DMPA for Endometrial Hyperplasia Without Atypia
DMPA is not recommended as a treatment for endometrial hyperplasia without atypia; oral medroxyprogesterone acetate (MPA) or levonorgestrel-releasing intrauterine devices (LNG-IUD) are the preferred progestin-based therapies. 1
Why DMPA is Not the Appropriate Choice
Formulation and Indication Issues
The FDA-approved injectable DMPA formulation is specifically designed for contraception, not for treating endometrial hyperplasia. The FDA label explicitly states that "because of its prolonged action and the resulting difficulty in predicting the time of withdrawal bleeding following injection, medroxyprogesterone acetate is not recommended in secondary amenorrhea or dysfunctional uterine bleeding. In these conditions oral therapy is recommended." 2
DMPA causes unpredictable menstrual irregularities in nearly all patients initially, which would mask the ability to monitor treatment response and could obscure symptoms of disease progression. 1, 3
Monitoring and Response Assessment Challenges
Endometrial hyperplasia without atypia requires regular monitoring every 6 months with endometrial biopsies to assess treatment response. 4 The irregular bleeding patterns caused by DMPA would make clinical assessment extremely difficult and potentially delay recognition of treatment failure or progression.
Treatment should continue until no pathological changes are observed in two consecutive endometrial biopsies, which requires predictable withdrawal bleeding patterns that DMPA cannot provide. 4
Recommended Treatment Options
First-Line: Oral Progestins or LNG-IUD
Oral medroxyprogesterone acetate (MPA) is the standard progestin therapy for endometrial hyperplasia without atypia. Studies demonstrate regression rates of 82.5-90% with oral MPA regimens. 5
The levonorgestrel-releasing intrauterine system (LNG-IUD) is associated with higher regression rates, lower recurrence rates, and fewer adverse events compared to oral progestins, making it an excellent first-line option. 4
The CDC Medical Eligibility Criteria classifies endometrial hyperplasia as Category 1 (no restrictions) for all progestin-only contraceptives including oral progestin-only pills, DMPA, and implants, but this classification refers to contraceptive use in women who happen to have hyperplasia, not therapeutic use for treating the condition. 1
Dosing Regimens for Oral MPA
Cyclic MPA (15 mg for 10-14 days per month) is safer and more acceptable to patients compared to continuous MPA, with equivalent efficacy (90% vs 82.5% regression rates). 5
High-dose MPA regimens have been used successfully for atypical hyperplasia in fertility-sparing cases, but standard doses are appropriate for non-atypical hyperplasia. 6
Clinical Pitfalls to Avoid
Do not confuse contraceptive indications with therapeutic indications. While DMPA may be used for contraception in women with endometrial hyperplasia, it is not a treatment for the hyperplasia itself. 1
Do not use DMPA in patients requiring close monitoring of endometrial response, as the prolonged irregular bleeding will interfere with clinical assessment. 2
Ensure proper follow-up with endometrial sampling every 6 months to document regression and detect any progression to atypical hyperplasia or carcinoma. 4
Special Considerations
For patients desiring fertility preservation with atypical hyperplasia, oral MPA or megestrol acetate (MA) are recommended, with LNG-IUD as an alternative option. 1
Hysterectomy is not the preferred treatment for endometrial hyperplasia without atypia, but should be considered for treatment failures or recurrent disease. 4