Can a patient with atypical endometrial hyperplasia retain the ovaries?

Ovarian Preservation in Atypical Endometrial Hyperplasia

After completion of childbearing (or after the age of potential pregnancy), standard treatment with hysterectomy and bilateral salpingo-oophorectomy is recommended for atypical endometrial hyperplasia. 1

When Ovarian Preservation Can Be Considered

Preservation of the ovaries can be considered in selected cases, depending on the patient's age and genetic risk factors. 1 Specifically, ovarian preservation may be appropriate for:

• Women younger than 45 years old with confirmed atypical hyperplasia/endometrial intraepithelial neoplasia (AH/EIN) 2
• Patients with no family history of ovarian cancer risk (no BRCA mutation, no Lynch syndrome) 2
• Patients who have undergone hysterectomy but meet the above criteria 1

Absolute Contraindications to Ovarian Preservation

The following patients must undergo bilateral salpingo-oophorectomy and cannot retain ovaries:

• Patients with Lynch syndrome or BRCA mutations - these patients require prophylactic bilateral salpingo-oophorectomy and are not candidates for ovarian preservation 2, 3
• Postmenopausal women - hysterectomy with bilateral salpingo-oophorectomy is the standard treatment 4, 5
• Patients age 45 or older - ovarian preservation criteria specifically exclude this age group 2
• Patients with obvious ovarian or extra-uterine disease on imaging 2

Critical Clinical Algorithm

Step 1: Confirm Diagnosis and Staging

• Expert gynaecopathologist must confirm AH/EIN diagnosis to exclude concurrent endometrial cancer 1, 3
• Pelvic MRI is mandatory to exclude myometrial invasion and assess for adnexal involvement 2, 3
• Rule out synchronous ovarian malignancy - 7-29% of young endometrial cancer patients may have concurrent ovarian pathology 2

Step 2: Assess Patient Eligibility

• Age < 45 years 2
• No family history of hereditary cancer syndromes (Lynch syndrome, BRCA) - if family history present, genetic counseling and testing required 2, 3
• Patient has completed childbearing or is undergoing definitive hysterectomy 1

Step 3: Surgical Approach

• If all criteria met: Perform hysterectomy with bilateral salpingectomy and ovarian preservation 1, 2
• If any criteria not met: Perform hysterectomy with bilateral salpingo-oophorectomy 1, 3

Important Caveats and Common Pitfalls

The Salpingectomy Requirement

Even when ovaries are preserved, bilateral salpingectomy is recommended to reduce future ovarian cancer risk 2. This is a critical distinction - the tubes should be removed even if the ovaries are retained.

The Fertility Preservation Context

If a patient with AH/EIN is undergoing fertility-sparing treatment (progestin therapy without hysterectomy), this is an entirely different scenario:

• After completion of childbearing, hysterectomy AND bilateral salpingo-oophorectomy is recommended 1, 3
• Ovarian preservation in this context is NOT standard - the recommendation is for complete removal of both uterus and adnexa after fertility goals are met 1, 3

Genetic Risk Assessment is Non-Negotiable

Failure to identify Lynch syndrome or BRCA mutations before ovarian preservation is a critical error. 2 These patients require:

• Prophylactic bilateral salpingo-oophorectomy at age 40 for Lynch syndrome 3
• No consideration of ovarian preservation regardless of age 2

The Age 45 Cutoff

The evidence consistently uses age 45 as the upper limit for considering ovarian preservation 2. This reflects both:

• Declining ovarian function and hormonal benefit after this age
• Increasing cancer risk with age 1

Evidence Quality and Consensus

The recommendation for bilateral salpingo-oophorectomy after childbearing completion achieved 100% consensus among guideline panel members 1. The allowance for selective ovarian preservation based on age and genetic factors represents a Level IV evidence, Strength B recommendation 1, reflecting expert consensus rather than high-quality randomized data.

In premenopausal women with early-stage endometrial cancer, ovarian preservation has been shown safe with 16-year follow-up 1, but this data applies to endometrial cancer, not specifically to atypical hyperplasia undergoing definitive surgery.

Practical Implementation

For a patient with atypical hyperplasia who has completed childbearing:

1. Age < 45 + no Lynch/BRCA → Hysterectomy with bilateral salpingectomy, ovarian preservation possible 1, 2
2. Age ≥ 45 OR Lynch/BRCA positive → Hysterectomy with bilateral salpingo-oophorectomy mandatory 1, 2, 3
3. Any uncertainty about genetic risk → Genetic counseling before surgery 2

The default and standard approach remains hysterectomy with bilateral salpingo-oophorectomy - ovarian preservation is the exception, not the rule. 1, 3