1. Endometrial hyperplasia
Dr Esraa AL-Maini
Endometrial hyperplasia

2. Endometrial thickness guidelines
premenopausal women : Endometrial thickness in normal endometrial vary according to day of cycle ≤ 4 mm on day 4 of the menstrual cycle ≤ 8 mm by day 8.

3. Persistent endometrial thickness, independent of cycle day, measuring =>12 mm should be further evaluated especially for women those with risk factors for endometrial carcinoma .

4. Etiology for endometrial hyperplasia.
A-Endogenous estrogen. The most common cause Chronic anovulation is associated with _the polycystic ovary syndrome(PCOS) _ ovarian tumor (eg, granulosa cell tumor _ obese women B- Exogenous estrogen.

5. Classification endometrial hyperplasia
The World Health Organization classification of endometrial hyperplasia is based upon two factors: 1. Simple or complex glandular/stromal architectural pattern 2. The presence or absence of nuclear atypia

6. . Endometrial carcinoma is more than 10-fold more likely in atypical hyperplasia (simple or complex). Cancer occurs after a diagnosis of simple ˂ complex ˂ simple atypical, ˂ and complex atypical hyperplasia respectively.

7. Risk factors
1-Increasing age 2-Unopposed estrogen therapy 3-Late menopause (after age 55) 4-Nulliparity 5-Polycystic ovary syndrome (Chronic anovulation) 6-Obesity 7-Diabetes 8-Hereditary nonpolyposis colorectal cancer 9-Tamoxifen 10-Early menarche 11-Estrogen secreting tumor 12-Family history of endometrial, ovarian, breast, or colon cancer

8. Clinical manifestations.
Endometrial hyperplasia should be suspectedin: 1- Women with heavy, prolonged, frequent (ie, less than 21 days). 2- Irregular uterine bleeding. Abnormal uterine bleeding in perimenopausal or postmenopausal women is the most common clinical symptom of endometrial neoplasia, although such bleeding is usually (80%) due to a benign condition.

9. Indication for evaluation of the endometrium
1Abnormal -uterine bleeding with risk factors (eg, chronic anovulation, obesity, tamoxifen) 2-Failure to respond to medical treatment for abnormal uterine bleeding 3-unopposed estrogen replacement therapy 4- Asymptomatic women with benign appearing endometrial cells ,presence of endometrial cells on Pap smear if they are at increased risk of endometrial cancer 5-Women with hereditary nonpolyposis colorectal cancer

10. Diagnostic evaluation of the endometrium
1-Office biopsy.
2-D/C biopsy.
3-Hysteroscopic guided biopsy.

11. B. Indications for additional diagnostic evaluation
1-Endometrial hyperplasia with atypia is diagnosed by office biopsy, further evaluation is needed to exclude a coexistent endometrial adenocarcinoma, which is present in 25%. Dilation and curettage (D&C)
hysterectomy should be considered, especially in postmenopausal women or those no longer considering future fertility.

12. 2. Non diagnostic office biopsy
2. Non diagnostic office biopsy. Endometrialhyperplasia/cancer needs to be excluded in women with a non diagnostic office biopsy. hysteroscopy/directed biopsy 3. Persistent bleeding. After benign endometrial biopsy or treatment of endometrial pathology. Transvaginal sonography with or without hysteroscopy/directed biopsy 4. Postmenopausal women.

13. Premenopause
With a typia
With out a typia
Post menopause
With a typia

14. TREATMENT A. Premenopausal women-NO atypia
1-Progestins with follow-up sampling to document regression. A-Medroxyprogesterone acetate (MPA) 10 mg daily should be prescribed for 12 to 14 days each month for three to six months. Regression occurs in 80% B-Micronized progesterone ( mg) in a vaginal cream

15. C-Insertion of a levonorgestrel containing intrauterine contraception (IUC) is also effective. 2-Ovulation induction is another option for younger women with endometrial hyperplasia without atypia who desire pregnancy Follow up; _if the patient has not resumed normal cyclic menstruation preventative treatment should be initiated. -A re biopsy is required if abnormal uterine bleeding recurs.

16. 2. Premenopausal women with atypia.
Endometrial hyperplasia with atypia
further evaluated by D&C or hystroscope directed boipsy,there is no coexistent adenocarcinoma
Treat with progesteron: continuous oral megestrol acetate 40 mg twice per day every day is initiated in women who wish to preserve childbearing potential. Medroxyprogesterone acetate 10 mg/day

17. Follow up: A repeat endometrial biopsy should be performed in three months. A- Hysterectomy is recommended if atypical hyperplasia persists. Hysterectomy is the treatment of choice for women who are not planning future pregnancy or who are unable to comply with medical therapy and follow-up endometrial sampling.

18. B- If regression with no evidence of hyperplasia, the patient should pursue fertility options. C-If childbearing is delayed, progestin therapy should be continued. Options include megestrol acetate, MPA, oral contraceptive pills, depot medroxyprogesterone acetate, or a progestin releasing intrauterine contraception. Repeating an endometrial biopsy every months should be considered initially.

19. If persist no pregnancy not comply Hystrectomy indicated
premenopuse
No atypia
Progesteron
Ovulation induction
With a typia
biopsy
If persist no pregnancy not comply
Hystrectomy indicated
3months biopsy
Progesterone
If delyed treat repeated biopsy 6-12months
Hystrectomypregnancy advice

20. Postmenopausal women
No atypia. Exclude ovarian/adrenal tumors and use of exogenous hormone therapy treatment continuous medroxyprogesterone acetate (MPA) 10 mg daily for three months biopsy should be performed immediately after cessation of therapy regression occure in 86%.

21. If follow-up endometrial biopsy shows persistent If the patient continues to have bleeding: Hysterectomy should be offered or she can continue treatment with follow up biopsies every 6 to 12 months.

22. HRT at diagnosis of endometrial hyperplasia,If If endometrial hyperplasia has regressed; -Treatment is discontinued -Resumption of hormone replacement therapy is desired -Concurrent progestin treatment at higher doses and for longer intervals is advised -Repeat endometrial biopsy in three to six Months - These patients often obese should lose weight

23. Post menopaual women with Endometrial hyperplasia with atypia is considered a premalignant condition, preferably treated with hysterectomy.

24. If hysterectomy is not an option
Continuous oral megestrol acetate at doses of 40 mg two to four times per day
MPA 10 mg/day can be administered after Coexistent endometrial cancer has been excluded by hysteroscopy with directed biopsies.
An endometrial biopsy should be performed after three months of therapy.

25. Exclude ovarian and adrenal tumour Treat with progesteron
Post menopause
No atypia
Exclude ovarian and adrenal tumour
Treat with progesteron
3month biopsy
Or can continue treatment 6-12months biopsy
Hystrectomy if bleeding
Weight loss
atypia
If not an option so pregesteron after Biopsy
3-6 moths biopsy
Hystrctomy

26. THANK YOU