Thomas Z, Abbas T, Sasson SBradford Royal Infirmary, Bradford

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BACKGROUND

•Endometrial hyperplasia is a pathological

condition characterised by hyperplastic changes in

the endometrial glandular and stromal structures

lining the uterine cavity

•The revised 2014 World health organization ( WHO

)classification separates endometrial hyperplasia

into two groups : 1) hyperplasia without atypia and

2) atypical hyperplasia

•Endometrial hyperplasia with atypia is a significant

clinical concern as it can have concurrent or be a

precursor of endometrial cancer

•Accurate diagnosis is essential for optimal

management of patients and reversion to normal

endometrium is the key with meticulous follow up

•It is often associated with multiple identifiable risk

factors and treatment should also aim to modify

and monitor these factors .

•We have audited our practice on the follow up of

endometrial hyperplasia in a large District General

Hospital.

OBJECTIVES

•The aim was to evaluate the follow -up

management options given to patients diagnosed

with endometrial hyperplasia

•Treatment effectiveness - regression, relapse and

progression were assessed

•The necessity for a separate pipelle clinic for

endometrial hyperplasia follow ups was also

evaluated.

•The list of follow ups from the hysteroscopy clinic

over a year (Aug 2017-18)was obtained and

retrospective analysis of electronic records for 44

patients performed

•The RCOG/BSGE Green -top Guideline for

Endometrial Hyperplasia was used as the standard .

RESULTS

•68%(30/44) were managed with intrauterine

progestogen (LNG-IUS),25%(11/44) had oral

progestogen and 7% declined treatment and chose

observation alone

•The interval for the first repeat sample for both

groups was a mean of 8.6 months

•8 patients had more than 3 repeat samples,which

predated the RCOG/BSGE Guideline on

Hyperplasia.

•30%(13/44) patients had a hysteroscopy at this

follow up visit due to irregular bleeding .The

majority 86%(38/44)had an adequate sample

noting progesterone effect in 73%(32/44)

RECOMMENDATIONS

REFERENCES

RESULTS

•The majority of patients were aged between 46-65

years, 82%(26/33)were multiparous.75%(33/44) were

post-menopausal .

•The body mass index(BMI)data was available for 26

patients, of which 65%(16/26) were of BMI >35

•Other risk factors were evaluated,one patient had

polycystic ovarian syndrome(PCOS )and no patients

were on hormone replacement therapy(HRT) or

tamoxifen

•At first diagnosis,77%(34/44)were endometrial

hyperplasia without atypia and 23%(10/44) had

hyperplasia with mild focal/focal atypia

• Raised BMI is an important risk factor for endometrial

hyperplasia ,documentation was available in only 26

patients. 61.5%(16/26) of them had BMI >35.

•The mean interval for the first repeat biopsy was

approximately 8.6 months for all hyperplasias detected.

This was against the standard of 3 months for atypia and

6 months for those without atypia after treatment .

•18% (8/44)of hyperplasia diagnosed was within a polyp,

only 37.5% (3/8)had follow up hysteroscopy.

Follow up of Endometrial Hyperplasia and treatment effect in a large

District General Hospital

16

10

18

BMI

>35

<35

No data

34

6

4

Histology at first diagnosis

Hyperplasia

without

atypia

Hyerplasia

with mild

focal atypia

Hperplasia

with focal

typia

ENDOMETRIAL POLYPS-18%(8/44)OF HYPERPLASIA

71% had BMI >35

50% had focal atypia

75% accepted IUS,25%had oral progestogen as treatment

37.5%had follow up hysteroscopy100% regression in follow up

FOCAL ATYPICAL

HYPERPLASIA -23%

(10/44) OF

HYPERPLASIA

20% had

BMI>35

50% identified

in polyps

70% accepted

IUS,30% had oral

progesterone as

treatment

20% had follow

up hysteroscopy

100% regression

in follow up

30

11

3

0

5

10

15

20

25

30

35

1 2 3 4

IUS

Oral

Progestogen

Observation

Of the 8 patients with endometrial hyperplasia

identified in a polyp,only 37.5%(3/8) had a follow

up hysteroscopy

Looking at treatment effect,100% had regression,

one patient (2.3%) had relapse who was then

treated with intrauterine progestogen and the

repeat biopsy was negative.There was no disease

progression.

CONCLUSIONS

•Clear documentation of BMI is essential

•On adherence with the RCOG guidelines,strict

follow up protocols have to be considered

•Endometrial hyperplasia with focal atypia is a

grey area and treatment has to be

individualised

•Considering focal atypical hyperplasia follow

up,hysteroscopy can be put into practice

•Hyperplasia was detected in 44 patients in this

period.Setting up a separate pipelle clinic could

free up some hysteroscopy slots.This requires

prior triage to ensure no abnormal bleeding

and for previous atypia to have hysteroscopy

slots

•To write up a local Guideline for Endometrial

Hyperplasia – and re audit practice

•Management of Endometrial Hyperplasia,Green-top Guideline No 67 RCOG/BSGE joint Guideline/February 2016

•Commission of the Gynaecological Oncology working Group (AGO).New WHO classification of Endometrial Hyperplasias.Emons et al .GeburtshilfeFrauenheilkd.2015;75(2):135-136

•Hysteroscopic Resection in Fertility Sparing Surgery for Atypical Hyperplasia and Endometrial Cancer:Safety and Efficacy.De Marzi P et al.Jminim Invasive Gynaecol.2015Nov-Dec;22(7):1178-82

•Prediction of Relapse After Therapy Withdrawal in Women with Endometrial Hyperplasia:A long term follow up study.Stetten ET et al.AnticancerRes.2017May;37(5):2529-2536

RISK FACTORS FOR ENDOMETRIAL HYPERPLASIA• Obesity • Diabetes and hypertension• Polycystic ovarian syndrome(PCOS)• Nulliparity• Hormone replacement therapy and

tamoxifen• Lynch syndrome