Larger studies are needed before surgical alternatives to hysterectomy can be routinely recommended for hyperplasia.
Thermal balloon ablation. Minassian and Mira16 reported use of thermal balloon ablation of the endometrium in a patient with complex endometrial hyperplasia with atypia.
The patient initially presented with a complaint of menorrhagia and had a preoperative endometrial biopsy that showed no evidence of hyperplasia. When she subsequently underwent a thermal balloon ablation procedure, a curettage specimen indicated complex hyperplasia with atypia. The patient underwent a hysterectomy 8 months later, at which time no pathologic evidence of persistent hyperplasia or carcinoma was found.
However, the authors recommend that ablation be avoided if hyperplasia is found on a preoperative sample, since postoperative surveillance of the endometrium would be impaired.16 This is also true for laser and resectoscopic therapy, since postoperative sampling would be potentially altered.
Laser therapy. Vilos and Ettler17 reported another case in which a patient with complex atypical hyperplasia underwent laser intrauterine thermal therapy. After 13 months of surveillance with transvaginal sonography, there was no evidence of disease.
Resectoscopic surgery also has been investigated in the treatment of atypical endometrial hyperplasia. Vilos et al18 successfully treated 8 patients using hysteroscopic endometrial resection. A larger study involving 73 women with hyperplasia without atypia showed complete regression in 71 of the 73 patients over an average of 34 months of follow-up.19
Abandon conservative therapy if hyperplasia persists after 12 months of treatment.
Patient counseling and follow-up
In women who wish to preserve fertility, management of endometrial hyperplasia can be a challenge. Fortunately, we now have sound data indicating that conservative treatment can be used for certain patients.
Regardless of the approach selected, thoroughly counsel patients about their options and follow-up closely.
When to change course
A bandon conservative therapy if progression to carcinoma is found during surveillance sampling or if hyperplasia persists after 12 months of treatment.
The authors express their gratitude to Ms. Karen Roeder for her assistance in formatting and preparing the figures.
The authors report no financial relationship with any companies whose products are mentioned in this article.
This work is supported in part by the Georgia Cancer Coalition.