Premenopausal patient with EH without atypia

EH: endometrial hyperplasia; EC: endometrial carcinoma; EMBx: endometrial biopsy; AUB: abnormal uterine bleeding; D&C: dilation and curettage; LNG: levonorgestrel.
* Risk factors for EC include chronic ovulatory dysfunction, obesity, early menarche, increasing age, tamoxifen therapy, and Lynch or Cowden syndrome. These vary in degree of risk, and the clinician must counsel the patient regarding whether a particular factor is clinically significant and should impact management.
¶ Progestin therapy is contraindicated in patients trying to conceive a pregnancy and may be contraindicated in patients with thrombotic and/or hepatic disorders or with progestin receptor-positive breast cancer. In addition, some patients decline therapy because they cannot tolerate progestins or they prefer to avoid hormonal therapy.
Δ The 52 mg LNG-releasing intrauterine device (Mirena or Liletta; LNG 52) appears to be the most effective progestin treatment, is easy to comply with, well-tolerated, and provides contraception. Other options include oral progestins or estrogen-progestin oral contraceptives.
◊ If the patient has risk factors for EC, a history of recurrent or persistent EH, or EH with atypia, confirm normal endometrium with 1 to 2 more EMBx performed every 3 to 6 months.
§ Progestin therapy may be given to select patients who are strongly motivated to preserve fertility and in whom physicians deem this an acceptable degree of risk.
¥ The options for progestin regimens for maintenance therapy are the same as for initial treatment. The duration of maintenance therapy may be indefinite and is typically at least 2 years. Decisions about discontinuing therapy are based on whether abnormal uterine bleeding is present and the risk of recurrent or progressive disease.