Management of Endometrial Intraepithelial.32

CLINICAL CONSENSUS
NUMBER 5
SEPTEMBER 2023
(REPLACES COMMITTEE OPINION NUMBER 631, MAY 2015)
Downloaded from http://journals.lww.com/greenjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0h
Management of Endometrial Intraepithelial Neoplasia or

CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 03/03/2024
Atypical Endometrial Hyperplasia

Committee on Clinical Consensus–Gynecology. This Clinical Consensus was developed by the American College of
Obstetricians and Gynecologists’ Committee on Clinical Consensus–Gynecology in collaboration with Lori Boardman, MD,
Akiva P. Novetsky, MD MS, and Fidel Valea, MD.
The Society of Gynecologic Oncology endorses this document.
Summary
Endometrial intraepithelial neoplasia (EIN) or atypical endometrial hyperplasia (AEH) often is a precursor lesion to
adenocarcinoma of the endometrium. Hysterectomy is the definitive treatment for EIN–AEH. When a conservative
(fertility-sparing) approach to the management of EIN–AEH is under consideration, it is important to attempt to exclude
the presence of endometrial cancer to avoid potential undertreatment of an unknown malignancy in those who have
been already diagnosed with EIN–AEH. Given the high risk of progression to cancer, those who do not have surgery
require progestin therapy (oral, intrauterine, or combined) and close surveillance. Although data are conflicting and
limited, studies have demonstrated that treatment with the levonorgestrel-releasing intrauterine device results in a
higher regression rate when compared with treatment with oral progestins alone. Limited data suggest that cyclic
progestational agents have lower regression rates when compared with continuous oral therapy. After initial
conservative treatment for EIN–AEH, early detection of disease persistence, progression, or recurrence requires careful
follow-up. Gynecologists and other clinicians should counsel patients that lifestyle modification resulting in weight loss
and glycemic control can improve overall health and may decrease the risk of EIN–AEH and endometrial cancer.
BACKGROUND categories of risk classification based on glandular

Endometrial intraepithelial neoplasia (EIN) or atypical complexity and nuclear atypia, was updated in 2014
endometrial hyperplasia (AEH), depending on classifi- to a two-tiered system: 1) hyperplasia without atypia
cation system used, is of clinical significance because (benign endometrial hyperplasia) and 2) atypical hyper-
often it is a precursor lesion to adenocarcinoma of the plasia or EIN (3–5). Subsequently, the 2020 World
endometrium (1, 2). There currently are two systems of Health Organization classification expanded on the
endometrial precancer nomenclature in common diagnostic criteria in the two-tiered system to include
usage. The WHO94 schema, which proposed four essential and desirable criteria (6). Essential criteria
The American College of Obstetricians and Gynecologists (ACOG) reviews its publications regularly; however, its publications may not reflect the most
recent evidence. A reaffirmation date is included in the online version of a document to indicate when it was last reviewed. The current status and any
updates of this document can be found on ACOG Clinical at acog.org/lot.
This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is
voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of
care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when,
in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources,
or advances in knowledge or technology.
While ACOG makes every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy,
reliability, or otherwise, either express or implied. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or
person. Neither ACOG nor its officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any
liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information
presented.
VOL. 142, NO. 3, SEPTEMBER 2023 CC Management of EIN-AEH 735
© 2023 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
SUMMARY OF CONSENSUS RECOMMENDATIONS
Detecting Concurrent Carcinoma
Gynecologists should attempt to exclude concurrent carcinoma in individuals with a working diagnosis of EIN–AEH. Hysteroscopic examination
with further sampling of the endometrium is the most accurate method for detecting a concurrent carcinoma.
Surgical Management
Hysterectomy is the definitive treatment for EIN–AEH. Gynecologists should not perform supracervical hysterectomy for the treatment of EIN–AEH.
Gynecologists should not perform endometrial ablation (thermal or electrocautery) for EIN–AEH due to high persistence and recurrence rates, as
well as potential difficulty in evaluating future bleeding episodes.
Nonsurgical Management
Clinicians should recommend progestational agents as treatment for EIN–AEH for patients in whom hysterectomy is not an option.
Data on the superiority of either oral or intrauterine progestational agents are lacking, though limited data suggest that intrauterine progestational
administration may be associated with a higher rate of disease regression when compared with oral administration alone in patients with EIN–
AEH.
There is insufficient evidence to recommend any one formulation of oral progestational agent over another.
Follow-up
For those initially treated with progestational agents, gynecologists should perform repeat histologic assessment for response to treatment for
EIN–AEH within 3–6 months.
After initial progestin treatment, gynecologists may consider long-term maintenance therapy with progestational agents for patients with con-
tinuing risk factors for endometrial cancer.
Counseling Patients on Lifestyle Modifications
Gynecologists and other clinicians should counsel patients that lifestyle modification resulting in weight loss and glycemic control can improve
overall health and may decrease the risk of EIN–AEH and endometrial cancer.
EIN–AEH, endometrial intraepithelial neoplasia or atypical endometrial hyperplasia.
for atypical hyperplasia or EIN include crowded glandu- Epidemiology

lar architecture and altered epithelial cytology distinct Estrogenic stimulation of the endometrium, unop-
from the surrounding endometrium or entrapped non- posed by progestins, causes proliferative glandular
neoplastic glands or both. Desirable criteria include the epithelial changes or hyperplasia. Hyperplasia, due to
following: loss of immunoreactivity for PTEN, PAX2, or prolonged exposure to estrogens, is biologically
mismatch repair proteins. In the EIN schema developed distinct from the precancerous lesion EIN–AEH. The
by the International Endometrial Collaborative Group, precursor lesion of type I endometrioid adenocarci-
endometrial precancer is termed endometrial intraepi- noma is EIN–AEH. Making the distinction between
thelial neoplasia, and pathologic criteria were used to hyperplasia and EIN–AEH is important, because each
develop three disease categories: 1) endometrial hyper- condition has differing cancer risks and requires dif-
plasia, 2) endometrial intraepithelial neoplasia, and 3) ferent interventions to avoid undertreatment or
adenocarcinoma (7). The American College of Obstetri- overtreatment.
cians and Gynecologists (ACOG) does not recommend Cancer of the endometrium is rising in the United
one terminology schema over another. This topic has States, with an estimated incidence of 66,200 cases
been updated to reflect newer data on the management and 13,030 deaths in 2023 (8). Disparities in care linked
of EIN–AEH. This guidance applies to those patients to differences in race, ethnicity, geography, and socio-
who have already received a diagnosis of EIN–AEH. economic status have been associated with poorer
736 CC Management of EIN-AEH OBSTETRICS & GYNECOLOGY

outcomes. Data show that Black individuals with endo- Study Selection
metrial cancer have a 55% higher 5-year mortality risk Qualifying studies passed both title and abstract screen
when compared with White individuals (9). Although and full-text screen and met the following inclusion criteria:
Black patients are more likely to be diagnosed with conducted in countries ranked very high on the United
nonendometrioid (aggressive) histologies (10), this Nations Human Development Index (14), included female
alone does not explain the disparity in mortality. Survival participants, and included all study designs. Studies that
by Black individuals is lower than for White individuals, passed full-text screen by the authors were included in a
even when controlling for stage, grade, histologic sub- summary evidence map (Appendix 2, available online at
type, and age. Asian/Pacific Islander patients also have http://links.lww.com/AOG/D270). In one case, a study
been found to more frequently present with advanced was identified after the literature search was concluded that
disease when compared with White patients (11), and did not meet one of the inclusion criterion (15). Although the
Black, Hispanic, and American Indian/Alaska Native study was conducted in a country that is not ranked as very
individuals are less likely to receive guideline- high on the United Nations Human Development Index, the
compliant treatment (10). In addition to disparities by data were deemed necessary to demonstrate
race and ethnicity, factors such as insurance status the comparative regression efficacy of combined intrauter-
(Medicaid or Medicare vs private payer) and treatment ine and oral progestins compared with the levonorgestrel-
at low-volume medical centers are associated with
releasing intrauterine device (LNG-IUD) alone.
decreased survival rates (11). In a separate study, hav-
ing Black and Hispanic race and ethnicity, Medicaid Consensus Voting and
insurance or no insurance, and lower rates of education Recommendation Development
was associated with longer wait times for surgery after At a meeting of the Committee on Clinical Consensus–
diagnosis (12). Gynecology, a quorum of two-thirds of eligible voting mem-
bers was met, and the committee held a formal vote for
METHODS each proposed recommendation. All recommendation
statements met or exceeded the 75% approval threshold
This Clinical Consensus document was developed using
required for consensus.
an a priori protocol in conjunction with the authors listed
above. The a priori protocol was modeled after the
Use of Language
Clinical Consensus methodology, and a full description
of the Clinical Consensus methodology is published The American College of Obstetricians and Gynecolo-
separately (13). The description below is specific to this gists recognizes and supports the gender diversity of all
Clinical Consensus document. patients who seek obstetric and gynecologic care. In
original portions of this document, authors seek to use
Literature Search gender-inclusive language or gender-neutral language.
A literature search was performed from 2000 to When describing research findings, this document uses
October 2021 combining terms for endometrial hyper- gender terminology reported by investigators. To review
plasia and endometrial intraepithelial neoplasia with ACOG’s policy on inclusive language, see https://www.
terms related to concepts in the outline. The ACOG acog.org/clinical-information/policy-and-position-state-
medical librarians searched Cochrane Library, EM- ments/statements-of-policy/2022/inclusive-language.
BASE, PubMed, and MEDLINE for human-only studies
written in English. Cochrane trials from the Cochrane
Collaboration Registry of Controlled Trials from 2016 to
October 2021 were also saved. MeSH terms and Box 1. Progestational Agents for Treatment of
keywords can be found in Appendix 1 (available online Endometrial Intraepithelial Neoplasia or Atypical
at http://links.lww.com/AOG/D269). Search terms for Endometrial Hyperplasia
racial, ethnic, socio-economic, and vulnerable popula-
tion disparities in EIN–AEH were incorporated into the
literature review, and recommendations were drafted c Megestrol acetate
with the intent of promoting health equity and reducing c Medroxyprogesterone acetate
these disparities. A bridge literature search was com- c Levonorgestrel-releasing intrauterine device
pleted in March 2023. Any updated literature was c Levonorgestrel-releasing intrauterine device plus
incorporated into the text and recommendations, as oral progestin
appropriate.

progression to endometrial cancer. In a 2020 systematic
DETECTING CONCURRENT CARCINOMA review and meta-analysis, the risk of EIN–AEH progress-
ing to endometrial cancer was approximately 8% per
Gynecologists should attempt to exclude con-
year (18). Patients may choose to undergo hysterectomy
current carcinoma in individuals with a working
as definitive treatment for EIN–AEH. Depending on the
diagnosis of EIN–AEH. Hysteroscopic examina-
clinical situation, some patients, such as those who
tion with further sampling of the endometrium is
desire to preserve fertility, may choose less definitive
the most accurate method for detecting a con-
but still effective treatment strategies. Advantages of
current carcinoma.
management with hysterectomy include definitive
The percentage of patients diagnosed with EIN–AEH
assessment of a possible concurrent carcinoma (occur-

who undergo hysterectomy and have endometrial cancer
ring in approximately 30–50% of cases of EIN–AEH) and
in the hysterectomy specimen ranges from approximately
effective treatment of premalignant lesions that require
30% to nearly 50% (16–18). Thus, when a conservative
no further therapy or specific follow-up for EIN–AEH
(fertility-sparing) approach to the management of EIN–
(17,21,24). The decision to perform an oophorectomy in
AEH is under consideration, it is important to attempt to
premenopausal individuals should be a shared decision
exclude the presence of endometrial cancer to avoid
between the patient and clinician due to the risks asso-
potential undertreatment of an unknown malignancy in ciated with surgical menopause (eg, cognitive impair-
patients who have been already diagnosed with EIN– ment and cardiovascular disease) (25). These potential
AEH. Multiple methods are available to sample the endo- risks should be weighed against the risk of concurrent
metrium. The simplest method, in-office suction endome- occult endometrial cancer; in this case, oophorectomy
trial sampling performed with a plastic cannula, has a may be advised. Importantly, supracervical hysterectomy
long history of safety and efficacy and previously was for the treatment of EIN–AEH should not be performed
found to be comparable with uterine curettage when because of the inability to assess the lowest extent of the
used to diagnose endometrial cancer in women with lesion; it may involve the lower uterine segment or upper
abnormal bleeding (19). However, more recent data dem- endocervix.
onstrate a higher rate of endometrial cancer in hysterec- Due to the high rate of concurrent endometrial cancer
tomy specimens in patients with preoperative office in patients with EIN–AEH, when performing a hysterec-
Pipelle biopsy when compared with uterine dilation and tomy, the surgeon should consider intraoperative assess-
curettage (20,21). It is believed that “mass lesions” that ment of the uterine specimen for occult carcinoma
impinge on the endometrial cavity may deflect the pliable because it may identify the need for additional surgical
suction catheter and lead to ineffective sampling that management. This intraoperative evaluation should be
may miss endometrial pathology. directed by a qualified pathologist or a surgeon with
Hysteroscopic-guided uterine sampling is recommen- experience in evaluating uteri with endometrial cancer
ded, and data demonstrate its utility for the diagnosis of and should include gross examination of the open spec-
endometrial polyps, endometrial cancer, and endometrial imen and possible frozen section (26). The decision to
hyperplasia (22,23). There are several tissue-removal consult a gynecologic oncologist should be individual-
devices on the market that can provide simple, ized based on the patient and the health system’s avail-
hysteroscopic-guided resection of the endometrium. able resources (27). In settings without access to local
Although they morcellate the specimen, this is done in oncology expertise, there is no role for intraoperative
a contained environment and produces excellent sam- assessment of the specimen. If morcellation of the uter-
ples to evaluate, at the expense of clear orientation. ine specimen is needed to remove the uterus, it should
Sampling methods that yield crushed or very small sam- be done in a contained environment (eg, a bag) to pre-
ples (jawed devices) or cauterized samples (hot loops) vent any spill. Additionally, the surgeon should be aware
are not recommended, because it is difficult to ade- that morcellation may make it more difficult for the pathol-
quately evaluate the pathologic specimen due to the ogist to evaluate the specimen.
artifact produced by the sampling method. Gynecologists should not perform endometrial
ablation (thermal or electrocautery) for EIN–
AEH due to high persistence and recurrence
SURGICAL MANAGEMENT rates, as well as potential difficulty in evaluating
Hysterectomy is the definitive treatment for EIN– future bleeding episodes.
AEH. Gynecologists should not perform supracer- Endometrial ablation (thermal or electrocautery)
vical hysterectomy for the treatment of EIN–AEH. should not be used to treat EIN–AEH. The U.S. Food
The primary objectives in the management of a patient and Drug Administration includes the following contrain-
with EIN–AEH are to 1) rule out endometrial cancer and dication for the thermal (radio-frequency) endometrial
2) design a treatment plan that can prevent or delay ablation device: “A patient with known or suspected

endometrial carcinoma (uterine cancer) or pre-malignant with oral progestins alone (15, 40, 47). Continuous oral
change of the endometrium, such as unresolved adeno- progestins do demonstrate efficacy in the treatment of
matous hyperplasia” (28). EIN–AEH; one randomized trial found it to be nearly as
effective as treatment with the LNG-IUD (40). One study
observed an improved regression rate with combined
NONSURGICAL MANAGEMENT intrauterine and oral progestins (85%) compared with
Clinicians should recommend progestational the LNG-IUD alone (55%) (15).
agents as treatment for EIN–AEH for patients in Compared with systemic therapy, adverse events with
whom hysterectomy is not an option. the LNG-IUD are uncommon and similar to those
For some patients, hysterectomy may not be the most reported when the LNG-IUD is used for contraception
optimal strategy for treatment of EIN–AEH. Given the high (eg, expulsion, perforation, pelvic inflammatory disease).
risk of progression to cancer, patients who do not have Additionally, patient adherence with LNG-IUD therapy has
surgery require progestin therapy and close surveillance. been reported to be higher, with less weight gain, and
Many of the data on the use of progestational agents are patient-reported health status scores (physical function-
derived from the treatment of patients with simple and ing and energy levels) have been reported to improve
complex hyperplasia, often in the absence of cellular over time with this method (44,49). The American College
atypia. In those populations, treatment with progesta- of Obstetricians and Gynecologists supports insurance
tional agents has been shown to result in high rates of coverage for the most appropriate progestin therapy
regression (29–37). Although there are more limited data method for the patient based on individualized risks,
on the treatment of EIN–AEH with progestational agents, benefits, and preferences.
studies have found high rates of disease regression in There is insufficient evidence to recommend any
patients who are not candidates for definitive surgical one formulation of oral progestational agent
management and, instead, are managed with more con- over another.
servative approaches. A systematic review of outcomes To date, no direct comparisons between different oral
in patients with EIN–AEH or grade 1 adenocarcinoma progestin formulations have been published. However,
demonstrated an initial response to progestins of 86%, megestrol acetate or medroxyprogesterone acetate are
with a complete response (resolution) of 66% for those recommended given that the majority of studies on
with EIN–AEH (38). Oral, intrauterine, and combined management of EIN–AEH with progestational agents
modes of administration have been shown to be effec- used one of these two agents. Limited data suggest that
tive, with rates of disease regression ranging from nearly cyclic progestational agents have lower regression rates
50% to greater than 90%, depending on study and when compared with continuous oral therapy (40).
method of administration (15,38–44). Data support that
continuous oral therapy is more effective than the use of
cyclical therapy (40). Among all methods, adverse effects FOLLOW-UP
were generally well-tolerated by patients. Vaginal bleed- For patients initially treated with progestational
ing may be more common with the intrauterine mode of agents, gynecologists should perform repeat
administration, and nausea may be more associated with histologic assessment for response to treatment
oral progestational agents. Data on use of the LNG-IUD for EIN–AEH within 3–6 months.
for management of EIN–AEH are from the 52-mg LNG- After initial conservative treatment for EIN–AEH (treat-
IUD, with a delivery rate of 20 micrograms/day ment with progestational agents), early detection of dis-
(15,41,42,44–48). Throughout this article, discussion of ease persistence, progression, or recurrence requires
the LNG-IUD will refer to the 52-mg device with a delivery careful follow-up. The initiation and frequency of histo-
rate of 20 micrograms/day within 5 years of placement. logic assessment depends on numerous factors, includ-
See Box 1 for progestational agents used for the treating the choice of treatment, menopausal status, and the
ment of EIN–AEH. presence of obesity and other risk factors associated
Data on the superiority of either oral or intrauter- with endometrial cancer. Surveillance after total hysterec-
ine progestational agents are lacking, though tomy for EIN–AEH with pathologic confirmation of the
limited data suggest that intrauterine progesta- absence of coexisting endometrial carcinoma is not rec-
tional administration may be associated with a ommended, because surgery eliminates the risk of dis-
higher rate of disease regression when com- ease progression (24).
pared with oral administration alone in patients For patients managed with progestational agents,
with EIN–AEH. repeat histologic assessment within 3–6 months is rec-
Although data are conflicting and limited, studies have ommended to determine treatment response. There are
demonstrated that treatment with the LNG-IUD results in several types of potential outcomes to treatment (50).
a higher regression rate when compared with treatment The first is resolution (complete response) of the

hyperplasia, with a repeat endometrial sampling demon- grade 1 adenocarcinoma (n5391) (38). Some experts
strating atrophic, secretory, or proliferative endometrium. recommend discontinuing surveillance biopsies after 2
Secondly, regression is considered to have occurred years for patients without evidence of persistent disease,
when the repeat sampling still reveals hyperplasia but recurrence, or progression of disease and who are
without atypia. The third type of outcome is persistence asymptomatic without vaginal bleeding. However, both
of disease with no change in histology at the time of the patients and clinicians should be vigilant of clinical
repeat sampling. Finally, there can be progression to changes, such as symptoms of recurrence (eg, vaginal
cancer. Review of the biopsy results and consultation bleeding), and the need for follow-up (biopsy, pathology
with a pathologist may assist with the individualization review, or consultation with a gynecologic oncologist).
After initial progestin treatment, gynecologists
of a patient’s follow-up plan. If there is no response or

some regression during the initial 3–6 months of therapy, may consider long-term maintenance therapy
an additional 3–6 months of therapy may be considered with progestational agents for patients with con-
after discussion with the patient. If there is no response tinuing risk factors for endometrial cancer.
after 9–12 total months of therapy, other management After initial treatment with progestational agents,
options, including definitive surgery, should be medical management with these agents may be contin-
discussed. ued in patients who remain at risk for the development of
In a systematic review of 111 women with EIN–AEH endometrial cancer due to the following: factors such as
and 280 women with early-stage endometrial carcinoma increasing age, late menopause, nulliparity, and chronic
treated with progestational agents, the median time to anovulation; higher-risk conditions (Lynch syndrome,
complete response (resolution), in studies in which time Cowden syndrome); modifiable risk factors, such as the
to response was reported, was 6 months (ranging from 1 use of unopposed estrogen therapy; and potentially
to 18 months) (38). After 3 months of treatment, failure to modifiable risk factors, such as obesity and type 2
detect exogenous progesterone effect is associated with diabetes mellitus. In a case–control study of 138 women
lack of response (44). Nonresponse after 6 months of diagnosed with endometrial cancer at least 1 year after
treatment with the LNG-IUD was associated with an index biopsy of endometrial hyperplasia and a
increased uterine diameter (9.3 vs 8 cm; P5.04) (51). matched control group, the risk of progression of the 42
Whether it is preferable to discontinue oral progestins women with atypical hyperplasia (all of whom received
and wait for a withdrawal bleed before endometrial sam- hormonal treatment [eg, medroxyprogesterone acetate])
pling or proceed with sampling while the patient con- to carcinoma was 8.2% through 4 years (95% CI 1.3–
tinues oral progestin treatment remains unclear (24). In 14.6%); cumulative risk steadily rose to 27.5% (95% CI
patients being treated with the LNG-IUD, histologic sam- 8.6–42.5%) at 19 years after the index biopsy (56). Most
pling may be completed with the device in place. The studies, however, have follow-up periods of insufficient
utility of pretreatment hormone receptor expression (PR- length to inform approaches to long-term maintenance.
A and PR-B) in predicting relapse after progestin-based Guidance on how long to continue the use of an LNG-IUD
therapy has been demonstrated (52–54). or systemic progestational agents to prevent long-term
The optimal interval and duration of endometrial recurrence has not been determined.
sampling after complete response (resolution) with
treatment with progestational agents have not been Future Fertility
established (38,55). In a retrospective observational A systematic review and systematic review and meta-
cohort study of 245 women with EIN–AEH managed with analysis focused on fertility-sparing therapy for premen-
suction dilation and curettage to rule out occult malig- opausal women with EIN–AEH reported pregnancy rates
nancy followed by treatment with LNG-IUD or oral pro- ranging from 26.3% to 41.0% for premenopausal individ-
gestin therapy, 28 patients (11.4%) progressed to cancer, uals who opted for management with progestational
with a median time to cancer diagnosis of 9.5 months agents (38, 43). For those who received fertility-sparing
(interquartile range 3.5–28.6 months) (46). Based on what treatment for EIN–AEH or endometrial cancer, the use of
is known about potential progressive disease, it is rea- assisted reproductive technology was common (57), and
sonable to continue endometrial sampling in patients the live-birth rate in women using assisted reproductive
treated with progestational agents every 3–6 months technology was higher than that of women who attemp-
for up to 2 years. The recurrence rate of EIN–AEH ted to achieve pregnancy spontaneously (39.4% vs
remains elevated after initial response to conservative 14.9%; P5.001) (43). A retrospective analysis of 63
management with progestational agents. patients (42 with endometrial cancer and 21 with EIN–
A systematic review reported a recurrence rate of AEH) who underwent fertility-sparing treatment reported
approximately 23% for patients treated for EIN–AEH that, of the 31 patients who achieved remission with
(n5111) and a median time to recurrence of 24 months medroxyprogesterone acetate and metformin, in vitro fer-
(ranging 4–72 months) for those treated for EIN–AEH or tilization and embryo transfer resulted in 19 pregnancies

(61.3%) and 14 live births (45.2%) (58). A small prospec- diets) were nearly four times more likely to respond to
tive cohort study (n560) found that in vitro fertilization the LNG-IUD (adjusted odds ratio 3.95, 95% CI 1.3–12.5;
after conservative fertility-sparing management of EIN– P5.02) (48). Telemedicine and text-based weight-loss
AEH or grade 1 endometrial adenocarcinoma was not interventions for individuals with endometrial hyperplasia
associated with an increased risk of recurrence (59). or type 1 endometrial cancer and obesity have demon-
Because many patients will have conditions that can strated effectiveness in assisting patients with weight
negatively affect fertility (eg, polycystic ovarian syndrome, loss (62). Discussions about the diagnosis of EIN–AEH
obesity, and diabetes), active management to achieve or early-stage endometrial cancer may be a useful time
pregnancy should be discussed and referral to an infer- to discuss potential lifestyle modifications and related
tools for weight loss.
tility specialist should be considered.
COUNSELING PATIENTS ON LIFESTYLE FURTHER RESEARCH

MODIFICATIONS Limitations of the current literature include the use of
Gynecologists and other clinicians should coun- inconsistent terminology for endometrial hyperplasia and,
sel patients that lifestyle modification resulting in many trials, the inclusion of individuals with endome-
in weight loss and glycemic control can improve trial hyperplasia without atypia. Although focus on EIN–
overall health and may decrease the risk of EIN– AEH is increasing, further research and larger sample
AEH and endometrial cancer. sizes are needed. Research should include patient-
More than 75% of endometrial cancer survivors have centered outcomes, with an emphasis on patient quality
obesity (60), defined as having a body mass index (BMI of life. To better understand optimal approaches to the
[calculated as weight in kilograms divided by height in management of EIN–AEH and existing disparities in treat-
meters squared]) of 30 or higher. They are more likely to ment and mortality, more research is needed on the
have obesity-related comorbidities and are at a greater causes of disease relapse and regression, particularly
risk of mortality compared with those without obesity. in historically excluded populations, including Black, His-
Many individuals who receive gynecologic care, including panic, and Indigenous patients. More research is needed
those in treatment for EIN–AEH or carcinoma as well as to identify treatments and interventional approaches that
survivors, are unaware of the link among obesity, endo- can eliminate disparities and ensure equity for all
metrial hyperplasia and cancer, and other comorbidities, patients.
including hypertension and type 2 diabetes (60–64). The number of individuals with risk factors for EIN–AEH
Weight loss of 7–10% of a person’s total body weight —in particular obesity—is increasing. More data are
has been found to have positive effects on health out- needed on potentially modifiable risk factors, including
comes. Education, counseling on options for lifestyle rigorous and adequately powered randomized controlled
modification leading to weight loss and improved glyce- trials with adequate duration of follow-up focusing on the
mic control, and shared decision making are compo- effects of dietary modifications, as well as medical and
nents of care that have the potential to affect surgical weight-loss management.
immediate and long-term outcomes. Additionally, research is needed on the utility of repeat
Gynecologists may consider counseling patients sampling for the exclusion of concurrent malignancy
being treated with an LNG-IUD for EIN–AEH who also when diagnosing EIN–AEH, the comparative effective-
have obesity about weight-loss interventions. In a pro- ness of different progestational agents, and the subtypes
spective study of 71 women with atypical hyperplasia of EIN–AEH, including molecular classification. Long-term
or grade 1 or 2 endometrioid adenocarcinoma being outcomes of patients who did not have definitive treat-
treated with the LNG-IUD, investigators assessed the ment (hysterectomy) are needed. The effect of combina-
uptake of bariatric surgery (offered to those with BMIs tion therapies for initial nonresponders, the utility of lower-
higher than 35) and the effects of more than 10% of body dose LNG-IUDs, and alternative approaches to monitor-
weight loss on progestin treatment response at 12 ing patients with EIN–AEH are other areas of needed
months (48). Ninety percent of participants were offered research.
bariatric surgery, and 36% subsequently underwent a
bariatric procedure. The remaining patients were encour-
aged to follow a low-calorie diet. Of 71 participants, 43 REFERENCES
1. Sherman ME. Theories of endometrial carcinogenesis: a multi-
(61%) responded to treatment, 23 (32%) had stable dis- disciplinary approach. Mod Pathol 2000;13:295–308. doi: 10.
ease, and five (7%) progressed during treatment with an 1038/modpathol.3880051
LNG-IUD. Excluding those who progressed, women who 2. Silverberg SG, Kurman RJ, Nogales F, Mutter GL, Kubik-Huch
lost more than 10% of their total body weight (86% of RA, Tavassoli FA. Epithelial tumours and related lesions. In:
bariatric patients and 23% of patients on low-calorie Tavassoli FA, Devilee P, editors. Pathology and genetics of

tumours of the breast and female genital organs. World Health 18. Doherty MT, Sanni OB, Coleman HG, Cardwell CR, McClug-
Organization classification of tumours. International Agency for gage WG, Quinn D, et al. Concurrent and future risk of endo-
Research on Cancer; 2003:221–32. metrial cancer in women with endometrial hyperplasia: a
3. Scully RE, Bonfiglio TA, Kurman RJ, Silverberg SG, Wilkinson systematic review and meta-analysis. PLoS One 2020;15:
EJ. Uterine corpus. In: Histological typing of female genital tract e0232231. doi: 10.1371/journal.pone.0232231
tumours. 2nd ed. Springer; 1994:13–30. 19. Ben-Baruch G, Seidman DS, Schiff E, Moran O, Menczer J.
4. Kurman RJ, Carcangiu ML, Herrington CS, Young RH, editors. Outpatient endometrial sampling with the Pipelle curette. Gyne-
WHO classification of tumours of female reproductive organs. col Obstet Invest 1994;37:260–2. doi: 10.1159/000292573
4th ed. International Agency for Research on Cancer; 2014. 20. Costales AB, Schmeler KM, Broaddus R, Soliman PT, Westin
SN, Ramirez PT, et al. Clinically significant endometrial cancer
5. Emons G, Beckmann MW, Schmidt D, Mallmann P; Uterus
risk following a diagnosis of complex atypical hyperplasia. Gy-
Commission of the Gynecological Oncology Working Group

necol Oncol 2014;135:451–4. doi: 10.1016/j.ygyno.2014.10.008
(AGO). New WHO classification of endometrial hyperplasias.
Geburtshilfe Frauenheilkd 2015;75:135–6. doi: 10.1055/s-0034- 21. Suh-Burgmann E, Hung Y, Armstrong MA. Complex atypical
1396256 endometrial hyperplasia: the risk of unrecognized adenocarci-
noma and value of preoperative dilation and curettage. Obstet
6. Kim KR, Lax S, Lazar A, Longacre T, Malpica A, Matias-Guiu X,
Gynecol 2009;114:523–9. doi: 10.1097/AOG.
et al. Tumours of the uterine corpus. In: WHO Classification of
0b013e3181b190d5
Tumours Editorial Board. Female genital tumours. 5th ed. Inter-
national Agency of Research on Cancer; 2020:245–308. 22. Bedner R, Rzepka-Górska I. Hysteroscopy with directed biopsy
versus dilatation and curettage for the diagnosis of endometrial
7. Mutter GL. Endometrial intraepithelial neoplasia (EIN): will it hyperplasia and cancer in perimenopausal women. Eur J Gy-
bring order to chaos? The Endometrial Collaborative Group. naecol Oncol 2007;28:400–2.
Gynecol Oncol 2000;76:287–90. doi: 10.1006/gyno.1999.5580
23. Dueholm M, Hjorth IM, Dahl K, Ørtoft G. Hysteroscopic
8. Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, resectoscope-directed biopsies and outpatient endometrial
2023. CA Cancer J Clin 2023;73:17–48. doi: 10.3322/caac. sampling for assessment of tumor histology in women with
21763 endometrial cancer or atypical hyperplasia. Eur J Obstet Gy-
9. Doll KM, Snyder CR, Ford CL. Endometrial cancer disparities: a necol Reprod Biol 2020;251:173–9. doi: 10.1016/j.ejogrb.2020.
race-conscious critique of the literature. Am J Obstet Gynecol 05.010
2018;218:474–82.e2. doi: 10.1016/j.ajog.2017.09.016 24. Trimble CL, Method M, Leitao M, Lu K, Ioffe O, Hampton M,
10. Whetstone S, Burke W, Sheth SS, Brooks R, Cavens A, Huber- et al. Management of endometrial precancers. Obstet Gynecol
Keener K, et al. Health disparities in uterine cancer: report from 2012;120:1160–75. doi: 10.1097/aog.0b013e31826bb121
the uterine cancer evidence review conference. Obstet Gynecol 25. Opportunistic salpingectomy as a strategy for epithelial ovarian
2022;139:645–59. doi: 10.1097/AOG.0000000000004710 cancer prevention. ACOG Committee Opinion No. 774. Ameri-
11. Fader AN, Habermann EB, Hanson KT, Lin JF, Grendys EC, can College of Obstetricians and Gynecologists. Obstet Gyne-
Dowdy SC. Disparities in treatment and survival for women with col 2019;133:e279–84. doi: 10.1097/AOG.0000000000003164
endometrial cancer: a contemporary national cancer database 26. Attard Montalto S, Coutts M, Devaja O, Summers J, Jyothirmayi
registry analysis. Gynecol Oncol 2016;143:98–104. doi: 10. R, Papadopoulos A. Accuracy of frozen section diagnosis at
1016/j.ygyno.2016.07.107 surgery in pre-malignant and malignant lesions of the endome-
12. Strohl AE, Feinglass JM, Shahabi S, Simon MA. Surgical wait trium. Eur J Gynaecol Oncol 2008;29:435–40.
time: a new health indicator in women with endometrial cancer. 27. Chaiken SR, Bohn JA, Bruegl AS, Caughey AB, Munro EG.
Gynecol Oncol 2016;141:511–5. doi: 10.1016/j.ygyno.2016.04. Hysterectomy with a general gynecologist vs gynecologic-
014 oncologist in the setting of endometrial intraepithelial neopla-
13. Clinical Consensus methodology. American College of Obste- sia: a cost-effectiveness analysis. Am J Obstet Gynecol 2022;
tricians and Gynecologists. Obstet Gynecol 2021;138:523–6. 227:609.e1–8. doi: 10.1016/j.ajog.2022.05.055
doi: 10.1097/AOG.0000000000004520 28. Novacept Inc. Summary of safety and effectiveness data: No-
14. United Nations Development Programme. Human Development vasureTM impedance controlled endometrial ablation system.
Index (HDI). Accessed June 7, 2023. https://hdr.undp.org/data- Novacept, Inc. Accessed March 20, 2023. https://www.access-
center/human-development-index#/indicies/HDI data.fda.gov/cdrh_docs/pdf/p010013b.pdf
15. Fang F, Xu H, Wu L, Hu L, Liu Y, Li Y, Zhang C. LNG-IUS 29. Clement NS, Oliver TR, Shiwani H, Sanner JR, Mulvaney CA,
combined with progesterone ameliorates endometrial thick- Atiomo W. Metformin for endometrial hyperplasia. The Co-
ness and pregnancy outcomes of patients with early-stage chrane Database of Systematic Reviews 2017, Issue 10. Art.
endometrial cancer or atypical hyperplasia. Am J Transl Res No.: CD012214. doi: 10.1002/14651858.CD012214.pub2
2021;13:5412–9. 30. Mittermeier T, Farrant C, Wise MR. Levonorgestrel-releasing
16. Trimble CL, Kauderer J, Zaino R, Silverberg S, Lim PC, Burke JJ intrauterine system for endometrial hyperplasia. The Cochrane
II, et al. Concurrent endometrial carcinoma in women with a Database of Systematic Reviews 2020, Issue 9. Art. No.:
biopsy diagnosis of atypical endometrial hyperplasia: a gyne- CD012658. doi: 10.1002/14651858.CD012658.pub2
cologic oncology group study. Cancer 2006;106:812–9. doi: 10. 31. Demir Karakilic I, Karabacak O, Karabacak N, Guler I, Korucuo-
1002/cncr.21650 glu U. Gonadotropin-releasing hormone analog combined with
17. Dolanbay M, Kutuk MS, Uludag S, Bulut AN, Ozgun MT, Ozcelik depot medroxyprogesterone acetate in the management of
B, et al. Concurrent endometrial carcinoma in hysterectomy endometrial hyperplasia a prospective randomized clinical
specimens in patients with histopathological diagnosis of endo- study. J Reprod Med 2016;61:361–7.
metrial hyperplasia in curettage specimens. Ginekol Pol 2015; 32. Moradan S, Nikkhah N, Mirmohammadkhanai M. Comparing
86:753–8. doi: 10.17772/gp/57813 the administration of letrozole and megestrol acetate in the

treatment of women with simple endometrial hyperplasia with- 45. Gallos ID, Krishan P, Shehmar M, Ganesan R, Gupta JK.
out atypia: a randomized clinical trial. Adv Ther 2017;34:1211– Relapse of endometrial hyperplasia after conservative treat-
20. doi: 10.1007/s12325-017-0509-8 ment: a cohort study with long-term follow-up. Hum Reprod
33. Nooh AM, Abdeldayem HM, Girbash EF, Arafa EM, Atwa K, 2013;28:1231–6. doi: 10.1093/humrep/det049
Abdel-Raouf SM. Depo-provera versus norethisterone acetate 46. Mandelbaum RS, Ciccone MA, Nusbaum DJ, Khoshchehreh M,
in management of endometrial hyperplasia without atypia. Re- Purswani H, Morocco EB, et al. Progestin therapy for obese
prod Sci 2016;23:448–54. doi: 10.1177/1933719115623643 women with complex atypical hyperplasia: levonorgestrel-
34. Sharifzadeh F, Aminimoghaddam S, Kashanian M, Fazaeli M, releasing intrauterine device vs systemic therapy. Am J Obstet
Gynecol 2020;223:103.e1–13. doi: 10.1016/j.ajog.2019.12.273
Sheikhansari N. A comparison between the effects of metfor-

min and megestrol on simple endometrial hyperplasia. Gynecol 47. Gallos ID, Shehmar M, Thangaratinam S, Papapostolou TK,
Endocrinol 2017;33:152–5. doi: 10.1080/09513590.2016. Coomarasamy A, Gupta JK. Oral progestogens vs
1223285 levonorgestrel-releasing intrauterine system for endometrial

35. Tasci Y, Polat OG, Ozdogan S, Karcaaltincaba D, Seckin L, hyperplasia: a systematic review and metaanalysis. Am J Ob-
Erkaya S. Comparison of the efficacy of micronized progester- stet Gynecol 2010;203:547.e1–10. doi: 10.1016/j.ajog.2010.07.
one and lynestrenol in treatment of simple endometrial hyper- 037
plasia without atypia. Arch Gynecol Obstet 2014;290:83–6. doi: 48. Barr CE, Ryan NA, Derbyshire AE, Wan YL, MacKintosh ML,
10.1007/s00404-014-3161-4 McVey RJ, et al. Weight loss during intrauterine progestin treat-
36. Tehranian A, Ghahghaei-Nezamabadi A, Arab M, Khalagi K, ment for obesity-associated atypical hyperplasia and early-
Aghajani R, Sadeghi S. The impact of adjunctive metformin stage cancer of the endometrium. Cancer Prev Res 2021;14:
to progesterone for the treatment of non-atypical endometrial 1041–50. doi: 10.1158/1940-6207.CAPR-21-0229
hyperplasia in a randomized fashion, a placebo-controlled, 49. Cholakian D, Hacker K, Fader AN, Gehrig PA, Tanner EJ III.
double blind clinical trial. J Gynecol Obstet Hum Reprod Effect of oral versus intrauterine progestins on weight in women
2021;50:101863. doi: 10.1016/j.jogoh.2020.101863 undergoing fertility preserving therapy for complex atypical
37. Uysal G, Acmaz G, Madendag Y, Cagli F, Akkaya H, Madendag hyperplasia or endometrial cancer. Gynecol Oncol 2016;140:
I, et al. The efficacy of dienogest in the treatment of simple 234–8. doi: 10.1016/j.ygyno.2015.12.010
endometrial hyperplasia without atypia. Gynecol Obstet Invest 50. Mentrikoski MJ, Shah AA, Hanley KZ, Atkins KA. Assessing
2018;83:151–5. doi: 10.1159/000477618 endometrial hyperplasia and carcinoma treated with progestin
38. Gunderson CC, Fader AN, Carson KA, Bristow RE. Oncologic therapy. Am J Clin Pathol 2012;138:524–34. doi: 10.
and reproductive outcomes with progestin therapy in women 1309/AJCPM2TSDDF1MHBZ
with endometrial hyperplasia and grade 1 adenocarcinoma: a 51. Pal N, Broaddus RR, Urbauer DL, Balakrishnan N, Milbourne A,
systematic review. Gynecol Oncol 2012;125:477–82. doi: 10. Schmeler KM, et al. Treatment of low-risk endometrial cancer
1016/j.ygyno.2012.01.003 and complex atypical hyperplasia with the levonorgestrel-
39. Janda M, Robledo KP, Gebski V, Armes JE, Alizart M, Cum- releasing intrauterine device. Obstet Gynecol 2018;131:109–
mings M, et al. Complete pathological response following lev- 16. doi: 10.1097/AOG.0000000000002390
onorgestrel intrauterine device in clinically stage 1 endometrial 52. Gunderson CC, Dutta S, Fader AN, Maniar KP, Nasseri-Nik N,
adenocarcinoma: results of a randomized clinical trial. Gynecol Bristow RE, et al. Pathologic features associated with resolution
Oncol 2021;161:143–51. doi: 10.1016/j.ygyno.2021.01.029 of complex atypical hyperplasia and grade 1 endometrial ade-
40. Orbo A, Vereide A, Arnes M, Pettersen I, Straume B. Levonor- nocarcinoma after progestin therapy. Gynecol Oncol 2014;132:
gestrel-impregnated intrauterine device as treatment for endo- 33–7. doi: 10.1016/j.ygyno.2013.11.033
metrial hyperplasia: a national multicentre randomised trial. 53. Gallos ID, Devey J, Ganesan R, Gupta JK. Predictive ability of
BJOG 2014;121:477–86. doi: 10.1111/1471-0528.12499 estrogen receptor (ER), progesterone receptor (PR), COX-2,
41. Baker J, Obermair A, Gebski V, Janda M. Efficacy of oral or Mlh1, and Bcl-2 expressions for regression and relapse of
intrauterine device-delivered progestin in patients with complex endometrial hyperplasia treated with LNG-IUS: a prospective
endometrial hyperplasia with atypia or early endometrial ade- cohort study. Gynecol Oncol 2013;130:58–63. doi: 10.1016/j.
nocarcinoma: a meta-analysis and systematic review of the ygyno.2013.04.016
literature. Gynecol Oncol 2012;125:263–70. doi: 10.1016/j.ygy- 54. Sletten E, Arnes M, Lyså L, Larsen M, Ørbo A. Significance of
no.2011.11.043 progesterone receptors (PR-A and PR-B) expression as predic-
42. Gallos ID, Krishan P, Shehmar M, Ganesan R, Gupta JK. LNG- tors for relapse after successful therapy of endometrial hyper-
IUS versus oral progestogen treatment for endometrial hyperplasia: a retrospective cohort study. BJOG 2019;126:936–43.
plasia: a long-term comparative cohort study. Hum Reprod doi: 10.1111/1471-0528.15579
2013;28:2966–71. doi: 10.1093/humrep/det320 55. Ørbo A, Arnes M, Vereide AB, Straume B. Relapse risk of
43. Gallos ID, Yap J, Rajkhowa M, Luesley DM, Coomarasamy A, endometrial hyperplasia after treatment with the
Gupta JK. Regression, relapse, and live birth rates with fertility- levonorgestrel-impregnated intrauterine system or oral proges-
sparing therapy for endometrial cancer and atypical complex togens. BJOG 2016;123:1512–9. doi: 10.1111/1471-0528.13763
endometrial hyperplasia: a systematic review and metaanaly- 56. Lacey JV Jr, Sherman ME, Rush BB, Ronnett BM, Ioffe OB,
sis. Am J Obstet Gynecol 2012;207:266.e1–12. doi: 10.1016/j. Duggan MA, et al. Absolute risk of endometrial carcinoma
ajog.2012.08.011 during 20-year follow-up among women with endometrial
44. Westin SN, Fellman B, Sun CC, Broaddus RR, Woodall ML, Pal hyperplasia. J Clin Oncol 2010;28:788–92. doi: 10.1200/JCO.
N, et al. Prospective phase II trial of levonorgestrel intrauterine 2009.24.1315
device: nonsurgical approach for complex atypical hyperplasia 57. Koskas M, Uzan J, Luton D, Rouzier R, Daraï E. Prognostic
and early-stage endometrial cancer. Am J Obstet Gynecol factors of oncologic and reproductive outcomes in fertility-
2021;224:191.e1–15. doi: 10.1016/j.ajog.2020.08.032 sparing management of endometrial atypical hyperplasia and

adenocarcinoma: systematic review and meta-analysis. Fertil
Sterility 2014;101:785–94.e3. doi: 10.1016/j.fertnstert.2013.11.
028 Appendices
58. Mitsuhashi A, Habu Y, Kobayashi T, Kawarai Y, Ishikawa H, Usui
1. Literature Search Strategy: http://links.lww.com/AOG/
H, Shozu M. Long-term outcomes of progestin plus metformin D269
as a fertility-sparing treatment for atypical endometrial hyper-
plasia and endometrial cancer patients. J Gynecol Oncol 2019; 2. Evidence Map: http://links.lww.com/AOG/D270
30:e90. doi: 10.3802/jgo.2019.30.e90
59. Vaugon M, Peigné M, Phelippeau J, Gonthier C, Koskas M. IVF

impact on the risk of recurrence of endometrial adenocarci-
CONFLICT OF INTEREST STATEMENT
noma after fertility-sparing management. Reprod BioMedicine All ACOG committee members and authors have
Online 2021;43:495–502. doi: 10.1016/j.rbmo.2021.06.007 submitted a conflict of interest disclosure statement
60. Jernigan AM, Maurer KA, Cooper K, Schauer PR, Rose PG, related to this published product. Any potential conflicts
Michener CM. Referring survivors of endometrial cancer and have been considered and managed in accordance with
complex atypical hyperplasia to bariatric specialists: a pro- ACOG’s Conflict of Interest Disclosure Policy. The ACOG
spective cohort study. Am J Obstet Gynecol 2015;213:350. policies can be found on acog.org. For products jointly
e1–10. doi: 10.1016/j.ajog.2015.05.015
developed with other organizations, conflict of interest
61. Linkov F, Edwards R, Balk J, Yurkovetsky Z, Stadterman B, disclosures by representatives of the other organizations
Lokshin A, et al. Endometrial hyperplasia, endometrial cancer are addressed by those organizations. The American
and prevention: gaps in existing research of modifiable risk
College of Obstetricians and Gynecologists has neither
factors. Eur J Cancer 2008;44:1632–44. doi: 10.1016/j.ejca.
2008.05.001 solicited nor accepted any commercial involvement in the
development of the content of this published product.
62. Haggerty AF, Huepenbecker S, Sarwer DB, Spitzer J, Raggio G,
Chu CS, et al. The use of novel technology-based weight loss
interventions for obese women with endometrial hyperplasia Published online on August 17, 2023.
and cancer. Gynecol Oncol 2016;140:239–44. doi: 10.1016/j. Copyright 2023 by the American College of Obstetricians and Gyne-
ygyno.2015.11.033 cologists. All rights reserved. No part of this publication may be re-
produced, stored in a retrieval system, posted on the internet, or
63. Haggerty AF, Sarwer DB, Schmitz KH, Ko EM, Allison KC, Chu transmitted, in any form or by any means, electronic, mechanical,
CS. Obesity and endometrial cancer: a lack of knowledge but photocopying, recording, or otherwise, without prior written permission
opportunity for intervention. Nutr Cancer 2017;69:990–5. doi: from the publisher.
10.1080/01635581.2017.1359313 American College of Obstetricians and Gynecologists
409 12th Street SW, Washington, DC 20024-2188
64. Raffone A, Travaglino A, Saccone G, D’Alessandro P, Arduino
B, Mascolo M, et al. Diabetes mellitus is associated with occult Management of endometrial intraepithelial neoplasia or atypical endo-
cancer in endometrial hyperplasia. Pathol Oncol Res 2020;26: metrial hyperplasia. Clinical Consensus No. 5. American College of
1377–84. doi: 10.1007/s12253-019-00684-3 Obstetricians and Gynecologists. Obstet Gynecol 2023;142:735–44.


Management of Endometrial Intraepithelial.32

Uploaded by

Copyright:

Available Formats

Management of Endometrial Intraepithelial.32

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Management of Endometrial Intraepithelial.32

Uploaded by

Copyright:

Available Formats

CLINICAL CONSENSUS

Management of Endometrial Intraepithelial Neoplasia or

Atypical Endometrial Hyperplasia

BACKGROUND categories of risk classification based on glandular

VOL. 142, NO. 3, SEPTEMBER 2023 CC Management of EIN-AEH 735

© 2023 by the American College of Obstetricians

Detecting Concurrent Carcinoma

Counseling Patients on Lifestyle Modifications

EIN–AEH, endometrial intraepithelial neoplasia or atypical endometrial hyperplasia.

for atypical hyperplasia or EIN include crowded glandu- Epidemiology

736 CC Management of EIN-AEH OBSTETRICS & GYNECOLOGY

© 2023 by the American College of Obstetricians

VOL. 142, NO. 3, SEPTEMBER 2023 CC Management of EIN-AEH 737

© 2023 by the American College of Obstetricians

assessment of a possible concurrent carcinoma (occur-

738 CC Management of EIN-AEH OBSTETRICS & GYNECOLOGY

© 2023 by the American College of Obstetricians

VOL. 142, NO. 3, SEPTEMBER 2023 CC Management of EIN-AEH 739

© 2023 by the American College of Obstetricians

of a patient’s follow-up plan. If there is no response or

740 CC Management of EIN-AEH OBSTETRICS & GYNECOLOGY

© 2023 by the American College of Obstetricians

tility specialist should be considered.

COUNSELING PATIENTS ON LIFESTYLE FURTHER RESEARCH

VOL. 142, NO. 3, SEPTEMBER 2023 CC Management of EIN-AEH 741

© 2023 by the American College of Obstetricians

Commission of the Gynecological Oncology Working Group

742 CC Management of EIN-AEH OBSTETRICS & GYNECOLOGY

© 2023 by the American College of Obstetricians

Sheikhansari N. A comparison between the effects of metfor-

1223285 levonorgestrel-releasing intrauterine system for endometrial

VOL. 142, NO. 3, SEPTEMBER 2023 CC Management of EIN-AEH 743

© 2023 by the American College of Obstetricians

59. Vaugon M, Peigné M, Phelippeau J, Gonthier C, Koskas M. IVF

744 CC Management of EIN-AEH OBSTETRICS & GYNECOLOGY

© 2023 by the American College of Obstetricians

You might also like