What is the treatment for proliferative endometrium (biopsy)?

Treatment for Proliferative Endometrium on Biopsy

Progestin-based therapy is the recommended treatment for proliferative endometrium on biopsy, with options including megestrol acetate, medroxyprogesterone acetate, or a levonorgestrel-releasing intrauterine device. 1

Understanding Proliferative Endometrium

Proliferative endometrium represents a state of unopposed estrogen stimulation that can progress to endometrial hyperplasia or cancer if left untreated. In postmenopausal women, this finding is particularly concerning as it indicates abnormal endometrial stimulation when the endometrium should be atrophic.

Treatment Options

First-line Treatment:

• Progestin-based therapy 1
  • Megestrol acetate
  • Medroxyprogesterone acetate
  • Levonorgestrel-releasing intrauterine device

Medroxyprogesterone acetate works by transforming proliferative endometrium into secretory endometrium, effectively counteracting the proliferative effects of estrogen 2. A durable complete response occurs in approximately 50% of patients treated with progestin therapy 1.

Treatment Considerations:

1. For women desiring fertility preservation:

   • Continuous progestin-based therapy may be considered for highly selected patients 1
   • Close monitoring with endometrial sampling (biopsies or D&C) every 3-6 months
   • Not recommended for high-risk patients with high-grade histologies

2. For women not concerned with fertility:

   • Total hysterectomy with bilateral salpingo-oophorectomy (TH/BSO) is the definitive treatment option, especially for those with risk factors for progression 1

3. For medically inoperable patients:

   • Hormonal therapy with progestins is appropriate for those who cannot undergo surgery 1
   • Consider endometrial biopsies every 3-6 months for monitoring

Monitoring and Follow-up

• For patients receiving progestin therapy, perform endometrial sampling (biopsies or D&C) every 3-6 months 1
• Consider TH/BSO if:
  • Endometrial abnormalities persist after 6-12 months of progestin therapy
  • Disease progression is documented on follow-up biopsies
  • After childbearing is complete (for those on fertility-sparing therapy)

Risk Factors Requiring Special Consideration

• Age >60 years: Higher risk of progression to cancer 3
• BMI >35 kg/m²: 2.3-fold increased risk of progression to cancer 3
• Extensive or complex papillary proliferation: Higher risk of concurrent or subsequent endometrial hyperplasia and carcinoma 4

Contraindications to Progestin Therapy

Exercise caution with progestin therapy in patients with:

• History of breast cancer
• Previous stroke or myocardial infarction
• History of pulmonary embolism or deep vein thrombosis
• Active smoking 1

Long-term Outcomes

Research indicates that postmenopausal women with proliferative endometrium have a 4-fold greater incidence of developing endometrial hyperplasia or cancer compared to those with atrophic endometrium (11.9% vs 2.9%) 3. This underscores the importance of appropriate treatment and long-term monitoring, especially in postmenopausal women.