A 55-year-old lady, G3 P3, with DM type 2 and a BMI of 35, visits your clinic for her annual examination. A Pap test is performed at that time, and the result is notable for atypical glandular cells. She also reports having intermittent vaginal bleeding.
(A) pelvic ultrasonography
(B) progestin therapy
(C) levonorgestrel intrauterine device
(D) dilation and curettage
Endometrial hyperplasia management is determined by several factors:
- Patient’s age
- Medical history
- Desired fertility
- The degree of hyperplasia.
Therefore, proper endometrial hyperplasia classification is essential for optimizing therapeutic management. The revised 2014 World Health Organization (WHO) classification is recommended. This separates endometrial hyperplasia into two groups based upon the presence of cytological atypia: i.e.
- Hyperplasia without atypia and
- Atypical hyperplasia
Atypical endometrial hyperplasia (AEH) has a substantially higher chance of developing into endometrial cancer (up to 50%). In patients with AEH, the rate of concomitant endometrial carcinoma may be as high as 40%. A pre-treatment pelvic MRI is advised to rule out invasive endometrial cancer or concomitant ovarian cancer. Because of the potential for progression or underlying malignancy, women with atypical hyperplasia should undergo a total hysterectomy. It is recommended to use a laparoscopic approach. Postmenopausal women should additionally have a bilateral salpingo-oophorectomy due to the high risk of endometrial cancer. In premenopausal women, the decision should be made on an individual basis; nonetheless, removing the ovaries via a second operation is likely if endometrial cancer is found in the hysterectomy specimen. Due to the potential risk of residual hyperplasia and/or cancer both subtotal hysterectomy and endometrial ablation are contraindicated.
- Royal College of Obstetricians and Gynecologists. (2016). Green-top Guideline No. 67. Retrieved from https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/management-of-endometrial-hyperplasia-green-top-guideline-no-67/
- National Institute for Health and Care Excellence. 2021. Heavy menstrual bleeding: assessment and management (NICE guideline [NG88]). Retrieved from https://www.nice.org.uk/guidance/ng88/chapter/recommendations
- Endometrial intraepithelial neoplasia. Committee Opinion No. 631. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:1272–8.