Conservative management of atypical hyperplasia and grade i endometrial carcinoma: Review of the literature and presentation of a series

Objective: The purpose of this study was to evaluate the safety of fertility-sparing treatment in young women with atypical hyperplasia (AH) or grade 1 endometrial cancer (EC). Design: This study was designed as a retrospective cohort study. Methods: All women ≤45 years of age with AH or grade 1 EC treated at Mayo Clinic between January 1, 1985 and December 31, 2005 were identified. Patient demographics, management, and follow-up data were retrospectively abstracted and analyzed. Results: Ninety-four women were treated for AH or grade 1 EC, 71 underwent immediate surgical treatment, and 23 elected to preserve fertility Among the latter, complete data were available for 21 patients (16 with AH and 5 with EC at initial diagnosis). During the first course, 11 received medroxyprogesterone acetate (MPA), 7 received megestrol acetate (MA), 1 received oral contraceptive pills, and 2 were observed. Response after the first course (median duration 6.1 months) was 71% overall; 81% in AH patients versus 40% in EC patients (p=0.11). All patients treated with MPA versus 43% treated with MA (p=0.01) responded. All 3 who did not respond after the first course responded to the second course with regression to benign endometrium (median duration 3.3 months). Overall response rate after two courses was 81% and 94.4% among those treated solely with progestins. Among those who continued fertility-preserving therapy after two courses, the recurrence rate was 39%; all patients with EC had a recurrence. All recurrences were confined to the uterus. Conclusions: Conservative management of AH and grade 1 EC appears to be an effective, but temporary alternative to hysterectomy for carefully selected, highly motivated women. Once childbearing is complete, women should be offered definitive surgical treatment.