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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