Endometrial hyperplasia and atypia — structured oral station (12 minutes)

Opening prompt — "What does atypical hyperplasia mean, and why is it a serious diagnosis?"

Model response — classification and risk: ^[1][2]

• "Atypical hyperplasia is the modern WHO 2014 term for endometrial hyperplasia with cytologic atypia — also called endometrial intraepithelial neoplasia or EIN."^[3]
• "Atypia is the dominant predictor of progression: Kurman 1985 found 23 percent of atypical hyperplasia progressed to carcinoma, compared with 1.6 percent of hyperplasia without atypia; complex atypical was 29 percent."
• "But the more immediate risk is concurrent disease: the GOG cohort found a 42.6 percent rate of concurrent endometrial carcinoma at hysterectomy within 12 weeks of an AH biopsy, with 30.9 percent myoinvasive."

Probe 1 — "What is your first-line management for this 54-year-old?"

• "Total hysterectomy, with BSO because she is postmenopausal. This is recommended because of the risk of concurrent or future invasive malignancy. Laparoscopic preferred."
• "I would refer to gynaecological oncology, consent for cancer surgery in case intra-operative staging is needed, and avoid morcellation to prevent upstaging occult carcinoma."^[3]

Probe 2 — "She asks whether the LNG-IUS would be simpler. How do you answer?"

• "The LNG-IUS is first-line for hyperplasia without atypia — Gallos 2013 showed 94.8 percent regression versus 84.0 percent with oral progestogen. But for atypical hyperplasia, hysterectomy is the default."
• "The LNG-IUS is reserved for AH when the woman wishes to preserve fertility or is unfit for surgery — with strict surveillance: biopsy every 3 months until two consecutive negatives, then 6 to 12 monthly until hysterectomy once fertility is complete."^[3][4]

Probe 3 — "How does your management differ in a 32-year-old who wants children?"

• "Fertility-sparing: LNG-IUS first-line, oral progestogen second-line; refer to fertility services; achieve regression before attempting conception."
• "Surveillance: biopsy every 3 months until two consecutive negatives, then 6 to 12 monthly."
• "Counsel clearly: relapse is common (13.7 percent on LNG-IUS), and hysterectomy is recommended once fertility is no longer required."^[3][4]

Probe 4 — "The pathologist phones to say the slides are 'difficult'. What do you do?"

This is a scored communication and clinical-knowledge domain: ^[2]

• "AH has well-documented pathology discordance. The GOG study found 25.6 percent of community AH biopsies were down-graded and 29.1 percent up-graded to frank carcinoma at central review."^[2]
• "I would request review by an experienced gynaecological pathologist, repeat sampling if focal, and refer to gynaecological oncology before any operative plan is finalised."

Probe 5 — "She is frightened. What do you say?"

Communication domain — demonstrate it out loud: ^[3]

• Move to her eye level, use her name, acknowledge the fear: "Your biopsy shows a precancerous change called atypical hyperplasia. We take it seriously because in around four women in ten with this result, an early cancer is already present in the uterus when we operate. That's why I'm recommending a hysterectomy — to fully remove the uterus and give you a clear answer."^[3]
• Offer a clear plan, a timeline, and a named contact for between visits.