In a 55‑year‑old woman with atypical endometrial hyperplasia after dilation and curettage, should I proceed with total hysterectomy and bilateral salpingo‑oophorectomy or manage conservatively with progestin therapy?

Surgical Management is Recommended for a 55-Year-Old Woman with Atypical Endometrial Hyperplasia

At age 55, total hysterectomy with bilateral salpingo-oophorectomy is the definitive treatment for atypical endometrial hyperplasia and should be performed. 1, 2, 3

Why Surgery is the Standard of Care at This Age

Hysterectomy Eliminates Cancer Risk

• Atypical hyperplasia/endometrial intraepithelial neoplasia (AH/EIN) carries a 50% risk of concurrent endometrial cancer that may be missed on D&C sampling alone. 2
• Total hysterectomy with bilateral salpingo-oophorectomy represents the curative treatment that eliminates both the existing atypical hyperplasia and the risk of progression to endometrial cancer. 2
• This is the definitive treatment recommended by the European Society of Gynaecological Oncology. 1, 2

Conservative Management is Reserved for Specific Circumstances Only

Conservative progestin therapy is only appropriate for highly selected patients who meet ALL of the following strict criteria: 1, 2

• Desire for fertility preservation (not applicable at age 55)
• Referral to specialized centers
• Confirmation of AH/EIN diagnosis by specialist gynaecopathologist
• Pelvic MRI excluding myometrial invasion and adnexal involvement
• Full informed consent that this is non-standard treatment
• Willingness to accept close follow-up with endometrial sampling every 3-6 months

At age 55, fertility preservation is not a consideration, which eliminates the primary indication for conservative management. 1, 2

Limitations of Progestin Therapy

Poor Response Rates and High Recurrence

• Complete response occurs in only approximately 50% of patients with atypical hyperplasia treated with progestins. 2, 4
• Even after achieving complete response, recurrence rates remain high at 35%. 2
• In one study, only 53.8% of patients with grade 1 endometrial cancer achieved complete remission with oral progestins, and 26.1% of those who achieved remission had disease recurrence. 4

Treatment Duration and Monitoring Burden

• Progestin therapy requires at least 6 months to accurately assess treatment response. 5
• Endometrial sampling must be performed every 3-6 months during treatment. 2
• If hyperplasia persists after 6-12 months of progestin therapy, hysterectomy becomes necessary anyway. 2

Contraindications to Consider

Progestins are contraindicated in patients with: 2

• History of breast cancer
• History of stroke or myocardial infarction
• Pulmonary embolism or deep vein thrombosis
• Active smoking

Surgical Approach

Recommended Procedure

• Total hysterectomy with bilateral salpingo-oophorectomy is the standard surgical approach. 1, 2
• Minimally invasive surgery (laparoscopic or robotic) is recommended when feasible. 1
• For patients medically unfit for laparoscopy/laparotomy, vaginal hysterectomy with bilateral salpingo-oophorectomy is an alternative. 1

Lymphadenectomy Considerations

• Systematic lymphadenectomy is not routinely required for atypical hyperplasia without confirmed cancer. 1
• If cancer is discovered on final pathology, staging decisions depend on grade, depth of myometrial invasion, and histologic type. 1

Special Consideration: Lynch Syndrome Screening

• Approximately 5% of endometrial cancers are linked to Lynch syndrome, particularly in younger patients. 2
• While this patient is 55 years old, if there is any family history suggestive of Lynch syndrome, genetic counseling should be considered. 2

Common Pitfalls to Avoid

Do Not Delay Surgery for Prolonged Medical Management

• At age 55 without fertility concerns, attempting conservative management exposes the patient to unnecessary risk of progression to invasive cancer. 2, 3
• The 50% risk of concurrent cancer means that half of these patients already have malignancy that requires definitive surgical treatment. 2

Do Not Rely on D&C Alone for Diagnosis

• D&C can miss concurrent endometrial cancer in patients with atypical hyperplasia. 2
• Final pathology after hysterectomy frequently reveals more advanced disease than suggested by preoperative sampling. 3

Ensure Bilateral Salpingo-Oophorectomy is Performed

• After completion of childbearing (clearly applicable at age 55), hysterectomy with bilateral salpingo-oophorectomy is strongly recommended for all patients with atypical hyperplasia. 1, 2
• This eliminates future cancer risk from both endometrial and ovarian sources. 2