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Total abdominal hysterectomy with bilateral salpingo-oopherectomy
3%
1/30
Partial, cervix-sparing hysterectomy
17%
5/30
Start combination estrogen and progestin therapy
10%
3/30
Start progestin-only therapy
47%
14/30
Observation with annual endometrial biopsies
20%
6/30
Select Answer to see Preferred Response
This patient presents with endometrial hyperplasia with atypia, which can be treated with progestin-only therapy in patients who are hoping to become pregnant in the near future. Endometrial hyperplasia is a common cause of irregular vaginal bleeding. Biopsy can show atypia, which carries a 20-30% chance of malignant conversion, or lack of atypia, which carries a <5% risk of malignant conversion. Patients without atypia can be safely treated with progestin-only therapy. In patients with atypia, total abdominal hysterectomy is preferred; however, progestin-only therapy should be considered in patients who wish to become pregnant. In these patients, during progestin therapy, pregnancy will be inhibited, but once a therapeutic response is achieved, the medication can be stopped and attempts at pregnancy can immediately commence. Of note, endometrial ablation is contraindicated in both situations, as it can prevent accurate biopsies in the future. Buchanan et al. discuss endometrial cancer, the most common gynecological cancer in the United States. They note that the most common presentation of endometrial cancer is postmenopausal bleeding. While biopsy is required for diagnosis, total abdominal hysterectomy with bilateral salpingo-oopherectomy is usually required for staging. Reed et al. performed a retrospective cohort study to determine whether progestin therapy affects the persistence or progression of atypical endometrial hyperplasia. Among 70 women with atypical hyperplasia, progestin therapy was associated with a decreased risk of persistence or progression of the disease (RR 0.39, 95% CI 0.21-0.70). Moreover, a duration of at least 3 months of progestin treatment demonstrated a 67% decreased risk of persistence or progression of atypical hyperplasia. Illustration A shows a normal endometrial biopsy. Illustration B shows endometrial hyperplasia without atypia, with noted increased ratio of glandular:stromal tissue. Illustration C shows endometrial hyperplasia with atypia, with noted increased nuclear:cytoplasmic ratio. Incorrect Answers: Answer 1: Total abdominal hysterectomy with bilateral salpingo-oopherectomy is the method of choice for staging endometrial cancer. Answer 2: This is not the approach of choice for endometrial hyperplasia or endometrial cancer. Answer 3: Estrogen exposure will further exacerbate endometrial hyperplasia. Answer 5: Annual endometrial biopsies are not the treatment of choice for endometrial hyperplasia, with or without atypia.
3.7
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