LNG-IUD more beneficial than systemic progestin to treat complex atypical endometrial hyperplasia in obese women

Reference

Mandelbaum RS, Ciccone MA, Nusbaum DJ, et al. Progestin therapy for obese women with complex atypical hyperplasia: levonorgestrel-releasing intrauterine device vs systemic therapy. Am J Obstet Gynecol 2020;223(1):103e.1-103e.13.

Synopsis

Although the gold standard of treatment for complex atypical endometrial hyperplasia is still hysterectomy, progestin therapy has been used for women who prefer to avoid surgery and/or preserve fertility. This cohort study (N = 245) analyzed the outcomes for women from one institution who chose treatment with progestin therapy, comparing local progestin therapy with LNG-IUD (n = 69) with systemic progestin (n = 176). All women underwent suction curettage prior to initiation of progestin therapy. Systemic therapy was with oral medroxyprogesterone acetate for the majority of women (140/176; 79%). The majority of women were Hispanic (65%), obese (84%), and nulligravid (52%). During the follow-up period, 120 (49%) women eventually underwent hysterectomy, and 28 (11%) women progressed to endometrial cancer. All of the incident cancers were well-differentiated and did not recur after hysterectomy during follow-up for a median of 42 months. Complete resolution of complex atypical endometrial hyperplasia within 1 year favored the LNG-IUD group (78% vs 47%; P < .001). Similarly, the rate of progression to cancer was decreased in the LNG-IUD group (5% vs 16%; P = .006). Sensitivity analysis based on obesity classes indicated the morbidly obese group (body mass index of at least 40 kg/m2) had the most marked benefit (adjusted complete response rate 4.72; 95% CI 2.8 - 7.9). Of note is that the use of LNG-IUD rose markedly over the course of the study period.