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Gynaecological Oncology
Hormone Replacement Therapy After Gynaecological Cancers
Nicoletta Biglia, Elisa Peano, Valentina Bounous, Giulia Moggio, Paola Sgandurra and Piero Sismondi
Department of Oncological Gynaecology, University of Turin, Institute for Cancer Research and Treatment (IRCC), Candiolo, and
‘Umberto I’ Mauriziano Hospital, Turin
Abstract
Thousands of women are treated each year for gynaecological cancers; many of these women are already experiencing then menopause,
while other younger patients will go into early menopause due to surgery, chemotherapy and/or radiotherapy to the pelvic region.
Oestrogen-deficiency-derived symptoms deeply affects the quality of life of patients. The aim of this article is to review the biological and
clinical evidence in favour of and against the use of hormone replacement therapy (HRT) after gynaecological cancers. With the exception
of breast and endometrial cancer, there is no biological evidence that HRT increases the risk of recurrence. Since no randomised
controlled studies are available, for endometrial cancer survivors the decision of HRT use should be shared with symptomatic patients
after adequate discussion about therapy risk and benefits. For breast cancer survivors, HRT remains contraindicated and new data from
the largest clinical trial about using tibolone in this group of patients show an increased risk of recurrence. Non-hormonal treatment is
suggested to relieve menopausal symptoms.
Keywords
Menopause, hot flushes, hormone replacement therapy, gynaecological cancer survivors
Disclosure: The authors have no conflicts of interest to declare.
Received: 20 February 2009 Accepted: 23 March 2009
Correspondence: Nicoletta Biglia, Mauriziano ‘Umberto I’ Hospital, Largo Turati 62-10128 Turin, Italy. E:
nbiglia@mauriziano.it
Most gynaecological and breast cancers occur in menopausal women; The effect of HRT on the risk of recurrence of EC after primary surgery
however, at diagnosis there is a significant group of women who are is unknown, although retrospective studies have pointed to an
not yet in menopause. The surgical treatment of most pelvic tumours absence of adverse outcomes.
3–5
However, the tumour characteristics,
includes the removal of the ovaries, irrespective of age. For breast the initiation time of HRT after surgery and the type of hormonal
cancer patients, the widespread use of adjuvant chemotherapy and/or compounds used (oestrogens alone or associated with different
ovarian ablation treatments is responsible for iatrogenic menopause in progestins) varied significantly in these studies. Moreover, the lack of
younger women who experience severe vasomotor symptoms, most a control group and the retrospective type of analysis are limiting
noticeably hot flushes and night sweats. Long-term problems factors. Suriano et al.
6
published a matched control study on HRT
associated with oestrogen deficiency include urogenital and skin evaluating 130 patients with low-risk EC. Of these, only 14% had stage
atrophy, an increased risk of cardiovascular disease and osteoporosis. II–III or G3 carcinoma, and lymph nodes were positive in only one
As progress in the diagnostic and therapeutic fields has improved the case. Hormone users have a statistically significant longer disease-
prognosis of these patients, it has also become relevant to guarantee free interval than non-oestrogen users (p<0.006) at a mean follow-up
a good quality of life. The use of hormone replacement therapy (HRT) of 83 months. In the group receiving HRT, there were only two pelvic
in gynaecological cancer survivors is widely debated; however, clinical recurrences versus 11 recurrences (eight pelvic and three distant) in
and epidemiological results are scarce. This article aims to review the the non-treated group, and the survival curve was clearly favourable
available data in an attempt to draw conclusions as to whether HRT in the treated patient group (p<0.006).
should be used in certain cases.
The need for adding progestins to oestrogens in these patients is
Endometrial Cancer unknown at present. Progesterone inhibits the stimulatory effects of
Endometrial cancer (EC) is the most common malignancy of the oestrogen on normal and hyperplastic endometrium, but high-dose
female genital tract. At the time of diagnosis, 84% of patients had progestin as adjuvant treatment after EC surgery does not affect the
tumour limited to the uterus, with an approximate 80–90% five-year recurrence rate.
survival rate.
1
The association between unopposed oestrogens and an
increase of EC in non-hysterectomised post-menopausal women has In the prospective, double-blind, randomised study from the
been recognised for over 30 years.
2
Although there were no Gynaecologic Oncology Group (GOG),
7
1,236 women were randomly
convincing scientific data, for many years HRT was considered to be assigned to oestrogens alone (ORT) or placebo for a period of three
contraindicated in patients treated for EC because of the possible years after surgery for EC. After the publication of the results of the
stimulatory effect of oestrogens on occult neoplastic foci. Women’s Health Initiative (WHI) in July 2002,
8
enrolment decreased
68 © TOUCH BRIEFINGS 2009
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