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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
      • An increase in the number of endometrial
      • glands
      • Usually associated with unopposed estrogen
      • Varying types - simple w/wo atypia
      • - complex w/wo atypia
    • 3.  
    • 4.  
    • 5.  
    • 6. Endometrial Hyperplasia
      • An increase in the number of endometrial
      • glands
      • Usually associated with unopposed estrogen
      • Varying types - simple w/wo atypia
      • - complex w/wo atypia
    • 7. Endometrial Hyperplasia Related to Unopposed Estrogen Stimulation
      • Annovulation (PCO)
      • Increasing age
      • Estrogen replacement therapy
      • Obesity
    • 8. Endometrial Hyperplasia
      • An increase in the number of endometrial
      • glands
      • Usually associated with unopposed estrogen
      • Varying types - simple w/wo atypia
      • - complex w/wo atypia
    • 9. Types of Endometrial Hyperplasia
      • Glands Stroma
      • Simple increased abundant
      • Complex increased little
    • 10. Risks of Hyperplasia Progressing to Endometrial Cancer
      • Simple w/o atypia ~1%
      • Complex w/o atypia ~5%
      • Simple with atypia ~10%
      • Complex with atypia ~25%
    • 11. Endometrial Hyperplasia Presents As:
      • Menorrhagia
      • Metorrhagia
      • Postmenopausal bleeding
      • Thickened Stripe
    • 12. Methods of Working Up Abnormal Uterine Bleeding
    • 13. Diagnostic Indications for Hysteroscopy
      • Abnormal Bleeding
      • Questionable Ultrasound
      • Abnormal HSG
      • Infertility
      • Pregnancy wastage
      .
    • 14. Surgical Indications for Hysteroscopy
      • Directed Biopsies
      • Polypectomy
      • Submucosal Myomectomy
      • Transection of Septum
      • Adhesiolysis
      • Endometrial Ablation
      • Sterilization
      .
    • 15. Other Methods of Endometrial Sampling
      • Endometrial Biopsy
      • Aspiration Curettage
      • D & C
    • 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?
      • Reason:
      • It misses large areas of endometrium
      • Does not give selected tissue to pathologist
      • Frequently misses polyps and fibroids
      Conclusion: No
    • 22. Is The D&C Therapeutic? Conclusion: No Reason:
      • Fails to diagnose or remove polyps or fibroids
      • No proven decrease in blood loss*
      *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)
      • Less painful (p=<0.0001)
      • Equally accurate (p=0.18)
      • More accurate for hyperplasia
      • Look beyond cavity
      • More readily available
      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
      • Hysteroscopy for:
      • Biopsying small lesions
      • Identifying polyps and fibroids
      Aspiration curettage for :
      • Obtaining large amounts of tissue
    • 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
        • A thickened stripe and a negative endometrial biopsy give a presumptive diagnosis of an endometrial polyp.
    • 42. Endometrial Cancer in Polyps
      • # Cases Malig Symptomatic
      • Shushan 300 4 (1.3%) 100%
      • Ben Aire 430 13 (3.0%) ---
      • Martin-Ondarza 1492 27 (1.8%) 74%
      • 1. Shushan A. Gynecol Obstet Invest. 2004;58(4):212-5.
      • 2. Ben-Aire A. Eur J Obstet Gynecol Reprod Biol. 2004 Aug 0:115(2):206-10.
      • 3. Martin-Ondarza C. Eur J Gynaecol Oncol. 2005;26(1):55-8.
    • 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
      • AEH None <50% >50%
      • Grade 1 8 6 1
      • Grade 2 0 1 1
      • Grade 3 0 0 1
      • AEH-CA
      • Grade 1 6 3 3
      • Grade 2 0 4 1
      • Grade 3 1 0 0
    • 45. Conclusion
      • Unopposed estrogen puts patients at risk
      • A common problem for hysteroscopists
      • Atypical hyperplasia is usually best treated by surgery
      • Atypical hyperplasia & cancer in polyps is usually also found in surrounding endometrium
    • 46.  
    • 47.  
    • 48. Thank You For Your Attention © 2003 Michael Paulson