Prolonged use of gonadotropin-releasing hormone agonist and tibolone as add-back therapy for the treatment of endometrial hyperplasia

Therapeutic options for management of endometrial hyperplasia

Endometrial hyperplasia (EH) comprises a spectrum of changes in the endometrium ranging from a slightly disordered pattern that exaggerates the alterations seen in the late proliferative phase of the menstrual cycle to irregular, hyperchromatic lesions that are similar to endometrioid adenocarcinoma. Generally, EH is caused by continuous exposure of estrogen unopposed by progesterone, polycystic ovary syndrome, tamoxifen, or hormone replacement therapy. Since it can progress, or often occur coincidentally with endometrial carcinoma, EH is of clinical importance, and the reversion of hyperplasia to normal endometrium represents the key conservative treatment for prevention of the development of adenocarcinoma. Presently, cyclic progestin or hysterectomy constitutes the major treatment option for EH without or with atypia, respectively. However, clinical trials of hormonal therapies and definitive standard treatments remain to be established for the management of EH. Moreover, therapeutic options for EH patients who wish to preserve fertility are challenging and require nonsurgical management. Therefore, future studies should focus on evaluation of new treatment strategies and novel compounds that could simultaneously target pathways involved in the pathogenesis of estradiol-induced EH. Novel therapeutic agents precisely targeting the inhibition of estrogen receptor, growth factor receptors, and signal transduction pathways are likely to constitute an optimal approach for treatment of EH.

Long-term clinical outcomes following resectoscopic endometrial ablation of non-atypical endometrial hyperplasia in women with abnormal uterine bleeding

STUDY OBJECTIVE

To determine the feasibility, efficacy, and long-term clinical outcomes of resectoscopic endometrial ablation as primary treatment of simple endometrial hyperplasia (SH) and complex endometrial hyperplasia (CH) without atypia in women with abnormal uterine bleeding (AUB).

DESIGN

Prospective follow-up study (Canadian Task Force classification II-2).

SETTING

Teaching hospital.

PATIENTS

One hundred sixty-one women with hyperplasia, either SH (n = 107) or CH (n = 54).

INTERVENTIONS

From January 1990 through December 2012, one of us performed 4729 primary resectoscopic endometrial ablation procedures in women with AUB. This group included 161 women with endometrial hyperplasia, identified either at office biopsy (n = 62) or incidentally during routine hysteroscopic endometrial ablation (n = 99). Endometrial tissue obtained at dilation and curettage and/or resected during resectoscopic surgery enabled identification of atypical hyperplasia in 6 patients (4 CH, 2 SH) and 1 patient with adenosarcoma. One patient with atypical CH and the patient with adenosarcoma underwent hysterectomy. The remaining 159 women, including 5 with atypical hyperplasia (3 CH, 2 SH), underwent resectoscopic endometrial ablation (102 SH, 52 CH) as primary treatment. Patient median age was 50 years (range, 30-87 years), and body mass index was 32 (range, 17-59). Comorbidities included hypertension in 25 patients, diabetes in 14, cerebrovascular disease in 3, cardiovascular disease in 7, and hypothyroidism in 8. Office biopsy demonstrated proliferative endometrium in 68 patients, SH in 43, CH in 19, and inadequate findings in 13. In 18 women, we were unable to perform biopsy because of cervical stenosis, morbid obesity, or patient intolerance. Endometrium was resected in 120 patients, electrocoagulated in 34, and a combination of procedures in 5, using a 9-mm (26F) resectoscope, 1.5% glycine, and 120W power. Patients were followed up annually. Three patients were lost to follow-up, and 1 died of an unrelated cause 5 years after surgery.

MEASUREMENTS AND MAIN RESULTS

One uterine perforation occurred, which required no additional treatment. After endometrial ablation, SH was identified in 70 patients, and CH in 35 patients. At a median follow-up of 7 years (range, 1.5-18), 12 patients underwent hysterectomy to treat persistent bleeding (n = 6), benign ovarian cyst (n = 2), pelvic organ prolapse (n = 1), chronic pelvic pain (n = 2), or myomas (n = 1). Uterine histopathology in 11 patients demonstrated no residual endometrial hyperplasia. We were unable to obtain a pathology report for 1 patient. The remaining 138 women were satisfied with the treatment, with no further bleeding or pain in 132 (95.7%). Six patients (4.3%) had monthly spotting.

CONCLUSION

When performed by surgeons experienced in hysteroscopy, resectoscopic endometrial ablation is feasible, safe, and effective for treatment of SH and CH without atypia in women with AUB.

The use of an oral contraceptive containing estradiol valerate and dienogest before office operative hysteroscopy: a feasibility study

To investigate the impact of a 3 months preoperative administration of an oral contraceptive, containing dienogest (DNG) and estradiol valerate (E₂V) on the outcome of office operative hysteroscopy (OOH). One-hundred and forty-two patients diagnosed at office hysteroscopy as having an asynchronous endometrium associated with either a broad-base sessile endometrial polyp (>1.5, <2.5 cm) or a uterine septum (>1/3 uterine cavity) or scheduled for tubal sterilization were enrolled into a prospective case-control study at University "Federico II" of Naples. 86/142 patients accepted the preoperative hormonal treatment (Group A), while 56/142 refused, thus becoming controls (Group B). Group A underwent OOH during the 10th-20th days of the third cycle of treatment. In Group B OOH was performed at enrolment, together with the diagnostic procedure. The study outcomes were: endometrial pattern, success rate, operating time, degree of surgical difficulty and pain score. An overall improvement of the endometrium was reported in 100% of cases in Group A. A statistically significant difference in success rate could not be demonstrated between two groups. Operative procedures were performed significantly quicker and easier in Group A than Group B (p < 0.001 and p < 0.05, respectively). The mean Visual Analog Scale (VAS) score was significantly lower in Group A (p < 0.001). A short pretreatment with combined oral contraceptive (COC) containing E₂V/DNG seems to have a favorable impact on endometrium which in turn may result in an improvement of the overall outcomes of OOH.

Gonadotrophin receptor hormone analogues in combination with add-back therapy: an update

Gonadotrophin receptor hormone analogues (GnRHa) have been used in a range of sex hormone-dependent disorders. In the management of premenstrual syndrome, they can completely abolish symptoms. The success of GnRHa in the treatment of endometriosis and adjuvant therapy in the management of fibroids is proven. This efficacy does not come without a cost and the side-effects of the hypo-estrogenic state have limited their application. The use of add-back therapy to counter these effects has enabled wider application, longer durations of treatment and an increase in compliance. This review article is an update on the evidence supporting gonadotrophin receptor hormone analogues in combination with add-back therapy.

Les hyperplasies de l’endomètre

Endometrial hyperplasias can be divided into two categories based on the presence or absence of cytological atypia and further classified as simple or complex according to the extent of architectural abnormalities. They are usually diagnosed because of irregular bleeding in perimenopause. Hysteroscopy with a biopsy gives a more accurate diagnosis than transvaginal ultrasonography, sonohysterography, or blind curettage. Endometrial hyperplasias with no cytological atypia, regarded as a response to unopposed endogenous estrogenic stimulation, are normally treated with progestins. The intra-uterine route (levonorgestrel intra-uterine system) is more effective and better tolerated than the oral route. Either conservative surgery (endometrial resection, thermal ablation) or radical surgery (hysterectomy) in the case of other genital diseases is performed on women who did not respond to medical treatment. Endometrial hyperplasias with cytological atypia, considered as intra-epithelial neoplasias, are traditionally treated by hysterectomy. The absence of management protocols in the literature offers various treatment options and indications. Gonadotropin-releasing hormone agonists, danazol, or aromatase inhibitor are effective, but have adverse effects and are expensive. Endometrial ablation can be performed as a first line therapy in women suffering from bleeding related to hyperplasia without cytological atypia. Medical treatment may be offered to young women suffered from hyperplasias with cytological atypia and desiring pregnancy.

The role of hormones for the treatment of endometrial hyperplasia and endometrial cancer

PURPOSE OF REVIEW

Hormone therapy has been palliative for advanced/ recurrent endometrial cancer. High remission rates are seen in well-selected stage I, grade 1 endometrial cancer of young women using hormone therapy (usually progestins) as fertility-preserving treatment. Many other hormones, such as gonadotropin-releasing hormone analogs (GnRHa), selective estrogen receptor modulators, aromatase inhibitors, intrauterine progestins, and others are potential modalities. This review updates the recent publications in this area.

RECENT FINDINGS

Two reports investigating different scheduling of tamoxifen and progestins indicated that tamoxifen may be a valuable adjunct to progestin therapy. GnRHa has been used adjunctively to tamoxifen as second-line hormone therapy for fertility sparing after progestin failed. Aromatase inhibitors have shown their potential in treating endometrial cancer and endometrial hyperplasia as single agent or in combination with progestins. Intrauterine progestins seem efficacious in treating endometrial hyperplasia; its applications on endometrial cancer patients, however, have been limited to postmenopausal women with poor surgical risk.

SUMMARY

Translational research based on molecular mechanisms is mandatory to a more appropriate utilization of hormone therapy. The role of dose, scheduling, route of administration of progestins as well as the addition of other hormonal agents should be further explored by well designed randomized controlled trials.