Case study: Endometrial hyperplasia

Nurse Practitioner, May 1999

Maxine was a 50-year-old woman, gr 3, p 3, with irregular and heavy menstrual bleeding. Another provider had diagnosed endometrial hyperplasia 2 years previously. Maxine was given 10 mg of medroxyprogesterone acetate (MPA) 10 mg daily for the last 10 days of her cycle for 6 months. The irregular bleeding and heavy flow resolved.

Repeat endometrial biopsy showed no hyperplasia. However, she experienced severe adverse effects throughout the course of treatment, including a 25 lb weight gain, bloating, mood swings, depression, and daily headaches that increased in severity. After treatment with MPA, her periods returned to normal cycles and flow. Maxine discontinued the MPA and the adverse effects dissipated.

She now complained of a recurrence of heavy, prolonged periods, cycling every 18 days with flow as long as 12 days; she often had to use 10 to 12 sanitary napkins in 1 day. A new symptom was uterine cramping. Review of signs and symptoms and family history were negative. Maxine had a long history of obesity but was exercising and watching her diet. She was a nonsmoker.

Her primary complaints were regarding the short cycles and heavy flow, which left her feeling "drained and exhausted." She denied experiencing vasomotor symptoms and vaginal dryness.

Physical examination revealed a moderately obese white female, 5 feet 7 inches tall and weighing 210 lb. Blood pressure was 126/70 mm Hg. Remarkable findings were a moderate amount of bright red blood in the vagina and a slightly enlarged uterus. Ultrasound confirmed a slightly enlarged uterus with a 22 mm endometrium. Endometrial biopsy was performed: The pathology report showed simple cystic hyperplasia. The blood test results, including lipid panel and thyroid function tests, were within normal limits. Hemoglobin was 12.6 grams/dl. Folliclestimulating hormone was 16 milli-international unit/ml.

Treatment options were discussed with Maxine, including observation with regular endometrial biopsies and treatment with MPA, norethindrone acetate, or micronized progesterone (MP). Maxine emphatically stated that she would "rather have a hysterectomy than take that medicine [MPA] again." She had no other indications for surgical intervention. She was, however, willing to try MP from cycle days 12 through 26.

After one cycle, flow had diminished slightly and she experienced no adverse effects. After several cycles, cycle length returned to 27 to 28 days with a decreasing flow. Cramping was gone. After 6 months of MP therapy, ultrasound showed a 4 mm endometrium. Endometrial biopsy revealed normal tissue with no hyperplasia. Maxine said she felt "incredibly well" when taking MP and no longer wished to consider hysterectomy.

Discussion

Although MPA is well-documented for the treatment and prevention of endometrial hyperplasia, it has a high incidence of undesirable adverse effects that prompts many patients to discontinue its use. Because Maxine emphatically did not wish to restart MPA, had that been her only option, she probably would have refused treatment, thereby increasing her risk of developing progressive hyperplasia and even uterine cancer. Offering a better-- tolerated alternative, the clinician enabled the patient to continue treating her hyperplasia adequately without subjecting her to the risks of major surgery.

Maxine's body size and continuation of menses suggest that estrogen reserve was adequate and MP alone would suffice for a while. She should be carefully monitored for other menopausal problems, including osteoporosis and cardiovascular disease. As her symptoms indicate, estrogen can be added to her regimen for relief of vasomotor symptoms and optimal protection of bone and cardiovascular status.

MP provided an option for treating a potentially dangerous condition without inducing the serious adverse effects that the patient had previously experienced.