Medicus April 2016

C L I N I C A L E D G E

other studies suggest that estrogen therapy is safe to use in endometrial cancer. Other Uterine Tumours Endometrial stromal sarcomas account for 0.2 per cent of uterine malignancies. Of those diagnosed, 25 per cent are pre- menopausal with the mean age being 42-58 years. It is thought that exposure to tamoxifen and un-opposed estrogens can lead to its development. Current treatment requires hysterectomy with bilateral salpingectomy and depending on the stage, hormone therapy using prostins, gonadotropin- releasing hormone analogues and aromatase inhibitors in order to cause a hypo-estrogenic state. There have been several case series including that of Pink et al and Spano et al that have demonstrated that HRT has had a negative impact on the disease. Ovarian Carcinoma Ovarian cancer affects 10.9 per 100,000 women and is ranked as the second most commonly diagnosed gynaecological cancer. The average age of diagnosis is 64.4 years with a five-year survival of 43.4 per cent. It often presents at a late stage due to lack of distinct symptoms in its early stages. Epithelial ovarian carcinoma including, low malignant potential borderline tumours of the ovary, are the most common comprising of 90-95 per cent of cases. Germ cell tumours and sex-cord stromal tumours account for the remaining 5-10 per cent in equal numbers. Current management usually involves cytoreductive surgery combined with chemotherapy, which can result in iatrogenic menopause. Although there have been conflicting analyses concerning as to whether HRT causes epithelial ovarian cancer, there have been no published studies showing adverse outcomes with use of HRT post treatment in these types of ovarian cancers. Hopkins’ et al systematic review suggested that HRT had no significant impact on recurrence, progression free survival or mortality of epithelial ovarian cancer. This has further been demonstrated in a prospective cohort study by Mascarenhas et al, which looked at HRT before and after diagnosis of borderline tumours (150 patients) and epithelial ovarian cancers (649 patients) on five-year survival. In the epithelial type, no statistically significant impact on survival was found in women who had used HRT prior to treatment as compared to those who had not received it. Post surgery HRT was found to improve survival in those with epithelial type ovarian cancer. For those with borderline Thus hormone replacement therapy is an absolute contraindication in endometrial stromal sarcomas.

ovarian tumours, no impact of HRT was seen.

In endometrioid epithelial type ovarian cancer, studies have not showed an altered course of the disease post treatment with HRT. However, as it is an estrogen sensitive tumour, it has been suggested that with stage 3 endometriod adenocarcinoma, HRT should not be used due to potential residual disease after surgery. Granulosa cell tumours usually present with signs of hyperestrogenism as they secrete steroid hormones. In women who require bilateral salpingo-oophorectomy, HRT should not be prescribed as it is endocrinologically active and hormone dependent. However, it should be noted that no studies have been performed in this area. Ovarian germ cell tumours that occur primarily in the younger population (between 10-30 years of age) have no evidence to suggest that HRT is contraindicated. Cervical Carcinoma Cervical cancer is the third most commonly diagnosed gynaecological malignancy affecting 771 new women a year. The average age of diagnosis was 50.2 years. Squamous cell carcinomas make up 80 per cent of cases, with adenocarcinoma accounting for 15 per cent and adeno- squamous lesions for about 5 per cent . Treatment depends on staging and on whether the patient opts for fertility preserving surgery. Therefore treatment ranges from trachelectomy to radical hysterectomy with pelvic dissection or chemo-radiotherapy. Squamous cell carcinoma of the cervix has a low rate of metastasis to the ovary and is not a hormone responsive disease, which suggests that HRT is safe to use. Studies have also shown that Human Papilloma Virus (HPV) is not affected by HRT. After surgery or radiotherapy of stage 1 or 2 adenocarcinoma of the cervix, Ploch et al’s study showed that there was no effect on survival with HRT. The risk of ovarian metastases in cervical adenocarcinoma is approximately 4.6 per cent and so it is more likely that oophorectomy will be performed in surgical treatment in patients with disease of stage 1b and above. As they are usually a younger age group, the need for HRT is greater. Radiotherapy treatment in itself can result in early menopause, with the risk increasing with age and dose due to damage of primordial follicles. Women can opt to undergo ovarian transposition in an effort to preserve fertility and prevent ovarian failure in 83 per cent of cases. Chemoradiation carries a 68 per cent risk of menopause as Continued on page 49

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