Debating points of endometrium hyperplasia case management
AbstractObjective. Endometrial hyperplasia (EH) is a progressive estrogen-dependent pathology widely spread among women of any age. Pathogenesis is multifactorial, but the role of hormonal homeostasis disturbance in the genesis and evolution of hyperplastic processes of endometrium is indisputable. There is enough evidence of role of hyperestrogenemia on the background of endometrium receptor function variance. The choice of therapy methods of EH suggests two approaches: conservative (medication) treatment or surgical interference. A unique approach does not exist, the choice of therapeutic management of EH depends on the patient's age, pathology stage, its possible relapse, histological picture. A relapse of hyperplastic processes of endometrium especially on the background of uterine myoma and/or with endometriosis in premenopausal and postmenopausal patients demands more extensive indications to radical surgery (hysterectomy). However, at initial stages, when a hormonal balance recovery in women of the reproductive age willing to remain fertile is achievable and can result in endometrium initial functional stage, many specialists favor a conservative treatment.
Aims: 1) comparison of efficiency of different methods of treatment of EH; 2) representation of recent pharmacologic methods of EH treatment.
Material and methods. To form the review on the EH problem and methods of its treatment, PubMed, EMBASE, Medline, and the Cochrane Library were searched for randomized trials in 2013-2014, limited to English literature in the area.
Results. Conservative treatment (medication) of EH is associated with endometrium proliferation regression on the background of retained fertility, and, therefore, a conservative approach combined with hormonal therapy is an adequate method for patients with EH. At the same time, in some patients hysterectomy is the only possible treatment on the background of potential malignancy of the pathology with its further progress into a tumor, provided there are no contraindications to the invasive surgery of such degree.
Conclusion: in treatment of patients of the reproductive age willing to retain fertility, levonorgestrel-releasing intrauterine system (LNG-IUS) presents a new promising therapeutic medium, causing a partial inhibition of endometrial function and is much more preferable as compared to oral hormonal treatment, especially taking into consideration the fact that there is no precisely determined hormone-based drugs dosage or the duration of progestin treatment. Further trials are required. LNG-IUS can be effective both as an independent means and as combined with hysteroscopy, as a means of post-operational therapy, providing a more expensive effect of EH treatment. Hysterectomy is recommended to pre-and postmenopausal patients with atypical EH provided there are no contraindications to a major surgical interference.
Keywords:atypical endometrial hyperplasia, anovulation, proliferation, progesterone, levonorgestrel-releasing intrauterine system, gonado-trophin-releasing hormone agonists, progesterone resistance, hysteroscopy, hysterectomy