In an obese young woman with focal atypical endometrial hyperplasia who had a levonorgestrel‑releasing intrauterine device placed at hysteroscopy, what is the appropriate next step in management?

Management of Focal Atypical Endometrial Hyperplasia with LNG-IUD Already Placed

In an obese young woman with focal atypical endometrial hyperplasia who already has an LNG-IUD placed at hysteroscopy, the appropriate next step is close surveillance with repeat endometrial sampling at 3-month intervals to monitor for regression, with the expectation that 84-92% of cases will achieve complete regression within 12 months. 1, 2

Surveillance Protocol

• Perform endometrial biopsy at 3-month intervals following LNG-IUD insertion to assess for regression of atypical hyperplasia 2, 3
• Continue surveillance for at least 12 months, as most patients (84-92%) achieve complete regression within this timeframe 1, 2
• If regression is not achieved by 12 months, extend surveillance to 24 months, as an additional 3-7% of patients may achieve regression during this extended period 1, 2

Expected Outcomes

• Complete regression occurs in 78.6-92.7% of patients with atypical endometrial hyperplasia treated with LNG-IUD, depending on whether focal resection was also performed 1, 2
• The mean time to regression is approximately 4.5-9 months, with 66% achieving regression within the first 3 months 3
• Relapse rates are considerably lower (3.9-18.2%) with LNG-IUD compared to progestin therapy alone 1

When to Consider Hysterectomy

• Proceed to hysterectomy if there is progression to endometrial cancer on follow-up biopsy 1
• Consider hysterectomy if persistent atypia remains after 24 months of treatment 2
• Hysterectomy is indicated if the patient develops severe atypia or shows no response to treatment 2

Monitoring for IUD-Related Issues

• At each follow-up visit, assess for IUD displacement by checking for visible strings and performing bimanual examination 4
• Rule out pregnancy with urine testing if bleeding patterns change, as pregnancy can occur despite LNG-IUD 4
• If irregular bleeding persists, evaluate for IUD displacement, sexually transmitted infections, or new pathologic uterine conditions such as polyps or fibroids before attributing symptoms to the hyperplasia 5, 6

Critical Clinical Pitfalls to Avoid

• Do not delay surveillance biopsies, as close monitoring is essential to detect progression to cancer early 2
• Do not remove the LNG-IUD prematurely if the patient is tolerating it well, as regression may take up to 24 months 1, 2
• Do not assume amenorrhea or oligomenorrhea indicates treatment failure—approximately half of LNG-IUD users experience this by 2 years, and it does not require treatment 5, 6
• Do not attribute persistent bleeding to the LNG-IUD without first ruling out displacement, infection, or new pathology 5, 4

Fertility Preservation Considerations

• If the patient desires future fertility, the LNG-IUD can be removed once complete regression is confirmed on at least two consecutive biopsies 1
• Among patients who had the LNG-IUD removed after achieving regression, 40% achieved natural conception and live birth 1
• Counsel the patient that close surveillance will be required even after LNG-IUD removal, as recurrence can occur 1