Cervical cancer

Endometrial hyperplasia: management and follow-up

Patient management tactics directly depend on the presence of cellular atypia. The total duration of treatment varies from 9 to 12 months.

• Without atypia (and glandular polyps): Treatment efficacy is monitored using ultrasound (echography) and endometrial aspiration at 6 and 12 months. Clinical follow-up lasts for at least 1–2 years, provided there is a persistent normalization of the menstrual cycle or the onset of stable postmenopause.
• With atypia (and adenomatous polyps): Stricter monitoring is required. Ultrasound is performed at 3, 6, and 12 months. A critically important step is performing diagnostic dilation and curettage along with hysteroscopy 3 months after initiating therapy. Clinical follow-up for the atypical form is carried out lifelong (or at least 2 years of stable postmenopause/normal cycle for less severe forms).

Medical therapy regimens for hyperplastic processes

Various groups of hormonal drugs are used for treatment. The choice of dosage depends on the form of the disease.

Therapy for forms without atypia (6–12 month course):

1. Norethisterone (norkolut, primolut-nor): 10 mg daily or continuously from the 5th to the 25th day of the cycle.
2. Medroxyprogesterone (provera): 10–20 mg daily. Depot form (depo-provera) — 200–600 mg intramuscularly once a week.
3. HPC (hydroxyprogesterone caproate): 250–500 mg intramuscularly twice a week (or on the 14th and 21st days of the cycle).
4. GnRH agonists: Buserelin (nasal spray 0.9 mg/day, divided into 3 doses) or injections of Goserelin / Diphereline (3.6 mg subcutaneously once every 28 days, a course of 3–4 injections).

Therapy for forms with atypia (6–12 month course): Drug dosages are increased. Medroxyprogesterone is prescribed at 100 mg daily, and HPC at 500 mg twice a week. Additionally, the following may be used:

• Danazol: 600 mg daily.
• Gestrinone: 2.5 mg 2–3 times a week.
• Gestonorone caproate (depostat): 200 mg once a week.
• Goserelin / Diphereline: administration of a depot dose of 10.8 mg subcutaneously once a month is possible (course — 2 injections).

Endometrial polyps: surgical and hormonal stages

The main method of treatment is targeted polypectomy. To prevent recurrences, radical removal is necessary—excision of the polyp along with the basal layer of the endometrium at the site of its stalk attachment. This is feasible exclusively under hysteroscopic guidance using mechanical, laser, or electrosurgical instruments. Electrosurgical excision is particularly indicated for fibrous, sessile, and recurrent formations. In perimenopause, it is advisable to combine polypectomy with endometrial ablation.

Following the removal of glandular and glandular-fibrous polyps, hormone therapy is prescribed. In the reproductive and perimenopausal periods, the regimens correspond to the treatment of hyperplasia without atypia.

Hormone therapy in postmenopause (6-month course):

Intrauterine adhesions (Asherman's syndrome)

Asherman's syndrome is the formation of intrauterine adhesions leading to partial or complete obliteration of the uterine cavity. The pathogenesis involves traumatic, infectious, and neurovisceral theories.

The primary etiological factor is mechanical trauma to the basal layer of the endometrium (following rough curettage, childbirth, or abortion in the wound phase). A secondary factor is the accession of infection.

Patients with a missed miscarriage are at particularly high risk. Retained placental tissue acts as a trigger: it provokes the activation of fibroblasts and collagen synthesis even before normal endometrial regeneration occurs. Other causes include surgical interventions (myomectomy, metroplasty), endometrial ablation, previous endometritis, and the use of intrauterine devices (IUDs).

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Mechanisms of action of gonadotropin-releasing hormone agonists (Buserelin, Goserelin) in hyperplastic processes.
• Technique of hysteroscopic polypectomy and endometrial ablation.
• Differential diagnosis of glandular, glandular-fibrous, and adenomatous polyps.
• Pathogenesis of the neurovisceral theory of intrauterine adhesions.

Other topics in the "Gynecology" section

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