What is the first-line treatment for endometrial hyperplasia?

First-Line Treatment for Endometrial Hyperplasia

The first-line treatment for endometrial hyperplasia is progestin therapy, with options including oral medroxyprogesterone acetate (MPA), megestrol acetate (MA), or a levonorgestrel-releasing intrauterine device (LNG-IUS). 1

Treatment Approach Based on Hyperplasia Type

Endometrial Hyperplasia Without Atypia

• Preferred treatment: Progestin therapy 2

  • LNG-IUS is associated with higher regression rates, lower recurrence rates, and fewer adverse events compared to oral progestins 2
  • Oral options include:
    • Medroxyprogesterone acetate
    • Megestrol acetate

• Monitoring during treatment:

  • Ultrasound and endometrial biopsies every 6 months 2
  • Continue treatment until no pathological changes are observed in two consecutive endometrial biopsies

Endometrial Hyperplasia With Atypia (Atypical Hyperplasia)

• Standard treatment: Minimally invasive hysterectomy with bilateral salpingectomy 2
• For patients desiring fertility preservation or <45 years old:
  • LNG-IUS is the preferred medical therapy 2
  • More frequent monitoring with endometrial biopsies every 3 months 2
  • Continue treatment until no pathological changes in two consecutive biopsies

Efficacy of Progestin Therapy

• Overall clinical response rate: approximately 93% 3
• Overall pathological response rate: approximately 92% 3
• Durable complete response occurs in approximately 50% of patients treated with progestin therapy 1
• Median time to complete response: 6 months (range 3-21 months) 4

Monitoring Protocol

1. For hyperplasia without atypia: Endometrial sampling every 6 months 2
2. For atypical hyperplasia: Endometrial sampling every 3 months 2
3. Treatment adjustments based on response to medication
4. Continue treatment until two consecutive negative biopsies

Special Considerations

Fertility Preservation

• For women desiring fertility preservation, continuous progestin therapy is appropriate for selected patients 1
• After disease regression, assisted reproductive technologies should be considered to help achieve pregnancy 2
• Note: Pregnancy success rates may be limited (approximately 10% in some studies) 5

Risk Factors for Non-Response to Treatment

• History of prior abnormal bleeding 3
• Presence of associated pelvic pathology 3
• Use of progestins other than medroxyprogesterone acetate 3

Cautions with Progestin Therapy

Exercise caution in patients with:

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

Treatment Failure or Recurrence

• Consider hysterectomy if:
  • Endometrial abnormalities persist after 6-12 months of progestin therapy
  • Disease progression is documented
  • After childbearing is complete 1
• For recurrent atypical hyperplasia, total hysterectomy is recommended 2

Important Clinical Caveat

While progestin therapy is effective for endometrial hyperplasia, it is important to note that current evidence does not support the use of progestins in the adjuvant treatment of endometrial cancer 6. Careful diagnosis and distinction between hyperplasia and cancer is essential for appropriate treatment selection.