Guideline No. 392-Classification and Management of Endometrial Hyperplasia
Guideline No. 392-Classification and Management of Endometrial Hyperplasia
复制标题
DOI：
10.1016/j.jogc.2019.03.025
复制
发表时间：
2019-12-01
影响因子：
1.8
通讯作者：
Sebastianelli, Alexandra
中科院分区：
文献类型：
--
作者：
Auclair, Marie-Helene;Yong, Paul J.;Sebastianelli, Alexandra
目的：本指南的目的是帮助初级保健医生和妇科医生对疑似子宫内膜增生的妇女进行初步评估，建议所有卫生保健提供者使用2014年世界卫生组织子宫内膜增生分类，并指导诊断为子宫内膜增生的妇女的最佳治疗。目标用户：医生，包括妇科医生、产科医生、家庭医生、普通外科医生、急诊医学专家；护士，包括注册护士和执业护士；医学实习生，包括医学生、住院医师和研究员；以及所有其他医疗服务提供者。目标人群：成年女性（18岁及以上）表现为怀疑或确认子宫内膜增生。选择：讨论涉及到药物治疗以及手术治疗的妇女有和没有不典型子宫内膜增生。证据：本指南使用以下术语在PubMed、Cochrane Wiley和Cochrane系统评价中检索相关研究，可单独检索也可合并检索，检索范围限于2000年以来发表的英文材料、人类受试者：（子宫内膜增生，子宫内膜上皮内瘤变，子宫内膜取样，子宫内膜刮除，诊断）和（治疗，黄体酮治疗，手术，液化石油醇，芳香酶抑制剂，二甲双胍），和（肥胖）。该搜索于2018年4月进行。相关证据按以下顺序入选：荟萃分析、系统评价、指南、随机对照试验、前瞻性队列研究、观察性研究、非系统评价、病例系列和报告。通过交叉参考已确定的综述来确定其他重要文章。纳入的研究总数为2152项，其中82项纳入本综述。验证方法：内容和建议由作者起草并同意。加拿大妇科肿瘤学会的执行和董事会审查了内容并提交了意见供考虑，加拿大妇产科学会的董事会批准了最终草案的出版。证据质量采用建议分级评估、发展和评价（GRADE）方法框架中描述的标准进行评级。还包括对强建议和弱建议的解释。调查结果摘要可应要求提供。益处、危害和/或成本：预计该指南将使患有子宫内膜增生的妇女受益。这应指导患者在对这种情况进行内科和外科治疗前的知情同意。指南更新：证据将在出版5年后进行审查，以决定是否全部或部分更新指南。然而，如果重要的新证据在5年周期之前发表，审查过程可能会加快，以便更快地更新一些建议。摘要语句:1。除了与雌激素暴露相关的流行病学危险因素外，经间出血和绝经后出血与子宫内膜增生的风险增加有关。子宫内膜取样应按照已发表的算法进行，特别注意40岁或以上或体重指数为30 kg/m(2)或更高（中等）的妇女。由于大多数没有异型性的子宫内膜增生的病例在医学上都得到了成功的治疗，子宫切除术不被认为是一线治疗，手术保留在特定情况下（中度）。微创子宫切除术是子宫内膜增生的首选方法，因为它可以降低围手术期的发病率和死亡率（高）。如果子宫切除术指的是无异型性的子宫内膜增生，那么绝经后妇女也应该进行双侧输卵管卵巢切除术。由于患有良性疾病（中度）的年轻妇女切除卵巢会增加死亡率和发病率，因此绝经前妇女的决定是个体化的。由于潜在的恶性或发展为子宫内膜癌的风险，子宫切除术和双侧输卵管-卵巢切除术是非典型子宫内膜增生的推荐治疗方法。绝经前妇女卵巢保留可考虑（低）。没有证据支持在子宫内膜增生病例中进行常规术中冷冻切片分析（低）。没有证据支持常规淋巴结切除术治疗不典型子宫内膜增生（中度）。没有足够的证据支持子宫内膜消融作为无异型性子宫内膜增生的一线手术治疗（低）。子宫内膜息肉中发现的子宫内膜增生应根据其组织学分类进行治疗（低）。卫生保健提供者应使用2014年世界卫生组织子宫内膜增生的组织病理学分类（强，低）。如果怀疑子宫内膜癌，在门诊环境中使用管道设备进行子宫内膜组织取样是诊断的最合适的第一步（强，高）。2 .初次观察或药物治疗后出现异常子宫出血复发症状者，应重新进行子宫内膜活检（强，高）。应评估子宫内膜增生患者的可逆危险因素，并接受临床医生的教育和支持，以治疗和逆转这些情况（强，高）。可观察到无异型性的子宫内膜增生患者。如果增生不能通过观察解决或出现异常子宫出血（弱、低），可给予激素治疗。左炔诺孕酮宫内系统应作为无异型性子宫内膜增生的一线治疗，因为它的有效性和良好的副作用（强，高），并且由于它可以在有治疗反应的患者中保留5年（强，中等）。低剂量口服和注射黄体酮仍然是一个可接受的治疗选择，妇女子宫内膜增生，有或没有异型性渴望替代治疗方式（强，高）。对于口服黄体酮的患者，我们建议开始时低剂量至少6个月。我们建议在治疗中以及治疗结束后3周对子宫内膜进行评估，以确保正确的解释（强烈，非常低）。无异型性子宫内膜增生的手术治疗应保留给以下患者：不希望保留其生育能力，在随访期间进展为非典型增生或癌，药物治疗12个月后增生未消退或完成黄体酮治疗后复发，治疗后仍出现异常子宫出血，或子宫内膜监测或药物治疗下降（强，高）。如果手术指征为无异型性的子宫内膜增生，手术应包括全子宫切除术和机会性输卵管切除术，根据绝经状态（强、中度）进行或不进行双侧卵巢切除术。全子宫切除术联合双侧输卵管-卵巢切除术被推荐用于治疗绝经前和绝经后妇女的不典型增生（强，中度）。绝经前妇女应讨论卵巢保存（强烈，适度）。我们建议在所有子宫内膜增生（强、低）的病例中，应避免次全（宫颈上）子宫切除术和分块术。
Objective: The aim of this guideline is to aid primary care physicians and gynaecologists in the initial evaluation of women with suspected endometrial hyperplasia, to recommend the use of the 2014 World Health Organization classification for endometrial hyperplasia by all health care providers, and to guide the optimal treatment of women diagnosed with endometrial hyperplasia.Intended Users: Physicians, including gynaecologists, obstetricians, family physicians, general surgeons, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; medical trainees, including medical students, residents, and fellows; and all other health care providers.Target Population: Adult women (18 years and older) presenting with suspected or confirmed endometrial hyperplasia.Options: The discussion relates to the medical therapy as well as surgical treatment options for women with and without atypical endometrial hyperplasia.Evidence: For this guideline, relevant studies were searched in PubMed, Cochrane Wiley, and the Cochrane Systematic Reviews using the following terms, either alone or in combination, with the search limited to English language materials, human subjects, and published since 2000: (endometrial hyperplasia, endometrial intraepithelial neoplasia, endometrial sampling, endometrial curettage, diagnosis) AND (treatment, progestin therapy, surgery, LNG-IUS, aromatase inhibitors, metformin), AND (obesity). The search was performed in April 2018. Relevant evidence was selected for inclusion in the following order: meta-analyses, systematic reviews, guidelines, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. Additional significant articles were identified through cross-referencing the identified reviews. The total number of studies identified was 2152, and 82 studies were included in this review.Validation Methods: The content and recommendations were drafted and agreed upon by the authors. The Executive and Board of the Society of Gynecologic Oncology of Canada reviewed the content and submitted comments for consideration, and the Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework. The interpretation of strong and weak recommendations was also included. The Summary of Findings is available upon request.Benefits, Harms, and/or Costs: It is expected that this guideline will benefit women with endometrial hyperplasia. This should guide patient informed consent before both medical and surgical management of this condition.Guideline Update: Evidence will be reviewed 5 years after publication to decide whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations.Summary Statements:1. In addition to epidemiologic risk factors related to estrogen exposure, intermenstrual bleeding and postmenopausal bleeding are associated with increased risk of endometrial hyperplasia. Endometrial sampling should be carried out as per published algorithms with particular attention to women 40 years or older or with a body mass index of 30 kg/m(2) or greater (moderate).2. Since the majority of cases of endometrial hyperplasia without atypia are successfully managed medically, hysterectomy is not considered first-line treatment and surgery is reserved for specific circumstances (moderate).3. A minimally invasive approach to hysterectomy is preferred for endometrial hyperplasia as it decreases perioperative morbidity and mortality (high).4. If hysterectomy is indicated for endometrial hyperplasia without atypia then postmenopausal women should also be offered bilateral salpingo-oophorectomy. This decision is individualized for premenopausal women due to increased mortality and morbidity associated with removal of the ovaries in young women with benign disease (moderate).5. Hysterectomy and bilateral salpingo-oophorectomy are the recommended treatment for atypical endometrial hyperplasia due to the underlying risk of malignancy or progression to endometrial cancer. Retention of the ovaries in premenopausal women may be considered (low).6. There is no evidence to support routine intraoperative frozen section analysis in cases of endometrial hyperplasia (low).7. There is no evidence to support routine lymphadenectomy for atypical endometrial hyperplasia (moderate).8. There is insufficient evidence to support endometrial ablation as first-line surgical treatment for endometrial hyperplasia without atypia (low).9. Endometrial hyperplasia found in endometrial polyps should be treated according to its histologic classification (low).Recommendations:1. Health care providers should use the 2014 World Health Organization histopathologic classification of endometrial hyperplasia (strong, low). If endometrial cancer is suspected, endometrial tissue sampling using a Pipelle device in an outpatient setting is the most appropriate first step for diagnosis (strong, high).2. Those with recurrent symptoms of abnormal uterine bleeding after initial observation or medical treatment should be reassessed with an endometrial biopsy (strong, high).3. Patients with endometrial hyperplasia should be assessed for reversible risk factors and receive education and support from their clinicians in order to treat and reverse those conditions (strong, high).4. Patients with endometrial hyperplasia without atypia can be observed. They can be offered hormonal treatment if hyperplasia does not resolve with observation or experience abnormal uterine bleeding (weak, low).5. The levonorgestrel intrauterine system should be used as the first-line treatment for endometrial hyperplasia without atypia due to its effectiveness and favourable side effect profile (strong, high) and due to the fact that it can be kept in place for 5 years in patients showing treatment response (strong, moderate).6. Low-dose oral and injectable progestins remain an acceptable treatment option for women with endometrial hyperplasia with and without atypia desiring an alternative treatment modality (strong, high). For patients on oral progestins, we suggest starting on a low dose for a minimum of 6 months. We suggest that assessment of the endometrium be done mid-therapy as well as 3 weeks after completion of treatment to ensure proper interpretation (strong, very low).7. Surgical treatment of endometrial hyperplasia without atypia should be reserved for patients who do not want to preserve their fertility and experience progression to atypical hyperplasia or carcinoma during follow-up, whose hyperplasia fails to regress after 12 months of medical treatment or relapses after completing treatment with progestins, who continue to experience abnormal uterine bleeding despite treatment, or who decline endometrial surveillance or medical treatment (strong, high).8. If surgery is indicated for endometrial hyperplasia without atypia, the procedure should include total hysterectomy with opportunistic salpingectomy, with or without bilateral oophorectomy depending on menopausal status (strong, moderate).9. Total hysterectomy with bilateral salpingo-oophorectomy is recommended for treatment of atypical hyperplasia in premenopausal and postmenopausal women (strong, moderate). In premenopausal women, ovarian preservation should be discussed (strong, moderate).10. We recommend that subtotal (supracervical) hysterectomy and morcellation be avoided in all cases of endometrial hyperplasia (strong, low).