What is the cause of daily heavy bleeding in a 45-year-old woman with endometrial hyperplasia?

From the Guidelines

The patient should be treated for endometrial hyperplasia with a progestin-containing regimen, such as medroxyprogesterone acetate 10-20 mg daily for 10-14 days per month for 3-6 months, and weight loss should be recommended to reduce the risk of progression to endometrial cancer, as supported by the most recent guidelines 1. The recommended treatment is based on the patient's diagnosis of endometrial hyperplasia, which is likely due to unopposed estrogen stimulation. The patient's obesity, with a BMI of 38 kg/m2, contributes to increased peripheral conversion of androgens to estrogens in adipose tissue, leading to unopposed estrogen stimulation of the endometrium.

• Key factors to consider in the patient's treatment include:
  • The patient's age, 45, which suggests she may be in perimenopause, increasing her risk for endometrial hyperplasia and potentially endometrial cancer
  • The patient's obesity, which is a significant risk factor for endometrial cancer, with a relative risk of 2.54 for obesity compared to normal weight 1
  • The importance of follow-up endometrial sampling after 3-6 months of therapy to ensure regression of the hyperplasia
  • The potential need for surgical management with hysterectomy if the hyperplasia persists or if atypia is present Alternatively, a levonorgestrel-releasing intrauterine device could be considered as a treatment option. Regular follow-up is essential to monitor treatment response and prevent progression to more serious conditions, such as endometrial cancer, which has a high incidence in women with risk factors like obesity and unopposed estrogen exposure 1.

From the FDA Drug Label

1. Use with Estrogen Studies of the addition of a progestin product to an estrogen replacement regimen for seven or more days of a cycle of estrogen administration have reported a lowered incidence of endometrial hyperplasia Morphological and biochemical studies of endometrial suggest that 10–13 days of a progestin are needed to provide maximal maturation of the endometrium and to eliminate any hyperplastic changes. The patient has been diagnosed with endometrial hyperplasia, and the use of a progestin product, such as medroxyprogesterone acetate, for 10-13 days may help to eliminate hyperplastic changes and provide maximal maturation of the endometrium 2.

• The treatment should be carefully considered, as the patient has a history of irregular menstrual bleeding and is at risk for endometrial hyperplasia.
• The dosage and duration of treatment with medroxyprogesterone acetate should be determined by the clinician, taking into account the patient's individual needs and medical history.

From the Research

Endometrial Hyperplasia Treatment

The patient's endometrial biopsy reveals endometrial hyperplasia, which can be treated with progestogen therapy 3.

Progestogen Therapy Options

There are different types of progestogen therapy, including levonorgestrel-releasing intrauterine device (LNG-IUD) and oral medroxyprogesterone acetate (MPA) 4, 5.

• Key differences between these options include:
  • Efficacy: LNG-IUD has been shown to be more effective than MPA in treating simple endometrial hyperplasia 4, 5
  • Side effects: MPA has been associated with more side effects than LNG-IUD 4
  • Patient satisfaction: Patients have reported higher satisfaction rates with LNG-IUD compared to MPA 4

Progesterone and Endometrial Safety

Progesterone acts to counteract the proliferative effects of estradiol on the endometrium, and progestogens are used in menopausal hormone therapy to protect the endometrium against the effects of estrogens 3, 6.

• Key points to consider:
  • Micronized progesterone may be safer for the breast but less efficient than synthetic progestin on the endometrium 3, 6
  • Progestogen therapy can help prevent or treat endometrial hyperplasia and reduce the risk of endometrial cancer 3