What is the best treatment for a 45-year-old woman with a thickened endometrium (hyperplasia) who has had 6 children?

Treatment of Thickened Endometrium in a 45-Year-Old Multiparous Woman

For a 45-year-old woman with 6 children and thickened endometrium, hysterectomy with bilateral salpingo-oophorectomy is the definitive treatment if endometrial hyperplasia with atypia or endometrial cancer is confirmed, while oral progestins are appropriate only for non-atypical hyperplasia in women who have completed childbearing and wish to avoid surgery. 1

Critical First Step: Establish the Diagnosis

Before determining treatment, the exact pathologic diagnosis must be confirmed through proper tissue sampling:

• Dilatation and curettage (D&C) with or without hysteroscopy is mandatory to obtain adequate tissue for accurate histologic diagnosis, as it is superior to office endometrial biopsy for determining grade and excluding invasive cancer 1
• The pathology must be reviewed by a specialist gynaecopathologist to confirm whether this represents simple hyperplasia, complex hyperplasia, atypical hyperplasia/endometrial intraepithelial neoplasia (AH/EIN), or endometrial carcinoma 1
• Pelvic MRI should be performed to assess for myometrial invasion and exclude adnexal involvement if there is any concern for malignancy 1

Treatment Algorithm Based on Pathologic Diagnosis

If Atypical Hyperplasia (AH/EIN) or Endometrial Cancer is Confirmed:

Hysterectomy with bilateral salpingo-oophorectomy is the standard treatment for this patient who has completed childbearing 1

• Total hysterectomy and bilateral salpingo-oophorectomy without vaginal cuff is the standard surgical approach for clinical Stage I disease 1
• Minimally invasive surgery (laparoscopic or robotic) is recommended for low- and intermediate-risk endometrial pathology 1
• Pelvic lymphadenectomy can be considered for staging in cases of atypical hyperplasia or low-grade endometrial cancer, though it is optional for low-risk disease 1
• After completion of childbearing, hysterectomy and salpingo-oophorectomy is recommended even for patients initially treated conservatively with progestins 1

If Non-Atypical Hyperplasia (Simple or Complex Without Atypia) is Confirmed:

Oral progestin therapy is the appropriate medical management, though hysterectomy remains an option for definitive treatment:

• Medroxyprogesterone acetate (MPA) 400-600 mg/day or megestrol acetate (MA) 160-320 mg/day for at least 6 months is the standard hormonal treatment 1
• Levonorgestrel-releasing intrauterine device (LNG-IUD) is an alternative option that may provide local endometrial suppression 1
• Response must be assessed at 6 months with repeat D&C to confirm regression of hyperplasia 1
• If no response is achieved after 6 months, hysterectomy should be performed 1
• Even with successful treatment, hysterectomy should be strongly recommended after completion of childbearing given the risk of recurrence (30-40%) 1

Why Oral Contraceptive Pills Are NOT the Answer

Oral contraceptive pills are not the standard treatment for endometrial hyperplasia or thickened endometrium in this clinical scenario:

• The evidence-based guidelines consistently recommend high-dose progestins (MPA 400-600 mg/day or MA 160-320 mg/day), not the low-dose progestins found in oral contraceptive pills 1
• Oral contraceptive pills contain insufficient progestin doses to adequately treat endometrial hyperplasia or suppress endometrial proliferation in established disease 2, 3
• For a 45-year-old woman who has completed childbearing, definitive surgical management is more appropriate than prolonged medical therapy with uncertain compliance and follow-up 1

Critical Caveats and Pitfalls

Age and fertility status matter: This patient is 45 years old with 6 children, meaning fertility preservation is not a consideration. The guidelines specifically state that fertility-sparing therapy with progestins is reserved for younger women who desire future childbearing and requires specialized center referral, close follow-up, and eventual hysterectomy after childbearing completion 1

Risk of concurrent malignancy: Women with atypical hyperplasia have a significant risk of concurrent endometrial carcinoma, and endometrial cancer in women ≤45 years is not necessarily low-risk disease, with 30% having occult metastatic disease in some series 4

Inadequate sampling leads to underdiagnosis: Office endometrial biopsy may miss focal areas of atypia or cancer, which is why D&C is superior and mandatory before committing to conservative management 1

Progestin therapy requires strict monitoring: If medical management is chosen for non-atypical hyperplasia, patients must undergo repeat endometrial sampling every 6 months and be willing to accept close surveillance 1