(50)--子宫内膜增生的分类和管理.pdf

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1、JOINT GOC-SOGC CLINICAL PRACTICE GUIDELINENo.392,December,2019Guideline No.392-Classification andManagement of Endometrial HyperplasiaIt is SOGC policy to review the content 5 years after publication,at which time the document may be re-affirmed or revised to reflectemergent new evidence and changes

2、 in practice.This Clinical Practice Guideline has been prepared by the Societyof Gynecologic Oncology of Canada(GOC)GuidelinesCommittee and the Society of Obstetricians and Gynaecologistsof Canada(SOGC)s Clinical Practice Gynaecology Committee;reviewed by the SOGCs Guideline Management and Oversight

3、Committee and approved by the Executive and Board for GOCand by the Board of the SOGC.Marie-H?el?ene Auclair,MDCM,Montr?eal QCPaul J.Yong,MD,Vancouver,BCShannon Salvador,MD,Montreal,QCJackie Thurston,MD,Calgary,ABTerence(Terry)J.Colgan,MD,Toronto ONAlexandra Sebastianelli,MD,Qu?ebec,QCGOC Guidelines

4、 Committee(2018):Shannon Salvador,MD,Westmount,QC;Alexandra Sebastianelli,MD,Quebec,QC;Lua Eiriksson,MD,Hamilton,ON;Erin Dean,MD,Winnipeg,MB;Stephanie Scott,MD,Halifax,NS;Ji-Hyun Jang,MD,Vancouver,BCSOGC Clinical Practice Gynaecology Committee(2018):Alaa Awadalla,MD,Winnipeg,MB;Annette Bullen,RN,Cal

5、edonia,ON;Susan Goldstein,MD,Toronto,ON;NicholasLeyland,MD,Hamilton,ON;Ally Murji,MD,Toronto,ON;FrankPotestio,MD,Thunder Bay,ON;David Rittenberg,MD,Halifax,NS(co-chair);Jackie Thurston,MD,Calgary,AB;WendyWolfman,MD,Toronto,ON(co-chair);Grace Yeung,MD,Toronto,ON;Paul Yong,MD,Vancouver,BCDisclosure st

6、atements have been received from all authors.Dr.Alexandra Sebastianelli was a speaker for Astra Zeneca.Noadditional conflicts of interest were declared by the other authors.Key Words:Endometrial hyperplasia,endometrial cancer,endometrial biopsy,progestin,hysterectomyCorresponding author:Dr.Alexandra

7、 Sebastianellialexandra.sebastianellifmed.ulaval.caCHANGES IN PRACTICE?Canada-wide adoption of the World Health Organizationclassification for endometrial hyperplasia?Introduction of the levonorgestrel intrauterine system into thetreatment algorithm for endometrial hyperplasia?Preference of the mini

8、mally invasive approach whenhysterectomy is indicated for endometrial hyperplasiaJ Obstet Gynaecol Can 2019;41(12):17891800https:/doi.org/10.1016/j.jogc.2019.03.025 2019 The Society of Obstetricians and Gynaecologists of Canada/LaSocit des obsttriciens et gyncologues du Canada.Published byElsevier I

9、nc.This document reflects clinical and scientific consensus on the date issued and is subject to change.The information should not be construed asdictating an exclusive course of treatment or procedure to be followed.Local institutions can dictate amendments to these opinions.They shouldbe well-docu

10、mented if modified at the local level.None of these contents may be reproduced in any form without prior written permission of thepublisher.All people have the right and responsibility to make informed decisions about their care in partnership with their health care providers.In order tofacilitate i

11、nformed choice,patients should be provided with information and support that is evidence-based,culturally appropriate,and tailored totheir needs.This guideline was written using language that places women at the centre of care.The SOGC is committed to respecting the rights of all peopleincluding tra

12、nsgender,gender non-binary,and intersex peoplefor whom the guideline may apply.We encourage health care providers toengage in respectful conversation with patients regarding their gender identity and their preferred gender pronouns to be used as a critical part ofproviding safe and appropriate care.

13、The values,beliefs,and individual needs of each patient and their family should be sought and the finaldecision about the care and treatment options chosen by the patient should be respected.DECEMBER JOGC D?ECEMBRE 2019?1789Downloaded for Anonymous User(n/a)at National Cheng Kung University from Cli

14、nicalK by Elsevier on December 03,2019.For personal use only.No other uses without permission.Copyright 2019.Elsevier Inc.All rights reserved.AbstractObjective:The aim of this guideline is to aid primary care physiciansand gynaecologists in the initial evaluation of women withsuspected endometrial h

15、yperplasia,to recommend the use of the2014 World Health Organization classification for endometrialhyperplasia by all health care providers,and to guide the optimaltreatment of women diagnosed with endometrial hyperplasia.Intended Users:Physicians,including gynaecologists,obstetricians,family physic

16、ians,general surgeons,emergency medicinespecialists;nurses,including registered nurses and nursepractitioners;medical trainees,including medical students,residents,and fellows;and all other health care providers.Target Population:Adult women(18 years and older)presenting withsuspected or confirmed e

17、ndometrial hyperplasia.Options:The discussion relates to the medical therapy as well assurgical treatment options for women with and without atypicalendometrial hyperplasia.Evidence:For this guideline,relevant studies were searched inPubMed,Cochrane Wiley,and the Cochrane Systematic Reviewsusing the

18、 following terms,either alone or in combination,with thesearch limited to English language materials,human subjects,andpublished since 2000:(endometrial hyperplasia,endometrialintraepithelial neoplasia,endometrial sampling,endometrialcurettage,diagnosis)AND(treatment,progestin therapy,surgery,LNG-IU

19、S,aromatase inhibitors,metformin),AND(obesity).Thesearch was performed in April 2018.Relevant evidence was selectedfor inclusion in the following order:meta-analyses,systematicreviews,guidelines,randomized controlled trials,prospective cohortstudies,observational studies,non-systematic reviews,case

20、series,and reports.Additional significant articles were identified throughcross-referencing the identified reviews.The total number of studiesidentified was 2152,and 82 studies were included in this review.Validation Methods:The content and recommendations were draftedand agreed upon by the authors.

21、The Executive and Board of theSociety of Gynecologic Oncology of Canada reviewed the contentand submitted comments for consideration,and the Board of theSociety of Obstetricians and Gynaecologists of Canada approvedthe final draft for publication.The quality of evidence was ratedusing the criteria d

22、escribed in the Grading of RecommendationsAssessment,Development and Evaluation(GRADE)methodologyframework.The interpretation of strong and weak recommendationswas also included.The Summary of Findings is available uponrequest.Benefits,Harms,and/or Costs:It is expected that this guideline willbenefi

23、t women with endometrial hyperplasia.This should guidepatient informed consent before both medical and surgicalmanagement of this condition.Guideline Update:Evidence will be reviewed 5 years after publicationto decide whether all or part of the guideline should be updated.However,if important new ev

24、idence is published prior to the 5-yearcycle,the review process may be accelerated for a more rapidupdate of some recommendations.Summary Statements:1.In addition to epidemiologic risk factors related to estrogen expo-sure,intermenstrual bleeding and postmenopausal bleeding areassociated with increa

25、sed risk of endometrial hyperplasia.Endome-trial sampling should be carried out as per published algorithms withparticular attention to women 40 years or older or with a body massindex of 30 kg/m2or greater(moderate).2.Since the majority of cases of endometrial hyperplasia without atypiaare successf

26、ully managed medically,hysterectomy is not consid-ered first-line treatment and surgery is reserved for specific circum-stances(moderate).3.A minimally invasive approach to hysterectomy is preferred for endo-metrial hyperplasia as it decreases perioperative morbidity and mor-tality(high).4.If hyster

27、ectomy is indicated for endometrial hyperplasia without aty-pia then postmenopausal women should also be offered bilateralsalpingo-oophorectomy.This decision is individualized for premeno-pausal women due to increased mortality and morbidity associatedwith removal of the ovaries in young women with

28、benign disease(moderate).5.Hysterectomy and bilateral salpingo-oophorectomy are the recom-mended treatment for atypical endometrial hyperplasia due to theunderlying risk of malignancy or progression to endometrial cancer.Retention of the ovaries in premenopausal women may be consid-ered(low).6.There

29、 is no evidence to support routine intraoperative frozen sectionanalysis in cases of endometrial hyperplasia(low).7.There is no evidence to support routine lymphadenectomy for atypi-cal endometrial hyperplasia(moderate).8.There is insufficient evidence to support endometrial ablation asfirst-line su

30、rgical treatment for endometrial hyperplasia without aty-pia(low).9.Endometrial hyperplasia found in endometrial polyps should betreated according to its histologic classification(low).Recommendations:1.Health care providers should use the 2014 World Health Organiza-tionhistopathologicclassification

31、ofendometrialhyperplasia(strong,low).If endometrial cancer is suspected,endometrial tis-sue sampling using a Pipelle device in an outpatient setting is themost appropriate first step for diagnosis(strong,high).2.Those with recurrent symptoms of abnormal uterine bleeding afterinitial observation or m

32、edical treatment should be reassessed withan endometrial biopsy(strong,high).3.Patients with endometrial hyperplasia should be assessed for revers-ible risk factors and receive education and support from their clini-cians in order to treat and reverse those conditions(strong,high).4.Patients with en

33、dometrial hyperplasia without atypia can beobserved.They can be offered hormonal treatment if hyperplasiadoes not resolve with observation or experience abnormal uterinebleeding(weak,low).5.The levonorgestrel intrauterine system should be used as the first-line treatment for endometrial hyperplasia

34、without atypia due to itseffectiveness and favourable side effect profile(strong,high)anddue to the fact that it can be kept in place for 5 years in patientsshowing treatment response(strong,moderate).6.Low-dose oral and injectable progestins remain an acceptabletreatment option for women with endom

35、etrial hyperplasia with andwithout atypia desiring an alternative treatment modality(strong,high).For patients on oral progestins,we suggest starting on a lowKEY MESSAGES?A universal system for classification that follows the WorldHealth Organization classification for endometrial hyperplasiashould

36、be used?Patients should receive encouragement and support to modifyreversible risk factors for endometrial cancer?The levonorgestrel intrauterine system should be used as thefirst-line treatment for endometrial hyperplasia without atypia?A minimally invasive approach to hysterectomy is preferred for

37、endometrial hyperplasiaJOINT GOC-SOGC CLINICAL PRACTICE GUIDELINE1790?DECEMBER JOGC D?ECEMBRE 2019Downloaded for Anonymous User(n/a)at National Cheng Kung University from ClinicalK by Elsevier on December 03,2019.For personal use only.No other uses without permission.Copyright 2019.Elsevier Inc.All

38、rights reserved.dose for a minimum of 6 months.We suggest that assessment ofthe endometrium be done mid-therapy as well as 3 weeks aftercompletion of treatment to ensure proper interpretation(strong,very low).7.Surgical treatment of endometrial hyperplasia without atypiashould be reserved for patien

39、ts who do not want to preserve theirfertility and experience progression to atypical hyperplasia orcarcinoma during follow-up,whose hyperplasiafails to regressafter 12 months of medical treatment or relapses after completingtreatment with progestins,who continue to experience abnormaluterine bleedin

40、g despite treatment,or who decline endometrialsurveillance or medical treatment(strong,high).8.If surgery is indicated for endometrial hyperplasia without atypia,the procedure should include total hysterectomy with opportunisticsalpingectomy,with or without bilateral oophorectomy dependingon menopau

41、sal status(strong,moderate).9.Total hysterectomy with bilateral salpingo-oophorectomy is recom-mended for treatment of atypical hyperplasia in premenopausaland postmenopausal women(strong,moderate).In premeno-pausal women,ovarian preservation should be discussed(strong,moderate).10.We recommend that

42、 subtotal(supracervical)hysterectomy andmorcellation be avoided in all cases of endometrial hyperplasia(strong,low).Guideline No.392-Classification and Management of Endometrial HyperplasiaDECEMBER JOGC D?ECEMBRE 2019?1791Downloaded for Anonymous User(n/a)at National Cheng Kung University from Clini

43、calK by Elsevier on December 03,2019.For personal use only.No other uses without permission.Copyright 2019.Elsevier Inc.All rights reserved.INTRODUCTIONThe incidence of endometrial hyperplasia increaseswith age,with an overall estimate of 133 per 100 000woman-years.It is rarely seen in women under t

44、he age of30 and reaches its peak in women aged 50 to 54.1Advan-ces in genetics have led to a new understanding of its path-ogenesis and a modification of the traditional 4-tierclassification of simple and complex hyperplasia with andwithout atypia.In 2014,the World Health Organizationmodified the 19

45、94 classification to include only 2 catego-ries:(1)hyperplasia without atypia and(2)hyperplasia withatypia:atypical hyperplasia or endometrial intraepithelialneoplasia(EIN).2,3The risk factors associated with endo-metrial hyperplasia with or without atypia are the same asthose associated with endome

46、trioid endometrial carcino-mas and result in unopposed estrogen exposure of theendometrium from endogenous or exogenous sources.4Atypical endometrial hyperplasia is thought to be a precur-sor lesion to type I endometrial carcinomas as both share asimilar profile of genetic alterations and monoclonal

47、growth.4,5In fact,up to 60%of patients with EIN havealready developed or will develop an invasive endometrialcancer.6Hyperplasia without atypia rarely progresses toendometrial carcinoma(1%3%),and it does not sharethe same genetic mutations as its counterpart.2,7Whereasatypical hyperplasia warrants a

48、 more definitive treatmentapproach,non-atypical hyperplasia can be managed con-servatively.The quality of evidence was rated using the cri-teria described in the Grading of RecommendationsAssessment,Development and Evaluation(GRADE)methodology framework(Table 1).The interpretationof strong and weak

49、recommendations is described inTable 2.CLINICAL PRESENTATIONRisk FactorsRisk factors for endometrial hyperplasia can be dividedinto(1)menstrual factors(e.g.,older age or postmeno-pausal status,nulliparity or infertility,early menarche orlater menopause,anovulation,menopausal transition and/or polycy

50、stic ovarian syndrome;(2)iatrogenic factors(e.g.,unopposed exogenous estrogen therapy or tamoxifen);and(3)comorbidities(e.g.,obesity,diabetes,hypertension,or Lynch syndrome).8SymptomsIn premenopausal women,symptoms include abnormaluterine bleeding(e.g.,disturbances in regularity,frequency,duration,a