HRT after Gynaecological Cancers. Richard Hutson Gynaecological Oncologist St James s Institute of Oncology

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1 HRT after Gynaecological Cancers Richard Hutson Gynaecological Oncologist St James s Institute of Oncology

2 Overview HRT per se Endometrial cancer. Ovarian cancer. Breast cancer. Cervical & Vulval cancer. Summary.

3 What is HRT? Menopause is a normal physiological event. Can be induced surgically/medically/ radiologically. Oestrogen +/- Progesterone. Oral/Transdermal/Gel/Vaginal rings/iud Sequentially/Continuous combined. Testosterone can be added not covered.

4 Key Indication for HRT Troublesome vasomotor symptoms. Affects 80% women perimenopausally. Severe in 20%. Median duration 4 years; 10% 12 years.

5 Benefits 87% reduction in vasomotor symptoms. Reduction in fracture risk. Improves vaginal dryness and sexual function. Improves sleep and joint symptoms. Reduction in coronary artery disease. Reduction in colon cancer. Improvement in cognitive function.

6 Risks of HRT Thromboembolic disease and Strokes transdermal better than oral. Breast, Endometrial and Ovarian Cancer. Reactivation of Cancer. Gall bladder disease.

7 Oestrogens and Malignancy Not carcinogenic Increase rate of cell division and proliferation Enhance susceptibility to environmental carcinogens

8 Why HRT for Women with Cancer? Premature menopause induced by treatment Chemotherapy will cause POF in >80% aged <40 Greater proportion of their life menopausal

9 HRT and Endometrial Cancer RR increases with increased duration of use RR with > 10 years E 2 therapy = 9.5 Risk still significantly increased >5 years after cessation Concurrent use of progestogens reduces RR But dependent on number of days

10 HRT after Endometrial Cancer 70% of women cured by primary treatment Risk of recurrence in stage I grade I = 0-3% No increased risk of recurrence in women given E 2 in this group Creasman 86, Lee 90 improved survival For G3 consider each case individually

11 HRT and Ovarian Cancer Rodriguez (2001) risk of death of ovarian cancer doubled if E 2 used > 10 years MWS increased of 1.2 in current useres. Effect wore off 15 years after cessation Increased risk of serous and endometriod tumours E 2 < 10 years not associated with increased risk

12 HRT after Ovarian Cancer Stage I and fertility sparing surgery may have HRT Eeles et al 91 showed no survival difference regardless of disease stage Germ cell tumours may receive HRT Sex cord-stromal tumours lack hormone receptors and may be given HRT

13 HRT and Breast Cancer Combined HRT increases the risk of breast cancer. WHI study 0.1% over 5 years. Minimal short term. Breast cancer tends to be less aggressive Effects of HRT wear off and disappear after 5 years? Increased incidence if progestogens were testosterone derived

14 HRT after Breast Cancer A number of studies show no difference in survival/recurrence in those receiving HRT Node negative women HRT is reasonable Caution in the elderly Some recommend HRT only for ER neg. tumours Consider alternatives

15 Summary of Risks/Benefits of HRT use

16 Standardised Incidence Rates for Ovarian, Endometrial and Breast Cancer Ovarian Cancer Endometrial Cancer Incidence rate (95% CI) per 1000 over 5 years Breast Cancer Never users of HRT Current users of oestrogen only Current users of oestrogen + progestagen

17 HRT and Gallbladder Disease Increases the risk of cholecystitis. Risk reduced with transdermal rather than oral oestrogen. Avoids one cholecystectomy every 140 users.

18 HRT and Cervical Cancer SCC are not thought to be sensitive to E 2 Theoretical concerns exist with adenocarcinomas Stage I and II appear to do better if given HRT

19 HRT and Vulval Cancers No justification for withholding treatment!

20 Alternatives to HRT SSRI paroxetine, fluoxetine, citalopram. Avoid if on tamoxifen. Gabapentin effective as low dose oestrogen. Clonidine. Relaxation therapy. Black cohosh.

21 Prescribing of HRT following Gynaecological Cancer SCC s of vulva/vagina/cervix are not sensitive to oestrogen. HRT may be given to selected patients following treatment for endometrial cancer. HRT can be given to women previously treated for ovarian cancer

22 Summary Ensure women are well informed of risks versus benefits Prescribing should be done individually HRT may be used after any gynaecological malignancy where fertility was preserved HRT may be used where steroid receptor proteins are absent/inactive In early stage endometrial/cervical HRT

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