Women should be counseled that medical treatment is not the definitive treatment modality and lacks good scientific evidence [9]. She should be willing to accept the definitive treatment after pregnancy in the form of hysterectomy and bilateral salpingo-oophorectomy as the recurrence rates are high after discontinuation of medical treatment. Extensive counseling about conservative management includes the success and relapse rates, risk of metastasis, and side effects of hormones. The patient should be advised to be compliant with follow-up protocols, need for repeated sampling of endometrium and consequent risk of Asherman’s syndrome [9]. The woman should be encouraged to opt for assisted reproductive techniques soon after remission to achieve pregnancy as soon as possible. Patients with Lynch syndrome or HNPCC or autosomal dominant cancer syndromes (like Cowden syndrome) should be referred for genetic counseling so that the woman and her relatives can be given education and information on prevention strategies and any intervention instituted. Counseling sessions should be teamwork of gynecologists, oncologists, infertility specialists, and psychosocial experts and should involve the woman’s family with a carefully written down plan, before initiation of treatment. The economic burden and feasibility should be included in the decision-making process.

Endometrial sampling using office based techniques (Vabra aspirator, Pipelle, and Karman cannula) have a sensitivity of 68–92 % and a false positive rate of 10 % [12]. However, some studies have shown that samples using dilatation and curettage or fractional curettage are less likely to change on expert review as compared to office sampling specimens [13]. Addition of hysteroscopy to sampling has the advantage of visually guided biopsies and identification and removal of focal lesions with a sensitivity and specificity of 80–98 % and 92–96 % respectively [14, 15].

Imaging plays an important role in evaluating the stage of disease. Transvaginal ultrasound (TVS) helps in evaluation of endometrial thickness, lesions, myometrial invasion, and adnexal involvement but is limited by its inability to evaluate the pelvic and paraaortic nodes. Its efficacy is almost similar to magnetic resonance imaging (MRI).

Contrast enhanced MRI has a high diagnostic accuracy for detection of myometrial invasion and cervical extension, with 95 % sensitivity, 60–70 % specificity, and a total accuracy of 88–90 % [16, 17]. The sensitivity and specificity of detection of lymph node involvement is 72 % and 92 %, respectively [18]. Positron emission tomography using [18F]-fluoro-2-deoxy-D-glucose has a sensitivity ranging from 28.6 % to 60 % and a high specificity of up to 98 % in identifying pelvic and para-aortic lymph-node metastasis, but has a limited role in conservative management [19].

As ovarian malignancy can be missed in up to 9–14 % cases even on MRI, a diagnostic laparoscopy can be considered in suspected cases [9]. The latter also has the advantage of lymph node biopsy when suspected on imaging.

There is no well-defined protocol of follow up after conservative management, and it varies with different institutions. As the time of response to therapy is variable (4–60 weeks), with a median duration of 12 weeks, a repeat hysteroscopy and biopsy can be performed after 3–6 months. A transvaginal scan (TVS) and Pap smear should be performed every 3 months. Endometrial thickness less than 5 mm is suggestive of response [30]. MRI or laparoscopy can be performed six monthly to one yearly whenever indicated [10].

If no cancer detected at this point of time, treatment should be continued for three more months to consolidate the response [9]. In case of tumor progression or persistence of disease, patient should be counseled regarding hysterectomy, possibility of ovarian metastasis should be ruled out by MRI or laparoscopy and a repeat MRI can be done to revise staging. In case the patient still insists on conservative therapy, an endometrial sampling should be done after 3 months. Additionally, complications of hormone therapy like deep vein thrombosis should be ruled out. Consultation with specialists in reproductive medicine should be taken to achieve pregnancy soon after remission.

In a systematic metaanalysis, complete response rates were reported to be around 53 %; 25 % had initial response followed by recurrence within 24 months while 22 % failed to respond to hormone therapy [27]. In another recent meta-analysis of 34 observational studies, Gallos et al. reported that fertility sparing hormonal treatment was associated with a pooled regression rate of 76.2 %, relapse rate of 40.6 %, and live birth rate of 28 % [31].

The most common causes of failure to response are occult extrauterine or ovarian metastasis, lymph node involvement, and presence of synchronous ovarian tumor [9]. Lymph node metastasis may be seen in 3 % cases with myometrial invasion >50 % [32].

Prognosis is good with a 5-year survival up to 95 % in stage I, low grade disease [1]. Positive estrogen and progesterone receptor and negative HER-2 receptor status indicates good prognosis.

Ovarian preservation and hysterectomy alone gives an option of oocyte retrieval with surrogacy for childbearing and is labeled as partial preservation of fertility [10]. Moreover it also helps delay menopause. However, it is associated with risks of missing out a synchronous ovarian malignancy or an occult metastatic disease in the ovaries. Up to 22 % of young women with stage I cancers may have extrauterine disease and a 5–25 % incidence of any stage synchronous ovarian malignancy, which is at least five times greater than women older than 45 years [6, 7]. Criterion for ovarian preservation is similar to that described in the section on “Counseling” and must be individualized after weighing risks and benefits .

In a study of 251 women, younger than 45 years, 75.3 % had FIGO Stage I disease, there was no statistically significant difference in overall survival and disease free survival in Stage I patients with or without BSO [33]. According to the data of the SEER study, 5-year survival was 98 % for patients with 1988 FIGO IA endometrial cancers, with or without ovarian preservation [34]. Among patients with 1988 FIGO IC (2009 FIGO IB) endometrial cancer, survival was 89 % in the oophorectomy group and 86 % with ovarian preservation which was not statistically significant.

The most common cause of infertility is chronic anovulation, followed by endometriosis, Asherman’s syndrome post treatment, and male factor infertility. All efforts should be made to achieve successful conception soon after histological remission is achieved which is usually by 16 weeks of therapy [30]. Assisted reproductive techniques (ART) must be offered especially to women with history of infertility. Ovulation induction with clomiphene citrate or human menopausal gonadotrophins can be given in patients with chronic anovulation. Intrauterine insemination (IUI) can be done in patients with coexistent male infertility. In case the patient fails to respond, in vitro fertilization (IVF) is recommended [20]. It has an added advantage of cryopreservation of embryos for future cycles. Failure to achieve pregnancy after ART may be due to an impaired endometrial response because of primary endometrial disease, repeated endometrial samplings, and thin endometrium due to high-dose progestin treatment [35].