Sunday morning’s John I. Brewer Memorial Lecture considered the value of hormonal treatment for atypical endometrial hyperplasia vs. the more common hysterectomy.
Debaters David E. Cohn, MD, professor in the Department of Obstetrics and Gynecology and director of the Division of Gynecologic Oncology at The Ohio State University College of Medicine, and Amanda Nickles Fader, MD, associate professor and director, The Kelly Gynecologic Oncology Service and Johns Hopkins Hospital in Baltimore, agreed that both forms of treatment have benefits depending on patient needs.
Dr. Cohn believes that hysterectomy needs to remain the standard of care for atypical endometrial hyperplasia in those who are good surgical candidates without interest in remaining fertile, as it’s the most effective to prevent endometrial cancer.
In a prospective cohort study published in 2006 that Dr. Cohn mentioned, 289 women with atypical endometrial hyperplasia on biopsy or curettage found that 42.6 percent had endometrial cancer at hysterectomy within 12 weeks of sampling.
Hysterectomy has a much higher success rate for preventing cancer when compared with hormonal therapy, he said. Hormones also require an almost indefinite duration of therapy.
Dr. Cohn sited a meta-analysis of 34 observational studies involving management with progestins for atypical endometrial hyperplasia. While 86 percent of the women saw regression, 3.6 percent of the women had ovarian cancer as an outcome, and 1.9 percent had advanced endometrial cancer.
“That’s sobering news about the potential for bad outcomes with progestins,” he said.
He agreed with an ACOG committee opinion from 2015 that said progestin treatment was an unproven but commonly used alternative to hysterectomy, but optimal doses and duration of treatment need to be defined and post-hormonal surveillance and frequency is yet to be determined.
“There are a lot of unanswered questions in my mind as well of those of ACOG about when to use progestins,” Dr. Cohn said.
Dr. Fader said that the current management strategy is driven more by fear than by evidence despite excellent results from progestin therapy shown in recent years.
“Times have changed. As recently as 15 years ago, hysterectomy seemed like the only alternative… but in contemporary times, a number of organ-sparing treatment possibilities have emerged. And it’s time for us to move from a hysterectomy-only mantra to having options for the contemporary woman,” she said.
Almost all endometrial hyperplasia is sensitive to hormonal treatment, Dr. Fader said, and most — including atypical hyperplasia — regresses or remains unchanged without therapy and doesn’t progress to cancer.
She mentioned more than 150 retrospective studies and 12 prospective studies found that progestin treatment brings about atypical hyperplasia regression in 75 to 95 percent of cases. One review of four large studies found that progestin was associated with regression in 90 percent of women with hyperplasia arising from unopposed estrogen therapy.
The changing patient demographic also means hormonal treatment should be considered. Morbidly obese patients and patients who want to remain fertile make up more than 40 percent of today’s atypical hyperplasia population.
Dr. Fader said that atypical hyperplasia was mostly a public health problem related to excess weight and endogenous estrogen production. Since many of the women who develop hyperplasia are younger than 45, fertility issues matter, so it’s time to explore lifestyle modifications and medical options beyond hysterectomy.
The presenters agreed about the impact of the obesity epidemic on hyperplasia. Dr. Cohn said that early data about bariatric surgery shows promise that it might convert abnormal endometrium into normal endometrium without hysterectomy. This talk will be available to replay after it airs live. After a short processing delay, it will remain available through the close of the meeting. Simply go to www.acog.org/colloquia.