PROS & CONS

Endometrial hyperplasia
Direct endometrial sampling or
induce withdrawal bleeding first?
Kanadi Sumapraja

DEPARTEMEN OBSTETRI DAN GINEKOLOGI FKUI-RSCM

 CASE I CASE II CASE III
Identity Mrs SN, 46 yo, P2A1 Mrs Y, 49 yo, P2A1 Mrs. SS, 47 yo, P1A0

Chief complaint HMB since 3 months (currently not Acute AUB (active bleeding) HMB exacerbate since 2 months
bleeding)

History Change pad until 10x/day HMB 3 months. HMB since 5 months BA, took
No pain, no mass palpated, no other Took norethisterone 2x5 mg 1 month norethisterone 2x5 mg since then
complain before. (continuous)
IUD (+)

Risk Factors DM (-) DM (-) DM (+) since 2018

obese grade I (BMI 26) obese grade I (BMI 27) BMI 24

Physical Finding Stable hemodynamic Stable hemodynamic Stable hemodynamic

Normal gyn finding Slightly enlarged uterus Normal gyn finding

US Exam Retroflexed uterus Intramural leiomyoma @anterior corpus Anteflexed uterus

EL 12.8 mm, regular 33x26 mm, posterior corpus 17x12 mm EL 13.3 mm
Endometrial polyp 10x7 mm EL 18.9 mm Other wnl
Other wnl IUD in situ

Laboratory Hb 11.4 Hb 8.7 Hb 10.6

Diagnosis AUB-M due to endometrial hyperplasia, AUB M due to suspected endometrial AUB-M due to suspected endometrial
endocervical polyp hyperplasia, multiple leiomyoma hyperplasia

Management Diagnostic curettage followed by progestin Curettage followed by progestin therapy Diagnostic curettage
therapy

Histopathology Endocervical polyp, endometrial Endometrium resembling secretory phase that Endometrial polyp
hyperplasia without atypia may be found under influence of strong
exogenous progestogen. No endometrial
hyperplasia.
What is the best evaluation methods for patient with heavy menstrual
bleeding but currently not in acute bleeding?

NON-STRUCTURAL
STRUCTURAL
What is the best evaluation methods for patient with heavy menstrual
bleeding but currently not in acute bleeding?

ABNORMAL UTERINE BLEEDING

History taking Laboratory US evaluation

Bleeding pattern Initial laboratory testing – Uterus evaluation
(Regular or irregular) general condition, hemostasis
Symptoms
Past illness
Past medical procedure
Can we give progestin therapy as first line therapy in perimenopausal HMB
suspected hyperplasia?

Endometrial hyperplasia is defined as irregular proliferation of the endometrial glands

with an increase in the gland to stroma ratio when compared with proliferative
endometrium.

Proliferation phase Hyperplasia non-atypic

Can we give progestin therapy as first line therapy in perimenopausal HMB
suspected hyperplasia?
Endometrial hyperplasia develops when estrogen, unopposed by progesterone,
stimulates endometrial cell growth by binding to estrogen receptors in the nuclei of
endometrial cells.
RISK FACTORS
 Patients (n=28) Controls (n = 28) Statistical
significance
Age (years) 48.6 (+3.7) 46.6 (+ 4.2) P > 0.05
AUB in the perimenopause is
Estradiol (mmol/L) 0.55 (+0.57) 0.24 (+ 0.13) P = 0.031 associated with increased serum
FSH (IU/L) 21.2 (+23.1) 11.8 (+ 3.7) P > 0.05
estradiol
Moen et al, 2004
 NON-ATYPICAL HYPERPLASIA ATYPICAL HYPERPLASIA

The main actions of P or a progestin is the secretory transformation of an estrogen-primed

endometrium.
Progestin prevents the over-proliferation of the endometrial tissue, but the degree to which this
effect is achieved depends upon the antiestrogenic properties of the progestin and the dose and
duration of treatment – Transformation dose.
Progestin’s transformation dose
Can we delay the endometrial sampling?
What is the best timing for endometrial sampling?

Endometrial
sampling

MEDICAL TREATMENT
SURGICAL TREATMENT

Marsden DE., et al. Best Pract Res Clin Obstet Gynecol 2001;15:393-405
Does progestin supplementation prior to endometrial sampling will
influence histopathology result?
Does progestin supplementation prior to endometrial sampling will
influence histopathology result?
Does progestin supplementation prior to endometrial sampling will
influence histopathology result?

McPhail index: testing the ability of the progestin to transform

the endometrium, in rabbits.
Does progestin supplementation prior to endometrial sampling will
influence histopathology result?

Significant reduction in glandular cellularity but did not coincide with apoptotic activity
Amezkua et al, 2000
In acute AUB due to suspected hyperplasia, should we performed
curettage? Hysteroscopy? Or medical management?

Dilatation n Hysteroscopy Medical

Curettage
Diagnostic Not specific More specific No diagnostic
(esp. other pathology)
Treatment Less time More time Longer time
Skill Common Specific training Not required
Equipment More available Specific Not required
In patient with history of progestin therapy and still have AUB, how long
can we wait for evaluation? What is the next best diagnostic tool?

Can’t wait any longer - ASAP

In patient with history of progestin therapy and still have AUB, how long
can we wait for evaluation? What is the next best diagnostic tool?
What is the next management if patient do not want operative option?
 Abnormal Uterine Bleeding
Suspected endometrial hyperplasia
Premenopause

TVUS > 7mm

Endometrial biopsy

Normal Hyperplasia Cancer

Non-Atypical Atypical
 Normal Hyperplasia Cancer

Non-Atypical Atypical

Progestin 1st line 1st line Oncologist

Progestin Hysterectomy
2nd line 2nd line
Hysterectomy Progestin

Continuous MPA 10-20 mg/day

Continuous Norethisterone 10-15 mg/day
LNG-IUS
At least for 6 months
 Progestin
for 6 months Hysterectomy

Endometrial biopsy Progression

Regression Persistence

Endometrial biopsy Progestin

After 6 months for 6 months
Hysterectomy

Relapse Regression Endometrial biopsy

Annual endometrial biopsy Regression