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What Causes Recurrence Of Endometrial Hyperplasia?

Posted on Mon, 10 Feb 2014

Question: Dear Doctor, 31yr old w pcos. Purgeon and IUI to have baby number 1 in 2010. XXXXXXX 2013- thick lininig of uterine wall 14mm- biopsy, revelved complex hyperplasia with no atipia. TX- 90days provera. Repeated biopsy, was much better, hyperplasia was pretty much gone, there was few fragments floating around. Bleed. Re took provera 6weeks later, no period.... ( first that has ever happened, been on provera few times a year for 5-6years.) Back to my Fertility Specialist- ultrasound showed 14mm, didnt want to start purgeon, until speaks with other Doctors on team.. Any thoughts, on why this would be 14mm again, after tx was sucessful just 2months ago? Why did this provera not work this time...? Maybe not even dose? Lost on this one! Thank you for taking the time to read! Cheers!

Answered by Dr. Aarti Abraham (-10 hours later)

Brief Answer: DISCUSSED BELOW Detailed Answer: Hello XXXXXXX Thanks for writing to us with your health concern. See , endometrial hyperplasia is notorious for recurrence, and very common in women with PCOS. 14mm is definitely hyperplastic endometrium. Now the question is - why was the endometrium not shed off this time in response to Provera . Ideally it should have. What is your height and weight, if I might enquire ? Sometimes, if you are heavy, a proportionately heavy dosage is needed. Generally 10 mg twice or thrice a day is given. The length of treatment ( 10 days ) is enough to induce bleeding. May I also know - the previous 90 days Provera that you mentioned - was it continuous, or cyclical with breaks in between ? Right now, you need a further course of Provera ( increased dosage ) for another ten days atleast. Only post the withdrawal bleed, you would be able to start the stimulation cycle with Puregon. Sometimes, just sometimes, endometrial hyperplasia is refractory to medical management ( read Provera generally ) , and then a therapeautic and diagnostic curettage might be required. All the best Please feel free to sound me out further on this one. Wish you good health always !

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Aarti Abraham (8 hours later)

Dear Dr XXXXXXX Thank you for taking the time to write me back, and give me some highlights on your expertise with this matter. When I was diagnosed w complex hyperplasia Aug 2013- I did 90days of the Provera, all together, no stopping. I started to break thru bleed after 60days of taking Provera 10mg od. I then repeated biopsy end of Nov, and results came back, that it was improved w the provera, but some fragments were still seen. Fertility specialist was happy with this, and I was advised, to start Provera again on Dec 23-Jan 1st and get a cycle... I didnt get a cycle, little bit of spotting but really nothing. Today went back to start Purgeon, and noted on ultrasound the lining was 14mm thick still... I did get BW today, and the numbers were perfect.. Great for a day 3 start, but the lining is not adding up. Estrogen was 214, FSH 5.2, LH,12, Prolactin 11 and Progestrone was 1.67. My own Doctor is away for a couple of days, but another Doctor in clinic thought we should repeat biopsy... Do you think that is necessary? Just did this end of Nov after 90days of Provera tx. I am over weight yes, last 8-10yrs. 5 foot 10 and 280pounds. Thick boned. Was successful with Puregon 125 shots and IUI to have baby girl in 2010. My questions are- Do you think Hyperplasia could come back so soon?? I had a c-section, is 14mm maybe the normal for me, and we should start with puregon? Should I repeat biopsy ( again?) Should I request another 10days of provera, and hope a cycle comes on? Thank you for taking the time to review my health concerns, XXXXXXX :)

Answered by Dr. Aarti Abraham (3 hours later)

Brief Answer: UP THE DOSE AND TAKE ANOTHER 10 DAYS OF PROVERA. Detailed Answer: Hello Thank you for briefing me in such detail with regards to your history and treatment so far. Firstly, 14 mm is not normal for anybody, C section or not. 14 mm IS hyperplastic. I do not think you should have a biopsy so soon again. For your body type, I think 10 mg OD for just 10 days has been an insufficient dose. Now I have not scanned you or examined you, so I hope you understand these limitations . I would say that you should request for another 10 days of Provera, upping the dose, making it 10 mg TDS ( thrice a day ) or atleast BD ( twice a day ). I think you would bleed in response to that dose. Even if the Blood work is alright, there is no point in starting the IUI with a 14 mm lining. It would not be conducive , infact, it will be counter productive for the whole procedure. All the best and take care. Will be available anytime to discuss this further as it develops.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Aarti Abraham (18 hours later)

Dear Dr XXXXXXX Thank you once again for your responses here I really appreciate your input on this matter. My own Fertility Specialist, also GYN, has requested yet another biopsy. I'm going to see him tomorrow, to speak with him. I have no problems with having another biopsy, but I would really like to know... How do we get rid of this 14mm hyperplasia? I have done the 90days continued tx, and biopsy showed much better results with the Provera. Just in six to seven weeks, this is still 14mm. In your personal opinion... What treatment(s), should I do, to get rid of this completely... If I up the dose and take another 10days of Provera ( which I want to do), and I bleed,and have another ultrasound.. if this shows increased lining again, what is my next step for treatments? We were hoping to start with the puregon, and IUI, but I understand, this is not an option. Should we re think our path? I have read IUDs and Birth Control Pills are effective in tx. What are your thoughts? I want to have a good conversation tomorrow with my Doctor, but would like your inputs.. Appreciate all your time! Thanks, XXXXXXX :) PS- I'm now "following" you on facebook!

Answered by Dr. Aarti Abraham (6 hours later)

Brief Answer: DETAILED BELOW Detailed Answer: Hello again XXXXXXX Yes I could see you and your XXXXXXX on Facebook. Stay Blessed ! As for the hyperplasia, yes, it might recur again so soon, particularly in women with PCOS. Another biopsy would be thought of, to confirm that this is not complex hyperplasia ( endometrial hyerplasia is of many types, classified based on biopsy, and complex ones, or ones with atypia, are those that recur frequently ). If you up the dose and bleed, there would be no hyperplasia ( bleeding ensures that the lining gets shed off ). But yes I agree, it is a temporary measure, as you seem to be prone to it. Once you bleed, you can then proceed with the IUI right from the second or third day of bleeding ( after confirming that the lining is thin enough on ultrasound ). Birth control pills when taken cyclically mitigate the risk of hyperplasia to a great extent, they would help your PCOS too. It is an option to be discussed and considered with your doctor ( after the IUI is attempted - in the next cycle ). All the best. Thank you for all the appreciation and kindness.

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Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar