Management of Atypical Endometrial Hyperplasia with a Focus on Conservative Treatment

Abstract

Study Objective To compare local management of women diagnosed with atypical endometrial hyperplasia (AH) against RCOG Greentop Guideline No. 67 “Management of endometrial hyperplasia,” with specific emphasis on conservative treatment. Design An existing database of patients with endometrial pathology from 2012 to 2019 was used to identify 118 cases of AH. Patient demographics, management, and follow up were interrogated. Setting NHS Lanarkshire, Scotland (population 655,000). Patients or Participants Patient age ranged from 26-83 years with 50% over the age of fifty. 75% of patients were postmenopausal and 90% were overweight (BMI >25). Interventions Seventy-eight women (66%) had immediate hysterectomy. Thirty-five women (30%) underwent conservative management and five (4%) were lost to follow up. Conservative treatment comprised of levonorgestrel-releasing intrauterine system (LNG-IUS) (67%), oral progestogens (18%), GnRH analogues (9%), weight loss alone or no management (6%). Measurements and Main Results Follow up biopsy results in the conservative treatment group showed regression in fourteen patients (67%), persistence in five (23%) and progression to endometrial cancer in two (10%). Low rates of progression (12% overall) and persistence were observed overtime alongside continued regression rates. Eight women (23%) managed conservatively subsequently progressed to hysterectomy. Four of which required surgery due to the development of endometrial carcinoma. Conclusion Local management is consistent with current RCOG guidelines with more than half of women proceeding immediately to hysterectomy. The majority of patients managed conservatively had the LNG-IUS, consistent with guidelines. Follow up was appropriate in terms of monitoring and tissue sampling with four cases of endometrial cancer detected. This emphasises the importance of regular monitoring. Over 90% had an elevated BMI, a known risk factor for developing AH. Literature supports weight loss in improving regression rates in this demographic. In some cases, an initial conservative approach may allow peri-operative optimisation and risk factor modification which has a role in improving surgical outcomes. To compare local management of women diagnosed with atypical endometrial hyperplasia (AH) against RCOG Greentop Guideline No. 67 “Management of endometrial hyperplasia,” with specific emphasis on conservative treatment. An existing database of patients with endometrial pathology from 2012 to 2019 was used to identify 118 cases of AH. Patient demographics, management, and follow up were interrogated. NHS Lanarkshire, Scotland (population 655,000). Patient age ranged from 26-83 years with 50% over the age of fifty. 75% of patients were postmenopausal and 90% were overweight (BMI >25). Seventy-eight women (66%) had immediate hysterectomy. Thirty-five women (30%) underwent conservative management and five (4%) were lost to follow up. Conservative treatment comprised of levonorgestrel-releasing intrauterine system (LNG-IUS) (67%), oral progestogens (18%), GnRH analogues (9%), weight loss alone or no management (6%). Follow up biopsy results in the conservative treatment group showed regression in fourteen patients (67%), persistence in five (23%) and progression to endometrial cancer in two (10%). Low rates of progression (12% overall) and persistence were observed overtime alongside continued regression rates. Eight women (23%) managed conservatively subsequently progressed to hysterectomy. Four of which required surgery due to the development of endometrial carcinoma. Local management is consistent with current RCOG guidelines with more than half of women proceeding immediately to hysterectomy. The majority of patients managed conservatively had the LNG-IUS, consistent with guidelines. Follow up was appropriate in terms of monitoring and tissue sampling with four cases of endometrial cancer detected. This emphasises the importance of regular monitoring.