Endometriyal Hiperplazide Yönetim
Özet
Endometriyal hiperplazi (EH), tipik olarak atipisiz ve atipili (EIN) olmak üzere ikiye ayrılır; atipili türde endometriyal karsinoma ilerleme riski neredeyse dört kat daha yüksektir ve vakaların %40'ına karsinom eşlik eder. İleri yaş, obezite, diyabet ve atipi varlığı karsinomun en güçlü belirleyicileriyken, atipisiz türün kansere ilerleme olasılığı %10'dan azdır. Hastalığın yönetiminde yaş (>50), BMI (>25), nulliparite, diyabet, lezyon/uterus boyutu ve yetersiz progestin tedavisi risk faktörleridir. Yetersiz hücre gelen durumlarda pipelle biyopsi veya D&C yapılır; fertilite koruyucu yaklaşım öncesinde karsinomu dışlamak için mutlaka D&C uygulanmalıdır. Atipisiz EH'de histerektomi yerine LNG-RİA, oral megestrol asetat veya oral MPA ile progestin tedavisi önerilir; LNG-RİA, sistemik progestinlere kıyasla daha yüksek gerileme ve daha düşük nüks oranlarına sahiptir. Atipili EH'de ise histerektomi temel tedavi olup, bilateral ooferektomi rutinde gerekli değildir. Tamoksifen kullanımı postmenopozal hastalarda karsinom riskini artırır ancak asemptomatik hastalarda rutin tarama önerilmez; tamoksifen alan atipisiz hastalarda yakın gözlem veya histerektomi seçilebilirken, LNG-RİA kullanımı onkolog görüşüyle bireyselleştirilmelidir.
Endometrial hyperplasia (EH) is classified into non-atypical and atypical (EIN) types, with the atypical form carrying a nearly four-fold higher risk of progressing to endometrial carcinoma and coexisting with carcinoma in 40% of cases. While advanced age, obesity, diabetes, and the presence of atypia are the strongest predictors of concurrent carcinoma, the probability of non-atypical EH progressing to cancer is less than 10%. Risk factors for recurrence and progression include age >50, BMI >25, nulliparity, diabetes, lesion/uterine size, and the absence of adequate progestin therapy. In patients with non-diagnostic histopathology, pipelle biopsy or D&C is performed, and D&C must be mandatory to exclude carcinoma before planning fertility-sparing approaches. For non-atypical EH, progestin therapy via LNG-IUS, oral megestrol acetate, or oral MPA is recommended over hysterectomy, as LNG-IUS provides higher regression and lower recurrence rates than systemic progestins. Hysterectomy is the recommended treatment for atypical EH, though bilateral oophorectomy is not routinely required. Tamoxifen use increases carcinoma risk in postmenopausal women, but routine screening is not recommended for asymptomatic patients; while close observation or hysterectomy are options for non-atypical patients on tamoxifen, the use of LNG-IUS should be individualized based on consultations with the patient and their oncologist.
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