Detailed information and a list of references can be found in Chapter 2.5 of the FertiPROTEKT book, "Indications and fertility preservation methods for oncological and non-oncological disorders", which can be downloaded free of charge.
Endometrial hyperplasia is a change in the lining of the uterus which, untreated, can lead to endometrial cancer in approximately 1-3% of cases in the absence of atypia (i.e. changes in cell nuclei) and in 30% of cases with atypia.
Type I carcinoma is estrogen-dependent and has typical risk factors which often occur in connection with an unfulfilled wish to conceive. 3-14% of women with endometrial cancer are under 40 years old. Endometrial cancer with a low tumour stage and a good chance of recovery is typically found in these young women.
fertility preservation problems due to treatment
In contrast to other cancers, there is no damage to the ovaries as a result of chemotherapy. Either progestogens (corpus luteum hormone) are used, which do not lead to damage to the ovaries, or a hysterectomy is performed with removal of the ovaries and fallopian tubes.
The therapeutic standard for endometrial hyperplasia is progestogen treatment and uterine cavity monitoring using hysteroscopy and curettage for histological examination of the endometrium. The desire to have children should be fulfilled quickly. Removal of the uterus should be considered once family planning is completed.
A hysterectomy together with removal of the ovaries and fallopian tubes are performed as standard for the treatment of endometrial cancer. This treatment has a very good prognosis for carcinoma types I, FIGO 1a, G2. Removal of local lymph nodes is also indicated at higher stages.
Data on the possibility and the risks of fertility preserving treatment in early endometrial cancer is limited. Fertility preservation with preservation of the ovaries and the uterus may be considered in individual cases in younger women with a diagnosis of well-differentiated type I, FIGO 1a endometrial cancer (minimal tumour spread). Accompanying high-dose hormone therapy with progestogens is recommended for at least 6-9 months.
Because there is still a lack of data regarding a standardized approach, decisions on fertility preservation in endometrial cancer should be made on an individual basis.
The following currently applies if preservation of the uterus can be considered (depending on the extent of the tumour):
- Explanation of increased risk of relapse,
- Risk of inadequate staging because of abstaining from hysterectomy
- Complete removal of the tumour (curettage!)
- High-dose hormone therapy for at least 6-12 months
- Follow-up every 3 months with hysteroscopy and biopsy
- Shortest possible time until pregnancy occurs after cessation of hormone therapy
- Complete cure in 50-84%, depending on the study.
practical approach if fertility preservation is considered
The risk of subsequent ovarian cancer must be considered when the ovaries are preserved. However, this risk is probably less than 1% with an early cancer. After family planning is completed, stage-adapted therapy should be performed, usually in the form of complete surgery.