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Henderson I, Black N, Khattak H, UKARCOG Working Group Authors, Gupta JK, Rimmer MP. Diagnosis and management of endometrial hyperplasia: A UK national audit of adherence to national guidance 2012-2020. PLoS Med 2024; 21:e1004346. [PMID: 38421942 PMCID: PMC10903889 DOI: 10.1371/journal.pmed.1004346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 01/12/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Endometrial hyperplasia (EH) is a precusor lesion for endometrial cancer (EC), the commonest gynaecological malignancy in high-income countries. EH is a proliferation of glandular tissue, classified as either non-atypical endometrial hyperplasia (NEH) or, if the cytological features are abnormal, atypical endometrial hyperplasia (AEH). The clinical significance of AEH is that patients face both a high risk of having occult EC and a high risk of progression to EC if untreated. Recommendations on the care of women with EH were introduced by United Kingdom-wide guidance (Green-top Guide No. 67, 2016). National adherence to guidance is unknown. We aimed to describe the care of patients with EH; to compare the patterns of care for those with EH with national guidance to identify opportunities for quality improvement; and to compare patterns of care prior to and following the introduction of national guidance to understand its impact. METHODS AND FINDINGS In this UK-wide patient-level clinical audit, we included 3,307 women who received a new histological diagnosis of EH through a gynaecology service between 1 January 2012 and 30 June 2020. We described first-line management, management at 2 years, and surgical characteristics prior to and following national guidance for EH using proportions and 95% confidence intervals (CIs) and compared process measures between time periods using multilevel Poisson regression. Of the 3,307 patients, 1,570 had NEH and 1,511 had AEH between 2012 and 2019. An additional 85 patients had NEH and 141 had AEH during 2020. Prior to national guidance, 9% (95% CI [6%, 15%]) received no initial treatment for NEH compared with 3% (95% CI [1%, 5%]) post-guidance; 31% (95% CI [26%, 36%]) and 48% (95% CI [43% 53%]) received an intrauterine progestogen, respectively, in the same periods. The predominant management of women with AEH did not differ, with 68% (95% CI [61%, 74%]) and 67% (95 CI [63%, 71%]) receiving first-line hysterectomy, respectively. By 2 years, follow-up to histological regression without hysterectomy increased from 38% (95% CI [33%, 43%]) to 52% (95% CI [47%, 58%]) for those with NEH (rate ratio (RR) 1.38, 95% CI [1.18, 1.63] p < 0.001). We observed an increase in the use of total laparoscopic hysterectomy among those with AEH (RR 1.26, 95% CI [1.04, 1.52]). In the later period, 37% (95% CI [29%, 44%]) of women initially diagnosed with AEH who underwent a first-line hysterectomy, received an upgraded diagnosis of EC. Study limitations included retrospective data collection from routine clinical documentation and the inability to comprehensively understand the shared decision-making process where care differed from guidance. CONCLUSIONS The care of patients with EH has changed in accordance with national guidance. More women received first-line medical management of NEH and were followed up to histological regression. The follow-up of those with AEH who do not undergo hysterectomy must be improved, given their very high risk of coexistent cancer and high risk of developing cancer.
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Affiliation(s)
- Ian Henderson
- The United Kingdom Audit and Research Collaborative in Obstetrics and Gynaecology, London, United Kingdom
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom
| | - Naomi Black
- The United Kingdom Audit and Research Collaborative in Obstetrics and Gynaecology, London, United Kingdom
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Hajra Khattak
- The United Kingdom Audit and Research Collaborative in Obstetrics and Gynaecology, London, United Kingdom
- Elizabeth Garret Anderson Institute for Women’s Health, University College London, London, United Kingdom
| | | | - Janesh K. Gupta
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Birmingham Women’s and Children’s NHS Hospital Trust, Birmingham, United Kingdom
| | - Michael P. Rimmer
- The United Kingdom Audit and Research Collaborative in Obstetrics and Gynaecology, London, United Kingdom
- Medical Research Council Centre for Reproductive Health, Institute of Regeneration and Repair, University of Edinburgh, United Kingdom
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Elassall GM, Sayed EG, Abdallah NA, El-Zohiry MM, Radwan AA, AlMahdy AM, Sedik AS, Elazeem HASA, Shazly SA. Levonorgestrel-releasing intrauterine system versus systemic progestins in management of endometrial hyperplasia: A systemic review and meta-analysis. J Gynecol Obstet Hum Reprod 2022; 51:102432. [PMID: 35760334 DOI: 10.1016/j.jogoh.2022.102432] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/15/2022] [Accepted: 06/20/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Endometrial hyperplasia is associated with varying risk of endometrial cancer. The aim of this review is to assess effectiveness of levonorgestrel-releasing intrauterine system (LNG-IUS), compared to systemic progestins, in management of endometrial hyperplasia MATERIALS AND METHODS: A search on studies comparing LNG-IUS to systemic progestins was conducted on Scopus, Web of science, Cochrane, PubMed and Embase databases, from the date of inception to September 20th, 2020. Studies were excluded if they were non-comparative, animal studies, review articles, case reports, case series, and conference papers. Primary outcomes include resolution/regression rate, failure rate, and hysterectomy rate. Analysis was pooled using random effect model and was expressed as pooled odds ratios (OR) and 95% confidence interval (CI). Quality assessment was performed using Cochrane Risk of Bias Tool and the Newcastle-Ottawa Scale (NOS) assessment tool. MOGGE Meta-analysis Matrix was used to illustrate multiple subgroup analyses. RESULTS Out of 341 studies retrieved from literature search, 12 were eligible. LNG-IUS yielded significantly higher resolution/regression rate (91.3% vs 68.6%, OR 3.42, 95% CI 1.86-6.30). Failure and hysterectomy rates were significantly lower in LNG-IUS group compared to systemic progestins' group (19.2% vs. 32.3%, OR 0.34, 95% CI 0.20-0.57 and 9.3% vs. 24.1%, OR 0.41, 95% CI 0.29-0.57, respectively). Subgroup analysis of studies including complex hyperplasia only did not show significant difference in resolution/regression rate was not statistically significant. CONCLUSION LNG-IUS is associated with high success rate in management of women with endometrial hyperplasia. However, specific effectiveness of LNG-IUS on more advanced histologic subtypes is less studied.
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Affiliation(s)
- Gena M Elassall
- Middle-East Obstetrics and Gynecology Graduate Education (MOGGE) Foundation Research Office, Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Esraa G Sayed
- Middle-East Obstetrics and Gynecology Graduate Education (MOGGE) Foundation Research Office, Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Nada A Abdallah
- Middle-East Obstetrics and Gynecology Graduate Education (MOGGE) Foundation Research Office, Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mariam M El-Zohiry
- Middle-East Obstetrics and Gynecology Graduate Education (MOGGE) Foundation Research Office, Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed A Radwan
- Middle-East Obstetrics and Gynecology Graduate Education (MOGGE) Foundation Research Office, Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - AlBatool M AlMahdy
- Middle-East Obstetrics and Gynecology Graduate Education (MOGGE) Foundation Research Office, Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed S Sedik
- Middle-East Obstetrics and Gynecology Graduate Education (MOGGE) Foundation Research Office, Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Hossam Aldein S Abd Elazeem
- Middle-East Obstetrics and Gynecology Graduate Education (MOGGE) Foundation Research Office, Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Sherif A Shazly
- Middle-East Obstetrics and Gynecology Graduate Education (MOGGE) Foundation Research Office, Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt.
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Alshdaifat EH, El-Deen Al-Horani SS, Al-Sous MM, Al-Horani S, Sahawneh FE, Sindiani AM. Histopathological pattern of endometrial biopsies in patients with abnormal uterine bleeding in a tertiary referral hospital in Jordan. Ann Saudi Med 2022; 42:204-213. [PMID: 35658582 PMCID: PMC9167457 DOI: 10.5144/0256-4947.2022.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Abnormal uterine bleeding (AUB) is a symptom that deviates from the normal menstrual cycle. AUB is characterized by changes in the frequency, volume, and duration of the menstrual flow. The etiology of AUB, which varies with age, may be attributed to both structural and non-structural causes. OBJECTIVES Determine the histopathological pattern of endometrial biopsies in patients with AUB across different age and parity groups who have undergone dilation and curettage (D&C), along with the discrepancy between D&C and histopathological findings after hysterectomy. DESIGN Retrospective chart review SETTING: Tertiary referral hospital PATIENTS AND METHODS: We collected data on all patients diagnosed with AUB between January 2015 and December 2020. Histopathological findings of all D&C endometrial biopsy samples were examined after being categorized by age and parity groups. Sensitivity, specificity, positive predictive value, and NPV were calculated to evaluate the diagnostic accuracy of D&C. MAIN OUTCOME MEASURES Histopathological pattern of D&C endometrial biopsies by age and parity groups. SAMPLE SIZE 3233 patients. RESULTS Most patients were in the 18-39 year age group, with normal cyclical findings being the most common histopathological finding. Malignant lesions were observed in 42 patients with a majority being older than 50 years. In 13.3% (42/316) of patients, D&C failed to detect intrauterine disorder that was found on hysterectomy. The overall accuracy of D&C in determining the existence of normal versus pathological findings was 75.60%, the sensitivity was 72.90%, the specificity was 77.90%, the positive predictive value was 73.86% and the NPV was 77.05% in our patients. CONCLUSION Normal cyclic changes account for the highest proportion of histopathological findings. However, hyperplasia and malignancies are important causes of perimenopausal and postmenopausal bleeding. While the use of D&C as a sampling tool for AUB cases remains questionable, the use of D&C in diagnosing premalignant and malignant cases is highly effective. LIMITATIONS Single-center, retrospective design, incomplete medical records, and inter-rater reliability could not be determined. CONFLICT OF INTEREST None.
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Affiliation(s)
| | | | - Majd Mahmoud Al-Sous
- From the Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Sharaf Al-Horani
- From Department of Obstetrics and Gynecology, Jordan University of Science and Technology, Irbid, Jordan
| | | | - Amer Mahmoud Sindiani
- From Department of Obstetrics and Gynecology, Jordan University of Science and Technology, Irbid, Jordan
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Kim MK, Seong SJ, Park DC, Hong JH, Roh JW, Kang SB. Comparison of diagnostic accuracy between endometrial curettage and aspiration biopsy in patients treated with progestin for endometrial hyperplasia: a Korean Gynecologic Oncology Group study. J Gynecol Oncol 2020; 31:e51. [PMID: 32266800 PMCID: PMC7286758 DOI: 10.3802/jgo.2020.31.e51] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/21/2020] [Accepted: 01/27/2020] [Indexed: 12/12/2022] Open
Abstract
Objective To compare the diagnostic accuracy of dilatation and curettage (D&C) versus endometrial aspiration biopsy in follow-up evaluation of patients treated with progestin for endometrial hyperplasia (EH) Methods A prospective multicenter study was conducted from 2015 to 2018. Patients with EH were treated with progestin, one of the following three treatment regimens: oral medroxyprogesterone acetate (MPA) 10 mg/day for 14 days per cycle, continuous MPA 10 mg/day or the levonorgestrel-releasing intrauterine system (LNG-IUS). At 3 or 6 months of treatment, endometrial tissues were obtained via 2 methods in each patient: aspiration biopsy, followed by D&C. The primary outcome was the consistency of the histologic results between the 2 methods. The secondary outcome was the regression rate at 6 months of treatment. Results The study population comprised 65 patients (55 with non-atypical hyperplasia, 10 with atypical hyperplasia). During the follow-up, a comparison of the pathologic results from aspiration biopsy and D&C was carried out for the 65 cases. Thirty-eight cases were diagnosed as EH by D&C. Among these, only 24 were diagnosed with EH from aspiration biopsy, for a diagnostic concordance of 63.2% (ĸ=0.59). Forty-four patients were followed up at 6 months, and the regression rate was 31.8% (14/44). Responses were obtained for 41.7% (5/12) of the cyclic MPA group, 58.3% (7/12) of the continuous MPA group and 10% (2/20) of the LNG-IUS group. Conclusion As a follow-up evaluation of patients treated with progestin for EH, aspiration biopsy is less accurate than D&C and might not be a reliable method. Trial Registration ClinicalTrials.gov Identifier: NCT02412072
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Affiliation(s)
- Mi Kyoung Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Seok Ju Seong
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Korea.
| | - Dong Choon Park
- Department of Obstetrics and Gynecology, St. Vincent's Hospital, Catholic University College of Medicine, Suwon, Korea
| | - Jin Hwa Hong
- Department of Obstetrics and Gynecology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Ju Won Roh
- Department of Obstetrics and Gynecology, CHA Ilsan Medical Center, CHA University, Goyang, Korea
| | - Soon Beom Kang
- Department of Obstetrics and Gynecology, Hosan Women's Hospital, Seoul, Korea
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Kogan EA, Unanyan AL, Namiot VA, Baburin DV, Udaltsov SN. A Precision Approach to the Diagnosis and Choice of Tactics in the Treatment of Endometrial Hyperplasia in Perimenopause. Biophysics (Nagoya-shi) 2019. [DOI: 10.1134/s0006350919040055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Suidan RS, He W, Sun CC, Zhao H, Fleming ND, Ramirez PT, Soliman PT, Westin SN, Lu KH, Giordano SH, Meyer LA. Impact of body mass index and operative approach on surgical morbidity and costs in women with endometrial carcinoma and hyperplasia. Gynecol Oncol 2017; 145:55-60. [PMID: 28131529 PMCID: PMC5557389 DOI: 10.1016/j.ygyno.2017.01.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 01/18/2017] [Accepted: 01/20/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the impact of body mass index (BMI) and operative approach on surgical morbidity and costs in patients with endometrial carcinoma (EC) and hyperplasia (EH). METHODS All women with BMI data who underwent surgery for EC or EH from 2008 to 2014 were identified from MarketScan, a healthcare claims database. Differences in 30-day complications and costs were compared between BMI groups and stratified by surgical modality. RESULTS Of 1112 patients, 35%, 36%, and 29% had a BMI of ≤29, 30-39, and ≥40kg/m2, respectively. Compared to patients with a BMI of 30-39 and ≤29, women with a BMI ≥40 had higher rates of venous thromboembolism (3% vs 0.2% vs 0.3%, p<0.01) and wound infection (7% vs 3% vs 3%, p=0.02). This increase was driven by the subset of patients who had laparotomy and was not seen in those undergoing minimally invasive surgery (MIS). Median total costs for women with a BMI ≥40, 30-39, and ≤29 were U.S. $17.3k, $16.8k, and $16.6k respectively (p=0.53). Costs were higher for patients who had laparotomy than those who had MIS across all BMI groups, with the cost difference being highest in morbidly obese women (≥40: $21.6k vs $14.9k, p<0.01; 30-39: $18.9k vs $16.1k, p=0.01; ≤29: $19.3k vs $15k, p<0.01). Patients who had complications had higher costs compared to those who did not, with a higher cost difference in the laparotomy group ($27.7k vs $16.4k, p<0.01) compared to the MIS group ($19.9k vs $15k, p<0.01). CONCLUSIONS MIS may increase the value of care by minimizing complications and decreasing costs. This may be most pronounced in morbidly obese women.
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Affiliation(s)
- Rudy S Suidan
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Weiguo He
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Nicole D Fleming
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Pamela T Soliman
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Shannon N Westin
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Karen H Lu
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
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Rezk M, Masood A, Dawood R. Perimenopausal bleeding: Patterns, pathology, response to progestins and clinical outcome. J OBSTET GYNAECOL 2016; 35:517-21. [PMID: 25383726 DOI: 10.3109/01443615.2014.977781] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This prospective observational study was done on 400 perimenopausal patients who presented with abnormal uterine bleeding with selective endometrial lesions diagnosed on histopathology. Patients were followed to determine their response to progestin therapy and their final clinical outcome. The commonest bleeding pattern was menorrhagia (67.5%), the commonest pathology was simple endometrial hyperplasia without atypia (31%). 142 cases with non- atypical endometrial hyperplasia received progestin therapy with follow up, 100 cases (70.4%) experienced lesion regression, 38 cases (26.7%) experienced persistence and four cases (2.9%) experienced progression to atypia. Low dose progestin therapy (< 20 mg/day) was more effective when used for 4-5 months. Hysterectomy was done for 44 cases, due to atypical endometrial hyperplasia, persistence and progression of non atypical hyperplasia. Perimenopausal bleeding is mostly dysfunctional in origin but organic lesions remained a major concern which requires endometrial sampling with proper interpretation to achieve better clinical outcome.
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Affiliation(s)
- M Rezk
- a Department of Obstetrics and Gynecology , Faculty of Medicine, Menoufia University , Shibin Elkom, Menoufia , Egypt
| | - A Masood
- a Department of Obstetrics and Gynecology , Faculty of Medicine, Menoufia University , Shibin Elkom, Menoufia , Egypt
| | - R Dawood
- a Department of Obstetrics and Gynecology , Faculty of Medicine, Menoufia University , Shibin Elkom, Menoufia , Egypt
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Ørbo A, Arnes M, Lyså LM, Borgfeldt C, Straume B. HE4 is a novel tissue marker for therapy response and progestin resistance in medium- and low-risk endometrial hyperplasia. Br J Cancer 2016; 115:725-30. [PMID: 27537387 PMCID: PMC5023780 DOI: 10.1038/bjc.2016.247] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/04/2016] [Accepted: 07/12/2016] [Indexed: 11/12/2022] Open
Abstract
Background: The aim of the present study was to investigate whether changes in the tissue expression of human epididymis-specific protein 4 (HE4) could predict therapy resistance and relapse after progestin hormone therapy for medium- and low-risk endometrial hyperplasia. Methods: Endometrial biopsies were obtained from women participating in a multicentre RCT performed according to the CONSORT guidelines; the women were randomly assigned to either LNG-IUS; 10 mg of oral medroxyprogesterone acetate (MPA) administered for 10 days per cycle; or 10 mg of oral MPA administered daily for 6 months. Of the 153 women who completed therapy, 141 had adequate material for immunohistochemistry in pre- and post-treatment biopsies. An antibody to HE4 (clone 12A2 monoclonal IgG1 antibody, Fujirebio Diagnostics, Inc.) was used for the immunohistochemical staining of the pre- and post-treatment biopsies from each participant. The expression of HE4 staining was evaluated by the histological score (H-score) using light microscopy. Results: Changes in the expression of HE4 (H-score) during therapy were related to the therapy group (P<0.001) and therapy response (P<0.001) of the individuals but could not predict relapse (P>0.05). Changes in the intracellular bodies were shown to predict both the therapy response (P=0.038) and relapse (P=0.014). Conclusions: Changes in the expression of HE4 during progestin therapy regimens can predict therapy response or indicate progestin resistance for medium- and low-risk endometrial hyperplasia.
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Affiliation(s)
- Anne Ørbo
- Department of Clinical Pathology, University Hospital of Tromsø, N-9038 Tromsø, Norway.,Research Group for Gynaecologic Oncology, Department of Medical Biology, Faculty of Health Sciences, University of Tromsø, N-9037 Tromsø, Norway
| | - Marit Arnes
- Research Group for Gynaecologic Oncology, Department of Medical Biology, Faculty of Health Sciences, University of Tromsø, N-9037 Tromsø, Norway
| | - Lena Myreng Lyså
- Department of Clinical Pathology, University Hospital of Tromsø, N-9038 Tromsø, Norway
| | - Christer Borgfeldt
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund, Sweden
| | - Bjørn Straume
- Department of Community Medicine, Faculty of Health Sciences, University of Tromsø, N-9037 Tromsø, Norway
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Bourdel N, Chauvet P, Tognazza E, Pereira B, Botchorishvili R, Canis M. Sampling in Atypical Endometrial Hyperplasia: Which Method Results in the Lowest Underestimation of Endometrial Cancer? A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2016; 23:692-701. [DOI: 10.1016/j.jmig.2016.03.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 03/22/2016] [Accepted: 03/22/2016] [Indexed: 11/25/2022]
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Nooh AM, Abdeldayem HM, Girbash EF, Arafa EM, Atwa K, Abdel-Raouf SM. Depo-Provera Versus Norethisterone Acetate in Management of Endometrial Hyperplasia Without Atypia. Reprod Sci 2015; 23:448-54. [DOI: 10.1177/1933719115623643] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Ahmed Mohamed Nooh
- Obstetrics and Gynecology Department, Zagazig University Students’ Hospital, Zagazig, Egypt
| | | | - Ehab F. Girbash
- Obstetrics and Gynecology Department, Zagazig University Faculty of Medicine, Zagazig, Egypt
| | - Essa M. Arafa
- Obstetrics and Gynecology Department, Zagazig University Faculty of Medicine, Zagazig, Egypt
| | - Khalid Atwa
- Obstetrics and Gynecology Department, Suez Canal University Faculty of Medicine, Ismailia, Egypt
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Kim MK, Seong SJ, Lee TS, Ki KD, Lim MC, Kim YH, Kim K, Joo WD. Comparison of diagnostic accuracy between endometrial curettage and pipelle aspiration biopsy in patients treated with progestin for endometrial hyperplasia: a Korean Gynecologic Oncology Group Study (KGOG 2019). Jpn J Clin Oncol 2015. [PMID: 26206899 DOI: 10.1093/jjco/hyv106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
A prospective multicenter trial has been started in Korea to evaluate the diagnostic accuracy of endometrial aspiration biopsy compared with dilatation and curettage in patients treated with progestin for endometrial hyperplasia. For conservative treatment of endometrial hyperplasia, orally administered progestins are most commonly used method with various treatment regimens and more recently, the levonorgestrel-releasing intrauterine system also has been used successfully to treat endometrial hyperplasia. However, there is no report about the accuracy of endometrial sampling during hormonal treatment for follow-up evaluation of endometrial hyperplasia. Patients with histologically confirmed endometrial hyperplasia are offered hormonal treatment with any one of the following three options: oral medroxyprogesterone acetate 10 mg/day for 14 days per cycle, continuous oral medroxyprogesterone acetate 10 mg/day or insertion of levonorgestrel-releasing intrauterine system. Histological surveillance is performed at 3 months or 6 months following initial treatment. Endometrial tissues are obtained via endometrial aspiration biopsy using a pipelle and dilatation and curettage. In the case of levonorgestrel-releasing intrauterine system, endometrial aspiration biopsy will be done with levonorgestrel-releasing intrauterine system in uterus and then, after the removal of levonorgestrel-releasing intrauterine system, dilatation and curettage will be done. The biopsy findings will be compared. The primary endpoint is to compare the pathological outcome of endometrial aspiration with dilatation and curettage. The secondary endpoint is the response rate with three types of progestin treatment at 6 months.
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Affiliation(s)
- Mi Kyoung Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul
| | - Seok Ju Seong
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul
| | - Taek Sang Lee
- Department of Obstetrics and Gynecology, SMG-SNU Boramae Medical Center, Seoul
| | - Kyung-Do Ki
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Seoul
| | - Myong Cheol Lim
- Center for Uterine Cancer and Gynecologic Cancer Branch, National Cancer Center, Goyang
| | - Yun Hwan Kim
- Department of Obstetrics and Gynecology, Ewha Womans University College of Medicine, Seoul
| | - Kidong Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam
| | - Won Duk Joo
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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Management of Endometrial Hyperplasia: A Survey of Members of the Korean Gynecologic Oncology Group. Int J Gynecol Cancer 2015; 25:1277-84. [PMID: 26067858 DOI: 10.1097/igc.0000000000000483] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES This study aimed to investigate the current management of endometrial hyperplasia (EH) in Korea. MATERIALS AND METHODS This was an electronic survey, which included 40 questions, that was distributed to the members of the Korean Gynecologic Oncology Group in 2014. RESULTS In total, 50 (69%) of 72 members responded to the survey. The oral progestogens were the most popular choices for managing EH without atypia (simple hyperplasia(SH), 64%; complex hyperplasia (CH), 52%). In the case of CH with atypia, most of the gynecologist respondents would perform hysterectomy (95.9%). For fertility preservation, the oral progestogens were the most popular choices (SH, 75.5%; CH, 56.3%), followed by the levonorgestrel-releasing intrauterine system (LNG-IUS). More than 70% of the respondents reported use of dilatation and curettage as a follow-up method. CONCLUSIONS Our survey results show that most of Korean gynecologic oncologists still prefer oral progestogens for conservative management of EH, notwithstanding the many successful reports on the LNG-IUS. As a follow-up evaluation method, dilatation and curettage is mostly used. To identify the optimum therapy, a randomized controlled trial comparing the LNG-IUS with continuous oral progestogens is required. Furthermore, a large-scale prospective study to confirm the most reliable technique for follow-up evaluation is necessary.
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Emarh M. Cyclic versus continuous medroxyprogesterone acetate for treatment of endometrial hyperplasia without atypia: a 2-year observational study. Arch Gynecol Obstet 2015; 292:1339-43. [PMID: 26015309 DOI: 10.1007/s00404-015-3749-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 05/11/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess the efficacy, safety and acceptability of cyclic medroxyprogesterone acetate (MPA) compared to continuous MPA for treatment of endometrial hyperplasia (EH) without atypia. MATERIALS AND METHODS A prospective observational study conducted on premenopausal women with EH without atypia (n = 80) who were randomly assigned into two groups; 40 patients received cyclic 15 mg MPA and 40 patients received continuous 15 mg MPA. Follow-up endometrial sampling was done after 6 months. Primary outcome measure was regression of hyperplasia. Secondary outcome measures include side effects and patient acceptability. RESULTS There was no significant difference between the two groups regarding regression of endometrial hyperplasia (90 % in the cyclic MPA group in comparison to 82.5 % in the continuous MPA group with p value >0.05). There was a significant higher women suffering from nausea, acne and menstrual changes in the continuous MPA group (p value <0.05). Cyclic MPA regimen was more acceptable to the patients in comparison to continuous MPA intake. CONCLUSIONS Cyclic MPA regimen seems a safer and more acceptable therapy in comparison to continuous MPA regimen in patients with endometrial hyperplasia without atypia. Larger studies are warranted to confirm these results.
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Affiliation(s)
- Mohamed Emarh
- Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt.
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Shukla V, Chandra V, Sankhwar P, Popli P, Kaushal JB, Sirohi VK, Dwivedi A. Phytoestrogen genistein inhibits EGFR/PI3K/NF-kB activation and induces apoptosis in human endometrial hyperplasial cells. RSC Adv 2015; 5:56075-56085. [DOI: 10.1039/c5ra06167a] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2025] Open
Abstract
Endometrial hyperplasia is an estrogen-dependent disease and is the most frequent precursor of endometrial cancer, diagnosed in pre- and peri-menopausal women.
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Affiliation(s)
- Vinay Shukla
- Division of Endocrinology
- CSIR-Central Drug Research Institute
- Lucknow-226031
- India
| | - Vishal Chandra
- Division of Endocrinology
- CSIR-Central Drug Research Institute
- Lucknow-226031
- India
| | - Pushplata Sankhwar
- Department of Obstetrics and Gynecology
- King George's Medical University
- Lucknow-226001
- India
| | - Pooja Popli
- Division of Endocrinology
- CSIR-Central Drug Research Institute
- Lucknow-226031
- India
| | - Jyoti Bala Kaushal
- Division of Endocrinology
- CSIR-Central Drug Research Institute
- Lucknow-226031
- India
| | - Vijay Kumar Sirohi
- Division of Endocrinology
- CSIR-Central Drug Research Institute
- Lucknow-226031
- India
| | - Anila Dwivedi
- Division of Endocrinology
- CSIR-Central Drug Research Institute
- Lucknow-226031
- India
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Smith PP, O'Connor S, Gupta J, Clark TJ. Recurrent Postmenopausal Bleeding: a Prospective Cohort Study. J Minim Invasive Gynecol 2014; 21:799-803. [DOI: 10.1016/j.jmig.2014.03.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 03/04/2014] [Accepted: 03/06/2014] [Indexed: 11/27/2022]
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Abstract
Progesterone plays an essential role in the maintenance of the endometrium; it prepares the endometrium for pregnancy, promotes decidualization, and inhibits estrogen-dependent proliferation. Progesterone function is often dysregulated in endometrial disease states. In addition, the PI3K/AKT signaling pathway is often overactive in endometrial pathologies and promotes the survival and proliferation of the diseased cells. Understanding how AKT influences progesterone action is critical in improving hormone-based therapies in endometrial pathologies. Here, we summarize recent studies investigating the crosstalk between the AKT pathway and progesterone receptor function in endometriosis and endometrial cancer.
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Affiliation(s)
- Irene I Lee
- Division of Reproductive Science in Medicine, Department of Obstetrics and Gynecology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - J Julie Kim
- Division of Reproductive Science in Medicine, Department of Obstetrics and Gynecology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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El Behery MM, Saleh HS, Ibrahiem MA, Kamal EM, Kassem GA, Mohamed MES. Levonorgestrel-Releasing Intrauterine Device Versus Dydrogesterone for Management of Endometrial Hyperplasia Without Atypia. Reprod Sci 2014; 22:329-34. [DOI: 10.1177/1933719114542014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Manal M. El Behery
- Department of Obstetrics & Gynecology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hend S. Saleh
- Department of Obstetrics & Gynecology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Moustafa A. Ibrahiem
- Department of Obstetrics & Gynecology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ebtesam M. Kamal
- Department of Obstetrics & Gynecology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Gamal A. Kassem
- Department of Obstetrics & Gynecology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Brownfoot FC, Hickey M, Ang WC, Arora V, McNally O. Complex atypical hyperplasia of the endometrium: differences in outcome following conservative management of pre- and postmenopausal women. Reprod Sci 2014; 21:1244-8. [PMID: 24516039 DOI: 10.1177/1933719114522517] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare the safety and regression rates of conservative treatments for complex atypical hyperplasia (CAH) between pre- and postmenopausal women. METHODS Historical cohort study of pre- and postmenopausal women with CAH managed conservatively at one center (Royal Women's Hospital, Melbourne, Australia) between September 1999 to June 2012. RESULTS Of the 153 women with CAH, 92 (60%) underwent hysterectomy and the remaining 61 were managed conservatively with oral or intrauterine progestogen: 42 were premenopausal and 19 were postmenopausal. Within 12 months, 32 (76%) premenopausal women demonstrated regression of CAH and none developed endometrial cancer. In contrast, only 4 (21%) postmenopausal women showed disease regression and 4 (21%) progressed to endometrial cancer. Over a median of 24 months, 3 premenopausal women relapsed with CAH and 2 developed endometrial cancer. Four premenopausal women had successful pregnancies. CONCLUSION Conservative treatment with progestogen in premenopausal women with CAH leads to high regression rates within the first 12 months. In contrast, postmenopausal women have high rates of ongoing disease and cancer progression and conservative therapy should be avoided.
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Affiliation(s)
- Fiona C Brownfoot
- Department of Obstetrics and Gynaecology, University of Melbourne, Royal Women's Hospital, Parkville, Melbourne, Victoria, Australia
| | - Martha Hickey
- Department of Obstetrics and Gynaecology, University of Melbourne, Royal Women's Hospital, Parkville, Melbourne, Victoria, Australia
| | - W Catarina Ang
- Department of Gynaecology, Royal Women's Hospital, Parkville, Melbourne, Victoria, Australia
| | - Vivek Arora
- Department of Gynaecological Oncology, Royal Women's Hospital, Parkville, Melbourne, Victoria, Australia
| | - Orla McNally
- Department of Gynaecological Oncology, Royal Women's Hospital, Parkville, Melbourne, Victoria, Australia
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Orbo A, Vereide A, Arnes M, Pettersen I, Straume B. Levonorgestrel-impregnated intrauterine device as treatment for endometrial hyperplasia: a national multicentre randomised trial. BJOG 2013; 121:477-86. [PMID: 24286192 PMCID: PMC4155866 DOI: 10.1111/1471-0528.12499] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2013] [Indexed: 11/28/2022]
Abstract
Objective The purpose of this study was to investigate if the levonorgestrel-impregnated intrauterine device (LNG-IUS, Mirena®) is safe and effective as therapy for low-risk and medium-risk endometrial hyperplasia compared with oral medroxyprogesterone (MPA). Design A multicentre randomised trial. Setting Norway. Population In all, 170 women aged 30–70 years with low- or medium-risk endometrial hyperplasia who met inclusion criteria. Methods Patients were randomly assigned to one of three treatment arms: LNG-IUS; oral MPA 10 mg administered for 10 days per cycle, or continuous oral MPA 10 mg daily, for 6 months. Main outcome measures The primary outcome measure was normalisation or persisting hyperplasia. Results After 6 months all three treatment regimens showed significant effect when the outcome was evaluated as therapy response or not (P < 0.001). Responses were obtained for all the women in the LNG-IUS group (53/53, 95% CI 0.93–1.0) and for 96% of the women in the continuous oral group (46/48, 95% CI 0.86–0.99). Only 69% of the women in the cyclic oral group were responders (36/52, 95% CI 0.55–0.81). Adverse effects were relatively common with minimal differences between therapy groups. Conclusion In the first trial of its kind, women treated with the LNG-IUS showed histologically normal endometrium after 6 months of therapy for endometrial hyperplasia. Cyclical progestogens are found to be less effective compared with continuous oral therapy and LNG-IUS and should not be used for this purpose.
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Affiliation(s)
- A Orbo
- Department of Clinical Pathology, University Hospital of North Norway, Tromsø, Norway; Research group for Gynaecological Cancer, Department of Medical Biology, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
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Gallos ID, Krishan P, Shehmar M, Ganesan R, Gupta JK. LNG-IUS versus oral progestogen treatment for endometrial hyperplasia: a long-term comparative cohort study. Hum Reprod 2013; 28:2966-71. [DOI: 10.1093/humrep/det320] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Clinical applications of levonorgestrel-releasing intrauterine system to gynecologic diseases. Obstet Gynecol Sci 2013; 56:67-75. [PMID: 24327984 PMCID: PMC3784091 DOI: 10.5468/ogs.2013.56.2.67] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 02/13/2013] [Accepted: 02/13/2013] [Indexed: 01/01/2023] Open
Abstract
The levonorgestrel-releasing intrauterine system (LNG-IUS), originally designed for contraception, has since been applied to various gynecologic diseases. This article summarizes the current status of clinical applications of LNG-IUS to the treatment of gynecologic diseases such as heavy menstrual bleeding, endometriosis, leiomyoma, adenomyosis, endometrial hyperplasia, and early-stage endometrial cancer.
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Kang S. Coexisting carcinoma in endometrial hyperplasia: does more risk factor mean better discrimination? J Gynecol Oncol 2013; 24:1-2. [PMID: 23346307 PMCID: PMC3549501 DOI: 10.3802/jgo.2013.24.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 12/18/2012] [Indexed: 11/30/2022] Open
Affiliation(s)
- Sokbom Kang
- Branch of Gynecologic Cancer Research, National Cancer Center, Goyang, Korea
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Clinical Outcome of Atypical Endometrial Hyperplasia Diagnosed on an Endometrial Biopsy. Am J Surg Pathol 2012; 36:1683-90. [DOI: 10.1097/pas.0b013e31825dd4ff] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Upson K, Allison KH, Reed SD, Jordan CD, Newton KM, Swisher EM, Doherty JA, Garcia RL. Biomarkers of progestin therapy resistance and endometrial hyperplasia progression. Am J Obstet Gynecol 2012; 207:36.e1-8. [PMID: 22727345 DOI: 10.1016/j.ajog.2012.05.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 04/12/2012] [Accepted: 05/10/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We sought to identify biomarkers associated with progestin therapy resistance and persistence/progression of endometrial hyperplasia. STUDY DESIGN We performed a nested case-control study among women with complex (n = 73) and atypical (n = 41) hyperplasia treated with oral progestin, followed up 2-6 months for persistence/progression. We evaluated index endometrial protein expression for progesterone receptor isoform A, progesterone receptor isoform B (PRB), PTEN, Pax-2, and Bcl-2. Odds ratios and 95% confidence intervals (CIs) were estimated. RESULTS Among women with atypical hyperplasia, high PRB expression was associated with 90% decreased risk of persistence/progression (95% CI, 0.01-0.8). High expression of progesterone receptor A and PRB suggested decreased risk of persistence/progression (odds ratio, 0.1; 95% CI, 0.02-1.0). These findings were not observed among women with complex hyperplasia. No associations were found with PTEN, Pax-2, and Bcl-2 protein expression. CONCLUSION PRB expression shows promise as a biomarker of progestin response. Further research is warranted to understand how PRB expression may guide treatment decisions.
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Affiliation(s)
- Kristen Upson
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA.
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Eddib A, Allaf B, Lee J, Yeh J. Risk for Advanced-Stage Endometrial Cancer in Surgical Specimens from Patients with Complex Endometrial Hyperplasia with Atypia. Gynecol Obstet Invest 2012; 73:38-42. [DOI: 10.1159/000329326] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 05/03/2011] [Indexed: 11/19/2022]
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Efficacy of oral or intrauterine device-delivered progestin in patients with complex endometrial hyperplasia with atypia or early endometrial adenocarcinoma: a meta-analysis and systematic review of the literature. Gynecol Oncol 2011; 125:263-70. [PMID: 22196499 DOI: 10.1016/j.ygyno.2011.11.043] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 11/21/2011] [Accepted: 11/23/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To investigate the efficacy of progestin treatment to achieve pathological complete response (pCR) in patients with complex atypical endometrial hyperplasia (CAH) or early endometrial adenocarcinoma (EC). METHODS A systematic search identified 3245 potentially relevant citations. Studies containing less than ten eligible CAH or EC patients in either oral or intrauterine treatment arm were excluded. Only information from patients receiving six or more months of treatment and not receiving other treatments was included. Weighted proportions of patients achieving pCR were calculated using R software. RESULTS Twelve studies met the selection criteria. Eleven studies reported treatment of patients with oral (219 patients, 117 with CAH, 102 with grade 1 Stage I EC) and one reported treatment of patients with intrauterine progestin (11 patients with grade 1 Stage IEC). Overall, 74% (95% confidence interval [CI] 65-81%) of patients with CAH and 72% (95% CI 62-80%) of patients with grade 1 Stage I EC achieved a pCR to oral progestin. Disease progression whilst on oral treatment was reported for 6/219 (2.7%), and relapse after initial complete response for 32/159 (20.1%) patients. The weighted mean pCR rate of patients with grade 1 Stage I EC treated with intrauterine progestin from one prospective pilot study and an unpublished retrospective case series from the Queensland Centre of Gynaecologic Oncology (QCGC) was 68% (95% CI 45-86%). CONCLUSIONS There is a lack of high quality evidence for the efficacy of progestin in CAH or EC. The available evidence however suggests that treatment with oral or intrauterine progestin is similarly effective. The risk of progression during treatment is small but longer follow-up is required. Evidence from prospective controlled clinical trials is warranted to establish how the efficacy of progestin for the treatment of CAH and EC can be improved further.
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Current management of endometrial hyperplasia—a survey of United Kingdom consultant gynaecologists. Eur J Obstet Gynecol Reprod Biol 2011; 158:305-7. [DOI: 10.1016/j.ejogrb.2011.05.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 05/12/2011] [Accepted: 05/13/2011] [Indexed: 11/23/2022]
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Abstract
Endometrial cancer covers several different types, the most prevalent in the developed world being endometrioid adenocarcinoma, which is estrogen-dependent and has a better prognosis compared to the non-estrogen-dependent types, e.g. papillary serous adenocarcinoma and clear cell carcinomas. Prognosis is also dependent on tumor differentiation and stage, and treatment should be adjusted accordingly. In this paper, the different types of endometrial cancer, staging, prognosis, diagnosis, prevention, treatment and their relationship to estrogen and other female hormones are reviewed.
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Affiliation(s)
- L S G Ulrich
- Department of Gynecology and Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Gallos ID, Shehmar M, Thangaratinam S, Papapostolou TK, Coomarasamy A, Gupta JK. Oral progestogens vs levonorgestrel-releasing intrauterine system for endometrial hyperplasia: a systematic review and metaanalysis. Am J Obstet Gynecol 2010; 203:547.e1-10. [PMID: 20934679 DOI: 10.1016/j.ajog.2010.07.037] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Revised: 05/22/2010] [Accepted: 07/21/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To conduct a systematic review and metaanalysis of studies evaluating the regression rate of endometrial hyperplasia with oral progestogens and levonorgestrel-releasing intrauterine system. STUDY DESIGN Searches were conducted on Medline, Embase, Cochrane Library, and Web of Science, and reference lists of relevant articles were examined. The methodologic index for nonrandomized studies was used for quality assessment. Metaanalysis was performed with random effects model. RESULTS There were 24 observational studies (1001 women), of low methodologic quality, evaluating the outcome of regression of endometrial hyperplasia with oral progestogens or levonorgestrel-releasing intrauterine system. Metaanalysis showed that oral progestogens achieved a lower pooled regression rate compared with levonorgestrel-releasing intrauterine system for complex (pooled rate, 66% vs 92%; P < .01) and atypical hyperplasia (pooled rate, 69% vs 90%; P = .03). There was no statistical difference in simple hyperplasia (pooled rate, 89% vs 96%; P = .41). CONCLUSION Oral progestogens appear to induce a lower disease regression rate than Levonorgestrel-releasing intrauterine system in the treatment of endometrial hyperplasia.
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Huang EC, Mutter GL, Crum CP, Nucci MR. Clinical outcome in diagnostically ambiguous foci of 'gland crowding' in the endometrium. Mod Pathol 2010; 23:1486-91. [PMID: 20676062 DOI: 10.1038/modpathol.2010.140] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Premalignant endometrial lesions (endometrial intraepithelial neoplasia (EIN)) are clonal neoplasms that arise focally and can be diagnosed using specific criteria: (1) area of glands exceeds that of stroma (glands/stroma >1), (2) nuclear and/or cytoplasmic features of epithelial cells differ between architecturally abnormal glands and normal background glands, and (3) maximum linear dimension exceeds 1 mm. However, localized groups of crowded endometrial glands may be encountered that do not fulfill all of the criteria for EIN, are interpreted as ambiguous, and are reported as 'focal gland crowding'. We conducted a retrospective study of gland crowding using a free-text index search for this term in our pathology files. The age of the patients, number of subsequent specimens, the duration, and the outcome of the follow-ups were recorded. Of the 71,579 consecutive gynecological pathology reports, 206 (0.3%) 'gland crowding' cases were identified, in which 69% (143/206) had follow-up sampling. Of these, 33 (23%) had an outcome diagnosis of EIN (27 cases; 19%) or carcinoma (6 cases; 4%). Included were 18 cases (55%) diagnosed within the first year and presumed concurrent, and an additional 15 (45%) discovered after 1 year and interpreted as a later phase of disease or new events. The term 'crowded glands' is a highly significant finding that carries a substantial risk of an outcome of EIN and occasionally malignancy. It underscores the importance of follow-up when some but not all of the criteria for EIN are encountered in the appropriate clinical setting.
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Affiliation(s)
- Eric C Huang
- Division of Women's and Perinatal Pathology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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31
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Reed SD, Newton KM, Garcia RL, Allison KH, Voigt LF, Jordan CD, Epplein M, Swisher E, Upson K, Ehrlich KJ, Weiss NS. Complex hyperplasia with and without atypia: clinical outcomes and implications of progestin therapy. Obstet Gynecol 2010; 116:365-373. [PMID: 20664397 PMCID: PMC2949551 DOI: 10.1097/aog.0b013e3181e93330] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Limited data exist to inform clinicians and patients as to the likelihood of long-term endometrial hyperplasia response to progestin therapy, especially for atypical hyperplasia. We evaluated women with complex and atypical endometrial hyperplasia, comparing those prescribed progestin with those not prescribed progestin. METHODS This retrospective cohort study was conducted in 1985-2005 among women aged 18-88 years at an integrated health plan in Washington State. Women were ineligible if they achieved an outcome (endometrial carcinoma, hysterectomy, or both) within 8 weeks of hyperplasia diagnosis. Exposure was progestin use for at least 14 days by duration and recency. Outcomes included rate of 1) endometrial carcinoma, 2) hysterectomy, or 3) both. Analyses performed included Kaplan-Meier, incident rate ratios, and Cox proportional hazard ratios. RESULTS One thousand four hundred forty-three eligible women were identified. One thousand two hundred one had complex (n=164 no progestin) and 242 had atypical (n=62 no progestin) hyperplasia. During follow-up, a median of 5.3 years (range 8 weeks to 20.8 years), 71 women were diagnosed with endometrial carcinoma (35 complex, 36 atypia) and 323 underwent hysterectomy (216 complex, 107 atypia). Among women with complex and atypical hyperplasia, rates of endometrial carcinoma among progestin users were 3.6 and 20.5 per 1,000 woman-years, respectively (compared with women who did not use progestin, 10.8 and 101.4). Among women with complex and atypical hyperplasia, rates of hysterectomy among progestin users were 23.3 and 61.4 per 1,000 woman-years, respectively (compared with women who did not use progestin, 55.1 and 297.3). CONCLUSION Endometrial carcinoma risk is diminished approximately threefold to fivefold in women diagnosed with complex or atypical endometrial hyperplasia and dispensed progestin; hysterectomy risk is also decreased. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Susan D Reed
- From the Division of Public Health Sciences, Fred Hutchinson Cancer Research Center; the Departments of Obstetrics and Gynecology, Epidemiology, and Pathology, University of Washington, Seattle, Washington; and Group Health Research Institute, Seattle, Washington
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Rice LW. Hormone prevention strategies for breast, endometrial and ovarian cancers. Gynecol Oncol 2010; 118:202-7. [DOI: 10.1016/j.ygyno.2010.03.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Revised: 03/19/2010] [Accepted: 03/25/2010] [Indexed: 10/19/2022]
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Lee SY, Kim MK, Park H, Yoon BS, Seong SJ, Kang JH, Jun HS, Park CT. The effectiveness of levonorgestrel releasing intrauterine system in the treatment of endometrial hyperplasia in Korean women. J Gynecol Oncol 2010; 21:102-5. [PMID: 20613900 DOI: 10.3802/jgo.2010.21.2.102] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2010] [Revised: 03/04/2010] [Accepted: 03/11/2010] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Levonorgestrel releasing intrauterine system (LNG-IUS) has been shown to treat patients with non-atypical & atypical endometrial hyperplasia (EH) successfully in many western studies. Our purpose was to examine the effectiveness of LNG-IUS in the treatment of Korean women with EH. METHODS We conducted a prospective observational study of 12 women diagnosed with EH and treated with LNG-IUS insertion between February 2007 and August 2009 at the Department of Gynecology of Gangnam CHA Hospital, CHA University School of Medicine. Baseline endometrial biopsies were done before insertion of LNG-IUS, and outpatient follow-up endometrial biopsies were undertaken at 3-month intervals after insertion of LNG-IUS. We investigated the regression rate and the time to regression. RESULTS Four patients had simple hyperplasia without atypia, 7 patients complex hyperplasia without atypia, and just 1 patient complex atypical hyperplasia. Complete regression of EH was achieved in all cases (100%, 12/12), with the significant proportion (66%, 8/12) achieving it within 3 months. The mean duration to regression was 4.5 months. All cases had regression within 9 months. In the case of complex atypical hyperplasia, the regression was attained at the 9th month after insertion of LNG-IUS. The mean follow-up duration was 12 months (range, 3 to 27 months). As long as LNG-IUS was maintained, the EH did not recur. CONCLUSION LNG-IUS appears to be as highly effective in treating Korean women with EH.
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Affiliation(s)
- Seo Yeong Lee
- Department of Obstetrics and Gynecology, CHA University School of Medicine, Seoul, Korea
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Salman MC, Usubutun A, Boynukalin K, Yuce K. Comparison of WHO and endometrial intraepithelial neoplasia classifications in predicting the presence of coexistent malignancy in endometrial hyperplasia. J Gynecol Oncol 2010; 21:97-101. [PMID: 20613899 DOI: 10.3802/jgo.2010.21.2.97] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2009] [Revised: 01/17/2010] [Accepted: 01/18/2010] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The most commonly used classification system for endometrial hyperplasia is the World Health Organization system which is based on subjective criteria. Another classification system is endometrial intraepithelial neoplasia (EIN) system which uses diagnostic criteria including cytological demarcation, crowded gland architecture, minimum size of 1 mm, and careful exclusion of mimics, and aims to identify a precancer or cancer. The objective of this study was to compare the two classification systems in terms of predicting the presence of a coexistent cancer in surgically treated patients. METHODS Biopsy and hysterectomy specimens of 49 women who were subjected to surgery with a preoperative diagnosis of endometrial hyperplasia (EH) according to the WHO system were re-evaluated retrospectively by using EIN system. RESULTS Among the 49 patients, 69.4% had complex atypical EH and 75.5% had EIN at biopsy specimens. EIN was detected in 94.1% of complex atypical EH, and 41.7% of non-atypical EH. Nine women (18.4%) had endometrial cancer. Among women with cancer, all had complex atypical EH or EIN. The rate of coexistent endometrial cancer was 26.5% in women with complex atypical EH and 24.3% in women with EIN. CONCLUSION Diagnoses of atypical or complex atypical EH and EIN had similar sensitivities and negative predictive values in predicting the coexistent endometrial cancer. Either of these two classification systems may be used safely when an experienced pathologist is available. However, use of the objective EIN system may be preferred whenever possible to prevent diagnostic errors in centers where an experienced pathologist is not available.
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Affiliation(s)
- Mehmet Coskun Salman
- Department of Obstetrics and Gynecology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Use of contraceptive methods among women with endometrial hyperplasia: a systematic review. Contraception 2010; 82:56-63. [PMID: 20682143 DOI: 10.1016/j.contraception.2010.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 02/02/2010] [Indexed: 11/24/2022]
Abstract
BACKGROUND The objective of this systematic review is to evaluate the evidence for the safety of contraceptive use among women with endometrial hyperplasia. STUDY DESIGN We searched the PubMed database for peer-reviewed articles published in any language from database inception through February 2009 concerning the safety of using any contraceptive method among women diagnosed with endometrial hyperplasia. We excluded case reports but included all other study designs. The quality of each individual piece of evidence was assessed using the United States Preventive Services Task Force grading system. RESULTS We identified nine articles that met the criteria for review. Each study examined levonorgestrel intrauterine devices (LNG-IUDs); no studies were identified that examined other contraceptive methods. Overall, these studies suggest that LNG-IUD use is not associated with adverse health events among women diagnosed with endometrial hyperplasia. Disease regression with LNG-IUD use was observed in all women in seven studies, in 90% of women in one study, and in 67% of women in one study. Limitations of the studies include small sample sizes and lack of a comparison group or nonrandomized assignment to LNG-IUD. CONCLUSIONS There is fair quality evidence indicating that use of the LNG-IUD is safe for women with endometrial hyperplasia and may have therapeutic benefits.
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Abstract
Progesterone is a key hormone in the endometrium that opposes estrogen-driven growth. Insufficient progesterone will result in unopposed estrogen action that could lead to the development of endometrial hyperplasia and adenocarcinoma. Although these endometrial neoplasias can regress in response to progestin treatment, this does not occur in all instances. To understand this resistance to progesterone and to improve on existing hormonal therapies, it is imperative that the molecular mechanisms of progesterone action through its receptor be deciphered in endometrial cancer. This review highlights what is known thus far regarding the efficacy of progestin therapy in the clinic and the role of progesterone in endometrial cancer cell behavior and gene regulation.
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Affiliation(s)
- J Julie Kim
- Department Obstetrics and Gynecology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois 60611, USA.
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Lacey JV, Sherman ME, Rush BB, Ronnett BM, Ioffe OB, Duggan MA, Glass AG, Richesson DA, Chatterjee N, Langholz B. Absolute risk of endometrial carcinoma during 20-year follow-up among women with endometrial hyperplasia. J Clin Oncol 2010; 28:788-92. [PMID: 20065186 DOI: 10.1200/jco.2009.24.1315] [Citation(s) in RCA: 157] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The severity of endometrial hyperplasia (EH)-simple (SH), complex (CH), or atypical (AH)-influences clinical management, but valid estimates of absolute risk of clinical progression to carcinoma are lacking. Materials and METHODS We conducted a case-control study nested in a cohort of 7,947 women diagnosed with EH (1970-2002) at one prepaid health plan who remained at risk for at least 1 year. Patient cases (N = 138) were diagnosed with carcinoma, on average, 6 years later (range, 1 to 24 years). Patient controls (N = 241) were matched to patient cases on age at EH, date of EH, and duration of follow-up, and they were counter-matched to patient cases on EH severity. After we independently reviewed original slides and medical records of patient controls and patient cases, we combined progression relative risks (AH v SH, CH, or disordered proliferative endometrium [ie, equivocal EH]) from the case-control analysis with clinical censoring information (ie, hysterectomy, death, or left the health plan) on all cohort members to estimate interval-specific (ie, 1 to 4, 5 to 9, and 10 to 19 years) and cumulative (ie, through 4, 9, and 19 years) progression risks. Results For nonatypical EH, cumulative progression risk increased from 1.2% (95% CI, 0.6% to 1.9%) through 4 years to 1.9% (95% CI, 1.2% to 2.6%) through 9 years to 4.6% (95% CI, 3.3% to 5.8%) through 19 years after EH diagnosis. For AH, cumulative risk increased from 8.2% (95% CI, 1.3% to 14.6%) through 4 years to 12.4% (95% CI, 3.0% to 20.8%) through 9 years to 27.5% (95% CI, 8.6% to 42.5%) through 19 years after AH. CONCLUSION Cumulative 20-year progression risk among women who remain at risk for at least 1 year is less than 5% for nonatypical EH but is 28% for AH.
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Affiliation(s)
- James V Lacey
- City of Hope, 1500 East Duarte Rd, Duarte, CA 91010-3000, USA.
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Beatty MN, Blumenthal PD. The levonorgestrel-releasing intrauterine system: Safety, efficacy, and patient acceptability. Ther Clin Risk Manag 2009; 5:561-74. [PMID: 19707273 PMCID: PMC2724187 DOI: 10.2147/tcrm.s5624] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The levonorgestrel-releasing intrauterine system (LNG-IUS) is a safe, effective and acceptable form of contraception used by over 150 million women worldwide. It also has a variety of noncontraceptive benefits including treatment for menorrhagia, endometriosis, and endometrial hyperplasia. The LNG-IUS has also been used in combination with estrogen for hormone replacement therapy and as an alternative to hysterectomy. Overall, the system is very well tolerated and patient satisfaction is quite high when proper education regarding possible side effects is provided. However, despite all of the obvious benefits of the LNG-IUS, utilization rates remain quite low in the developed countries, especially in the United States. This is thought to be largely secondary to the persistent negative impressions from the Dalkon Shield intrauterine experience in the 1970s. This history continues to negatively influence the opinions of both patients and health care providers with regards to intrauterine devices. Providers should resolve to educate themselves and their patients on the current indications and uses for this device, as it, and intrauterine contraception in general, remains a largely underutilized approach to a variety of women’s health issues.
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Affiliation(s)
- Megan N Beatty
- Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA
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Lacey JV, Mutter GL, Nucci MR, Ronnett BM, Ioffe OB, Rush BB, Glass AG, Richesson DA, Chatterjee N, Langholz B, Sherman ME. Risk of subsequent endometrial carcinoma associated with endometrial intraepithelial neoplasia classification of endometrial biopsies. Cancer 2008; 113:2073-81. [PMID: 18720479 PMCID: PMC2587088 DOI: 10.1002/cncr.23808] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Histopathologic diagnosis of endometrial biopsies is used to estimate the risk of progression to carcinoma and guide clinical management. Problems with the widely used World Health Organization (WHO) system for classifying endometrial hyperplasia (EH) have prompted the development of an alternative system based on endometrial intraepithelial neoplasia (EIN). The authors estimated progression risk associated with EIN among endometrial biopsies in a nested case-control study of EH progression. METHODS Index biopsies with original community pathology diagnoses of disordered proliferative endometrium (DPEM) or EH that were independently confirmed by a panel of pathologists were independently reviewed and assigned EIN classifications (inadequate, benign, EIN, or cancer) by a second panel of pathologists. Cases (N = 138) progressed to carcinoma at least 1 year (median, 6 years) after their index biopsy. Controls (N = 241) also had EH, did not progress to carcinoma, and were individually matched to cases based on age at EH, date of EH, and length of follow-up. By using conditional logistic regression, the authors estimated relative risks (RRs) with 95% confidence intervals (95% CIs) for progression to carcinoma for EIN versus benign. RESULTS In the EIN system, 71 (52.6%) cases and 159 (66.8%) controls were classified as benign and 42 (31.1%) cases and 65 (27.3%) controls were classified as EIN. The RR for EIN versus benign was 7.76 (95% CI, 3.36-17.91). In the WHO system, the RR for atypical hyperplasia (AH) versus DPEM, simple hyperplasia, or complex hyperplasia was 9.19 (95% CI, 3.87-21.83). CONCLUSIONS Among women observed for at least 1 year after receiving a biopsy-based EH diagnosis, EIN and AH were both found to have similarly increased risks of progression to carcinoma.
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Affiliation(s)
- James V Lacey
- Hormonal and Reproductive Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland 20852-7234, USA.
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The effectiveness of a levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of endometrial hyperplasia—A long-term follow-up study. Eur J Obstet Gynecol Reprod Biol 2008; 139:169-75. [DOI: 10.1016/j.ejogrb.2008.02.022] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Revised: 12/14/2007] [Accepted: 02/23/2008] [Indexed: 11/23/2022]
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Lacey JV. Invited Commentary: Endometrial Hyperplasia--Getting Back to Normal. Am J Epidemiol 2008. [DOI: 10.1093/aje/kwn165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Linkov F, Yurkovetsky Z, Taioli E, Havrilesky LJ, Maxwell GL, Lokshin A. Endometrial cancer: multiplexed Luminex approaches for early detection. ACTA ACUST UNITED AC 2008; 2:527-37. [DOI: 10.1517/17530059.2.5.527] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lacey JV, Ioffe OB, Ronnett BM, Rush BB, Richesson DA, Chatterjee N, Langholz B, Glass AG, Sherman ME. Endometrial carcinoma risk among women diagnosed with endometrial hyperplasia: the 34-year experience in a large health plan. Br J Cancer 2007; 98:45-53. [PMID: 18026193 PMCID: PMC2359718 DOI: 10.1038/sj.bjc.6604102] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Classifying endometrial hyperplasia (EH) according to the severity of glandular crowding (simple hyperplasia (SH) vs complex hyperplasia (CH)) and nuclear atypia (simple atypical hyperplasia (SAH) vs complex atypical hyperplasia (CAH)) should predict subsequent endometrial carcinoma risk, but data on progression are lacking. Our nested case-control study of EH progression included 138 cases, who were diagnosed with EH and then with carcinoma (1970-2003) at least 1 year (median, 6.5 years) later, and 241 controls, who were individually matched on age, date, and follow-up duration and counter-matched on EH classification. After centralised pathology panel and medical record review, we generated rate ratios (RRs) and 95% confidence intervals (CIs), adjusted for treatment and repeat biopsies. With disordered proliferative endometrium (DPEM) as the referent, AH significantly increased carcinoma risk (RR=14, 95% CI, 5-38). Risk was highest 1-5 years after AH (RR=48, 95% CI, 8-294), but remained elevated 5 or more years after AH (RR=3.5, 95% CI, 1.0-9.6). Progression risks for SH (RR=2.0, 95% CI, 0.9-4.5) and CH (RR=2.8, 95% CI, 1.0-7.9) were substantially lower and only slightly higher than the progression risk for DPEM. The higher progression risks for AH could foster management guidelines based on markedly different progression risks for atypical vs non-atypical EH.
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Affiliation(s)
- J V Lacey
- Hormonal and Reproductive Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD 20852-7234, USA.
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Abstract
Abnormal uterine bleeding in terms of menstrual disorders and postmenopausal bleeding are common clinical problems in both primary and secondary care. Advances in diagnostic and therapeutic technologies have offered opportunities to improve the outcomes of women suffering with these complaints. Future research should concentrate on a robust approach to the assessment of these health technologies, including the use of outcome assessments of importance to patients such as effects on health-related quality of life and taking account of patient preferences. In addition, economic evaluations need to be conducted alongside clinical research to facilitate a rational basis on which to allocate resources and upon which to base clinical decisions. Specific areas highlighted for research in this review include the role of diagnostic technologies incorporating the clinical context within which diagnostic work-up takes place. The clinical application of progesterone antagonists and selective progesterone receptor modulators is a developing area with potential for the treatment of menorrhagia. The place of minimally invasive therapies for the treatment of menstrual dysfunction and fibroid-associated menorrhagia needs more examination, as does the place of outpatient 'ambulatory' settings to provide convenient, effective 'see and treat' targeted services in both primary and secondary care.
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Affiliation(s)
- Nadia C Samuel
- Department of Obstetrics & Gynaecology, Birmingham Women's Hospital, Birmingham, UK
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Inki P. Long-term use of the levonorgestrel-releasing intrauterine system. Contraception 2007; 75:S161-6. [PMID: 17531611 DOI: 10.1016/j.contraception.2006.12.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2006] [Accepted: 12/16/2006] [Indexed: 10/23/2022]
Abstract
Since its launch in Finland in 1990, the levonorgestrel-releasing intrauterine system (LNG IUS) has become available in more than 100 countries throughout the world, with most countries also having the approval for the treatment of idiopathic menorrhagia and protection from endometrial hyperplasia during estrogen replacement therapy. After its introduction in Finland and Scandinavian countries, the LNG IUS has been available in most European countries since the mid to late 1990s and in the United States since 2001. Studies on the repeat use of the LNG IUS with second and third consecutive IUSs have shown high continuation rates and low rates of adverse effects. During repeat use of the LNG IUS, the bleeding pattern changes toward an increasing amenorrhea rate. With regard to the menorrhagia indication, the 5-year follow-up results of a randomized comparative trial of the LNG IUS and hysterectomy have shown equal satisfaction and improvement in health-related quality of life with both treatments. Although a proportion of women assigned to the LNG IUS group eventually underwent hysterectomy, the continuation rate of the LNG IUS for menorrhagia is clearly superior to that of conventional medical therapy (e.g., oral progestins). Use of the LNG IUS in combination with estrogen therapy in women undergoing menopausal transition seems to be well tolerated and associated with a favorable bleeding pattern.
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Affiliation(s)
- Pirjo Inki
- Bayer Schering Pharma AG, D-13342 Berlin, Germany.
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Götz S, Ortmann O. Blutungen in der Postmenopause. GYNAKOLOGISCHE ENDOKRINOLOGIE 2007. [DOI: 10.1007/s10304-007-0179-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Zhou J, Tomashefski JF, Khiyami A. ThinPrep Pap tests in patients with endometrial cancer: A histo-cytological correlation. Diagn Cytopathol 2007; 35:448-53. [PMID: 17580347 DOI: 10.1002/dc.20672] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The aim of this retrospective study was to correlate cytological diagnoses of endometrial cancers in ThinPrep Pap tests with the histological diagnoses. ThinPrep specimens from 67 patients within 12 mo of the histological diagnosis of endometrial cancer were studied. Of this study sample, 89.6% had abnormal Pap tests. Abnormal Pap tests occurred in 96.8, 68.4, and 100% of patients with grades 1, 2, or 3 endometrial cancers, respectively. Of patients with endocervical involvement, 88.9% had positive or suspicious Pap tests, compared with 41.1% without endocervical involvement (LR = 7.85, P < 0.01). Of patients with > or =50% myometrial invasion, 78.9% had positive or suspicious Pap tests, compared with 34.8% with less than 50% invasion (LR = 10.97, P < 0.01). Positive or suspicious Pap tests were found in 59.5 and 32.1% of those with tumors > or =3 cm or <3cm, respectively (LR = 4.85, P < 0.05).
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Affiliation(s)
- Jianhong Zhou
- Department of Pathology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44109, USA.
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Preoperative and postoperative histopathological findings in patients with endometrial hyperplasia. ACTA ACUST UNITED AC 2007; 60:372-6. [DOI: 10.2298/mpns0708372d] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Introduction. The aim of this study was to analyze and compare the histopathological findings in curettage and hysterectomy specimens, to evaluate the accuracy of histopathological diagnosis in curettage specimens, and to determine the frequency of coexisting endometrial carcinoma in patients with histopathological diagnosis of endometrial hyperplasia. Material and methods. Curettage and hysterectomy specimens of 135 female patients with initially diagnosed endometrial hyperplasia were retrospectively analyzed and compared. Results. Simple hyperplasia was found in 49 patients (36.3%), complex hyperplasia in 14 (10.4%), simple atypical hyperplasia in 24 (17.8%), and complex atypical hyperplasia in 48 (35.5%) patients. After hysterectomy, 59 (43.7%) patients were found to have simple hyperplasia, 12 (8.9%) complex hyperplasia, 15 (11.1%) simple atypical hyperplasia, 18 (20.7%) complex atypical hyperplasia, and 21 (15.5%) endometrial carcinoma. The accuracy of histopathological diagnosis of endometrial hyperplasia in curettage specimens was 82.2-89.6% and dependent on the types of hyperplasia. The frequency of coexisting endometrial carcinoma was significantly higher (p<0.001) in patients with atypical hyperplasia than in patients with hyperplasia without cytological atypia. After hysterectomy, coexisting endometrial carcinoma was found in 27.8% of patients with histopathological diagnosis of atypical hyperplasia in curettage specimens. In contrast to simple atypical hyperplasia, the frequency of coexisting endometrial carcinoma was significantly higher (p<0.05) in complex atypical hyperplasia. Conclusion. The frequency of coexisting endometrial carcinoma in hysterectomy specimens in patients with histopathological diagnosis of atypical hyperplasia in curettage specimens was relatively high and it should be taken into account when planning therapy. .
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