endometrial hyperplasia

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ENDOMETRIAL HYPERPLASIA/ENDOMETRIAL CANCER.

• PRESENTER DR S . P CHUWA MD MMED.
• FOR -MD III HKMU.

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• LAY OUT
• WHATS IS ENDOMETRIAL HYPERPLASIA VS ENDOMETRIAL
  CANCER
• PREDESPOSING FACTORS OF ENDOMETRIAL HYPERPLASIA
• MNX OF ENDOMETRIAL HYPERPLASIA
• ENDOMETRIAL CANCER/STAGE/MNX.

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ENDOMETRIAL HYPERPLASIA.

• DEFN is the thickening of the endometrial
  lining due to increase in in cells of irregular
  proliferating endometrial gland .
• Its an histological diagnosis.
• There greater gland to stromal ratio
• The trigger is chronic unpposed estrogen
  stimulation.

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• Factors responsible for unopposed estrogen
  stimulation increase risk of endometrial
  hyperplasia.
• Progestrone counter balance the effect of
  estrogen-reduce risk for hyperplasia.
• Endometrial hyperplasia initially a benign
  condition but persistent stimulation may develop
  into cancer-( endometrial cancer).

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AETIOLOGY/RISK FACTORS.

• A. Obesity
• B.Nulliparity
• C.Early menarche with late menopause-ie
  menopausegt52years.
• D.Family history of -1.endometrial cancer
  2.ovarian 3.colon cancer.

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• E.Polycstic ovarian syndrome(stein leventhal
  syndrome).
• F.Tamoxifen therapy(for breast cancer
  treatment).
• G.Granulosa/theca cell ovarian
  tumour.(feminizing ovarian tumours).
• H.Diabetes/hypertension

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• I.Post menopausal hormone replacement
  therapy without progesterone combination.
• J.White race.

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PROTECTIVE FACTORS.

• Multiparity
• normal weight
• Combined oral contraceptive use
• Progestin therapy
• menopause lt49 years
• Ovulation.

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Endometrial hyperplasia

• Types(Old Classification/traditional
  classification).
• 1. Simple or Cystic hyperplasia.
• 2. Complex or Adenomatous hyperplasia.
• 3. Atypical Hyperplasia

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Types

• 1. Simple or Cystic Hyperplasia
• - Enlarged glands of variable sizes, some are
  cystic lined with cubical/columnar epithelium,
  giving a SWISS CHEESE pattern.
• - There is no secretory activity of the glands
  (absence of progesterone)

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Simple hyperplasia
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2. Complex or Adenomatous Hyperplasia

• Epithelium is stratified.
• Proliferation of the stroma.
• Crowding of glands.
• Mitosis are frequent.

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Complex hyperplasia
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3. Atypical hyperplasia

• - Epithelium with atypia and prominent
  stratification.
• - Glands are distorted with intraglandular
  projections.
• - May be not distinguished from Cancer of
  Endometrium in severe cases.
• - 40 of cases may develop Cancer.

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Atypical Endometrial Hyperplasia
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International society of gynaecology-classificatio
n

• A.Simple hyperplasia-i.without atypia
• ii.with
  atypia
• B.Complex hyperplasia-i.Without atypia
• 
  ii.with atypia.
• atypical endometrial hyperplasias are
  associated with development endometrial
  adenocarcinoma.

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Classification
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DEFINITION OF TERMS

• Simple Hyperplasia-endometrium with dilated
  glands not crowded together with abundant
  endometrial stroma-same as cystic hyperplasia in
  traditional classification.
• Complex Hyperplasia-gland crowded together few
  endometrial stroma-gland are complex with out
  pouching pattern-resemble Adenomatous hyperplasia
  in traditional classification.
• These have low premalignant potential.

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• c.Atypia/without atypia
• Hyperplasia contains glands with cytologic atypia
• There is increase in nuclear cytoplasmic ration
  with irregularity in shape and size of
  nuclei(atypia).
• Degree of atypia is major determinant of
  malignant potential.

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• Atypia can further classified into mild,
  moderate and severe atypia.
• Severe atypia correspond with carcinoma in situ.
• The rate to which endometrial hyperplasia
  progress to malignancy has not been determine
  but can regress or turn to malignancy after
  several years .

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PRESENTATION.

• Menopause-
• Post menopausal bleeding.
• Perimenoupausal-present with
• -metrorrhagia or
• - menorrhagia.

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Investigations

• EUA, Dilatation and curretage for hystology
• Oestrogen and Progesterone levels
• Hysteroscopy
• Pelvic Ultrasound

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Differential Diagnosis

• Submucous Fibroids
• Endometrial polyp
• Endometrial carcinoma
• Cancer of cervix
• Cervical Endometriosis

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Management

• Treatment choice is determine by-
• Age of the patient
• Desire to maintain fertility/bare children
• Severerity of the hyperplasia
• 4.Ability to control the possible source of
  Estrogens

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Management

• General measures-
• Restore blood/Treat anaemia Haematinics
• Dilatation and curretage (DC) to control
  bleeding.

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Progesterons

• Decrease the risk of future hyperplasia and/or
  endometrial cancer
• Medroxyprogesterone 10 mg x 10 days monthly
  common regimen
• norethindrone acetate (Aygestin), norethindrone
  (Micronor), norgestrel (Ovrette).

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Intrauterine Contraception (IUCD)

• Levonorgestrel intrauterine Device (Mirena)
• Will result in amenorrhea or oligomenorrhea

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Oral Contraceptives

• Option for treatment of both the acute episode of
  bleeding and future episodes of bleeding
• Triphasil - norgestrel/ethinyl estradiol
  combination is what has been used
• Acute bleeding 1 tab QID, TDS, BD, taper for
  every three days then OD to complete the cycle,
  then use daily tabs for 2-3 cycles