Uterine- or fertility-sparing treatments offer reproductive-aged women with endometrial cancer the possibility of preserving fertility while achieving acceptable oncologic outcomes. Individualized treatment plans, careful patient selection, and close monitoring are essential to optimize reproductive outcomes and ensure the best possible care for these patients.

The most important thing when considering uterine-sparing management in endometrial cancer is for patients to be well informed. Because standard treatment (ie, total hysterectomy and bilateral salpingo-oophorectomy) works very well, particularly for early-stage and/or low-grade disease, patients need to understand that using nonstandard therapy may increase the risk of a less-than-optimal outcome. When a patient chooses not to have standard therapy, it is typically because they hope to preserve fertility or because they have a variety of medical problems that would make surgery quite hazardous.

If a patient with endometrial cancer is seeking to preserve their fertility, then they really should understand their chances of conceiving. Many patients think that they have a very high likelihood of future fertility, but, in fact, as a patient gets older, and particularly if they get heavier, the likelihood of being able to conceive is significantly diminished, even if they did not have cancer. So, again, patients need to understand the likelihood of achieving their fertility goals if they are going to embark on a nonstandard therapy.

We have learned through experience, particularly in the last decade or so, that there is a group of patients—namely, those with well-differentiated, localized tumors—in whom it appears we can relatively safely use uterine-sparing treatment. Hormone receptor expression in endometrial cancer is not quite as compelling as it is in breast cancer. If a woman has estrogen or progesterone receptors in her endometrial cancer, she has a better prognosis, but it is not that much better, and she is more likely to respond to hormonal therapy. Obviously, if we see that the patient does not have hormone receptors in the tumor, that would make us a little concerned that she might not respond to our interventions, which are hormonally based. We should share our concern with the patient but also explain that this factor is not necessarily a perfect predictor.

Ideally, I like to make sure that I have completely evaluated the endometrium, so I recommend a hysteroscopy in patients who are interested in fertility-sparing treatment. This is because our sampling techniques, while they are very good, are not perfect. Then I will typically do an endometrial resection or a dilation and curettage to remove as much of the tumor as possible to make sure that we have a good sampling of the tumor and that there is not a higher-risk type of endometrial cancer that might also be in the uterus.

For fertility-sparing treatments, we begin patients on some sort of continuous progestin therapy, either in the form of systemic progestins such as megestrol acetate or medroxyprogesterone acetate or a local application of continuous progesterone via a progestin-eluting intrauterine device. Typically, at the time of resection is when we will insert one of the progestin-eluting intrauterine devices.