Thomas Z, Abbas T, Sasson S Bradford Royal Infirmary, Bradford Insert your Logos BACKGROUND •Endometrial hyperplasia is a pathological condition characterised by hyperplastic changes in the endometrial glandular and stromal structures lining the uterine cavity •The revised 2014 World health organization ( WHO )classification separates endometrial hyperplasia into two groups : 1) hyperplasia without atypia and 2) atypical hyperplasia •Endometrial hyperplasia with atypia is a significant clinical concern as it can have concurrent or be a precursor of endometrial cancer •Accurate diagnosis is essential for optimal management of patients and reversion to normal endometrium is the key with meticulous follow up •It is often associated with multiple identifiable risk factors and treatment should also aim to modify and monitor these factors . •We have audited our practice on the follow up of endometrial hyperplasia in a large District General Hospital. OBJECTIVES •The aim was to evaluate the follow -up management options given to patients diagnosed with endometrial hyperplasia •Treatment effectiveness - regression, relapse and progression were assessed •The necessity for a separate pipelle clinic for endometrial hyperplasia follow ups was also evaluated. •The list of follow ups from the hysteroscopy clinic over a year (Aug 2017-18)was obtained and retrospective analysis of electronic records for 44 patients performed •The RCOG/BSGE Green -top Guideline for Endometrial Hyperplasia was used as the standard . RESULTS •68%(30/44) were managed with intrauterine progestogen (LNG-IUS),25%(11/44) had oral progestogen and 7% declined treatment and chose observation alone •The interval for the first repeat sample for both groups was a mean of 8.6 months •8 patients had more than 3 repeat samples,which predated the RCOG/BSGE Guideline on Hyperplasia. •30%(13/44) patients had a hysteroscopy at this follow up visit due to irregular bleeding .The majority 86%(38/44)had an adequate sample noting progesterone effect in 73%(32/44) RECOMMENDATIONS REFERENCES RESULTS •The majority of patients were aged between 46-65 years, 82%(26/33)were multiparous.75%(33/44) were post-menopausal . •The body mass index(BMI)data was available for 26 patients, of which 65%(16/26) were of BMI >35 •Other risk factors were evaluated,one patient had polycystic ovarian syndrome(PCOS )and no patients were on hormone replacement therapy(HRT) or tamoxifen •At first diagnosis,77%(34/44)were endometrial hyperplasia without atypia and 23%(10/44) had hyperplasia with mild focal/focal atypia • Raised BMI is an important risk factor for endometrial hyperplasia ,documentation was available in only 26 patients. 61.5%(16/26) of them had BMI >35. •The mean interval for the first repeat biopsy was approximately 8.6 months for all hyperplasias detected. This was against the standard of 3 months for atypia and 6 months for those without atypia after treatment . •18% (8/44)of hyperplasia diagnosed was within a polyp, only 37.5% (3/8)had follow up hysteroscopy. Follow up of Endometrial Hyperplasia and treatment effect in a large District General Hospital 16 10 18 BMI >35 <35 No data 34 6 4 Histology at first diagnosis Hyperplasia without atypia Hyerplasia with mild focal atypia Hperplasia with focal typia ENDOMETRIAL POLYPS- 18%(8/44)OF HYPERPLASIA 71% had BMI >35 50% had focal atypia 75% accepted IUS,25%had oral progestogen as treatment 37.5%had follow up hysteroscopy 100% regression in follow up FOCAL ATYPICAL HYPERPLASIA -23% (10/44) OF HYPERPLASIA 20% had BMI>35 50% identified in polyps 70% accepted IUS,30% had oral progesterone as treatment 20% had follow up hysteroscopy 100% regression in follow up 30 11 3 0 5 10 15 20 25 30 35 1 2 3 4 IUS Oral Progestogen Observation Of the 8 patients with endometrial hyperplasia identified in a polyp,only 37.5%(3/8) had a follow up hysteroscopy Looking at treatment effect,100% had regression, one patient (2.3%) had relapse who was then treated with intrauterine progestogen and the repeat biopsy was negative.There was no disease progression. CONCLUSIONS •Clear documentation of BMI is essential •On adherence with the RCOG guidelines,strict follow up protocols have to be considered •Endometrial hyperplasia with focal atypia is a grey area and treatment has to be individualised •Considering focal atypical hyperplasia follow up,hysteroscopy can be put into practice •Hyperplasia was detected in 44 patients in this period.Setting up a separate pipelle clinic could free up some hysteroscopy slots.This requires prior triage to ensure no abnormal bleeding and for previous atypia to have hysteroscopy slots •To write up a local Guideline for Endometrial Hyperplasia – and re audit practice •Management of Endometrial Hyperplasia,Green-top Guideline No 67 RCOG/BSGE joint Guideline/February 2016 •Commission of the Gynaecological Oncology working Group (AGO).New WHO classification of Endometrial Hyperplasias.Emons et al .Geburtshilfe Frauenheilkd.2015;75(2):135-136 •Hysteroscopic Resection in Fertility Sparing Surgery for Atypical Hyperplasia and Endometrial Cancer:Safety and Efficacy.De Marzi P et al.Jminim Invasive Gynaecol.2015Nov-Dec;22(7):1178-82 •Prediction of Relapse After Therapy Withdrawal in Women with Endometrial Hyperplasia:A long term follow up study.Stetten ET et al.Anticancer Res.2017May;37(5):2529-2536 RISK FACTORS FOR ENDOMETRIAL HYPERPLASIA • Obesity • Diabetes and hypertension • Polycystic ovarian syndrome(PCOS) • Nulliparity • Hormone replacement therapy and tamoxifen • Lynch syndrome