From the Guidelines
The management of endometrial proliferation with stromal breakdown diagnosed on endometrium biopsy should primarily involve hormonal therapy to regulate the endometrial cycle, with cyclic progestin therapy being the first-line treatment. This approach is based on the principle of opposing the unopposed estrogen effect that causes endometrial proliferation, thereby establishing regular shedding patterns and reducing the risk of progression to more severe pathologies such as endometrial hyperplasia or cancer 1.
Key Considerations in Management
- The first-line treatment typically involves cyclic progestin therapy, such as medroxyprogesterone acetate 10mg daily for 10-14 days per month, or norethindrone acetate 5mg daily for 10-14 days per month.
- This regimen should be continued for at least 3-6 months, with follow-up endometrial sampling to ensure resolution of the proliferation and stromal breakdown.
- Combined hormonal contraceptives (containing estrogen and progestin) are an alternative option, especially in younger women who also desire contraception.
- For perimenopausal women, a levonorgestrel intrauterine device (Mirena) provides both local progestin effect and contraception, which can be beneficial in managing endometrial proliferation while also addressing contraceptive needs.
Further Evaluation and Monitoring
- In cases of persistent abnormal bleeding despite hormonal therapy, further evaluation with hysteroscopy may be necessary to rule out focal lesions or other pathologies that may have been missed by endometrial sampling 1.
- Regular follow-up is essential to monitor response to therapy and rule out progression to more concerning pathologies, emphasizing the importance of a tailored approach to each patient's specific needs and response to treatment.
From the Research
Management of Proliferation Endometrium with Stromal Breakdown
The management of endometrial proliferation with stromal breakdown diagnosed on endometrium biopsy involves several considerations.
- The condition is characterized by the presence of proliferative endometrium with stromal breakdown, which can be diagnosed through endometrial biopsy 2.
- Studies have shown that proliferative endometrium is not associated with an increased risk of endometrial cancer, but it can be a precursor to endometrial hyperplasia or cancer 3.
- The use of progestins, such as medroxyprogesterone acetate, norethindrone acetate, and nomegestrol acetate, can induce epithelial cell secretion and decrease estrogen receptor and progesterone receptor expression in proliferative endometrium 4.
- Single-cell RNA sequencing has revealed multiple stromal populations in the human proliferative endometrium, suggesting specific stromal niches that can control inflammation and extracellular matrix composition 5.
- Different progestins can elicit divergent human endometrial transcriptomes and biofunctions, and their effects can be influenced by the presence or absence of estrogen 6.
Treatment Options
- Treatment options for endometrial proliferation with stromal breakdown may include progestin therapy to induce secretory transformation and reduce the risk of endometrial hyperplasia or cancer 3, 4.
- The choice of progestin and dosage may depend on individual factors, such as the presence of estrogen and the patient's medical history 6.
- Close monitoring and follow-up are essential to assess the response to treatment and detect any potential complications or progression to endometrial hyperplasia or cancer 3.