Postmenopausal patient: Management of EH with atypia

EH: endometrial hyperplasia; D&C: dilation and curettage; EC: endometrial carcinoma; EMBx: endometrial biopsy; TVUS: transvaginal ultrasound; LNG: levonorgestrel.
* Hysterectomy is not an option in some patients with comorbidities or who decline hysterectomy. For these patients, consult a gynecologic oncologist regarding further management.
¶ Progestins may be contraindicated in some patients with thrombotic and/or hepatic disorders or with progesterone 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, and is well-tolerated. Oral progestins are also an option.
◊ Transvaginal ultrasound should demonstrate an endometrial thickness <4 mm; if endometrial thickness is ≥4 mm a D&C with hysteroscopy should be performed.
§ The options for maintenance progestin regimens 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 upon whether abnormal uterine bleeding is present and the risk of recurrent or progressive disease.
¥ Risk factors for endometrial carcinoma include chronic ovulatory dysfunction, obesity, early menarche, late menopause, increasing age, tamoxifen therapy, Lynch syndrome, and Cowden syndrome. These vary in degree of risk, and the clinician must decide with the patient regarding whether a particular factor is clinically significant and should impact each management decision. Risk factors for EC are discussed in more detail separately.