Endometrial adenocarcinoma in young patients: evaluation and fertility-preserving treatment

Carcinoma of the endometrium is the most common female pelvic malignancy in the US. Although it is primarily a disease of the postmenopausal female, 25% of patients are premenopausal, with 3-5% in women 40 years old or younger. The younger group of women with endometrial carcinoma are frequently nulligravid with a history of infertility, and a strong desire to preserve fertility. This may pose a therapeutic dilemma for both patients and treating physicians. Medical treatment for young patients with grade 1 endometrial carcinoma who wish to preserve fertility is a reasonable and appealing option. A comprehensive evaluation prior to counseling the patient should include. A complete history and physical examination. A formal D&C with review of histology with an experienced gyn-onc pathologist. Evaluation of the pelvic and abdomen preferably with contrast-enhanced MRI or transvaginal ultrasound. In patients found to have a clinical stage I grade 1 tumor and who want to preserve fertility, thorough counseling including risks and benefits, and explanation that the data is partial and incomplete due to the lack of appropriate controlled studies is mandatory. In patients considered for medical treatment, a high dose progestin regimen should be started with endometrial sampling every 3 months until complete regression of the tumor is documented. For patients willing to conceive at this stage, treatment options should be discussed. In women who do not want pregnancy at this stage, a maintenance treatment with oral contraceptive agent or Depo-provera (medroxyprogesterone acetate 150 mg i.m. q 12 weeks) should be recommended, with periodic ultrasound evaluation of the endometrium. When the patient finishes her fertility plans, the option of hysterectomy should be considered. Although most responses are long standing, there is a small risk of progression during or after cessation of progestin therapy.