Diagnostic & Operative Hysteroscopy in Endometrial Hyperplasia Franklin D. Loffer. M.D. Associate Clinical Professor – Uni...
Endometrial Hyperplasia <ul><li>An increase in the number of endometrial </li></ul><ul><li>glands  </li></ul><ul><li>Usual...
 
 
 
Endometrial Hyperplasia <ul><li>An increase in the number of endometrial  </li></ul><ul><li>glands </li></ul><ul><li>Usual...
Endometrial Hyperplasia Related to Unopposed Estrogen Stimulation <ul><li>Annovulation (PCO) </li></ul><ul><li>Increasing ...
Endometrial Hyperplasia <ul><li>An increase in the number of endometrial </li></ul><ul><li>glands </li></ul><ul><li>Usuall...
Types of Endometrial Hyperplasia <ul><li>Glands Stroma </li></ul><ul><li>Simple increased abundant </li></ul><ul><li>Compl...
Risks of Hyperplasia Progressing to Endometrial Cancer <ul><li>Simple w/o atypia ~1% </li></ul><ul><li>Complex w/o atypia ...
Endometrial Hyperplasia Presents As: <ul><li>Menorrhagia </li></ul><ul><li>Metorrhagia </li></ul><ul><li>Postmenopausal bl...
Methods of Working Up Abnormal Uterine Bleeding
Diagnostic Indications for Hysteroscopy <ul><li>Abnormal Bleeding </li></ul><ul><li>Questionable Ultrasound </li></ul><ul>...
Surgical Indications for Hysteroscopy <ul><li>Directed Biopsies </li></ul><ul><li>Polypectomy </li></ul><ul><li>Submucosal...
Other Methods of Endometrial Sampling <ul><li>Endometrial Biopsy </li></ul><ul><li>Aspiration Curettage </li></ul><ul><li>...
Adequacy of Specimens From Pipelle Compared to Novak Endometrial Biopsies*
Sensitivity of Pipelle Sampling in Detection of Known Endometrial Cancer*
Comparison of Surface Area Sampled by Pipelle Biopsy vs Aspiration Curettage*
Adequacy of D&C in Sampling  Endometrium (60 pts)*
Adequacy of D&C in Emptying the Uterine Cavity (124 pts)*
Are Blind Biopsy Techniques Accurate Diagnostic Tools? <ul><li>Reason: </li></ul><ul><li>It misses large areas of endometr...
Is The D&C Therapeutic? Conclusion: No Reason: <ul><li>Fails to diagnose or remove polyps  or fibroids </li></ul><ul><li>N...
Reduction in Blood Loss After D&C in 22 Patients Hayes, et al, B J ObGyn, 1977
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...
Comparison of Sonohysterography in Patients With Abnormal Uterine Bleeding (N=113) <ul><li>Less painful (p=<0.0001) </li><...
How Good Is A Hysteroscopic View Alone? (4064 Patients) Hyperplasia (613 pts)   Endometrial CA (105 pts) Sensitivity 56.3%...
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  *Gim...
D&C Less Accurate Than Hysteroscopy* (60/342 cases 18%) Polyps 17 Fibroids 22 Benign endometrium 14 Atypical   5 Miscellan...
D&C More Accurate Than  Hysteroscopy* (11/342 cases 3%) Anovulatory  4 pts Atrophic  3 pts Endometritis  2 pts Hyperplasti...
 
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 ...
Evaluating Causes of AUB <ul><li>Hysteroscopy for: </li></ul><ul><li>Biopsying small lesions </li></ul><ul><li>Identifying...
Hysteroscopy With Tissue Sampling vs D&C – Sensitivity, Specificity and Predictive Value H/S   D&C Sensitivity  98%    65%...
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%) > 5...
Non-Office Diagnostic Hysteroscopy <50 y/o   >50 y/o (N=9)  (N=14) Cervical Stenosis  4  1 Vaginal Stenosis  0  6 Heavy Bl...
Significance of Hyperplasia With and Without Atypia
Untreated Atypical Endometrial Hyperplasia (mean 13.4 years) Regressed   29 pts    60% Persisted  8 pts  17% Progressed  1...
Risk of Carcinoma When Biopsy is Atypical Hyperplasia At hysterectomy 36 of 78 (46.2%) cases had invasive endometrial carc...
Risk of Carcinoma When Pathology Report for Biopsy is Atypical Hyperplasia Path Report # Pts # CA AEH 48 18 37.5% AEH – CA...
Polypoid Endometrium  is not the same as Endometrial Polyp Hysteroscopic Polypectomy
When To Hysteroscope <ul><ul><li>A thickened stripe and a negative endometrial biopsy give a presumptive diagnosis of an e...
Endometrial Cancer in Polyps <ul><li># Cases   Malig Symptomatic </li></ul><ul><li>Shushan  300 4 (1.3%) 100% </li></ul><u...
Endometrial Polyps Containing Atypical Hyperplasia or Cancer In Polyps   In Non Polyp Area   CA   Microinvasive AHP (29 pt...
Depth of Invasion & Grade of Endometrial Cancer in Patients with AEH & AEH-CA <ul><li>AEH   None   <50%   >50% </li></ul><...
Conclusion <ul><li>Unopposed estrogen puts patients at risk </li></ul><ul><li>A common problem for hysteroscopists </li></...
 
 
Thank You For Your Attention © 2003  Michael Paulson
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  • Indonesia Hyperplasia

    1. 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. 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>
    3. 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>
    4. 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>
    5. 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>
    6. 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>
    7. 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>
    8. 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>
    9. 12. Methods of Working Up Abnormal Uterine Bleeding
    10. 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>.
    11. 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>.
    12. 15. Other Methods of Endometrial Sampling <ul><li>Endometrial Biopsy </li></ul><ul><li>Aspiration Curettage </li></ul><ul><li>D & C </li></ul>
    13. 16. Adequacy of Specimens From Pipelle Compared to Novak Endometrial Biopsies*
    14. 17. Sensitivity of Pipelle Sampling in Detection of Known Endometrial Cancer*
    15. 18. Comparison of Surface Area Sampled by Pipelle Biopsy vs Aspiration Curettage*
    16. 19. Adequacy of D&C in Sampling Endometrium (60 pts)*
    17. 20. Adequacy of D&C in Emptying the Uterine Cavity (124 pts)*
    18. 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
    19. 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
    20. 23. Reduction in Blood Loss After D&C in 22 Patients Hayes, et al, B J ObGyn, 1977
    21. 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
    22. 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
    23. 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
    24. 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
    25. 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
    26. 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
    27. 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
    28. 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>
    29. 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
    30. 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
    31. 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
    32. 36. Significance of Hyperplasia With and Without Atypia
    33. 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
    34. 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
    35. 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
    36. 40. Polypoid Endometrium is not the same as Endometrial Polyp Hysteroscopic Polypectomy
    37. 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>
    38. 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>
    39. 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
    40. 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>
    41. 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>
    42. 48. Thank You For Your Attention © 2003 Michael Paulson

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