In a 45-year-old woman with a recent stroke and endometrial hyperplasia for whom a levonorgestrel-releasing intrauterine device and endometrial ablation are unavailable, what is the next medical management?

Oral Progestin Therapy for Endometrial Hyperplasia in Post-Stroke Patients

In a 45-year-old woman with recent stroke and endometrial hyperplasia when LNG-IUD and ablation are unavailable, initiate high-dose oral progestin therapy with medroxyprogesterone acetate 20 mg three times daily for 7 days to achieve acute bleeding control, followed by cyclic medroxyprogesterone acetate 10 mg daily on days 16-25 of each cycle for long-term management. 1, 2

Acute Management Phase (First 7 Days)

For immediate bleeding control:

• Medroxyprogesterone acetate 20 mg orally three times daily for 7 consecutive days stops acute bleeding within 24-48 hours in most patients 1
• Alternative: Norethindrone acetate 5 mg orally three times daily for 7 days 1
• This high-dose regimen is the most effective short-term oral intervention when LNG-IUD placement is not feasible 1

Long-Term Maintenance Phase

After acute control is achieved:

• Transition to cyclic medroxyprogesterone acetate 10 mg daily on days 16-25 of each menstrual cycle 1, 2
• This cyclic regimen reduces menstrual blood loss by approximately 87% 1
• Expect initial irregular bleeding that typically stabilizes to light bleeding over subsequent cycles 1

Critical Contraindications in This Patient

Given the recent stroke history, carefully evaluate:

• Combined hormonal contraceptives (estrogen-containing) are absolutely contraindicated due to increased stroke risk 3
• Progestin-only therapy (medroxyprogesterone acetate) does NOT increase stroke risk and is safe to use 3
• NSAIDs should be avoided or used with extreme caution given cardiovascular disease, as they increase risk of myocardial infarction and thrombosis 1

Monitoring Protocol

Endometrial surveillance:

• Perform endometrial sampling (biopsy or D&C) every 3-6 months during progestin therapy 3
• If endometrial hyperplasia persists after 6-12 months of treatment, consider pelvic MRI to exclude myoinvasion before continuing therapy 3
• Hysterectomy is recommended if documented progression occurs on biopsies or if hyperplasia persists beyond 12 months 3

Expected Outcomes and Efficacy

Comparative effectiveness data:

• Oral medroxyprogesterone acetate achieves 80-87% regression of endometrial hyperplasia without atypia 4, 5
• While less effective than LNG-IUD (which achieves 96-100% regression), oral progestin remains a reasonable alternative when IUD placement is contraindicated or unavailable 4, 5, 6
• Complete regression typically occurs within 3-9 months of cyclic therapy 6

Management of Persistent Bleeding

If bleeding continues despite oral progestin:

• Add NSAIDs (if cardiovascular status permits) for 5-7 days during active bleeding episodes 3, 1
• Consider short course (10-20 days) of low-dose estrogen therapy ONLY if medically eligible and stroke risk has been thoroughly reassessed 3
• However, given recent stroke, estrogen therapy carries significant risk and should generally be avoided 3

Common Pitfalls to Avoid

Key clinical caveats:

• Do NOT use combined oral contraceptives or any estrogen-containing preparations in this patient with recent stroke 3
• Progestin-only methods (oral, injectable, implant) do NOT increase stroke risk, unlike combined hormonal contraceptives 3
• Recurrence rate with oral progestin is approximately 12.5% compared to 0% with LNG-IUD, necessitating ongoing surveillance 5
• Patient satisfaction is lower with oral therapy compared to LNG-IUD due to side effects and irregular bleeding patterns 4, 5

Alternative Considerations

If oral progestin fails or is not tolerated:

• Depot medroxyprogesterone acetate injection (DMPA) provides progestin-only contraception without increased stroke risk 3
• Etonogestrel implant is another progestin-only option that does not increase stroke risk 3
• Hysterectomy remains definitive treatment if medical management fails after 6-12 months 3

Specific Monitoring Parameters

Before initiating therapy, document:

• Blood pressure (progestins may cause fluid retention requiring monitoring in patients with cardiovascular disease) 7
• Baseline endometrial biopsy confirming hyperplasia type (simple vs complex, with or without atypia) 3, 4
• Pregnancy test to rule out pregnancy 2, 7
• Liver function (progestins contraindicated in severe liver disease) 2, 7

During therapy, assess for:

• Breakthrough bleeding patterns (initial irregular bleeding is expected and typically improves) 1
• Signs of depression (progestins may exacerbate pre-existing depression) 7
• Fluid retention symptoms (especially given cardiovascular history) 7