Hysteroscopy in the management of endometrial hyperplasia and cancer in reproductive aged women: new developments and current perspectives

Abstract

Over the last twenty years, the incidence of early endometrial cancer (EC) and atypical endometrial hyperplasia (AEH) among women of reproductive age is increasing rapidly, likely due to a combination of factors including increased prevalence of obesity and delayed of childbirths. Regarding preoperative diagnosis of endometrial neoplasia, it is still debated which is the most accurate and reliable method to obtain endometrial histopathological samples with fractional dilatation and curettage (D&C) having been considered, for a long time, as the method of choice. Nowadays, the advent of in-office endometrial biopsy with or without hysteroscopy has radically changed the approach, giving the opportunity to perform the endometrial biopsy under direct visualization. However, the lack of agreement about its diagnostic accuracy is still relevant. Since a significant number of women with AEH and/or EC are of childbearing age, a fertility-sparing diagnostic and therapeutic approach should be considered in all cases.The feasibility, safety and efficacy of fertility-sparing strategies involving hysteroscopic focal resections in conjunction with hormonal therapies have been evaluated and beneficial effects have been confirmed in several studies and one meta-analysis. Both local and systemic administration of hormonal therapies are currently used. Oral progestin, including medroxyprogesterone acetate (MPA) and megestrol acetate, are the most commonly used therapies. Nowadays, new therapeutic approaches, such as levonorgestrel intrauterine systems (LNG-IUS), gonadotropin-releasing hormone (GnRH) agonists, combined megestrol acetate and metformin, and other combinations of therapies are also used as first line therapies or after the hysteroscopic resection of the lesion. However, it is still unclear which approach provides higher clinical response with lower relapse rate, in addition to preserving fertility in women desiring to conceive. The aim of this narrative review is to summarize the available evidence regarding the evaluation and management with fertility-sparing treatments options of women with AEC and EC.

In-office hysteroscopic removal of retained or fragmented intrauterine device without anesthesia: a cross-sectional analysis of an international survey

“…Even if contraception remains their main purpose, IUDs are also used for several non-contraceptive issues [ 2 ], especially with the advent of the levonorgestrel-releasing intrauterine system (LNG-IUS) device, which is considered a great treatment option for women with abnormal uterine bleeding and heavy menstrual bleeding, as well as dysmenorrhea [ 2 , 3 ]. Similarly, LNG-IUS are used for the conservative treatment of atypical endometrial hyperplasia and early endometrial cancer following hysteroscopic resection in reproductive age women [ 4 ] as well as the treatment of adenomyosis and endometriosis [ 2 ]. LNG-based IUDs are commonly used by women desiring to use local hormonal contraception [ 5 ].…”

Clinical, Sonographic, and Hysteroscopic Features of Endometrial Carcinoma Diagnosed after Hysterectomy in Patients with a Preoperative Diagnosis of Atypical Hyperplasia: A Single-Center Retrospective Study

“…Atypical vascularization usually includes the finding of abnormal vessel sprouts, tortuous vessels, vessel loops, branching with angles over 90°, narrowing of vessels, a disorganized network, and an overall irregular distribution with an area with dense vessels, varying with an area without vessels [ 23 ]. The abnormal vascularization has been reported to be suggestive of malignant neoplastic lesions of the endometrium, but this finding appears to have been derived from large retrospective cohorts and not from randomized controlled trials [ 24 ]. However, a simple increased vascular density must be combined with other parameters in the diagnosis of cancer [ 25 ].…”

Diagnosis and Prediction of Endometrial Carcinoma Using Machine Learning and Artificial Neural Networks Based on Public Databases

“…At present, EC is diagnosed mainly based on clinical symptoms, physical findings, results of laboratory investigations, and imaging examination. Endometrial biopsy under hysteroscopy seems to be the best method for the diagnosis of benign EC [ 17 , 18 ]. Fertility retention technology can effectively improve the quality of life of gynecological cancer patients, and has become the goal and hope for cancer survivors to live a better life [ 19 ].…”