Endometrial hyperplasia (EH), a known risk factor for endometrial cancer (EC), is an irregular proliferation of the adrenal glands increasing the gland to stroma ratio. If it manifests as atypical endometrial hyperplasia (AEH), it is categorized as a premalignant lesion or intraepithelial neoplasia.

Comparing Surgical & Conservative Management

The first-line treatment of AEH is a total hysterectomy with or without removing the ovaries and the fallopian tubes. Some patients, however, wish to retain their fertility or the surgical procedure is contraindicated due to underlying health concerns. In these cases, a conservative approach to the management of AEH is taken by assessing risk factors and using a hormonal intrauterine system as the first-line treatment. The second-line treatment is oral progestogens. The patient is then monitored with an endometrial biopsy every 3 months.

To determine whether the risk of progression to EC is affected by surgical management or conservative management of AEH, Anas Barakat, MD, and colleagues developed a retrospective cohort study consisting of 119 patients with AEH recruited between January 2015 and January 2020. Participants were divided into primary surgery (n=99) and conservative medical intervention groups.

As described by Dr. Barakat and colleagues in Cancer Diagnosis & Prognosis, “Our study is one of the few studies to compare the risk of EC in patients with AEH according to the mode of management: primary surgery and conservative.”

The Study Groups

The two groups did not differ significantly in age (p=0.467), BMI (p=0.267), menopausal status (p=0.063), history of hypertension (p=0.641), history of breast cancer (p=0.99), or family history of EH, cancer, or colorectal carcinoma (p=0.460).

Presenting complaints, however, were significantly different between the two groups (p=0.005). The group treated surgically had significantly more complaints of heavy menstrual bleeding, whereas the group treated conservatively had significantly more complaints of postmenopausal bleeding.

High Progression Risk in Both Groups

The number of patients who initiated follow-up was not statistically different between the two groups (p=0.761). Compared with the surgical group, the conservative group had a significantly higher proportion of patients who had follow-up (p<0.001). Also, the number of patients discharged was significantly higher in those managed with surgical intervention compared with those managed conservatively (p<0.001). The number of patients who died was significantly higher in the conservative group (p=0.015).

Co-existing EC was detected in 34% of the surgically managed group within three months. Of these patients, 97% were found to have endometrioid EC and 3% were found to have clear-cell EC. In the conservative group, 25% of patients progressed to EC within 5 years.

The results showed that there was no statistically significant difference in the risk of progression from AEH to EC in the group managed with surgical intervention compared with the group treated with conservative medical intervention. As explained by Dr. Barakat and colleagues, “The results revealed that the risk of EC was high for both arms of the study, and the highest EC risk was found in the patients with AEH managed surgically by primary hysterectomy. Hence the conservative management has a lower probability of developing EC, but it is difficult to rule out concurrent EC.”