BACKGROUND AND PURPOSE:

• For patients who desire fertility or are poor surgical candidates, treatment for complex atypical hyperplasia is an option  
• Mandelbaum et al. (AJOG, 2020) examined differences in complex atypical hyperplasia treatment effectiveness between
  • Levonorgestrel-releasing IUD
  • Systemic progestin therapy

METHODS:

• Retrospective study (2003 to 2018)
• Participants
  • Women with complex atypical hyperplasia who received progestin therapy 
• Exposures
  • Levonorgestrel-releasing IUD
  • Systemic progestin therapy
• Study design
  • Treatment response was assessed by histopathology on subsequent biopsies
  • Time-dependent analyses of complete response and progression to cancer were performed comparing exposures
  • Propensity score used to create a weighted cohort to account for treatment type
  • Impact of body habitus on treatment response was assessed

RESULTS:

• 245 women included
  • IUD: 69 women
  • Systemic: 176 women
  • Mean age 36.9 years | Mean BMI 40.0 kg/m2
• Systemic therapy
  • Oral megestrol acetate: 79.5%
  • Oral medroxyprogesterone acetate: 15.9%
  • Other oral or injectable progestins: 4.5%
• Levonorgestrel-releasing IUD group had
  • Higher rates of complete response
    • IUD: 78.7%
    • Systemic: 46.7%
    • Adjusted hazard ratio 3.32 (95% CI, 2.39 to 4.62)
  • Lower likelihood of progression to cancer
    • IUD: 4.5%
    • Systemic: 15.7%
    • aHR 0.28 (95% CI, 0.11 to 0.73)
• Class 3 obesity was associated with a higher relative benefit from IUD therapy in achieving complete response
  • Class 3 obesity: aHR 4.72 (95% CI, 2.83 to 7.89)
  • Class 1 and 2 obesity: aHR 1.83 (95% CI, 1.09 to 3.09)
  • Nonobese: aHR 1.26 (95% CI, 0.40 to 3.95)
• After 2007
  • LNG-IUD increased: 6.3% to 82.7%; 13.2-fold increase
  • Obesity rate increased: 77.8% to 88.2%; 13.4% relative increase
  • Improved rates of complete response increased: 32.9% to 81.4%; 2.5-fold increase (P = .005)

CONCLUSION:

• The patient population analyzed in this study was mostly comprised of women with obesity
• Localized progestin therapy with the levonorgestrel-releasing IUD may be a more effective treatment option for complex atypical hyperplasia, compared with systemic treatment
• The authors state that these improved outcomes, including complete response rates, were 

…most pronounced in morbidly obese women, who had a more than 4 times greater likelihood of complete response with the LNG-IUD

Moreover, treatment paradigm shifts toward increasing LNG-IUD use in an increasingly obese population led to improved complete response rates overall

Learn More – Primary Sources:

Progestin therapy for obese women with complex atypical hyperplasia: levonorgestrel-releasing intrauterine device vs systemic therapy

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