percent D&C Reduced 1 - 69.0 2 +33.6% 3 -8.4 4 -4.0 Nisson & Rybo, AJ OBG, 110:713, 1971
    • 25. Comparison of Sonohysterography in Patients With Abnormal Uterine Bleeding (N=113) <ul><li>Less painful (p=<0.0001) </li></ul><ul><li>Equally accurate (p=0.18) </li></ul><ul><li>More accurate for hyperplasia </li></ul><ul><li>Look beyond cavity </li></ul><ul><li>More readily available </li></ul>Wildrick T. et al Am J OB/GYN 1998; 174:1327
    • 26. How Good Is A Hysteroscopic View Alone? (4064 Patients) Hyperplasia (613 pts) Endometrial CA (105 pts) Sensitivity 56.3% 80.0% Specificity 89.1% 95.5% PPV 48.0% 81.5% NPV 92.0% 99.5% Accuracy 72.7% 89.8% Lasmar RB et al, J Minim Invasive Gynecol 2006; 13:409-412
    • 27. Accuracy of Hysteroscopy vs. D&C* H/S Bx = D&C 271 (79%) H/S Bx > D&C 60 (18%) H/S Bx < D&C 11 (3%) Total 342 *Gimpelson RJ et al; AJ OBG 168:489, 1988
    • 28. D&C Less Accurate Than Hysteroscopy* (60/342 cases 18%) Polyps 17 Fibroids 22 Benign endometrium 14 Atypical 5 Miscellaneous 2 Gimpelson RJ, AJ OBG, 158;489 1988
    • 29. D&C More Accurate Than Hysteroscopy* (11/342 cases 3%) Anovulatory 4 pts Atrophic 3 pts Endometritis 2 pts Hyperplastic 1 pt Polyp 1 pt Gimpelson RJ, AJ OBG, 158;489 1988
    • 30.  
    • 31. D&C vs Aspiration Curettage* D&C A.C. N=13,598 (N=5851) Safety (per 1,000) Hemorrhage 4 0 Infection 3-5 0-4 Perforation 6-13 0-4 Emergency lap 0.3-5 0 Adequate specimen 77-94% 85-99% Location out/in pt. Office Therapeutic effect nil nil *Grimes D., Am J ObG, 142:1, 1982
    • 32. Evaluating Causes of AUB <ul><li>Hysteroscopy for: </li></ul><ul><li>Biopsying small lesions </li></ul><ul><li>Identifying polyps and fibroids </li></ul>Aspiration curettage for : <ul><li>Obtaining large amounts of tissue </li></ul>
    • 33. Hysteroscopy With Tissue Sampling vs D&C – Sensitivity, Specificity and Predictive Value H/S D&C Sensitivity 98% 65% Specificity 100% 100% Predictive Value Positive 100% 100% Negative 1% 17% Loffer FD. Obstet Gynecol 1989; 73:16 Frankl
    • 34. Hysteroscopy 1992-1996 Diagnostic 296 pts Office < 50 y/o 193 (65.2%) > 50 y/o 60 (20.3%)* Out pt < 50 y/o 9 (3.0%) > 50 y/o 14 (4.7%) ** Out pt & other surg 20 (6.8%) Operative 218 pts * 3 failed, ** 1 failed
    • 35. Non-Office Diagnostic Hysteroscopy <50 y/o >50 y/o (N=9) (N=14) Cervical Stenosis 4 1 Vaginal Stenosis 0 6 Heavy Bleeding 2 1 Abnormal Ultrasound 1 2 Patient preference 2 3 Inpatient 0 1
    • 36. Significance of Hyperplasia With and Without Atypia
    • 37. Untreated Atypical Endometrial Hyperplasia (mean 13.4 years) Regressed 29 pts 60% Persisted 8 pts 17% Progressed 1 pt 23% Kurman RJ et al, Cancer 1985 56:405
    • 38. Risk of Carcinoma When Biopsy is Atypical Hyperplasia At hysterectomy 36 of 78 (46.2%) cases had invasive endometrial carcinoma. Miller C et al Am J OBG 199: 1-4,2008
    • 39. Risk of Carcinoma When Pathology Report for Biopsy is Atypical Hyperplasia Path Report # Pts # CA AEH 48 18 37.5% AEH – CA 30 18 60.0% Miller C et al Am J OBG 199: 1-4, 2008
    • 40. Polypoid Endometrium is not the same as Endometrial Polyp Hysteroscopic Polypectomy
    • 41. When To Hysteroscope <ul><ul><li>A thickened stripe and a negative endometrial biopsy give a presumptive diagnosis of an endometrial polyp. </li></ul></ul>
    • 42. Endometrial Cancer in Polyps <ul><li># Cases Malig Symptomatic </li></ul><ul><li>Shushan 300 4 (1.3%) 100% </li></ul><ul><li>Ben Aire 430 13 (3.0%) --- </li></ul><ul><li>Martin-Ondarza 1492 27 (1.8%) 74% </li></ul><ul><li>1. Shushan A. Gynecol Obstet Invest. 2004;58(4):212-5. </li></ul><ul><li>2. Ben-Aire A. Eur J Obstet Gynecol Reprod Biol. 2004 Aug 0:115(2):206-10. </li></ul><ul><li>3. Martin-Ondarza C. Eur J Gynaecol Oncol. 2005;26(1):55-8. </li></ul>
    • 43. Endometrial Polyps Containing Atypical Hyperplasia or Cancer In Polyps In Non Polyp Area CA Microinvasive AHP (29 pts) 19 pts (66%) 9 pts (31%) 4 pts CA (8 pts) 7 pts (88%) − 3 pts Mittal K et al. Int J Gynecol Pathol. 2008; 27:45-8
    • 44. Depth of Invasion & Grade of Endometrial Cancer in Patients with AEH & AEH-CA <ul><li>AEH None <50% >50% </li></ul><ul><li>Grade 1 8 6 1 </li></ul><ul><li>Grade 2 0 1 1 </li></ul><ul><li>Grade 3 0 0 1 </li></ul><ul><li>AEH-CA </li></ul><ul><li>Grade 1 6 3 3 </li></ul><ul><li>Grade 2 0 4 1 </li></ul><ul><li>Grade 3 1 0 0 </li></ul>
    • 45. Conclusion <ul><li>Unopposed estrogen puts patients at risk </li></ul><ul><li>A common problem for hysteroscopists </li></ul><ul><li>Atypical hyperplasia is usually best treated by surgery </li></ul><ul><li>Atypical hyperplasia & cancer in polyps is usually also found in surrounding endometrium </li></ul>
    • 46.  
    • 47.  
    • 48. Thank You For Your Attention © 2003 Michael Paulson

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