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Management of Endometrial Hyperplasia (GTG 67 - Feb 2016), Tamoxifen …

- - - - Indicated in women who fail to regress following observation and in symptomatic women with abnormal uterine bleeding
      - Higher regression rates (89-96%) compared with observation only (7.4-81%) and may reduce risk of progression to cancer and need for hysterectomy
      - First line: LNG-IUS for a minimum of 6 months
        
        Higher disease regression rate with more favourable bleeding profile and fewer adverse side effects.
        
        Minimises systemic absorption and achieves a higher concentration of levonorgestrel at the level of the endometrium compared with oral progestogens.
        
        Encourage to retain for up to 5 years as this reduces risk of relapse
        
        Higher regression rates shown from increasing treatment from 3 to 6 months: 84 to 100% for LNG-IUS and 50 to 64% for oral medroxyprogesterone
      - Second line: Continuous progestogens for a minimum of 6 months (medroxyprogesterone 10-20mg/day or norethisterone 10-15mg/day) for women who decline LNG-IUS
      - DO NOT use cyclical progestogens as they are less effective
      - Act by modifying the proliferative effects of oestrogen on the endometrium, inducing histological regression of endometrial hyperplasia with atypia
    - - Indications for hysterectomy
        
        Progression to atypical hyperplasia during follow-up
        
        No histological regression of hyperplasia despite 12 months of treatment
        
        Relapse of endometrial hyperplasia after completing progestogen treatment
        
        Persistence of abnormal bleeding symptoms
        
        Woman declines endometrial surveillance or compliance with medical treatment
      - Post-menopausal women: Offer total hysterectomy with bilateral salpingo-oophorectomy
        Pre-menopausal women: Individualised decision to remove ovaries, however consider bilateral salpingectomy to reduce risk of ovarian malignancy
      - Laparoscopy > total hysterectomy is preferable: Associated with shorter hospital stay, less post-operative pain, and quicker recovery
      - Endometrial ablation: Not recommended as complete endometrial destruction cannot be guaranteed and regeneration of ablated endometrial tissue may occur. Subsequent endometrial assessment with hysteroscopy or endometrial biopsy may be compromised due to intrauterine adhesions.
      - Consider oestrogen replacement, in the absence of contraindications, until natural menopause to minimise risks of surgical menopause