Endometrial cancer is the most common gynecological cancer in the United States, originating in the inner lining of the uterus. While it primarily affects women who have completed menopause, an increasing number of cases are being diagnosed in younger women, with approximately 7% of diagnoses occurring in those under the age of 45. This shift in patient demographics has made the preservation of fertility a major concern for many newly diagnosed individuals. The desire to maintain the ability to have children creates a complex challenge when faced with a cancer diagnosis.
Endometrial Cancer Diagnosis and Fertility
The definitive and most widely accepted treatment for endometrial cancer is a total hysterectomy, which involves the surgical removal of the uterus. This procedure is often accompanied by a bilateral salpingo-oophorectomy, removing both fallopian tubes and ovaries. Such a radical surgical intervention, while highly effective for curing the disease, permanently ends a woman’s reproductive capacity. Therefore, for any patient who has not completed childbearing, the diagnosis presents a direct conflict between oncologic cure and the desire for future fertility.
Criteria for Fertility Preservation
Fertility-sparing treatment is not the standard of care and is reserved for patients who meet strict medical criteria. The cancer must be classified as Stage I, meaning the disease is localized and confined to the endometrium, with no evidence of spread to the deeper muscle layer of the uterus. The tumor must also be low-grade, typically a Grade 1 well-differentiated endometrioid adenocarcinoma, as higher grades carry a greater risk of aggressive behavior. Specific imaging, most often a pelvic Magnetic Resonance Imaging (MRI), is required to confirm the absence of myometrial invasion, extrauterine disease, or synchronous ovarian cancer. Eligibility is determined only after a thorough pre-treatment workup confirms these favorable conditions.
Fertility-Sparing Treatment Approaches
The medical intervention used to treat the cancer while preserving the uterus centers on hormonal therapy, predominantly high-dose progestins. These agents, such as Megestrol Acetate (MA) or Medroxyprogesterone Acetate (MPA), work by suppressing the estrogen-triggered growth of the tumor. Oral progestins are commonly prescribed in high doses to induce a complete regression. Another option is the Levonorgestrel-releasing Intrauterine Device (LNG-IUD), which delivers a continuous, high concentration of progestin directly to the uterine lining. Combining the LNG-IUD with oral progestins, or performing a hysteroscopic resection of the visible tumor before starting hormone therapy, has shown promising results.
The treatment typically lasts between 6 and 12 months. Throughout this period, patients must undergo frequent and rigorous monitoring, including repeat endometrial biopsies or dilation and curettage procedures every three to six months. This monitoring is crucial to assess the treatment response and ensure the cancer is regressing. Treatment is considered successful only after achieving two consecutive biopsies that show a complete absence of cancer. If the disease persists or progresses after 6 to 12 months, the patient is advised to proceed with definitive surgical treatment.
Managing Pregnancy After Endometrial Cancer
Once a patient achieves complete remission, the focus shifts to attempting conception, often involving referral to a reproductive endocrinologist. Assisted Reproductive Technology (ART) is frequently utilized to maximize the chances of pregnancy and minimize the time the patient is off treatment. However, a pregnancy following fertility-sparing treatment is considered high-risk due to the patient’s underlying cancer history. The risk of cancer recurrence has been reported to be between 24% and 45% in various studies.
Close oncologic surveillance must continue throughout the pregnancy to monitor for any signs of recurrence. These pregnancies also carry increased obstetric risks, including a higher likelihood of miscarriage and preterm birth. The close partnership between the gynecologic oncologist and the obstetrician is essential for managing both the cancer surveillance and the pregnancy itself. Once the patient has completed their desired family, a definitive hysterectomy is usually recommended to eliminate the risk of late relapse.