TREATMENT: PREMENOPAUSAL AND POSTMENOPAUSAL
HYPERPLASIA WOMEN
A. IN YOUNG PATIENT WITH HMB AND PCOS THICKENED
ENDOMETRIUM:
Do Endometrial Sampling:
Hysteroscopy with targeted endom biopsy ( after a directed
biopsy, do an endometrial curettage to sample the background
endometrium. This will provide opportunity to confirm the
diagnosis of a TRUE pre malignant lesion and EXCLUDE an
associated endometrial CA)
and D and C are PREFERRED over endometrial biopsy since
accuracy of the endometrial biopsy in premenopausal women is
lower and dx of Endom CA may be misinterpreted as endom
hyperplasia in 15-25% of cases
D and C- better at evaluation tumor grade than office endometrial
biopsy with significantly less cases being upgraded
In premenopausal: Ultrasound measurement of endometrial
thickness in premenopausal women has NO diagnostic value
The decision to histologically evaluate below 45 years
should be based on symptomatology, risk factor and clinical
presentation
B. Patients with POSTMENOPAUSAL BLEEDING
Do endometrial Sampling thru:
1. Hysteroscopy with targeted endometrial biopsy:
GOLD STANDARD- targeted biopsy good for
focal , discrete lesions for less that 50% of the
endometrium
2. Endometrial biopsy with Pipelle- 98-100%
specificity – when tha CA occupies at least 50% of
endometrial surface, this is 100% accurate
3. D and C – under anesthesia – less likely to miss
CA than endometrial bipsy- better in predicting
tumor grade in premenopause
Hyperplasia without atypia- with coexistent invasive endom ca:
<1%
6 months to induce regression
If no regression after 6 months, progestin may be increased
If with atypia or CA, manage accordingly
Patient who do not respond after 12 months of tx, will not benefit
from extension in tx
Endo sampling after 6 months- to be done after withdrawal
bleeding- minimize architectural effects of progesterone
TREATMENT: a. LNG IUD x 6 months- first line
b. MPA 10 -20 mg OD x 3-6 months OR MPA
10-20 mg OD x 12-14 days each month x 3-6 months
c. Megestrol acetate- 40-160mg OD x 3-6
months
d. DMPA- 150 mg /IM every 3 months
endometrial biopsy
NORMAL: maintain LNG IUD or
Continue MPA 10mg OD for 12 months
Metanalysis: with oral progestin- 67-72% regression rate
LNG IUD – 81-94% regression rate
PERSISTENT HYPERPLASIA
A. LNG IUD PLUS oral progestin
B. Increase MPA to 20 mg OD x 3 months then
repeat biopsy
*** PORGESTERONE: COUNTERBALANCE
MITOGENIC EFECT OF ESTROGEN AND INDUCES
SECRETORY DIFFERENTIATION
DECREASEs glandular cellularity by inducing
apoptosis and inhibiting angiogenesis in the
myometrium underlying the hyperplastic
endometrium resulting to endometrial regression
Atypical hyperplasia- with coexistent invasive endom ca: up to
60%
Conservative mngt:
Important consideration: min treatment to induce regression: 6
months
Sample after 6 months to ensure there is no progression then
sample every 3 months therafter
Once endom is normal, co manage with Infertility specialist and
get pregnant
Once childbearing is complete, definitive mngt recommended
43-60% found to have co existent endometrial CA on histopath
Highest disease recurrence in two years: Endom biopsy every 6
month x 2 years
if atypia isnoted/CA- mng acdingly
EH- if failed tx
TREATMENT: PREMENOPAUSAL
a. LNG IUD – RELEASEs 15-20 MCG/DAY AND KEPT IN
PLACE FOR 3-6 MONTHS. ENDOMETRIAL BIOPSY CAN
BE PERFORMED WITH IUD INPLACE
Overall response rate: 83% in complex
hyperplasia with atypia and grade 1
endometrial CA with 17% progesterone
resistance ( potential biomarkers to
determine resistance: Pl3K/AKT/mTOR
b. Megestrol Acetate 80 mg BID x 3 months
c. MPA- 10-20 mg OD continuously x 3-6 months
endometrial biopsy

*** ASYMPTOMATIC POSTMENOPAUSAL WOMEN EMT >11mm -

PERSISTENT HYPERPLASIA:
1. LNG IUD PLUS ORAL PROGESTIn x 3 months
2. Increase Megestrol acetate to 160 mg BID x 3 months
endometrial CA risk of 6.7 % === DO endometrial biopsy
*** POSTMENOPAUSAL WOMEN WITH BLEEDING EMT >5mm =
Do Endom biopsy
Consider also other risk factors for endom CA

Endome biopsy
PATIENT WITH POSTMENOPAUSAL BLEEDING:
PERSISTENT HYPERPLASIA: EHBSO w/ or w/o BSO
IF NORMAL BIOPSY:
1. Continue LNG IUD x 3 months
2. Megestrol acetate 80 mg BID x 3 months
*** Refer to infertility specialst for active co management
***at any point during tx that vaginal bleeding recurs, do endom
biopsy . IF CA, manage accordingly
1. Do risk Assessment
2. If Initial episode of bleeding
Do: Transvaginal ultrasound
a. EMT </= 4 mm- expectant but if with
persistent bleeing, do Endometrial sampling
b. EMT >4mm – Endometrial sampling
3. Persistent/recurrent bleeding with Multiple risk factors
Do : Endometrial sampling then treat accordingly
EMT </= 4 mm = presence of thin, distinct endometrial
echo </=4mm is associated with a risk of malignancy in
1/917 Sensitivity 95% and Specificity 55%

POST MENOPAUSAL WOMEN with Hyperplasia with atypia =

EHBSO

HYPERPLASIA WITH ATYPIA

NOT DESIROUS OF PREGNANCY: EH WITH Or w/o BSO-

*** GROSS EXAMINATION OF SPECIMEN WITH OR W/O FROZEN

SECTION
- Intraoperative frozen section to r/o concurrent
adenoCA may be done
- Referred to gyne onco for intraoperative decisions

FACTORS CONTRIBUTING TO UNOPPOSED ESTROGEN

STIMULATION OF THE ENDOMETRIUM

1. Obesity – inc insulin resistance

Dec SHBG
Aromatization of adrogens to estrogen

Mngt: lifestyle change

2. PCOS – hyperinsulinemia
-increased FSH/LH
- Androgen excess
- anovulatpry cycles
Mngt: correct ovulatory dysfuntion
3. FUNCTIONAL TUMORS -
o Granulo Cell tumors
Mngt: remove tumor
4. Iatrogenic
o Estrogen treatment
o Mngt: stop all estrogens including topical
creams
5. Perimenopause
o Inc FSH
o Decrease ovarian reserve
o Anovulatory cycle