This document provides guidelines for the management of endometrial hyperplasia. It defines endometrial hyperplasia and discusses risk factors, classification systems, diagnostic workup, natural history, and treatment options. The main treatment approaches are progestogen therapy, typically using a levonorgestrel-releasing IUS, and hysterectomy for cases of progression or failure to respond to medical treatment. Hysterectomy is generally not recommended as first-line treatment due to the high rate of regression with progestogen therapy in most women.
Embryo implantation in the region of a previous caesarean section scar is a rare but potentially catastrophic complication of a previous cesarean birth.
Invited Lecture delivered by Dr Sujoy Dasgupta in a CME, sponsored by Serum Institute of India Pvt Ltd in the Convocation Ceremony of Interns at Sagor Dutta Medical College
Uterus Transplantation Utx (obstetric and gynecology) D.A.B.M
Is the surgical procedure whereby a healthy uterus is transplanted into an organism of which the uterus is absent or diseased.
As part of normal mammalian sexual reproduction, a diseased or absent uterus does not allow normal embryonic implantation, effectively rendering the female infertile.
This phenomenon is known as Absolute Uterine Factor Infertility (AUFI).
Uterine transplant is a potential treatment for this form of infertility.
Uterus is a dynamic, complex organ. It is hugely blood-flow dependent.
More than 116,000 Number of men, women and children on the national transplant waiting list as of August 2017.
33,611 transplants were performed in 2016.
20 people die each day waiting for a transplant.
every 10 minutes another person is added to the waiting list.
Embryo implantation in the region of a previous caesarean section scar is a rare but potentially catastrophic complication of a previous cesarean birth.
Invited Lecture delivered by Dr Sujoy Dasgupta in a CME, sponsored by Serum Institute of India Pvt Ltd in the Convocation Ceremony of Interns at Sagor Dutta Medical College
Uterus Transplantation Utx (obstetric and gynecology) D.A.B.M
Is the surgical procedure whereby a healthy uterus is transplanted into an organism of which the uterus is absent or diseased.
As part of normal mammalian sexual reproduction, a diseased or absent uterus does not allow normal embryonic implantation, effectively rendering the female infertile.
This phenomenon is known as Absolute Uterine Factor Infertility (AUFI).
Uterine transplant is a potential treatment for this form of infertility.
Uterus is a dynamic, complex organ. It is hugely blood-flow dependent.
More than 116,000 Number of men, women and children on the national transplant waiting list as of August 2017.
33,611 transplants were performed in 2016.
20 people die each day waiting for a transplant.
every 10 minutes another person is added to the waiting list.
In cases of Nulliparous prolapse or even patients deserving child bearing uterus preserving surgeries are done.
Recently even for prolapse if women want to preserve uterus for variety of reasons ,with newer minimally invasive methods it is now gaining popularity.Larger studies and longer followup is required.
Management of Endometrioma- Current UpdateSujoy Dasgupta
Invited Lecture by Dr Sujoy Dasgupta in the Webinar on "Update on Endometriosis" organized by AICC RCOG (All India Coordinating Committee of Royal College of Obstetricians and Gynaecologists) East Zone, held in December, 2021
interest in stem cells is raising in different field of medicine. The question is : is it successful in Gynecology or it is still too early to say that. The present talk may help to explore this .
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)Lifecare Centre
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)
MODERATOR
DR SHARDA JAIN
DR JYOTI AGARWAL
DR ILA GUPTA
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
Ovarian Hyperstimulation Syndrome(OHSS), is a Rare iatrogenic complication of ovarian stimulation occurring during the luteal phase or during early pregnancy where a patient's ovaries become swollen and fluid builds up around her abdomen
Selective progesterone receptor modulators (SPRMs)
Stimulates growth :
Up regulating epidermal growth factor (EGF)
Down regulating tumour necrosis factor-alpha expression
Inhibits growth :
Downregulating insulin-like growth factor-1 (IGF-1) expression
NO EFFECT ON ESTRADIOL LEVELS
Mifepristone : 5 or 10 mg per day for 1 year
Ulipristal acetate: 5-10mg/day for 13 weeks
Pro apoptotic and anti-proliferative effects on fibroid cells
In cases of Nulliparous prolapse or even patients deserving child bearing uterus preserving surgeries are done.
Recently even for prolapse if women want to preserve uterus for variety of reasons ,with newer minimally invasive methods it is now gaining popularity.Larger studies and longer followup is required.
Management of Endometrioma- Current UpdateSujoy Dasgupta
Invited Lecture by Dr Sujoy Dasgupta in the Webinar on "Update on Endometriosis" organized by AICC RCOG (All India Coordinating Committee of Royal College of Obstetricians and Gynaecologists) East Zone, held in December, 2021
interest in stem cells is raising in different field of medicine. The question is : is it successful in Gynecology or it is still too early to say that. The present talk may help to explore this .
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)Lifecare Centre
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)
MODERATOR
DR SHARDA JAIN
DR JYOTI AGARWAL
DR ILA GUPTA
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
Ovarian Hyperstimulation Syndrome(OHSS), is a Rare iatrogenic complication of ovarian stimulation occurring during the luteal phase or during early pregnancy where a patient's ovaries become swollen and fluid builds up around her abdomen
Selective progesterone receptor modulators (SPRMs)
Stimulates growth :
Up regulating epidermal growth factor (EGF)
Down regulating tumour necrosis factor-alpha expression
Inhibits growth :
Downregulating insulin-like growth factor-1 (IGF-1) expression
NO EFFECT ON ESTRADIOL LEVELS
Mifepristone : 5 or 10 mg per day for 1 year
Ulipristal acetate: 5-10mg/day for 13 weeks
Pro apoptotic and anti-proliferative effects on fibroid cells
Management of ovarian masses e Clinical situations & recommendations Apollo Hospitals
Adenexal mass is a common clinical presentation. This clinical situation is a problem that affects women of all ages. The biggest challenge is that one should not miss out on a diagnosis of malignant ovarian tumor. An ovarian mass or cyst that raises the suspicion of malignancy is a common dilemma in a gynecological practice. In the United States, a woman has a 5-10% lifetime risk of undergoing surgery for a suspected ovarian neoplasm and an estimated 13e21% chance of this turning into a diagnosis of ovarian cancer. Most of the adnexal masses are benign but the first responsibility of the treating gynecologist is to exclude malignancy. Management decisions often are influenced by the age and family history and presentation of the patient.
Borderline ovarian malignancy, also known as borderline ovarian tumor or ovarian tumors of low malignant potential (LMP), is a distinct category of ovarian tumors that fall between benign and malignant tumors in terms of their behavior and potential for spreading.
Characteristics and Diagnosis:
Histological Features: Borderline ovarian tumors have certain cellular abnormalities that suggest malignancy but lack the invasive qualities seen in fully malignant tumors.
Age Group: They often occur in women of childbearing age, and their incidence tends to be highest in women in their 30s and 40s.
Clinical Presentation: Borderline ovarian tumors may be asymptomatic or present with nonspecific symptoms like abdominal pain, bloating, or changes in urinary habits.
Imaging and Biopsy: Diagnosis typically involves imaging studies, such as ultrasound, and a biopsy or surgical removal of the tumor for a pathological examination to confirm its borderline nature.
Treatment and Prognosis:
Surgical Approach: The primary treatment for borderline ovarian tumors is usually surgery, which involves removing the affected ovary or ovaries. The goal is to perform a comprehensive surgical staging to assess the extent of disease without removing both ovaries unless necessary.
Chemotherapy: Unlike malignant ovarian tumors, borderline tumors are less likely to spread beyond the ovaries. In cases where there is evidence of disease spread or in certain high-risk situations, chemotherapy may be considered.
Prognosis: The overall prognosis for women with borderline ovarian tumors is generally favorable. The majority of patients have an excellent long-term survival rate, especially if the tumor is confined to the ovaries at the time of diagnosis.
Follow-Up and Recurrence:
Regular Monitoring: Given the potential for recurrence, patients with borderline ovarian tumors often undergo regular follow-up examinations, including imaging studies and blood tests (such as CA-125), to monitor for any signs of disease recurrence.
Reproductive Considerations:
Fertility-Sparing Options: For women who wish to preserve fertility, there may be options for fertility-sparing surgery in carefully selected cases where the tumor is unilateral, well-staged, and the patient desires future childbearing.
Conclusion:
Borderline ovarian malignancy represents a unique category in ovarian tumors, requiring a multidisciplinary approach involving gynecologic oncologists, pathologists, and other healthcare professionals. While generally associated with a favorable prognosis, individual cases can vary, and personalized treatment plans are essential for optimal outcomes. Regular follow-up and clear communication between patients and healthcare providers play a crucial role in managing and monitoring borderline ovarian tumors.
gestational trophoblastic disease is discussed in its basic knowledge update to enable undergraduate students help understand the disease, diagnose and treat GTD. also enables to follow and detect complications and malignant transformation of molar pregnancy. single drug and multiple dose chemotherapy depending on staging of the disease and related complications & side effects discussed.
Endometrial cancer in a woman undergoing hysteroscopy for recurrent ivf failurecare women scentre
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Francesca Gottschalk - How can education support child empowerment.pptxEduSkills OECD
Francesca Gottschalk from the OECD’s Centre for Educational Research and Innovation presents at the Ask an Expert Webinar: How can education support child empowerment?
Executive Directors Chat Leveraging AI for Diversity, Equity, and InclusionTechSoup
Let’s explore the intersection of technology and equity in the final session of our DEI series. Discover how AI tools, like ChatGPT, can be used to support and enhance your nonprofit's DEI initiatives. Participants will gain insights into practical AI applications and get tips for leveraging technology to advance their DEI goals.
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
International FDP on Fundamentals of Research in Social Sciences
at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar Kanvaria
Safalta Digital marketing institute in Noida, provide complete applications that encompass a huge range of virtual advertising and marketing additives, which includes search engine optimization, virtual communication advertising, pay-per-click on marketing, content material advertising, internet analytics, and greater. These university courses are designed for students who possess a comprehensive understanding of virtual marketing strategies and attributes.Safalta Digital Marketing Institute in Noida is a first choice for young individuals or students who are looking to start their careers in the field of digital advertising. The institute gives specialized courses designed and certification.
for beginners, providing thorough training in areas such as SEO, digital communication marketing, and PPC training in Noida. After finishing the program, students receive the certifications recognised by top different universitie, setting a strong foundation for a successful career in digital marketing.
A workshop hosted by the South African Journal of Science aimed at postgraduate students and early career researchers with little or no experience in writing and publishing journal articles.
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
management of endometrial_hyperplasia 2016_ small one water mark.pdf
1. Dr Muhamed Al Bellehy MD
Dr Muhamed Al Bellehy MD
Management of Endometrial Hyperplasia (RCOG 2016)
Algorithm for the management of endometrial hyperplasia
Abbreviations:
AH atypical
hyperplasia;
AUB abnormal uterine
bleeding;
BMI body mass index;
BSO bilateral salpingo-
oophorectomy;
EB endometrial biopsy;
EC endometrial cancer;
EH endometrial
hyperplasia without
atypia;
HRT hormone
replacement therapy;
LNG-IUS
levonorgestrel-
releasing intrauterine
system.
Notes:
a. Risk factors include obesity, HRT regimens, tamoxifen therapy and anovulation.
b. Consider ovarian conservation according to age, menopausal status and patient preferences. In addition to nonregression of
EH or persistence of AUB symptoms following nonsurgical treatments, a total hysterectomy may be indicated where there are
(i) adverse effects associated with medical treatment, (ii) concerns over compliance with treatment or follow-up, or (iii) patient
2. Dr Muhamed Al Bellehy MD
Dr Muhamed Al Bellehy MD
preferences e.g. high levels of anxiety.
c. The follow-up interval should be customised to each woman, taking into account baseline risk factors, associated symptoms
and response to treatment.
d. Regression – nonhyperplastic or nonmalignant endometrial sample or nondiagnostic endometrial sample from an
appropriately placed endometrial sampling device; persistence – no regression or progression of initial EH subtype after 3 or
more months; progression – development of AH or EC; relapse – recurrence of EH or AH after one or more negative EB
result(s).
e. In general, advise continuation of LNG-IUS for duration of its 5-year use, especially if EH associated with AUB or other baseline
risk factorsa and no adverse effects.
f. Start medical management if EH not treated initially. The decision to persist with medical management should be taken after
careful consideration and thorough discussion with the woman regarding the risks and benefits of prolonged medical treatment
compared with total hysterectomy ± BSO. Persistence beyond 12 months is associated with a significant risk of underlying
malignancy and a high risk of failure to regress such that a total hysterectomy ± BSO should be recommended.
g. At discharge, inform the woman of her estimated individual risk of recurrence, of the need to continue any risk-reducing
strategies and to present for an urgent review if any further episodes of AUB.
h. Review the appropriateness of ongoing endometrial surveillance, continuation of medical management or total hysterectomy
± BSO based on factors such as baseline risk factors including BMI, AUB symptoms, fertility requirements, compliance with
treatment and follow-up, medical comorbidities and risk–benefit ratio for total hysterectomy ± BSO.
Endometrial hyperplasia (EH) is defined
o as irregular proliferation of the endometrial glands with an increase in the gland to stroma ratio when
compared with proliferative endometrium.
Endometrial cancer is the most common gynaecological malignancy in the Western world and endometrial
hyperplasia is its precursor.
The most common presentation of endometrial hyperplasia is abnormal uterine bleeding (AUB). This includes
o heavy menstrual bleeding (HMB),
o intermenstrual bleeding,
o irregular bleeding,
o unscheduled bleeding on hormone replacement therapy (HRT)
o postmenopausal bleeding (PMB).
risk factors for endometrial hyperplasia?
the main risk factor unopposed estrogen
Known risk factors that reflect this aetiology:
o increased BMI excessive peripheral conversion of androgens in adipose tissue to estrogen
Obesity (a major risk factor)
advise women to lose weight_ bariatric surgery may reduce this risk.
severely obese women up to 10% asymptomatic EH
o anovulation: associated with the perimenopause or PCOS
likely to regress to normal once women with PCOS resume ovulation or perimenopausal
women reach the menopause;
o estrogen-secreting ovarian tumours e.g. granulosa cell tumours (40% prevalence of EH)
o Drug-induced endometrial stimulation:
unopposed systemic estrogen HRT in women with a uterus
combined HRT regimen alone is often sufficient in inducing regression of EH without
atypia.
over-the-counter preparations that may contain high potency estrogens.
long-term tamoxifen
other factors immunosuppression and infection.
3. Dr Muhamed Al Bellehy MD
Dr Muhamed Al Bellehy MD
o As renal graft recipients
renal graft recipients + AUB a 2-fold increased incidence of eh compared with
nontransplanted controls
How should endometrial hyperplasia be classified
1994 WHO classification
o based upon complexity of the glandular architecture and presence of nuclear atypia.
o It comprised 4 categories:
(i) simple hyperplasia,
(ii) complex hyperplasia,
(iii) simple hyperplasia with atypia
(iv) complex hyperplasia with atypia.
The endometrial intraepithelial neoplasia (EIN) classification 2003
o The EIN diagnostic schema comprises 3 categories –
benign (endometrial hyperplasia),
premalignant (a diagnosis of EIN based upon 5 subjective histological criteria)
malignant (endometrial cancer) –
o this classification is not extensively used in the UK.
The revised 2014 World Health Organization (WHO) classification is recommended.
o based upon the presence of cytological atypia
hyperplasia without atypia
atypical hyperplasia.
o the complexity of architecture is no longer part of the classification.
o Dx of EIN aka atypical hyperplasia.
workup
(Endometrial tissue specimens/ Endometrial sampling)
o DX requires histological examination of the endometrial tissue.
o are obtained either by
Outpatient endometrial biopsy: miniature outpatient suction devices that blindly abrade and/or
aspirate endometrial tissue from the uterine cavity
it is convenient _ high accuracy for diagnosing endometrial cancer.
o The accuracy for hyperplasia is more modest negative result 2% have EH.
inpatient endometrial sampling, such as D & C performed under general anaesthesia.
Diagnostic hysteroscopy Direct visualization and biopsy
to facilitate or obtain an endometrial sample, where outpatient sampling fails or is
nondiagnostic
For a polyp or other focal lesion
A transvaginal ultrasound scan (TVS)
o detects an irregularity of endometrial profile or an abnormal double layer endometrial thickness
measurement perform an endometrial biopsy
o in PMB
4. Dr Muhamed Al Bellehy MD
Dr Muhamed Al Bellehy MD
when the endometrial thickness is less than the cut-off 3 mm or 4 mm probability of cancer <
1%
a larger cut-off value has been suggested for HRT or tamoxifen, whether presenting with AUB or
asymptomatic.
o in premenopausal women
TVS is less sensitive to identifying EH or Ca
for PCOS + absent withdrawal bleeds or AUB RCOG TVS endometrial thickness < 7 mm
below this cut-off EH is unlikely.
o TVS to exclude the possibility of granulosa cell tumour of the ovary.
If an ovarian cyst ovarian tumour markers serum inhibin & estradiol if a granulosa cell
tumour is suspected.
Hysteroscopy
o When
Hysteroscopy allows additional endometrial assessment that may be necessary if
abnormal bleeding persists or
if intrauterine structural abnormalities such as polyps are suspected on TVS or
endometrial biopsy
where sampling is not possible or is nondiagnostic
Directed biopsies
o Advantages
Hysteroscopy can detect focal lesions such as polyps that may be missed by
blind sampling
o outpatient sampling.
o inpatient endometrial sampling
up to 10% of endometrial pathology can be missed
repeated curettage should be minimised to reduce incidence of
Asherman’s syndrome.
Diagnostic hysteroscopy can be conducted in the outpatient setting without the need for
anaesthesia
o The accuracy of hysteroscopy in diagnosing cancer and hyperplasia in women with AUB
hysteroscopy is more accurate in detecting than excluding endometrial disease and has a higher
accuracy for endometrial cancer than endometrial hyperplasia.
CT, diffusion-weighted MRI or biomarkers
insufficient evidence evaluating them as aids in the management of endometrial hyperplasia
their use is not routinely recommended.
CT or MRI
o CT scan
a preoperative CT scan for AH or grade 1 endometrial cancer could alter management in 4.3%.
not be routinely recommended.
o Diffusion-weighted MRI
(need more evidence) for
it may help in identifying women with invasive cancer
future potential to DX endometrial hyperplasia & other endometrial lesions.
biomarkers yet none of them predicts disease or prognosis accurately enough to be clinically useful.
5. Dr Muhamed Al Bellehy MD
Dr Muhamed Al Bellehy MD
o phosphatase and tensin homolog (PTEN), perhaps in combination with B-cell lymphoma 2 (BCL-
2) and BCL-2-like protein 4 (BAX),.
the natural history of hyperplasia without atypia and its risk for progression to cancer.
regression to normal
endometrium
persistent
EH
Progressed
simple
hyperplasia
74-81% 17- 18% 9% progressed to AH after 24 weeks of follow-
up
1% progressed to endometrial cancer after 12
years
complex
hyperplasia
75-79% 21-25% 3% progressed to endometrial cancer
RCOG
observation alone majority
will regress
Progestogens vs observation
alone higher disease
regression
cumulative long-term risk for progression to
cancer is < 5% over 20 years
For AH risk of endometrial cancer is > EH _ in 4 yrs 8%,
12.4% after 9 years and to 27.5% after 19 years.
associated with a rate of concomitant carcinoma of up to 43% in women undergoing hysterectomy
Management of endometrial hyperplasia
Treatment
o the first-line medical treatment
Observation alone with follow-up endometrial biopsies
to ensure disease regression, especially when identifiable risk factors can be reversed.
Progestogen treatment is indicated in women who fail to regress following observation alone
and in symptomatic women (AUB).
Reversible risk factors should be identified and addressed.
Observation alone is expected to fail where there is no identifiable reversible risk factor
causing the endometrial hyperplasia, (limited evidence)
o women with EH + AUB symptomatic treatment
o surgical management for EH Hysterectomy
observation only vs Progestogen treatment
the first-line medical treatment
progestogens (Effect of Progestogens modify the proliferative effects of estrogen on the endometrium)
o continuous oral progestogens
should be used for women who decline the LNG-IUS
6. Dr Muhamed Al Bellehy MD
Dr Muhamed Al Bellehy MD
Cyclical progestogens should not be used because they are less effective in inducing regression
compared with continuous oral progestogens or LNG-IUS.
Such as norethisterone (NET), MPA & megestrol acetate.
significant adverse effects & norethisterone at a high dose has similar contraindications to COCs.
disease regression rates were similar for all drugs.
MPA (10–20 mg/day) & NET (10–15 mg/day).
o local intrauterine [LNG-IUS] progestogens.
the first-line medical treatment because compared with oral progestogens it has
a higher disease regression rate less likely to need hysterectomy
RCT LNG-IUS VS oral continuous medroxyprogesterone
Regression rate After 3 months Regression rate After 6 months
LNG-IUS 84% 100%
oral MPA 50% 64%
recommended as first-line treatment for HMB.--> a more favourable bleeding profile _
a higher concentration of levonorgestrel at the level of the endometrium
provide effective contraception
minimises systemic absorption of hormones adverse effects more compliance
Duration of treatment & follow-up
duration of treatment
duration of treatment for oral progestogens For LNG-IUS
6 months up to 5 years
Cessation after 3–6 months of therapy is commonly practiced,
o may relate to fears over potential adverse effects from chronic
administration of high-dose and compliance issues
Endometrial surveillance By outpatient endometrial biopsy.
o review schedules take into account presence of AUB
Relapse
higher risk of disease relapse, persistence or progression, BMI ≥ 35 or treated with oral progestogens
relapse of complex EH following in 12.7% of treated with LNG-IUS vs 28.3% of treated with oral progestogens.
over a median follow-up of 67 months
for LNG-IUS
o only 3% of women with a BMI < 35 relapsed during follow-up.
o 33% of women with a BMI ≥ 35.
surgical management for EH Hysterectomy
Hysterectomy should not be considered as a first-line treatment
o because progestogen therapy induces histological and symptomatic remission in the majority of women.
Hysterectomy is indicated in women not wanting to preserve their fertility when (any of)
o progression to AH occurs during follow-up, or
o no histological regression of EH despite 12 months of treatment (then high cancer risk).
small increase in overall regression rates of EH beyond 12 months of treatment
7. Dr Muhamed Al Bellehy MD
Dr Muhamed Al Bellehy MD
o relapse after completing progestogen treatment
o persistence of bleeding symptoms,
o woman declines to undergo endometrial surveillance or comply with medical treatment.
Type ?
o women with EH +
Postmenopausal women total hysterectomy + BSO.
For premenopausal women total hysterectomy ± BSO
decision to remove ovaries should be individualised + consider bilateral salpingectomy (may
reduce risk of a ovarian malignancy).
approach A laparoscopic approach is preferable to an abdominal approach
should be avoided
o Supra cervical hysterectomy to ensure that all premalignant disease is eliminated.
o Endometrial ablation is
because
complete & persistent endometrial destruction cannot be ensured_ and regeneration of
ablated endometrial tissue may occur
intrauterine adhesion formation may preclude endometrial histological surveillance.
For AH
Lymphadenectomy should not be routinely performed
o because this would result in unnecessary surgical risk for the majority of women.
When endometrial cancer found during hysterectomy was usually early stage with low
risk of lymphovascular disease
intraoperative frozen section of the endometrium no benefit_ not a reliable indicator of final pathology.
What type of / method chosen for hysterectomy For women with AH
o A laparoscopic approach is preferable to an abdominal approach
as it is associated with a shorter hospital stay, less postoperative pain and quicker recovery.
Due to the risks of disseminating malignancy, morcellation of the uterus should be avoided.
allow staging _ some evidence
o in all peri- and postmenopausal total hysterectomy + BSO. Due to the risk of underlying
malignancy
o For premenopausal total hysterectomy + individualized decision to remove ovaries + bilateral
salpingectomy
bilateral salpingectomy should be considered as this may risk of future ovarian
malignancy.
the risks of surgical menopause have to be balanced against the risk of underlying cancer
and the need for further surgery to remove the ovaries.
Premenopausal women who undergo total hysterectomy + BSO consider estrogen
replacement, in absence of contraindications to its use, until the age of the natural
menopause
BSO is associated with increased mortality in women < 50 years who had hysterectomy for
benign disease
Fertility-sparing therapy in AH
counselling
o outcome for fertility one-quarter of women achieving a live birth
o risks of
underlying malignancy
8. Dr Muhamed Al Bellehy MD
Dr Muhamed Al Bellehy MD
progression to endometrial cancer.
risk of relapse is uncertain
pretreatment work-up
o to rule out
invasive endometrial cancer
EB by hysteroscopy to minimise the chance of missing cancer
or co-existing ovarian cancer.
o MRI, CT, TVS and serum CA125 to rule out endometrial cancer or ovarian cancer.
treatment
o First-line treatment LNG-IUS
o second-best alternative oral progestogens
o Once fertility is no longer required hysterectomy should be offered (d2 high risk of disease relapse).
Other hormonal therapies as a fertility-sparing treatment (The optimal treatment regimen is also ill-defined)
o oral progestogens
o LNG-IUS
o aromatase inhibitors
o gonadotrophin-releasing hormone agonists
Followed up after fertility-sparing treatment (see investigations) +
o TVS:
1. assessment of endometrial thickness
unlikely to be useful in view of
o the absence of validated reference ranges
o the difficulty in obtaining accurate measurements with LNG-IUS in place.
Outcome of fertility preservation
o Failure to regress a worrying sign for underlying endometrial cancer.
o relapse
The risk of relapse is especially high in the first 2 years from diagnosis.
If relapse occurs:
hysterectomy should be strongly recommended
o it is often associated with endometrial cancer at hysterectomy specimen.
If this is not possible or declined further cycle of progestogen treatment.
When to start fertility treatment? Disease regression (of AH or well-differentiated endometrial cancer)
should on at least one endometrial sample before women attempt to conceive.
initiate ART immediately following cessation of progestogen treatment
o compared to natural conception as live birth rate is higher and it may prevent relapse
Immediate ART avoids a prolonged interval of time without progestogen treatment
o LBR_ 26.3%
hyperplastic endometrium may predispose to infertility.
A hysterectomy should be recommended to women with AH once fertility is no longer required because of the
high relapse rate of disease and the potential for disease progression.
HRT and endometrial hyperplasia
Prevention
9. Dr Muhamed Al Bellehy MD
Dr Muhamed Al Bellehy MD
o All women taking HRT should be encouraged to report any unscheduled vaginal bleeding promptly.
o Systemic estrogen-only HRT should not be used in women with a uterus.
Women with endometrial hyperplasia + HRT _ who wish to continue HRT
o For sequential HRT preparation offer change to continuous progestogen intake _ LNG-IUS or a
continuous combined HRT
prevalence of EH compared with sequential regimens (not statistically significant)
Stopping sequential combined HRT may be sufficient to induce regression of endometrial
hyperplasia
o For continuous combined HRT
Consider LNG-IUS as a source of progestogen replacement.
Management of endometrial hyperplasia be managed in women on adjuvant treatment for breast cancer
Risk of developing endometrial hyperplasia on adjuvant treatment for breast cancer
Tamoxifen
o a SERM that
inhibits proliferation of
breast cancer by
competitive
antagonism at E
receptors.
it has a partial agonist
action on other
tissues, including
vagina and uterus
may promote development fibroids,
endometrial polyps & EH & risk of endometrial
cancer
Should women on tamoxifen be
treated with prophylactic
progestogen therapy
Some evidence LNG-IUS prevents
polyp formation & reduces
incidence of EH
Safety of LNG-IUS on breast cancer
recurrence risk remains uncertain
so its routine use cannot be
recommended.
risk increases with both dose and duration of
treatment.
Age
varies between pre- and postmenopausal
women.
o risk of endometrial cancer was not
statistically significant in women
aged ≤ 49 years and a statistically
significant in women aged ≥ 50 years
Management of women who develop EH while on
tamoxifen treatment
need for tamoxifen should be reassessed
management should be according to the
histological classification
aromatase inhibitors
(such as anastrozole,
exemestane and
letrozole)
Does not increase risk of EH and cancer or
vaginal bleeding.
have a similar regressing effect to tamoxifen
explored as treatment for EH in small
observational studies
.Management of endometrial hyperplasia confined to an endometrial polyp
Complete removal of the uterine polyp(s) +endometrial sample / biopsy + histological analysis from
background endometrium_ even if the endometrium looks healthy on hysteroscopy
o Concurrent endometrial hyperplasia in a polyp and the background endometrium 52%.
slightly more likely for Women with AH in a polyp than those with hyperplasia without atypia
Subsequent management should be according to the histological classification of endometrial hyperplasia.
o atypia may be restricted to foci within the polyp + In absence of background EH.
10. Dr Muhamed Al Bellehy MD
Dr Muhamed Al Bellehy MD
removal of the polyp may be curative (very little evidence).