Wednesday, May 18, 2016

Value of hormonal treatment in endometrial hyperplasia debated— News from ACOG Annual Clinical and Scientific Meeting 2016.

The John I. Brewer Memorial Lecture on Day 2 of the Annual Clinical and Scientific meeting, ACOG  2016 considered the role of hormones in treatment of Endometrial Hyperplasia vs the common surgery of Hysterectomy.

Debaters were David E. Cohn, MD, professor in the Department of Obstetrics and Gynecology and director of the Division of Gynecologic Oncology at The Ohio State University College of Medicine, and Amanda Nickles Fader, MD, associate professor and director, The Kelly Gynecologic Oncology Service and Johns Hopkins Hospital in Baltimore. They all agreed that when treatment is tailored according to patient need both forms can be beneficial.

Dr. Cohn opined that in patients who are fit for surgery and have completed the family the most effective and definitive way of preventing the transition into endometrial cancer is hysterectomy. He cited the 2006 prospective cohort study in which out of 289 women with atypical endometrial hyperplasia on biopsy or curettage,42.6 percent had endometrial cancer at hysterectomy within 12 weeks of sampling. He also said that hormonal treatment has to be continued for an indefinite period of time vs hysterectomy which is a one-step procedure with much higher success rates.

He also referred to a meta-analysis of 34 observational studies in which progestins were used to treat atypical endometrial hyperplasia. The statistical analysis showed that while 86% of women saw regression, 3.6% of women had ovarian cancer and 1.9% had advanced endometrial cancer.

He further quoted “That’s sobering news about the potential for bad outcomes with progestins.”

He acknowledged the committee opinion from 2015 that says “Progestin treatment was an unproven but commonly used alternative to hysterectomy, but optimal doses and duration of treatment need to be defined and post-hormonal surveillance and frequency is yet to be determined. It is also not determined whether it should be continuous or cyclical. And also lacks the optimal clinical as well as histological measures of response.”

He concluded by seconding the ACOG committee opinion of lots of unanswered questions regarding the use of progestins therapy.

The second debater Dr. Fader argued in favor of progestins therapy and stressed that the surgical option is chosen more out of fear than by evidence, nonetheless ample evidence exists in support of hormonal treatment.

As times have changed in last 15 years and in contemporary times, a number of organ-sparing treatments have become a reality. She further said “Almost all endometrial hyperplasia is sensitive to hormonal treatment and most — including atypical hyperplasia — regresses or remains unchanged without therapy and doesn’t progress to cancer.”

She presented evidence in the form of results of 150 retrospective studies and 12 prospective, in which progestin treatment brings about atypical hyperplasia regression in 75 to 95 percent of cases. 
Additional review of 4 large studies also showed that progestins were associated with regression of hyperplasia due to unopposed estrogens in 90% of patients.

Dr. Fader also said that with 40% of endometrial hyperplasia patients are obese or want to retain fertility, making hormonal treatment a valid choice for them. Endometrial hyperplasia is a public health problem due to increasing demographics of obesity and endogenous estrogen production, with many of the women younger than 45 years of age, which increases the need of exploring life style modifications and treatment beyond surgery a viable option.

Both the debaters agreed upon the impact of obesity on endometrial hyperplasia and the Dr.Cohn pointed out that early data on  bariatric surgery is promising in converting abnormal endometrium into normal endometrium without surgery. 


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