September 2003 obg management 19 endometrial hyperplasia. Endometrial hyperplasia eh is a condition in which the uterine lining is thicker than normal. Dec 03, 2018 endometrial hyperplasia refers to the thickening of the endometrium. Joint rcog, bsge and bgcs guidance for the management. It is most often diagnosed in postmenopausal women, but women at any age with unopposed estrogen from any source are at an increased risk for developing endometrial hyperplasia. Endometrial hyperplasia eh is a precancerous, nonphysiological, noninvasive proliferation of the endometrium that results in increased volume of endometrial tissue with alterations of glandular architecture shape and size and endometrial gland to stroma ratio of greater than 1. Olawaiyeg,mollybrewerh,daveborutai, jeanine villellaj,k, tom herzogl,fadiabushahinm, for the society of gynecologic oncology clinical. Standard management of endometrial cancer at diagnosis involves surgery, followed by chemotherapy andor radiation therapy. Clinical factors to consider in choosing a management approach include the following. Updates in the management of complex atypical hyperplasia. Nonatypical hyperplasiabenign endometrial hyperplasia eh without atypia is nonneoplastic and may exhibit increasing degrees of endometrial gland crowding. Pathology of the endometriumpathology of the endometrium.
Most authors agree that the risk of malignancy in endometrial polyps increases with age and that the risk of. Endometrial hyperplasia eh is a precancerous, nonphysiological, noninvasive proliferation of the endometrium that results in increased volume of endometrial tissue with alterations of glandular architecture endometrial glands to shape and size and. Treatment of simple and complex endometrial nonatypical hyperplasia with natural progesterone. Endometrial cancer is currently the commonest pelvic malignancy affecting american women, most of whom share the same pathophysiologic basis, that is, unopposed estrogenic stimulation. Minassian and mira 16 reported use of thermal balloon ablation of the endometrium in a patient with complex endometrial hyperplasia with atypia the patient initially presented with a complaint of menorrhagia and had a. Reference rcogbsge guideline on management of endometrial hyperplasia rcog 2016 feb pdf synthesized recommendation grading system for dynamed content the dynamed team systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decisionmaking see 7step evidence. Endometrial hyperplasia obstetrics, gynaecology and. Endometrial hyperplasia is a condition of excessive proliferation of the cells of the endometrium, or inner lining of the uterus. Although uncommon, both atypical hyperplasia and endometrial cancer may originate from endometrial polyps. Women who experience irregular menstrual cycles are more prone to this disease, as they do.
Progressionof endometrial hyperplasia hyperplasia without atypia rarely progresses to endometrial cancer, hyperplasia with atypia is a precancerous condition that may progress to overt malignancy. Endometrial hyperplasia micrograph showing simple endometrial hyperplasia, where the glandtostroma ratio is preserved but the glands have an irregular shape andor are dilated. Currently, the incidence of eh is indistinctly reported to be around 200,000. Endometrial hyperplasia is an overgrowth of the endometrium, the lining of the uterus, that may progress to or coexist with endometrial cancer. When is surgical management appropriate for women with endometrial hyperplasia without atypia.
Endometrial hyperplasia symptoms, causes, treatments. This includes heavy menstrual bleeding, intermenstrual bleeding, irregular bleeding, unscheduled bleeding on hormone replacement therapy hrt and postmenopausal bleeding. Prevention and treatment of endometrial hyperplasia. Making the distinction between hyperplasia and true precancerous lesions or true neoplasia has significant clinical effect because their differing cancer risks must be matched with an appropriate intervention to avoid undertreatment or overtreatment.
On the other hand, tvus scan was able to correctly identify absence of malignant changes in the endometrium. Jan 04, 2019 although endometrial hyperplasia usually is not cancerous, it is a risk factor for the development of cancer of the uterus. In some women it may progress to a cancer of the lining of the womb. Management of endometrial hyperplasia in postmenopausal women eh. The presence of atypia is the most worrisome feature as approximately 20% of those with atypical hyperplasia will have a concomitant endometrial carcinoma and a. At this magnification, complex endometrial hyperplasia with backtoback glandular crowding is evident. Endometrial pathology in the postmenopausal woman an evidence based approach to management mohamed otify msc mrcog,a, joanna fuller mrcog,a jackie ross frcog,b hizbullah shaikh,c jemma johns md mrcog d aclinical research fellow, suite 8, golden jubilee wing, kings college hospital, denmark hill, london se5 9rs, uk bconsultant gynaecologist. An update on the management of endometrial hyperplasia. Joint rcog, bsge and bgcs guidance for the management of. Endometrial hyperplasia is a precursor to the most common gynecologic cancer diagnosed in women.
Nonatypical hyperplasia benign endometrial hyperplasia eh without atypia is nonneoplastic and may exhibit increasing degrees of endometrial gland crowding. Diagnosis and management of endometrial hyperplasia. The diagnosis of endometrial hyperplasia is by biopsy or curettage of the uterine endometrium. Hysterectomy should not be considered as a firstline treatment. Biopsy refers to the removal of a sample of tissue to examine it under the microscope. The who94 schema classifies histology based on glandular complexity. Endometrial hyperplasia symptoms, causes, and treatments.
There is insufficient evidence evaluating computerised tomography ct, diffusionweighted magnetic resonance imaging mri or biomarkers as aids in the management of endometrial hyperplasia and their use is not routinely recommended. Endometrial cancer ec remains the most common malignancy of the female genital tract. Survival is gener ally defined by the stage of the disease and histology, with most patients at stage i and ii. May 10, 2015 management of endometrial hyperplasia 1. Endometrial hyperplasia eh is defined histologically as abnormal overgrowth of endometrial glands. Request pdf diagnosis and management of endometrial hyperplasia endometrial hyperplasia eh, with or without atypia, is a common gynecologic diagnosis and a known precursor of endometrial. Atypical types of endometrial hyperplasia, especially complex, increase your risk of getting cancer. Request pdf management of endometrial hyperplasia endometrial hyperplasia is a commonly seen clinical entity. The endometrium is the lining of the uterus, a hollow, muscular organ in a womans pelvis.
Endometrial cancer is a disease in which malignant cancer cells form in the tissues of the endometrium. Conservative management is recommended for endometrial hyperplasia without cytological atypia grade b recommendation. Diagnosis and management of endometrial hyperplasia journal of. The initial result of hyperestrogenism is the development of endometrial hyperplasia, which is reversible in most cases by appropriate hormonal therapy.
The value of mri in management of endometrial hyperplasia. Treatment of endometrial hyperplasia can be medical or surgical and is dependent on cause, malignant potential, fertility requirements and medical co morbidities. Depoprovera versus norethisterone acetate in management of endometrial hyperplasia without atypia. Conservative management of endometrial hyperplasia. Management of endometrial hyperplasia linkedin slideshare. It may return to normal without any treatment in some cases. Although endometrial hyperplasia occurs mostly in postmenopausal women, it can occur at much younger ages when estrogen is unopposed, as seen in polycystic ovarian syndrome and obesity some cases of endometrial hyperplasia, especially atypical, can progress to endometrial cancer, so it is important to study the two together. However, there are no studies evaluating ct use for following up of women with endometrial hyperplasia when treated conservatively. Dec 01, 2015 endometrial hyperplasia eh is a precancerous, nonphysiological, noninvasive proliferation of the endometrium that results in increased volume of endometrial tissue with alterations of glandular architecture shape and size and endometrial gland to stroma ratio of greater than 1. Endometrial pathology in the postmenopausal woman a an. Overview of endometrial hyperplasia, risk factors, classification and treatment options. In cases of protracted hormonal decline, incomplete to complete atrophy will result figure 1. In the setting of recurrent disease, secondary cytoreduction has been associated with progressionfree pfs and overall os survival. Pdf endometrial hyperplasia eh is comprised of a spectrum of changes in the endometrium ranging from a slightly disordered pattern that.
Problems in the differential diagnosis of endometrial. Although endometrial hyperplasia usually is not cancerous, it is a risk factor for the development of cancer of the uterus. Part i sgo clinical practice endometrial cancer working group, william m. Furthermore,if the endometrial thickness is 5 mm yet symptoms persist,then we agree that additional assessment with hysteroscopy andor transvaginal ultrasound should be undertaken. Endometrial hyperplasia eh, with or without atypia, is a common gynecologic diagnosis and a known precursor of endometrial carcinoma, the most common gynecologic malignancy. Introduction the endometrium lining of the uterus may develop endometrial hyperplasia eh, which includes nonneoplastic entities disordered proliferative endometrium, benign hyperplasia, simple and complex hyperplasias without atypia characterized by a proliferation of endometrial glands of irregular size and shape, and precancerous neoplasms endometrial.
Results from chronic estrogen stimulation unopposed by progesterone. Request pdf diagnosis and management of endometrial hyperplasia endometrial hyperplasia eh, with or without atypia, is a common gynecologic diagnosis. Controversies in the management of endometrial cancer. Introduction and background epidemiology endometrial hyperplasia is defined as irregular proliferation of the endometrial glands with an increase in the gland to stroma ratio when compared with proliferative endometrium. Diagnosis and management of endometrial hyperplasia request pdf. Endometrial hyperplasia, management of greentop guideline. Endometrial hyperplasia symptoms,causes,diagnosis and. This is the layer of cells that line the inside of your uterus.
The most common presenting symptom of endometrial hyperplasia is abnormal. Endometrial hyperplasia wide spectrum of patients associated with prolonged, unopposed exppgosure to estrogen therapy depends on type patient setting. Jun 02, 2011 endometrial hyperplasia is a condition that occurs due to the excessive growth of the lining and cells of the endometrium, i. If vaginal bleeding resumes, another endometrial biopsy should be performed 28, 29. See classification and diagnosis of endometrial hyperplasia. Up to now, the correct clinical evaluation of endometrial hyperplasias was made more difficult by the different classification systems still in use.
Although endometrial hyperplasia occurs mostly in postmenopausal women, it can occur at much younger ages when estrogen is unopposed, as seen in polycystic ovarian syndrome and obesity. Hkcog guidelines number 16 september 2015 3 for hysterectomy. This can be taken in several forms, including pill, shot, vaginal cream, or intrauterine device. In 1985, kurman et al 3 clarified the classification system for endometrial hyperplasia, proposing 2 broad categories. This paper outlines development of our current classification of endometrial hyperplasias in some detail to provide an understanding of the complexity of the problem of determining the malignant potential of the hyperplasias, which is the central issue in determining. The results of previous case series indicate that malignancy occurs within 0% to 12. Future studies will need to determine the optimal nonsurgical management of atypical endometrial hyperplasia or endometrial intraepithelial neoplasia, standardizing agent, dose, schedule. Treatment of endometrial hyperplasia with levonorgestrel releasing intrauterine devices. In general, estrogen causes stimulation or growth of the lining, while progesterone the antiestrogen hormone causes the uterine lining to shed, resulting in a menstrual period. Some cases of endometrial hyperplasia, especially atypical, can progress to endometrial cancer, so it is important to study the two together. Therapeutic options for management of endometrial hyperplasia vishal chandra,1,2, jong joo kim,3, doris mangiaracina benbrook,1 anila dwivedi,2 rajani rai3 1department of obstetrics and gynecology, university of oklahoma health sciences center, oklahoma city, ok, usa 2division of endocrinology, csircentral drug research institute, lucknow, india. Endometrial hyperplasia diagnosis and treatment medical. When your endometrium thickens, it can lead to unusual bleeding.
Obesity and having metabolic syndrome may increase the risk of endometrial cancer. A great majority of patients present with abnormal uterine bleeding. Endometrial cancer is the most common gynaecological malignancy in the western world and endometrial hyperplasia is its precursor. Treatment with progestin therapy may provide a safe alternative to hysterectomy. Review article therapeutic options for management of. Risk factors for endometrial carcinoma include chronic ovulatory dysfunction, obesity, early menarche, late menopause, increasing age, tamoxifen therapy, and lynch syndrome. This paper outlines development of our current classification of endometrial hyperplasias in some detail to provide an understanding of the complexity of the problem of determining the malignant potential of the hyperplasias, which is the central issue. Pathogenesis presentationdiagnosis endometrial hyperplasia and endometrial carcinoma clinical scenario 1 case scenario 2. Low to mediumrisk endometrial hyperplasia can be treated with nonsurgical options. Hkcog guidelines number 16 september 2015 hkcog guidelines. Endometrial hyperplasia endometrial hyperplasia covers a range of pathological changes in the uterine glands and stroma. It is commonly di agnosed in women with uterine bleeding. Taking tamoxifen for breast cancer or taking estrogen alone without progesterone can increase the risk of endometrial cancer. There are currently two systems of endometrial precancer nomenclature in common usage.
Endometrial hyperplasia is defined as irregular proliferation of the endometrial glands with an increase in the gland to stroma ratio when compared with proliferative endometrium. Prognostic factors for improved longterm os were the absence of residual disease. Varying shapessizes and presence of cytologic atypia results from chronic estrogen stimulation 4. Endometrial hyperplasia is of clinical significance because it is often a precursor lesion to adenocarcinoma of the endometrium. Aug 22, 2017 endometrial hyperplasia is a thickening of the inner lining of the womb uterus. The differential diagnosis of endometrial hyperplasia and welldifferentiated endometrioid adenocarcinoma is complicated not only by the resemblance of these lesions to each other, but also by. Larger studies are needed before surgical alternatives to hysterectomy can be routinely recommended for hyperplasia. The most common presentation of endometrial hyperplasia is abnormal uterine bleeding. Endometrial hyperplasia refers to the thickening of the endometrium.
Management is guided by the severity of histologic features, menopausal status, and fertility and contraception plans. However, welldesigned randomized trials for an optimal endometrial hyperplasia management are lacking, and guidelines for followup are also unclear. Pathophysiology and management of endometrial hyperplasia. Updates in the management of complex atypical hyperplasia endometrial intraepithelial neoplasia 12420 2 definition proliferation of endometrial glands. Glandtostroma ratio 50 percent and crowded appearance. The classification, diagnosis and management of endometrial. After the menopause, endometrial thickening may be indicative of proliferation, cystic atrophy, simple hyperplasia, complex hyperplasia, atypical hyperplasia, or endometrial cancer. Therapeutic options for management of endometrial hyperplasia. Endometrial hyperplasia obstetrics and gynecology wiley. Hyperplasia can be simple or complex, with or without atypia. Jun 19, 2018 standard management of endometrial cancer at diagnosis involves surgery, followed by chemotherapy andor radiation therapy. This condition is benign, but may lead to cancer at times. Endometrial hyperplasia abnormal proliferation of endometrial glandular epithelium and often stroma that lacks stromal invasionthat lacks stromal invasion. Pathogenesis presentationdiagnosis endometrial hyperplasia and endometrial carcinoma clinical scenario 1 case scenario 2 clinical scenario 3 clinical.
Complications of untreated or poorly controlled endometrial hyperplasia can be serious. Treatment options for endometrial hyperplasia depend on what type you have. In others, hormone treatment or an operation may be needed. Symptoms of endometrial hyperplasia vaginal discharge abdominal pain bleeding between menstrual periods heavy or prolonged menstrual periods 11. Lecturer of gynecology and obstetrics management of endometrial hyperplasia 2. If hysterectomy is performed for atypical endometrial hyperplasia or endometrial intraepithelial neoplasia, then intraoperative.