How to treat endometrial lesions

Nowadays, women's health has become a social concern. Many women suffer from gynecological diseases, but these are all treatable. The real disease that can make women turn pale is actually endometrial lesions. Now this problem is very tricky and it is also very difficult to treat medically, but there is still a way. So, how to treat endometrial lesions?

How to treat endometrial lesions?

1. Treatment principles The treatment of atypical endometrial hyperplasia must first determine the diagnosis and find out the cause of the atypical hyperplasia, whether there is polycystic ovary, functional ovarian tumors or other endocrine dysfunction. Those with any of the above conditions should receive targeted treatment. At the same time, symptomatic treatment can be started for atypical endometrial hyperplasia, using drug therapy or surgical treatment. The choice of these two treatment options should be based on age, type of endometrial hyperplasia, fertility requirements, etc.

(1) Different ages have different considerations:

① Young people who are eager to have children should avoid over-diagnosis and over-treatment. It is not uncommon for endometrial hyperplasia to be overdiagnosed as adenocarcinoma and even overtreated. It would be a serious mistake to remove the uterus without a clear diagnosis. In clinical practice, there are many examples of such mistakes. If the pathologist is not aware of the patient's fertility desire and the clinician does not emphasize it, misdiagnosis and mistreatment may be inevitable. Therefore, for the diagnosis of endometrial biopsy in young infertile women, if any doubt is found, multiple experts should be consulted to clarify the differential diagnosis of endometrial hyperplasia or endometrial adenocarcinoma to the greatest extent possible.

② Perimenopausal or postmenopausal women should be alert to the possibility of atypical endometrial hyperplasia and cancer coexisting, and should consider hysterectomy. Be careful not to be overly conservative and do not perform endarterectomy alone without ruling out the possibility of cancer, which may lead to adverse consequences. When the uterus is removed due to atypical endometrial hyperplasia, the removed uterus should be examined on the operating table to see if there is any co-existing cancer, and attention should be paid to whether there is any cancer infiltration into the muscle layer so as to select the appropriate surgical scope.

(2) Different types of intimal hyperplasia have different treatment principles:

① Simple and complex endometrial hyperplasia:

A. Young patients: Most of them suffer from anovulatory functional uterine bleeding. The basal body temperature should be measured. If it is confirmed to be monophasic anovulation, ovulation induction treatment can be used.

B. Reproductive period: Generally, one curettage can control bleeding. If bleeding still occurs after curettage, hysteroscopy and B-ultrasound should be performed to rule out submucosal fibroids or other organic lesions. Women with polycystic ovary syndrome who may also experience infertility during the reproductive period and clinically manifest as anovulation should be treated as those with polycystic ovary syndrome.

C. Menopausal transition period: It is often anovulatory functional uterine bleeding. If menstruation is infrequent and the amount of blood is heavy or the bleeding time is long after curettage and hemostasis, progesterone treatment should be given every two months, and follow-up observation should be conducted after 3 cycles.

D. Late menopause: Ask whether to use estrogen replacement therapy alone. After curettage, replacement therapy can be suspended or progestin can be added.

②Atypical endometrial hyperplasia:

A. Menopausal transition or postmenopause: hysterectomy. Since age is the main risk factor for malignant transformation of endometrial hyperplasia, hysterectomy is appropriate for patients in this age group.

B. Young people or those who wish to have children: drug treatment. Atypical hyperplasia is a potentially malignant precancerous lesion, and 20% will develop into cancer if left untreated. However, cancer is less common in young patients, and drug treatment is more effective for young and reproductive patients. Therefore, drug treatment can be chosen to preserve fertility function.

2. Medication

(1) Ovulation-inducing drugs: Ovulation-inducing drugs include chorionic gonadotropin and salpingotropin. It is generally used for patients with mild atypical endometrial hyperplasia. The dosage of clomiphene is 50-100 mg, once a day, taken on the 5th to 9th day of the cycle. If necessary, the medication period can be extended by 2 to 3 days.

(2) Progestin drugs: Progestin drugs can inhibit endometrial hyperplasia caused by estrogen. Its mechanism of action:

① Inhibit ovulation and the secretion of pituitary gonadotropin through the hypothalamus and pituitary gland, causing the serum E2 level to drop to the equivalent of the early follicular stage.

②Reduce the level of estrogen nuclear receptors in the endometrium.

③Inhibit endometrial DNA synthesis.

④ Increase the activity of estradiol dehydrogenase and isocitrate dehydrogenase, thereby increasing the conversion of estradiol to less active estrogens such as estrone.

Commonly used progestins include progesterone, hydroxyprogesterone caproate, medroxyprogesterone (progesterone acetate) and medroxyprogesterone acetate.

The method of use and dosage of medication vary according to the degree of endometrial atypical hyperplasia. For mild atypical hyperplasia, 30 mg of progesterone can be injected intramuscularly, starting on the 18th or 20th day of the cycle, and the medication should be taken for 5 to 7 days to transform the endometrium into the secretory phase. After that, when the bleeding is completely withdrawn and menstruation occurs, the proliferated endometrium will fall off. For patients with moderate or severe atypical hyperplasia, the drug is not used cyclically but continuously. The hormone dosages reported by the authors are inconsistent, with the lowest dose of medroxyprogesterone being only 10 to 30 mg/d and the highest dose being 200 to 800 mg/d. Depo-progesterone acetate 40-160 mg/d, hydroxyprogesterone caproate 125 mg/once every other day. Continuous medication must be taken. Intermittent medication will greatly affect the effect.

(3) Danazol is a derivative of ethinyl-testosterone and is a commonly used drug for the treatment of endometriosis. It has a strong anti-proliferative effect on the endometrium. Treatment with a dose of 200 mg/d for 3 months has a significant effect on endometrial hyperplasia.

(4) Cottonpol is an effective drug used in my country to treat endometrial hyperplastic functional uterine bleeding and endometriosis. Its mechanism of action is to inhibit the ovaries, and it also has a specific inhibitory effect on the endometrium. After treatment, the pathological morphology of the endometrium showed a high degree of atrophy and the ultrastructure showed obvious degenerative changes. Peking Union Medical College Hospital has observed preliminary results in the treatment of atypical endometrial hyperplasia with cottonypol. There was 1 case of atypical hyperplasia. After using sedative, the atypical hyperplasia of the endometrium improved, but it still recurred. After 8 months of treatment with cottonpol, the endometrium atrophied and the patient soon became pregnant and gave birth to a boy naturally.

(5) GnRH agonists first cause a substantial increase in blood gonadotropin levels, followed by a depletion of the gonadotropin reserve in the pituitary gland, which in turn inhibits the pituitary gland, causing estradiol levels to drop to postmenopausal levels. Therefore, it can also be used for atypical endometrial hyperplasia.

The above medicines all have a course of treatment of three months. After each course of treatment, a curettage or endometrial sampling is performed for histological examination. Depending on the response to the medication, the treatment may be stopped or the dosage of the medication may be increased or decreased as appropriate. The duration of treatment was inconsistent. Varying from 3 months, 6 months, 9 months, to 12 months, with an average of 9 months. The difference is related to the severity of the underlying cause of the disease. The dosage and duration of medication can be guided by the results of regular endometrial biopsy.

3. Disease monitoring during drug treatment During drug treatment, it is important to monitor atypical endometrial hyperplasia during the treatment process.

(1) Monitoring of the condition can guide the medication regimen: For some young patients with atypical endometrial hyperplasia, anovulation or corpus luteum deficiency is due to the lack or imbalance of certain links in the hypothalamic pituitary ovarian axis. This condition often lasts for a long time. In some cases reported in Peking Union Medical College Hospital, the course of the disease lasted for 8, 10 or 15 years. After treatment, ovulation function and endometrial hyperplasia will improve, and even some infertile cases can conceive, but after stopping the medication, they will become abnormal again. After repeated curettage, the endometrium will show atypical hyperplasia, which requires long-term treatment in stages or over years. Long-term drug treatment can also help prevent cancer. During this long process, the choice of drug dosage and duration of medication must be followed. Generally, one course of treatment is 3 months. After each course of treatment, a curettage or removal of the endometrium is performed for histological examination to monitor drug response and serve as a basis for medication. If the medication is effective, the endometrial glands will show secretory or atrophic changes, stromal cells will decidualize, and squamous metaplasia will occur. Once the endometrium has transformed to normal, progestin drugs can be discontinued. For infertile patients, immediately switch to ovulation-stimulating drugs to increase the chance of conception. If the endometrium does not respond well to the medication, the dosage needs to be increased and treatment continued. Neglecting to monitor drug response may result in over- or under-treatment.

(2) Monitoring of the disease can assist in the differential diagnosis of endometrial atypical hyperplasia and well-differentiated adenocarcinoma: Although endometrial cancer and endometrial atypical hyperplasia have their own characteristics in terms of tissue pathological morphology, it is sometimes difficult to make a correct judgment on the differentiation of severe atypical hyperplasia and well-differentiated adenocarcinoma based solely on the pathological examination results of the endometrium obtained by curettage. The two conditions respond differently to drug treatment and can be used as a reference for differential diagnosis.

(3) Monitoring of the disease can help detect stubborn cases early and pay attention to canceration: Although the canceration rate of atypical endometrial hyperplasia is only about 10% to 15%, we should be more vigilant for stubborn cases that do not heal for a long time and detect and treat them early.

4. Drug efficacy Lindahl (1990) reported 89 cases of endometrial hyperplasia. After treatment with high-dose progestin, 96.7% of the endometrium returned to normal. The lesion disappearance rate of drug-treated endometrial atypical hyperplasia and well-differentiated adenocarcinoma is shown in Table 4. The disappearance rate of endometrial lesions after progestin treatment is better than that of atypical hyperplasia, with the disappearance rate of lesions reaching 70% to 94%. The response of well-differentiated cancer is poor; however, the disappearance rate of lesions can reach 60% to 75%.

5. Pregnancy after progestin treatment After progestin treatment, when the endometrium has improved and the progestin is discontinued, ovulation induction or other medical techniques to assist pregnancy should be considered in a timely manner to prevent the recurrence of endometrial hyperplasia or well-differentiated cancer. According to the 6 groups of cases shown in Table 4, there were reports of pregnancy and childbirth after treatment. Kimmig (1995) and Keike have each reported successful conception with in vitro fertilization or gamete implantation after treatment of well-differentiated endometrial carcinoma with progesterone, one of which resulted in a triple pregnancy. Kurman's group (1985) found that 25% of patients under 40 years of age had full-term deliveries after treatment. There were 8 pregnancies after treatment at Peking Union Medical College Hospital, accounting for 30% of the uterus preservation. The severity of endometrial hyperplasia has a certain impact on the pregnancy rate. The pregnancy success rate is high in patients with complex hyperplasia, followed by mild atypical hyperplasia, and the pregnancy rate is low in patients with moderate atypical hyperplasia and severe atypical hyperplasia.

The above long article is about some common methods of treating endometrial lesions. Although there are many treatment methods now, no one method is the best. However, the above methods can be used to effectively control the disease, at least to control the development of the disease, and then slowly treat it. Strive for a speedy recovery.