Irregular proliferation of endometrial glands compared to endometrial stroma Increased glands to stroma ratio

1. Endometrial Hyperplasia
Kavya Liyanage

2. What is Endometrial Hyperplasia?
Irregular proliferation of endometrial
glands compared to endometrial stroma
Increased glands to stroma ratio

3. Why?
Usually happens due to unopposed exposure to estrogen
during peri-menopausal period
• Endogenous
• Exogenous

4. Endometrial
Hyperplasia
is
Premalignant

5. Risk factors
Obesity
Increased peripheral
conversion of
androgens into
estrogen in adipose
tissue
Anovulation
In perimenopause
In PCOS
Estrogen
secreting tumors
Granulosa cell tumor
Drug induced
Hormone replacement
therapy (HRT)
Long term tamoxifen
therapy

6. Common among
Women of 45 -55 years of age

7. Clinical presentation
Abnormal uterine bleeding (AUB)
Intermenstrual bleeding
Irregular menstrual bleeding
Post menopausal bleeding

8. ENDOMETRIAL
CARCINOMA
Until
otherwise
proven
In a
woman of
age >45
years
Abnormal
uterine
bleeding

9. Investigations
Trans vaginal ultrasound scan (TVUS)
Endometrial sampling
• Out-patient suction device (Pipelle biopsy)
• Dilatation and curettage (D&C) under anaesthesia
• Hysteroscopy and biopsy

10. Gold standard in diagnosis
Hysteroscopy and biopsy

11. TVUS possible findings
Endometrial polyps
Increased endometrial
thickness
Submucous fibroids
Retained IUCD
Ovarian masses

12. Increased endometrial thickness on TVUS
<4mm
• Follow up scan in 3
months
>4mm
• Hysteroscopy and biopsy

13. Indications for endometrial biopsy
• Risk factors for endometrial carcinoma
• Bleeding not responding to medical
management
• PCOS
• Endometrial polyp or focal thickening
detected on TVUS
Women under 45 years of age if
• Persistent AUB
• Endometrial polyp or focal thickening
detected on TVUS
Women over 45 years of age (all)

14. Which biopsy?
Office Endometrial Biopsy (Pipelle)
• Uniform endometrial thickness
on TVUS
Hysteroscopy and Biopsy
• Endometrial polyp or focal
thickening detected on TVUS
(structural abnormalities)
• Persistent AUB

15. WHO Classification
Endometrial
hyperplasia
without atypia
Endometrial
hyperplasia with
atypia

16. Endometrial Hyperplasia Without Atypia
Risk of
becoming
malignant is
<5% over 20
years

17. Management Plan
Expectant management & Follow up
• Correction of reversible risk factors
Medical management & Follow up
• Persistent symptoms
• No regression with 6 months of observation
Surgical management
• Not first line
• For women with no fertility wishes
• Total hysterectomy

18. Expectant management
Reduce weight if obese
Stop HRT

19. Medical management
Continuous oral progesterone - For women decline with LNG-IUS
Oral medroxyprogesterone acetate
10-20 mg / day
Oral norethisterone 10-15 mg per
day
1st line – Intrauterine progesterone
(Levenogestrel Intrauterine System LNG-IUS)

20. Progesterone
Reduce symptoms
Causes histological regression

21. Follow up
Follow up with biopsies 6
monthly
• At least two consecutive negative
biopsies to stop follow up
• If obesity like risk factors are
present, annual follow up
Keep LNG-IUS at least for 6
months or up to 5 years

22. Surgical management if
Progression into
atypical
hyperplasia while
on follow up
No histological
regression with 12
months of
treatment
Relapse after
treatment
Persistent bleeding
No compliance or
no follow up

23. Endometrial hyperplasia with atypia
Management depend on
fertility wishes of the woman

24. Women with no fertility wishes
Post menopausal
• Total hysterectomy and bilateral salphingoophoractomy
Pre menopausal
• Total hysterectomy and bilateral salphingectomy
• Oophorectomy is optional

25. Women with fertility wishes
Investigate to rule out
• Invasive endometrial carcinoma
• Coexisting ovarian carcinoma
Investigations
• MRI
• TVUS
• Tumor marker – serum CA 125
Medical management
with progesterone
Follow up biopsies until
surgery
• 3 monthly until 2 consecutively
negative samples
• Thereafter 6-12 monthly

26. Thank
You!