AUB-M

AUB-M : MALIGNANCY AND HYPERPLASIA

Kategori: Hiperplasia endometrium atipik, Carsinoma endometrium, Leiomyo sarcoma.

Klasifikasi (WHO ,2014): Hyperplasia without atypia, Atypical Hyperplasia

EIN Endometrial Intraepithelial Neoplasma

Sub Tipe benign Hyperplasia without atypia : oral progestin / LNGIUS
Sub tipe Atypical Hyperplasia dan malignansi : histerektomi

Faktor Risiko: Usia, obesitas, menarche dini, menopause lanjut (> 55 tahun), SOPK, diabetes mellitus,
nulliparitas, terapi tamoxifen, atau riwayat keluarga dengan Carsinoma Endometrium
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AUB-M : MALIGNANCY AND HYPERPLASIA

Prevalence:
• 3% -30% of women of reproductive age

Signs & Symptoms:

• Postmenopausal / intermenstrual bleeding / AUB
 Flour albus

Supportive examination:
• Endometrial biopsy
• Dilatation and curettage
• Immunohistochemistry of Vimentin: +
• Ultrasound
• Hysteroscopy
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AUB-M : MALIGNANCY AND HYPERPLASIA

Ultrasound examination:

• USG endometrial abnormalities are detected by:

 Endometrial thickness > 15 mm in premenopause and > 5 mm in postmenopause
 Granulomatous appearance on the surface of the endometrium and irregulariaty in the boundaries
of the endometrium and myometrium:
 stage IA  irregularity less than half the myometrium
 stage IB  irregularity of more than half the myometrium
 In stage I, the uterus is generally not enlarged (size is still normal)
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AUB-M : MALIGNANCY AND HYPERPLASIA

Color Doppler Ultrasound of Ca Endometrium :

 Abnormal endometrial morphology (heteroechoicism, irregularity, endometrial

thickness > 6 mm for postmenopause or > 15mm for premenopause)
 PI <1.50 or RI <0.56
 High systolic blood flow (High Impedancy Velocity) is 15 cm / second
 Neovascularization and vessel clustering in mass
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AUB-M : MALIGNANCY AND HYPERPLASIA

Transvaginal Color Doppler Ultrasound:

 The endometrium is clearer  the appearance of uterine abnormalities

becomes more significant
 Transvaginal ultrasound has good accuracy for endometrial cancer,
because it has a sensitivity of 98% and a specificity of 85%

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AUB-M : MALIGNANCY AND HYPERPLASIA

USG Transrectal ColourDoppler :

 Used if there are difficulties with using transvaginal ultrasound, such

as there has been a vaginal spread
 The use of Transrectal Color Doppler Ultrasound provides almost the
same accuracy

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ULTRASOUND EXAMINATION, IETA
(INTERNATIONAL ENDOMETRIAL TUMOR ANALYSIS):

Endometrial thickness of more than 4mm

in postmenopausal women can be
suspected of endometrial hyperplasia

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SONOHYSTEROGRAPHY

 The representation of the uterus and endometrium is clearer, so that

endometrial cancer can be detected accurately
 The representation of neovascularization is a vascular growth that enters the
endometrium
 The presence of heterogeneous, irregular endometrial tissue, forms of amorphic
growth and mass expansion in the endometrium
 Infiltration into the myometrium, parametrium, rectum, bladder, regional lymph
nodes is more clearly detected
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HYSTEROSCOPY

• Diagnostic hysteroscopy is a simple procedure that

can provide a good visualization of the whole uterine
cavity.
• Evaluate the results of conservative treatment
combine with progestin of Atipical Endometrial
Hyperplasia or Endometrial Cancer in young patients
desiring future fertility
• Identification of localized lesions is achievable allowing
for resection of all suspected lesions, including the
myometrium beneath the lesions to exclude tumor 10

invasion.
PENATALAKSANAAN AUB-M
Maglinancy & 1. HIPERPLASIA ENDOMETRIUM ATIPIK
hyperplasia

YA 2. INGIN HAMIL ? TIDAK

3. D&K dan Progestin (6 bulan) atau

4. Histerektomi
LNG-IUS atau Analog GnRH

5. Biopsi (akhir bulan ke-6) 6. Hiperplasia atipik menetap

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AUB-M : MALIGNANCY AND HYPERPLASIA

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MANAGEMENT OF HYPERPLASIA IN
PRE MENOPAUSAL WOMEN

Non atypical hyperplasia :

 Medroxyprogesterone acetate(MPA)10mg/day for 12-14 days every month for

three to six months (RCOGrecommends6months)
 Or therapy can be given LNG-IUS
 Endometrial surveillance should be done every 6 months. At least two consecutive 6-
month negative biopsies should be obtained before the patient is declared safe (in
patients with a BMI >35 it is recommended to do it annually after being declared safe)
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MANAGEMENT OF HYPERPLASIA IN
PRE MENOPAUSAL WOMEN

Atypical Hyperplasia :

For women who still want children:

 If the diagnosis has been confirmed and there is no coexistence with adenocarcinoma, a continuous
oral megestrol acetate can be given at a dose of 40mg twice or use intrauterine contraceptives
containing levonorgestrel (LNG-IUS).
 After three months of therapy, repeat endometrial biopsy
 If the histopathological examination results of the curette persist for 7-9 months, it can be said that
the therapy has failed, and a hysterectomy is recommended. 14
MANAGEMENT OF HYPERPLASIA IN
PRE MENOPAUSAL WOMEN

Non-atypical Hyperplasia :

 MPA 10 mg / day for 3 months / LNG-IUS  repeat endometrial sampling :

 If there has been regression in the endometrium, therapy can be discontinued
 If hyperplasia persists after 3 months of therapy & bleeding persists 
hysterectomy or continue therapy with evaluation every 6 to 12 months.
 In women who are at high risk of relapse, such as women with a BMI of 35 or greater
who are treated with oral progestogens, after two consecutive 6-month negative biopsies
endometrial biopsy is still considered for annual endometrial biopsy. 15
MANAGEMENT OF HYPERPLASIA IN
PRE MENOPAUSAL WOMEN

Atypical Hyperplasia :

• Hysterectomy and BSO can be offered

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TINGKAT KEBERHASILAN TERAPI HORMONAL PADA HIPERPLASIA
ENDOMETRIUM NON ATIPIK

 Efektivitas antara LNG IUS dan progesterone dari penelitian RCT dikatakan bahwa LNG
IUS angka keberhasilan lebih tinggi daripada progesterone oral.
 Setelah 3 bulan terapi (OR 2.3, 95 % CI 1.39 -3.82),
 Setelah 6 bulan terapi (OR 3.16, 95 % CI 1.8 –5.4),
 Setelah 12 bulan terapi (OR 5.73, 95 % CI 2.67 –12.33) ,
 Setelah 24 bulan terapi (OR 7.46, 95 % CI 2.55 –21.78)
 Dengan rincian pilihan terapi hormonal : Medroxyprogesterone (10 mg/ hari) angka
keberhasilan 60 %, Lynestrenol (15 mg/hari) angka keberhasilan 44 %, Norethisterone
(15 mg/ hari) angka keberhasilan 59 % 17
TINGKAT KEBERHASILAN TERAPI HORMONAL PADA HIPERPLASIA
ENDOMETRIUM NON ATIPIK

 Berdasarkan penelitian, penggunaan terapi hormonal (LNG IUS dan progesterone

oral) memiliki angka keberhasilan 85,6 %
 Dalam penelitian terhadap 242 wanita yang terdiagnosis hyperplasia endometrial
atipic penggunaan progesterone dapat mengurangi resiko kanker 5 x lipat
dibandingkan dengan yang tidak menggunakan progesterone.

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