For a 55-year-old postmenopausal woman with simple (non‑atypical) endometrial hyperplasia, is surgical management (total hysterectomy with bilateral salpingo‑oophorectomy) or medical management (progestin therapy) preferred?

Management of Simple (Non-Atypical) Endometrial Hyperplasia in a 55-Year-Old Postmenopausal Woman

For a 55-year-old postmenopausal woman with simple (non-atypical) endometrial hyperplasia, medical management with oral progestins is the preferred initial approach, reserving hysterectomy for treatment failures, persistent disease after 6-12 months, or patients with contraindications to progestin therapy. 1

Initial Management Strategy

Medical management with continuous oral progestins should be the first-line treatment for non-atypical endometrial hyperplasia in postmenopausal women. 1 The recommended regimens include:

• Medroxyprogesterone acetate (MPA) 10-20 mg daily (continuous dosing) 1
• Megestrol acetate 160-320 mg daily as an alternative 1
• Levonorgestrel-releasing intrauterine device may be considered if oral progestins are not tolerated 1

The rationale for medical management first is that non-atypical hyperplasia has high response rates of 92.5% with progestin therapy 2, and unlike atypical hyperplasia, carries a much lower risk of concurrent endometrial cancer or rapid progression. 3

Monitoring Protocol During Medical Management

Endometrial sampling must be performed every 3-6 months during progestin treatment to assess response and detect any progression. 1 This surveillance is critical because:

• Treatment should continue for at least 6 months before accurately assessing response 4
• Persistent architectural abnormalities or cytologic atypia at 7-9 months predict treatment failure and warrant surgical intervention 4
• 7.5% of patients have persistent or progressive lesions despite initial clinical response 2

When to Proceed to Hysterectomy

Total hysterectomy with bilateral salpingo-oophorectomy becomes the definitive treatment in the following scenarios:

• Persistent hyperplasia after 6-12 months of progestin therapy 1, 3
• Progression to atypical hyperplasia or carcinoma on follow-up biopsies 3
• Presence of endometrial cancer risk factors including obesity, diabetes, hypertension, or Lynch syndrome 3, 5
• Contraindications to progestin therapy including history of breast cancer, stroke, myocardial infarction, or active smoking 1
• Patient preference for definitive treatment after informed discussion of risks and benefits 3

For postmenopausal women at age 55, bilateral salpingo-oophorectomy should be performed concurrently with hysterectomy to eliminate ovarian cancer risk and avoid future surgery. 6, 3

Critical Contraindications to Progestin Therapy

Progestins are absolutely contraindicated in patients with:

• History of breast cancer 1
• Prior stroke or myocardial infarction 1
• Active thromboembolic disease (pulmonary embolism, deep vein thrombosis) 1
• Current smoking 1

In these patients, proceed directly to hysterectomy with bilateral salpingo-oophorectomy as the safest option. 3

Special Considerations for Postmenopausal Women

Postmenopausal women with non-atypical hyperplasia warrant more aggressive consideration for surgery compared to premenopausal women because:

• Significant risk of progression to endometrial cancer exists in the postmenopausal population 3
• No fertility preservation concerns at age 55 3
• Higher prevalence of comorbidities (obesity, diabetes, hypertension) that increase cancer risk 5
• Unopposed estrogen exposure from obesity or other sources continues without intervention 5

Surgical Approach When Indicated

Minimally invasive surgery (laparoscopic or robotic) is preferred over open abdominal hysterectomy when surgery is indicated, as it offers:

• Shorter hospital stays and faster recovery 7
• Lower perioperative morbidity 7
• Similar oncologic outcomes for benign and low-risk conditions 7

Vaginal hysterectomy is an acceptable alternative for patients who cannot tolerate laparoscopy. 6

Common Pitfalls to Avoid

Do not rely solely on clinical response (cessation of bleeding) to assess treatment efficacy - 84.6% of clinical non-responders have associated pelvic pathology requiring evaluation. 2 Histologic confirmation via endometrial biopsy is mandatory every 3-6 months. 1

Do not discontinue progestin therapy prematurely - architectural changes resolve later than cytologic changes, and treatment must continue for at least 6 months before assessing response. 4

Do not miss Lynch syndrome screening - approximately 5% of endometrial pathology is linked to hereditary cancer syndromes, particularly in younger patients, though less likely at age 55. 1 Consider family history assessment.

Do not use unopposed estrogen therapy if the patient requires hormone replacement for menopausal symptoms during or after treatment, as this can stimulate hyperplasia recurrence. 5

Algorithm Summary

1. Confirm diagnosis with endometrial biopsy reviewed by gynaecopathologist 1
2. Assess contraindications to progestin therapy (breast cancer, stroke, MI, smoking) 1
3. If contraindications present: proceed to hysterectomy with bilateral salpingo-oophorectomy 3
4. If no contraindications: initiate continuous oral progestin therapy (MPA or megestrol) 1
5. Monitor with endometrial sampling every 3-6 months 1
6. If complete response at 6-12 months: consider maintenance therapy or observation with continued surveillance 1
7. If persistent disease at 6-12 months or progression at any time: proceed to hysterectomy with bilateral salpingo-oophorectomy 1, 3