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Koysombat K, Mukherjee A, Nyunt S, Pedder H, Vinogradova Y, Burgin J, Dave H, Comninos AN, Talaulikar V, Bailey JV, Dhillo WS, Abbara A. Factors affecting shared decision-making concerning menopausal hormone therapy. Ann N Y Acad Sci 2024; 1538:34-44. [PMID: 39014999 DOI: 10.1111/nyas.15185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
Menopausal hormone therapy (MHT) is an effective treatment for menopause-related symptoms. Menopause management guidelines recommend a personalized approach to menopause care, including MHT use. Decision-making around menopause care is a complex, iterative process influenced by multiple factors framed by perspectives from both women and healthcare providers (HCPs). This narrative review aims to summarize evidence around factors affecting decision-making regarding menopause-related care. For HCPs, the provision of individualized risk estimates is challenging in practice given the number of potential benefits and risks to consider, and the complexity of the data available, especially within time-limited consultations. Women seeking menopause care have the difficult task of making sense of the benefit versus risk profiles to make choices in line with their decisional needs influenced by sociocultural/economic, educational, demographic, and personal characteristics. The press, social media, and influential celebrities also impact the perception of menopause and decision-making around it. Understanding these factors can lead to improved participation in shared decision-making, satisfaction with the decision and decision-making process, adherence to treatment, reduced decisional regret, efficient use of resources, and ultimately long-term satisfaction with care.
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Affiliation(s)
- Kanyada Koysombat
- Section of Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | | | - Sandhi Nyunt
- Section of Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Hugo Pedder
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Yana Vinogradova
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jo Burgin
- Centre for Academic Primary Care, Bristol Medical School, Bristol, UK
| | - Harshida Dave
- Woman representative with lived-experience of menopause, London, UK
| | - Alexander N Comninos
- Section of Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | | | - Julia V Bailey
- eHealth Unit, Department of Primary Care and Population Health, University College London, Royal Free Hospital, London, UK
| | - Waljit S Dhillo
- Section of Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Ali Abbara
- Section of Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
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Yang L, Fan Q, Wang J, Yang X, Yuan J, Li Y, Sun X, Wang Y. TRPS1 regulates the opposite effect of progesterone via RANKL in endometrial carcinoma and breast carcinoma. Cell Death Discov 2023; 9:185. [PMID: 37344459 DOI: 10.1038/s41420-023-01484-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 06/05/2023] [Accepted: 06/14/2023] [Indexed: 06/23/2023] Open
Abstract
Medroxyprogesterone (MPA) has therapeutic effect on endometrial carcinoma (EC), while it could promote the carcinogenesis of breast cancer (BC) by activating receptor activator of NF-kB ligand (RANKL). However, the selective mechanism of MPA in endometrium and breast tissue remains obscure. Multiomics analysis of chromatin immunoprecipitation sequencing (ChIP-seq) and RNA sequencing (RNA-seq) were performed in cell lines derived from endometrial cancer and mammary tumor to screen the differential co-regulatory factors of progesterone receptor (PR). Dual-luciferase assays and ChIP-PCR assays were used to validate the transcriptional regulation. Co-immunoprecipitation (Co-IP) and immunofluorescence assays were carried out to explore molecular interactions between PR, the cofactor transcriptional repressor GATA binding 1 (TRPS1), and histone deacetylase 2 (HDAC2). Subsequently, human endometrial cancer/breast cancer xenograft models were established to investigate the regulation effect of cofactor TRPS1 in vivo. In the current study, we found that MPA downregulated RANKL expression in a time- and dose-dependent manner in EC, while had the opposite effect on BC. Then PR could recruit cofactor TRPS1 to the promoter of RANKL, leading to histone deacetylation of RANKL to repress its transcription in EC, whereas MPA disassociated the PR/TRPS1/HDAC2 complex to enhance RANKL histone acetylation in BC. Therefore, TRPS1, the coregulator recruited by PR played a critical role in the selective mechanism of progesterone in EC and BC and could become a potential candidate for targeted therapy to improve the anticancer effect of MPA on EC and avoid its carcinogenic effect on BC.
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Affiliation(s)
- Linlin Yang
- Department of Gynecological Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Municipal Key Clinical Specialty, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China
| | - Qiong Fan
- Department of Gynecological Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Municipal Key Clinical Specialty, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China
| | - Jing Wang
- Department of Gynecological Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Municipal Key Clinical Specialty, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China
| | - Xiaoming Yang
- Department of Gynecological Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Municipal Key Clinical Specialty, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China
| | - Jiangjing Yuan
- Department of Gynecological Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Municipal Key Clinical Specialty, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China
| | - Yuhong Li
- Department of Gynecological Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Municipal Key Clinical Specialty, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China
| | - Xiao Sun
- Department of Gynecological Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
- Shanghai Municipal Key Clinical Specialty, Shanghai, China.
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China.
| | - Yudong Wang
- Department of Gynecological Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
- Shanghai Municipal Key Clinical Specialty, Shanghai, China.
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China.
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Zürcher A, Knabben L, Janka H, Stute P. Influence of the levonorgestrel-releasing intrauterine system on the risk of breast cancer: a systematic review. Arch Gynecol Obstet 2023; 307:1747-1761. [PMID: 35716207 PMCID: PMC10147797 DOI: 10.1007/s00404-022-06640-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/18/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE The intention of this systematic review was to analyze the literature on breast cancer (BC) and the use of the levonorgestrel-releasing intrauterine system (LNG-IUS). METHODS The literature was searched in Medline, Embase, Cochrane Library, CINAHL, Web of Science and ClinicalTrials.com and included search terms related to breast cancer and LNG-IUS. After elimination of duplicates, 326 studies could be identified and were assessed according to inclusion and exclusion criteria. In the end, 10 studies met the defined criteria and were included in the systematic review. RESULTS 6 out of the 10 selected studies were cohort studies, three were case-control studies and one a systematic review/meta-analysis. 6 found a positive association between BC and the use of LNG-IUS. One study only found an increased risk for invasive BC in the subgroup of women aged 40-45 years. In contrast, three studies showed no indication of a higher BC risk. CONCLUSION The results imply an increased BC risk in LNG-IUS users, especially in postmenopausal women and with longer duration of use. Positive effects of the LNG-IUS such as reduced risks for other hormonal cancers have been observed, were, however, not focus of this systematic review. The heterogeneity of the analyzed studies and vast number of confounding factors call for further investigations in this issue. Patients should be advised according to their individual risk profile and hormone-free alternatives may be considered for women with a history of BC.
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Affiliation(s)
| | - Laura Knabben
- Department of Obstetrics and Gynecology, Inselspital, University Clinic Bern, University of Bern, Friedbühlstrasse 19, 3010, Bern, Switzerland
| | - Heidrun Janka
- Medical Library, University Library Bern, University of Bern, Bern, Switzerland
| | - Petra Stute
- Department of Obstetrics and Gynecology, Inselspital, University Clinic Bern, University of Bern, Friedbühlstrasse 19, 3010, Bern, Switzerland.
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Heting M, Wenping L, Yanan W, Dongni Z, Xiaoqing W, Zhli Z. Levonorgestrel intrauterine system and breast cancer risk: An updated systematic review and meta-analysis of observational studies. Heliyon 2023; 9:e14733. [PMID: 37089342 PMCID: PMC10119507 DOI: 10.1016/j.heliyon.2023.e14733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 03/15/2023] [Accepted: 03/15/2023] [Indexed: 04/25/2023] Open
Abstract
Objectives Levonorgestrel intrauterine sustained release system (LNG-IUS) is an intrauterine hormonal contraceptive device. Breast cancer (BC) was the most common type of cancer in women in the world in 2020. The relationship between LNG-IUS and BC is controversial. We conducted an updated meta-analysis (larger sample capacity and including Asian data) to explore whether LNG-IUS can increase the risk of BC. Study design We performed a thorough review of peer-reviewed publications from January 2005 through November 2022 using combinations of search terms for BC risk and LNG-IUS in the PubMed, Cochrane, Embase, Science Direct, and Web of Science databases. Studies reporting BC risk estimates among users of LNG-IUS were included according to the PRISMA criteria. Two authors independently evaluated all studies identified from the databases using Endnote software, and a third author resolved disagreements. The quality of evidence was evaluated using the Newcastle‒Ottawa Scale (NOS). A funnel plot was generated to assess publication bias. Results We identified 3029 studies; 12 studies were included in our systematic review, and 6 studies involving 261,221 women were included in our meta-analysis. Two subgroup analyses were performed for different study designs. A total of 190,475 women were included in the meta-analysis of cohort studies, and the results were RR = 0.80 (95% CI 0.57-1.11, Z = 1.33, P = 0.18 > 0.05). The meta-analysis of the case‒control studies included 70,746 women, and the results were OR = 1.38 (95% CI 0.98-1.94, Z = 1.85, P = 0.06 > 0.05). Conclusions Evidence of an increased risk of BC was not observed among LNG-IUS users. Implications There are inconsistencies in existing studies that prevent us from confirming whether LNG-IUS can increase the risk of BC. Our updated meta-analysis preliminarily suggested that LNG-IUS did not increase the risk of BC, providing evidence for more clinically safe use and thus providing a better choice for contraception.
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Affiliation(s)
| | - Lu Wenping
- Corresponding author. Guang'anmen Hospital of Chinese Academy of Chinese Medical Sciences, Address: No. 5, Beixiange, Xicheng District, Beijing, 100053, China.
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FSRH Guideline (March 2023) Intrauterine contraception. BMJ SEXUAL & REPRODUCTIVE HEALTH 2023; 49:1-142. [PMID: 37188461 DOI: 10.1136/bmjsrh-2023-iuc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
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Levonorgestrelhaltige Hormonspirale und Mammakarzinomrisiko. GYNAKOLOGISCHE ENDOKRINOLOGIE 2022. [DOI: 10.1007/s10304-022-00461-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Katuwal S, Tapanainen J, Pukkala E. Multivariate analysis of independent roles of socioeconomic status, occupational physical activity, reproductive factors, and postmenopausal hormonal therapy in risk of breast cancer. Breast Cancer Res Treat 2022; 193:495-505. [PMID: 35366162 PMCID: PMC9090885 DOI: 10.1007/s10549-022-06571-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/12/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE This case-control study assesses the independent roles of reproductive history, postmenopausal hormonal therapy (HT), socioeconomic status (SES), and occupational physical activity on the risk of breast cancer (BC). METHODS Odds ratios (OR) were estimated from conditional logistic multivariate regression model in a data set of 19,253 Finnish women diagnosed with BC between 1994 and 2013 and 96,265 age-matched population controls. RESULTS Both pre- and postmenopausal white-collar workers had significantly increased risk of ductal and lobular BC as compared to manual workers. Moderate occupational physical activity reduced risk of lobular BC by 14%. There was a transient increase in the risk of BC observed after each birth followed by a protective effect starting some years after the delivery. As the number of children increased, the short-term excess risk was lower and protective effect was observed earlier. Continuous estrogen-progestin therapy (EPT) significantly increased the risk of both ductal and lobular BC and the magnitude of risk was directly proportional to duration of use (OR for 5+ years of use 2.26, 95% confidence interval 2.12-2.42). Monthly EPT for 5+ years increased the risk (OR 1.32, 95% CI 1.20-1.45). Users of estradiol plus levonorgestrel intrauterine system devices showed ORs of 1.56 (95% CI 1.45-1.69) and 2.18 (95% CI 1.81-2.64) for ductal and lobular BC, respectively. CONCLUSION This study concludes that pregnancy has a dual effect on BC risk, with a transient increase in risk followed by a long-term protective effect. The SES and HT have a large effect on BC risk while occupational physical activity has only a small independent effect.
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Affiliation(s)
- Sushmita Katuwal
- Faculty of Social Sciences, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland.
| | - Juha Tapanainen
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
- Department of Obstetrics and Gynecology, PEDEGO Research Unit, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Eero Pukkala
- Faculty of Social Sciences, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland
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Flores VA, Pal L, Manson JE. Hormone Therapy in Menopause: Concepts, Controversies, and Approach to Treatment. Endocr Rev 2021; 42:720-752. [PMID: 33858012 DOI: 10.1210/endrev/bnab011] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Indexed: 12/22/2022]
Abstract
Hormone therapy (HT) is an effective treatment for menopausal symptoms, including vasomotor symptoms and genitourinary syndrome of menopause. Randomized trials also demonstrate positive effects on bone health, and age-stratified analyses indicate more favorable effects on coronary heart disease and all-cause mortality in younger women (close proximity to menopause) than in women more than a decade past menopause. In the absence of contraindications or other major comorbidities, recently menopausal women with moderate or severe symptoms are appropriate candidates for HT. The Women's Health Initiative (WHI) hormone therapy trials-estrogen and progestin trial and the estrogen-alone trial-clarified the benefits and risks of HT, including how the results differed by age. A key lesson from the WHI trials, which was unfortunately lost in the posttrial cacophony, was that the risk:benefit ratio and safety profile of HT differed markedly by clinical characteristics of the participants, especially age, time since menopause, and comorbidity status. In the present review of the WHI and other recent HT trials, we aim to provide readers with an improved understanding of the importance of the timing of HT initiation, type and route of administration, and of patient-specific considerations that should be weighed when prescribing HT.
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Affiliation(s)
- Valerie A Flores
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lubna Pal
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - JoAnn E Manson
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Ángel-Parra C, Pascual-Domenech A, González-Mirasol E. Riesgo de cáncer de mama en portadoras de DIU de levonorgestrel. Revisión sistemática. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2021. [DOI: 10.1016/j.gine.2021.100668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Kowalczyk W, Waliszczak G, Jach R, Dulińska-Litewka J. Steroid Receptors in Breast Cancer: Understanding of Molecular Function as a Basis for Effective Therapy Development. Cancers (Basel) 2021; 13:4779. [PMID: 34638264 PMCID: PMC8507808 DOI: 10.3390/cancers13194779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 12/21/2022] Open
Abstract
Breast cancer remains one of the most important health problems worldwide. The family of steroid receptors (SRs), which comprise estrogen (ER), progesterone (PR), androgen (AR), glucocorticoid (GR) and mineralocorticoid (MR) receptors, along with a receptor for a secosteroid-vitamin D, play a crucial role in the pathogenesis of the disease. They function predominantly as nuclear receptors to regulate gene expression, however, their full spectrum of action reaches far beyond this basic mechanism. SRs are involved in a vast variety of interactions with other proteins, including extensive crosstalk with each other. How they affect the biology of a breast cell depends on such factors as post-translational modifications, expression of coregulators, or which SR isoform is predominantly synthesized in a given cellular context. Although ER has been successfully utilized as a breast cancer therapy target for years, research on therapeutic application of other SRs is still ongoing. Designing effective hormone therapies requires thorough understanding of the molecular function of the SRs. Over the past decades, huge amount of data was obtained in multiple studies exploring this field, therefore in this review we attempt to summarize the current knowledge in a comprehensive way.
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Affiliation(s)
- Wojciech Kowalczyk
- Chair of Medical Biochemistry, Jagiellonian University Medical College, 7 Kopernika St., 31-034 Kraków, Poland; (W.K.); (G.W.)
| | - Grzegorz Waliszczak
- Chair of Medical Biochemistry, Jagiellonian University Medical College, 7 Kopernika St., 31-034 Kraków, Poland; (W.K.); (G.W.)
| | - Robert Jach
- Department of Gynecology and Obstetrics, Jagiellonian University Medical College, 23 Kopernika St., 31-501 Kraków, Poland;
| | - Joanna Dulińska-Litewka
- Chair of Medical Biochemistry, Jagiellonian University Medical College, 7 Kopernika St., 31-034 Kraków, Poland; (W.K.); (G.W.)
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D'Alessandro G, Frigerio M, Barra F, Costantini S, Gustavino C, Ferrero S. Systematic review and meta-analysis on the impact of the levonorgestrel-releasing intrauterine system in reducing risk of ovarian cancer. Int J Gynaecol Obstet 2021; 156:418-424. [PMID: 33969485 PMCID: PMC9290617 DOI: 10.1002/ijgo.13737] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/07/2021] [Accepted: 05/07/2021] [Indexed: 11/12/2022]
Abstract
Background Ovarian carcinoma (OC) is one of the most widespread tumors in the world and is characterized by low survival rates. Objective To determine whether the levonorgestrel‐releasing intrauterine system (LNG‐IUS) can prevent OC. Search strategy The literature until December 2020 were systematically reviewed according to the PRISMA Statement for Reporting Systematic Reviews (PROSPERO: CRD42019137957). Selection criteria Studies assessing the impact of LNG‐IUS on the risk of OC were included. Data collection and analysis Data were extracted independently by two authors to ensure accuracy and consistency. Main results A total of 34 323 records were obtained, of which three satisfied the inclusion criteria. In total, 1687 events of OC in a population of 20 461 311 person‐years were considered. Data pooling revealed that the use of LNG‐IUS did not confer a lower risk of OC relative to the never‐use of LNG‐IUS, with an estimated odds ratio of 0.66 (95% confidence interval 0.41–1.08; I2 = 84%; P = 0.002). Conclusion The meta‐analysis did not demonstrate a preventive role of LNG‐IUS on OC. However, it was carried out on a few papers, and a definitive conclusion on the topic still cannot be drawn. Further studies are indicated in the future to define the impact of LNG‐IUS on OC. The meta‐analysis carried out on three papers did not demonstrate a preventive role of the levonorgestrel‐releasing intrauterine device on ovarian cancer.
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Affiliation(s)
- Gloria D'Alessandro
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genova, Genova, Italy
| | | | - Fabio Barra
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genova, Genova, Italy
| | - Sergio Costantini
- Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Claudio Gustavino
- Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genova, Genova, Italy
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Silva FR, Grande AJ, Lacerda Macedo AC, Colonetti T, Rocha MC, Rodrigues Uggioni ML, Silva BR, da Rosa MI. Meta-Analysis of Breast Cancer Risk in Levonorgestrel-Releasing Intrauterine System Users. Clin Breast Cancer 2021; 21:497-508. [PMID: 34045174 DOI: 10.1016/j.clbc.2021.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/18/2021] [Accepted: 03/26/2021] [Indexed: 12/24/2022]
Abstract
To map and assess evidence regarding use of the levonorgestrel-releasing intrauterine system (LNG-IUS) and its association with breast cancer, we conducted a systematic review and meta-analysis. A search strategy was developed using the terms "Levonorgestrel-releasing," "LNG-IUS," "intrauterine system," and "breast cancer. The electronic databases searched were MEDLINE, Embase, Cochrane Library, Latin American & Caribbean Health Sciences Literature, and Google Scholar for studies published until August 2020. We included observational studies: prospective or retrospective cohort, case-control, and cross-sectional. A total of 494 studies were identified, 294 studies were evaluated by title and abstract, and 262 were excluded because they did not meet the inclusion criteria. A total of 32 studies were read in full, and 24 were excluded. Thus, eight studies were included in the systematic review. The meta-analysis included four studies (two cohort and two case-control studies). Two subgroup analyses were performed for different study designs. The estimated relative risk for the two cohort studies (144,996 cases), with moderate-quality evidence, was 0.93 (95% confidence interval [CI], 0.840-1.03). The odds ratio estimated for the two case-control studies (5556 cases and 35987 controls), with moderate-quality evidence, was 1.07 (95% CI, 0.91-1.26). Evidence of an increased risk of breast cancer was not observed in levonorgestrel-releasing intrauterine system users.
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Affiliation(s)
- Fabio R Silva
- Laboratory of Biomedicine Translational, Postgraduate Program in Health Sciences, Universidade do Extremo Sul Catarinense, Criciúma, Santa Catarina, Brazil
| | - Antonio Jose Grande
- Laboratory of Evidence-Based Practice, Universidade Estadual de Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil
| | - Ana Cristina Lacerda Macedo
- Laboratory of Biomedicine Translational, Postgraduate Program in Health Sciences, Universidade do Extremo Sul Catarinense, Criciúma, Santa Catarina, Brazil
| | - Tamy Colonetti
- Laboratory of Biomedicine Translational, Postgraduate Program in Health Sciences, Universidade do Extremo Sul Catarinense, Criciúma, Santa Catarina, Brazil
| | - Marina C Rocha
- Laboratory of Biomedicine Translational, Postgraduate Program in Health Sciences, Universidade do Extremo Sul Catarinense, Criciúma, Santa Catarina, Brazil
| | - Maria Laura Rodrigues Uggioni
- Laboratory of Biomedicine Translational, Postgraduate Program in Health Sciences, Universidade do Extremo Sul Catarinense, Criciúma, Santa Catarina, Brazil
| | - Bruno R Silva
- Laboratory of Biomedicine Translational, Postgraduate Program in Health Sciences, Universidade do Extremo Sul Catarinense, Criciúma, Santa Catarina, Brazil
| | - Maria Inês da Rosa
- Laboratory of Biomedicine Translational, Postgraduate Program in Health Sciences, Universidade do Extremo Sul Catarinense, Criciúma, Santa Catarina, Brazil.
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Mastorakos G, Iatrakis G, Zervoudis S, Syropoulou S. Progestins and the Risk of Breast Cancer. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2021; 17:90-100. [PMID: 34539915 DOI: 10.4183/aeb.2021.90] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES The present paper aims to investigate the effects of both progesterone and progestin treatment mainly related to the occurrence of breast cancer in women. MATERIALS AND METHODS Extensive systematic bibliographic review of Greek and International articles was conducted through the electronic databases Pubmed, Cinahl, Uptodate, and Google Scholar for the identification of articles related to progesterone, progestins and breast cancer treatment. RESULTS Hormone therapy with the use of estrogen alone presents a small increased risk or does not present at all an increased risk of breast cancer. With ORs in some studies below 1.0 in current users for 3 plus years and safe option until 7 years, while in other studies the risk was increased with the ORs 1.29. However, the use of estrogen in combination with progestogens, depending on the type of progestogens, shows an increased risk of breast cancer, with the ORs to vary between 1.14- 2.38 from 3 to 5 years and is inversely proportional to the time of its use. This risk varies depending on the combination of the preparations. Other factors that are associated with breast cancer risk when receiving hormone therapy are the years that hormone therapy is taken, directly proportional to the risk. At higher risk are older women, women with low body mass index in menopause (BMI <25kg/m2) and women with increased mammographic breast density. Continued use of hormone therapy is associated with an increased risk for breast cancer compared to sequential. The risk became visible sooner to women who used in the past hormone therapy and were using it again. Starting hormone therapy in the immediate postmenopausal period also increased the risk for breast cancer. Hormone therapy was associated with tumors with positive estrogen and progesterone receptors, and also the lobular histological type was associated with its use. Tibolone use was associated with an increased risk.
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Affiliation(s)
| | - G Iatrakis
- Rea Hospital.,University West Attica of Athens, Athens, Greece
| | - S Zervoudis
- Rea Hospital.,University West Attica of Athens, Athens, Greece
| | - S Syropoulou
- University Kapodistrian.,Evaggelismos Hospital, Paphos, Cyprus
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14
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Romero SA, Young K, Hickey M, Su HI. Levonorgestrel intrauterine system for endometrial protection in women with breast cancer on adjuvant tamoxifen. Cochrane Database Syst Rev 2020; 12:CD007245. [PMID: 33348436 PMCID: PMC8092675 DOI: 10.1002/14651858.cd007245.pub4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Adjuvant tamoxifen reduces the risk of breast cancer recurrence in women with oestrogen receptor-positive breast cancer. Tamoxifen also increases the risk of postmenopausal bleeding, endometrial polyps, hyperplasia, and endometrial cancer. The levonorgestrel-releasing intrauterine system (LNG-IUS) causes profound endometrial suppression. This systematic review considered the evidence that the LNG-IUS prevents the development of endometrial pathology in women taking tamoxifen as adjuvant endocrine therapy for breast cancer. OBJECTIVES To determine the effectiveness and safety of the levonorgestrel intrauterine system (LNG-IUS) in pre- and postmenopausal women taking adjuvant tamoxifen following breast cancer for the outcomes of endometrial and uterine pathology including abnormal vaginal bleeding or spotting, and secondary breast cancer events. SEARCH METHODS We searched the following databases on 29 June 2020; The Cochrane Gynaecology and Fertility Group specialised register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO and Cumulative Index to Nursing and Allied Health Literature. We searched the Cochrane Breast Cancer Group specialised register on 4 March 2020. We also searched two trials registers, checked references for relevant trials and contacted study authors and experts in the field to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) of women with breast cancer on adjuvant tamoxifen that compared the effectiveness of the LNG-IUS with endometrial surveillance versus endometrial surveillance alone on the incidence of endometrial pathology. DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane. The primary outcome measure was endometrial pathology (including polyps, endometrial hyperplasia, or endometrial cancer), diagnosed at hysteroscopy or endometrial biopsy. Secondary outcome measures included fibroids, abnormal vaginal bleeding or spotting, breast cancer recurrence, and breast cancer-related deaths. We rated the overall certainty of evidence using GRADE methods. MAIN RESULTS We included four RCTs (543 women analysed) in this review. We judged the certainty of the evidence to be moderate for all of the outcomes, due to imprecision (i.e. limited sample sizes and low event rates). In the included studies, the active treatment arm was the 20 μg/day LNG-IUS plus endometrial surveillance; the control arm was endometrial surveillance alone. In tamoxifen users, the LNG-IUS probably reduces the incidence of endometrial polyps compared to the control group over both a 12-month period (Peto odds ratio (OR) 0.22, 95% confidence interval (CI) 0.08 to 0.64, I² = 0%; 2 RCTs, n = 212; moderate-certainty evidence) and over a long-term follow-up period (24 to 60 months) (Peto OR 0.22, 95% CI 0.13 to 0.39; I² = 0%; 4 RCTs, n = 417; moderate-certainty evidence). For long-term follow-up, this suggests that if the incidence of endometrial polyps following endometrial surveillance alone is assumed to be 23.5%, the incidence following LNG-IUS with endometrial surveillance would be between 3.8% and 10.7%. The LNG-IUS probably slightly reduces the incidence of endometrial hyperplasia compared with controls over a long-term follow-up period (24 to 60 months) (Peto OR 0.13, 95% CI 0.03 to 0.67; I² = 0%; 4 RCTs, n = 417; moderate-certainty evidence). This suggests that if the chance of endometrial hyperplasia following endometrial surveillance alone is assumed to be 2.8%, the chance following LNG-IUS with endometrial surveillance would be between 0.1% and 1.9%. However, it should be noted that there were only six cases of endometrial hyperplasia. There was insufficient evidence to reach a conclusion regarding the incidence of endometrial cancer in tamoxifen users, as no studies reported cases of endometrial cancer. At 12 months of follow-up, the LNG-IUS probably increases abnormal vaginal bleeding or spotting compared to the control group (Peto OR 7.26, 95% CI 3.37 to 15.66; I² = 0%; 3 RCTs, n = 376; moderate-certainty evidence). This suggests that if the chance of abnormal vaginal bleeding or spotting following endometrial surveillance alone is assumed to be 1.7%, the chance following LNG-IUS with endometrial surveillance would be between 5.6% and 21.5%. By 24 months of follow-up, abnormal vaginal bleeding or spotting occurs less frequently than at 12 months of follow-up, but is still more common in the LNG-IUS group than the control group (Peto OR 2.72, 95% CI 1.04 to 7.10; I² = 0%; 2 RCTs, n = 233; moderate-certainty evidence). This suggests that if the chance of abnormal vaginal bleeding or spotting following endometrial surveillance alone is assumed to be 4.2%, the chance following LNG-IUS with endometrial surveillance would be between 4.4% and 23.9%. By 60 months of follow-up, there were no cases of abnormal vaginal bleeding or spotting in either group. The numbers of events for the following outcomes were low: fibroids (n = 13), breast cancer recurrence (n = 18), and breast cancer-related deaths (n = 16). As a result, there is probably little or no difference in these outcomes between the LNG-IUS treatment group and the control group. AUTHORS' CONCLUSIONS: The LNG-IUS probably slightly reduces the incidence of benign endometrial polyps and endometrial hyperplasia in women with breast cancer taking tamoxifen. At 12 and 24 months of follow-up, the LNG-IUS probably increases abnormal vaginal bleeding or spotting among women in the treatment group compared to those in the control. Data were lacking on whether the LNG-IUS prevents endometrial cancer in these women. There is no clear evidence from the available RCTs that the LNG-IUS affects the risk of breast cancer recurrence or breast cancer-related deaths. Larger studies are necessary to assess the effects of the LNG-IUS on the incidence of endometrial cancer, and to determine whether the LNG-IUS might have an impact on the risk of secondary breast cancer events.
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Affiliation(s)
- Sally Ad Romero
- Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, USA
| | - Katie Young
- School of Medicine, University of California, San Diego, San Diego, USA
| | - Martha Hickey
- The University of Melbourne, The Royal Women's Hospital, Melbourne, Australia
| | - H Irene Su
- Department of Reproductive Medicine, University of California, San Diego, La Jolla, California, USA
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15
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Hamoda H, Panay N, Pedder H, Arya R, Savvas M. The British Menopause Society & Women's Health Concern 2020 recommendations on hormone replacement therapy in menopausal women. Post Reprod Health 2020; 26:181-209. [PMID: 33045914 DOI: 10.1177/2053369120957514] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
| | - Nick Panay
- Queen Charlotte's and Chelsea & Westminster Hospitals, London, UK
| | - Hugo Pedder
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Roopen Arya
- Haematological Medicine, King's College Hospital, London, UK
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16
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Moore NL, Hanson AR, Ebrahimie E, Hickey TE, Tilley WD. Anti-proliferative transcriptional effects of medroxyprogesterone acetate in estrogen receptor positive breast cancer cells are predominantly mediated by the progesterone receptor. J Steroid Biochem Mol Biol 2020; 199:105548. [PMID: 31805393 DOI: 10.1016/j.jsbmb.2019.105548] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 11/19/2019] [Indexed: 01/14/2023]
Abstract
Medroxyprogesterone acetate (MPA) is a first generation progestin that has been in clinical use for various hormonal conditions in women since the 1960s. Although developed as a progesterone receptor (PR) agonist, MPA also has strong binding affinity for other steroid receptors. This promiscuity confounds the mechanistic action of MPA in target cells that express multiple steroid receptors. This study is the first to assess the relative contribution of progesterone, androgen and glucocorticoid receptors in mediating the transcriptional activity of MPA on endogenous targets in breast cancer cells that endogenously express all three receptors at comparable levels. Gene expression profiling in estrogen receptor positive (ER+) ZR-75-1 breast cancer cells demonstrated that although the MPA-regulated transcriptome strongly overlapped with that of Progesterone (PROG), 5α-dihydrotestosterone (DHT) and Dexamethasone (DEX), it clustered most strongly with that of PROG, suggesting that MPA predominantly acts via the progesterone receptor (PR) rather than androgen receptor (AR) or glucocorticoid receptor (GR). Subsequent experiments manipulating levels of these receptors, either through specific culture conditions or with lentiviral shRNAs targeting individual receptors, also revealed a stronger contribution of PR compared to AR and GR on the expression of endogenous target genes that are either commonly regulated by all ligands or specifically regulated only by MPA. A predominant contribution of PR to MPA action in ER+ T-47D breast cancer cells was also observed, although a stronger role for AR was evident in T-47D compared to that observed in ZR-75-1 cells. Network analysis of ligand-specific and commonly regulated genes demonstrated that MPA utilises different transcription factors and signalling pathways to inhibit proliferation compared with PROG. This study reaffirms the importance of PR in mediating MPA action in an endogenous breast cancer context where multiple steroid receptors are co-expressed and has potential implications for PR-targeting therapeutic strategies in ER+ breast cancer.
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Affiliation(s)
- Nicole L Moore
- Dame Roma Mitchell Cancer Research Laboratories, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Adrienne R Hanson
- Dame Roma Mitchell Cancer Research Laboratories, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Esmaeil Ebrahimie
- Dame Roma Mitchell Cancer Research Laboratories, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Theresa E Hickey
- Dame Roma Mitchell Cancer Research Laboratories, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Wayne D Tilley
- Dame Roma Mitchell Cancer Research Laboratories, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.
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17
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Omar OAM, Ewies A. Re: The levonorgestrel-releasing intrauterine device induces endometrial decidualisation in women on tamoxifen. J OBSTET GYNAECOL 2020; 41:332. [PMID: 32068446 DOI: 10.1080/01443615.2020.1716315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Ola A M Omar
- General Surgery Department, Aswan University, Aswan, Egypt
| | - Ayman Ewies
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK.,Gynaecology Department, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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18
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Conz L, Mota BS, Bahamondes L, Teixeira Dória M, Françoise Mauricette Derchain S, Rieira R, Sarian LO. Levonorgestrel-releasing intrauterine system and breast cancer risk: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2020; 99:970-982. [PMID: 31990981 DOI: 10.1111/aogs.13817] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 01/18/2020] [Accepted: 01/20/2020] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Epidemiological studies have shown that some hormonal contraceptive methods are associated with increased breast cancer risk, especially if used over long periods. Our objective was to conduct a systematic review and meta-analysis of the literature on the risk of breast cancer development in women using the 52-mg levonorgestrel-releasing intrauterine system (LNG-IUS). MATERIAL AND METHODS We performed a thorough review of peer-reviewed publications from 10 January 1999, through 31 July 2019, using combinations of search terms for breast cancer risk and LNG-IUS in the Medline, EMBASE, LILACS (Latin American and Caribbean Health Sciences Literature), and Scielo databases. This review was registered in PROSPERO (CRD42017059076). Studies reporting breast cancer risk estimates among healthy users of LNG-IUS were included according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) criteria. Two authors performed data extraction, and a third author resolved disagreements. The quality of evidence was evaluated using the Downs and Black instrument. A funnel plot was generated, and a linear regression test of funnel plot asymmetry was used to assess publication bias. Finally, we performed a random-effects model (owing to high study heterogeneity) meta-analysis of seven suitable studies, stratified by the age distribution of patients (<50 years, ≥50 years, and mixed). RESULTS We identified 96 studies and manually cross-referenced and excluded duplicate articles. Seventy articles were excluded on the basis of the inclusion and exclusion criteria, resulting in the assessment of 26 full-text articles. Eight articles were considered adequate for inclusion in this systematic review, and seven studies were included in the meta-analysis. Three publications were case-control studies and five were cohort studies. According to the Downs and Black instrument, 5 studies were rated as "good" and 3 studies were deemed "fair". Our meta-analysis results indicated increased breast cancer risk in LNG-IUS users: for all women, odds ratio (OR) = 1.16 (95% CI 1.06-1.28, I2 = 78%, P < .01); for women aged <50 years, OR = 1.12 (95% CI 1.02-1.22, I2 = 66%, P = .02); and for women aged ≥50 years, OR = 1.52 (95% CI 1.34-1.72, I2 = 0%, P = .84). CONCLUSIONS Current evidence suggests that LNG-IUS users have an increased breast cancer risk regardless of age and indication. The effect of LNG-IUS on breast cancer risk seems to be larger in older users. However, our systematic review detected methodological issues across the available studies, and confounding factors may be responsible for at least a fraction of the risk effects associated with LNG-IUS use. Nevertheless, users of LNG-IUS should be aware of these trends. We believe that caution is needed, and risks should be balanced against proven health benefits (eg effective treatment of heavy menstrual bleeding and avoidance of surgical interventions), when prescribing LNG-IUS for long periods of use, especially in women with other known breast cancer risk factors such as old age, obesity, and familial predisposition.
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Affiliation(s)
- Livia Conz
- Department of Obstetrics and Gynecology, University of Campinas Medical School (UNICAMP), Campinas, Sao Paulo, Brazil.,Division of Gynecologic and Breast Oncology, Women's Hospital (CAISM), UNICAMP, Campinas, Sao Paulo, Brazil
| | - Bruna Salani Mota
- Setor de Mastologia da Clinica Ginecológica do ICESP - Instituto do Câncer do estado de São Paulo, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - FMUSP, Sao Paulo, Brazil
| | - Luis Bahamondes
- Department of Obstetrics and Gynecology, University of Campinas Medical School (UNICAMP), Campinas, Sao Paulo, Brazil
| | - Maíra Teixeira Dória
- Department of Obstetrics and Gynecology, University of Campinas Medical School (UNICAMP), Campinas, Sao Paulo, Brazil.,Division of Gynecologic and Breast Oncology, Women's Hospital (CAISM), UNICAMP, Campinas, Sao Paulo, Brazil
| | - Sophie Françoise Mauricette Derchain
- Department of Obstetrics and Gynecology, University of Campinas Medical School (UNICAMP), Campinas, Sao Paulo, Brazil.,Division of Gynecologic and Breast Oncology, Women's Hospital (CAISM), UNICAMP, Campinas, Sao Paulo, Brazil
| | - Rachel Rieira
- Universidade Federal de São Paulo - UNIFESP, Center of Health Tecnology, Hospital Sírio Libanês, Sao Paulo, Brazil
| | - Luis Otavio Sarian
- Department of Obstetrics and Gynecology, University of Campinas Medical School (UNICAMP), Campinas, Sao Paulo, Brazil.,Division of Gynecologic and Breast Oncology, Women's Hospital (CAISM), UNICAMP, Campinas, Sao Paulo, Brazil
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19
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Cenciarini ME, Proietti CJ. Molecular mechanisms underlying progesterone receptor action in breast cancer: Insights into cell proliferation and stem cell regulation. Steroids 2019; 152:108503. [PMID: 31562879 DOI: 10.1016/j.steroids.2019.108503] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/13/2019] [Accepted: 09/19/2019] [Indexed: 02/07/2023]
Abstract
The ovarian steroid hormone progesterone and its nuclear receptor, the Progesterone Receptor (PR), play an essential role in the regulation of cell proliferation and differentiation in the mammary gland. In addition, experimental and clinical evidence demonstrate their critical role in controlling mammary gland tumorigenesis and breast cancer development. When bound to its ligand, the main action of PR is as a transcription factor, which regulates the expression of target genes networks. PR also activates signal transduction pathways through a rapid or non-genomic mechanism in breast cancer cells, an event that is fully integrated with its genomic effects. This review summarizes the molecular mechanisms of the ligand-activated PR actions that drive epithelial cell proliferation and the regulation of the stem cell population in the normal breast and in breast cancer.
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Affiliation(s)
- Mauro E Cenciarini
- Instituto de Biología y Medicina Experimental (IBYME), CONICET, Vuelta de Obligado 2490, Buenos Aires C1428ADN, Argentina
| | - Cecilia J Proietti
- Instituto de Biología y Medicina Experimental (IBYME), CONICET, Vuelta de Obligado 2490, Buenos Aires C1428ADN, Argentina.
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20
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Depypere HT, Stanczyk FZ, Croubels S, Blondeel PN, Roche NA, Depypere BP, Vanhaecke L. Breast levonorgestrel concentrations in women using a levonorgestrel-releasing intrauterine system. Contraception 2019; 100:299-301. [PMID: 31302122 DOI: 10.1016/j.contraception.2019.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 06/12/2019] [Accepted: 07/03/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To measure breast tissue and serum LNG concentrations in women using a LNG-IUS. STUDY DESIGN This pilot study was performed in 25 healthy women undergoing breast surgery at the Ghent University hospital. LNG concentrations were measured in serum and microdissected breast tissue samples using a validated ultra-performance liquid chromatography/tandem mass spectrometry assay. RESULT(S) The mean LNG concentration in the 18 LNG-IUS users was 0.18±0.16 ng/mL in serum and 0.26±0.28 ng/g in breast tissue. For four women without any form of hormonal contraceptive (the negative controls), the mean concentrations were below the limit of quantification, i.e., 0.15 ng/mL and 0.20 ng/g, for serum and breast tissue, respectively. For the three positive controls the concentrations in the serum (20.5 and 3.4 ng/ml) and the breast (3.74 and 1.24 ng/g) were respectively for the 20 μg EE/100 μg users and 315 pg/ml in the serum and 1.17 ng/g in the breast for the minipill user. The intracellular free fraction of LNG may be as low as 0.008 ng/g. CONCLUSION(S) The concentration of LNG in breast epithelium cells in women using the LNG-IUS is very low. IMPLICATIONS The relationship between the serum and breast tissue levels of LNG was studied in women using a LNG-IUS or oral LNG-containing contraception. Compared to oral contraception, the tissue levels of LNG in LNG-IUS users are much lower in the breast. It is not known what level of LNG exposure in the breast would stimulate RANKL and WNT4 expression; such information is needed.
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Affiliation(s)
- Herman T Depypere
- Breast and Menopause Clinic, Ghent University Hospital, Ghent, Belgium.
| | - Frank Z Stanczyk
- Departments of Obstetrics and Gynecology, and Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Siska Croubels
- Department of Pharmacology, Toxicology & Biochemistry, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | - Phillip N Blondeel
- Department of Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium
| | - Nathalie A Roche
- Department of Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium
| | - Bernard P Depypere
- Department of Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium
| | - Lynn Vanhaecke
- Department of Veterinary Public Health & Food Safety, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
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21
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Black A, Guilbert E. Consensus canadien sur la contraception (partie 3 de 4): chapitre 7 - Contraception intra-utérine. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41 Suppl 1:S1-S23. [DOI: 10.1016/j.jogc.2019.02.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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22
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Del Pup L, Codacci-Pisanelli G, Peccatori F. Breast cancer risk of hormonal contraception: Counselling considering new evidence. Crit Rev Oncol Hematol 2019; 137:123-130. [DOI: 10.1016/j.critrevonc.2019.03.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 12/19/2022] Open
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23
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Gompel A, Ramirez I, Bitzer J. Contraception in cancer survivors - an expert review Part I. Breast and gynaecological cancers. EUR J CONTRACEP REPR 2019; 24:167-174. [PMID: 31033361 DOI: 10.1080/13625187.2019.1602721] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Objective: The efficacy of treatment for many cancers has increased dramatically in recent decades and there are a growing number of cancer survivors who need effective contraception. In this paper, a group of experts from the European Society of Contraception set out to define the most frequent cancers in women and summarise the guidelines, reviews and studies that provide information and guidance on contraception for each cancer. Methods: Epidemiological studies were analysed to determine the frequency of cancers in women of reproductive age. A narrative review was performed for each cancer, collecting data about the treatment of the disease, its impact on fertility, and the efficacy, health risks, possible benefits and contraindications of the contraceptive methods available. The recommendations were then summarised. Results: Owing to a large amount of information, the results are presented in two parts. Part 1 includes contraception after breast and gynaecological cancers. Part 2 summarises the findings and recommendations regarding contraception in women with skin, gastrointestinal, haematological and endocrine cancers.
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Affiliation(s)
- Anne Gompel
- a Department of Gynaecology, Faculty of Medicine , Paris Descartes University , Paris , France
| | - Isabel Ramirez
- b Sexual and Reproductive Health Service , UGC Dr Cayetano Roldan San Fernando Health Centre , Cadiz , Spain
| | - Johannes Bitzer
- c Department of Obstetrics and Gynaecology , Basel University Hospital , Basel , Switzerland
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24
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Llaneza P, Calaf J, Jurado AR, Mendoza N, Otero B, Quereda F, Sánchez-Borrego R, Lubian D. What do TSECs provide in the menopausal hormone therapy? Gynecol Endocrinol 2018; 34:826-832. [PMID: 29790381 DOI: 10.1080/09513590.2018.1474869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
Tissue-selective estrogen complex (TSEC) is projected as a progestogen-free option for the treatment of estrogen deficiency symptoms in postmenopausal, non-hysterectomized women. TSEC combines the benefits of estrogen with a selective estrogen receptor modulator (SERM), in this case bazedoxifene acetate (BZA), which has an antagonistic effect on the endometrium, thus avoiding the use of progestins. The authorized TSEC combination (conjugated estrogens [CE] 0.45 mg/BZA 20 mg) for the alleviation of vasomotor symptoms has been demonstrated in randomized clinical trials compared with placebo or menopausal hormone therapy (MHT). In addition, TSEC has shown improvements in quality of life and vaginal atrophy. In respect to MHT using progestins, the benefits of TSEC are found mainly in the bleeding pattern, amenorrhea rate, and reduction in mammary repercussion (i.e., breast tenderness and radiological density). The objective of this guide will be to analyze the efficacy and safety of TSEC consisting of CE/BZA in postmenopausal women.
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Affiliation(s)
- Placido Llaneza
- a Hospital Universitario Central de Asturias , Oviedo , Spain
| | | | | | - Nicolas Mendoza
- d Department of Obstetrics & Gynecology, University of Granada , Granada , Spain
| | - Borja Otero
- e Hospital Unversitario de Cruces , Bilbao , Spain
| | - Francisco Quereda
- f Department of Obstetrics & Gynecology, University of Miguel Henández , Elche , Alicante , Spain
| | | | - Daniel Lubian
- h Hospital Universitario de Puerto Real , Puerto Real , Spain
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25
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Goldstuck ND, Le HP. Delivery of progestins via the subdermal versus the intrauterine route: comparison of the pharmacology and clinical outcomes. Expert Opin Drug Deliv 2018; 15:717-727. [DOI: 10.1080/17425247.2018.1498080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Norman D. Goldstuck
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, University of Stellenbosch, Bellville, Western Cape, South Africa
| | - Hung P. Le
- Department of Physical Sciences, MacEwan University, Edmonton, Alberta, Canada
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26
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Proietti CJ, Cenciarini ME, Elizalde PV. Revisiting progesterone receptor (PR) actions in breast cancer: Insights into PR repressive functions. Steroids 2018; 133:75-81. [PMID: 29317254 DOI: 10.1016/j.steroids.2017.12.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 12/08/2017] [Accepted: 12/23/2017] [Indexed: 12/18/2022]
Abstract
Progesterone receptor (PR) is a master regulator in female reproductive tissues that controls developmental processes and proliferation and differentiation during the reproductive cycle and pregnancy. PR also plays a role in progression of endocrine-dependent breast cancer. As a member of the nuclear receptor family of ligand-dependent transcription factors, the main action of PR is to regulate networks of target gene expression in response to binding its cognate steroid hormone, progesterone. Liganded-PR transcriptional activation has been thoroughly studied and associated mechanisms have been described while progesterone-mediated repression has remained less explored. The present work summarizes recent advances in the understanding of how PR-mediated repression is accomplished in breast cancer cells and highlights the significance of fully understanding the determinants of context-dependent PR action.
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Affiliation(s)
- Cecilia J Proietti
- Instituto de Biología y Medicina Experimental (IBYME), CONICET, Vuelta de Obligado 2490, Buenos Aires C1428ADN, Argentina.
| | - Mauro E Cenciarini
- Instituto de Biología y Medicina Experimental (IBYME), CONICET, Vuelta de Obligado 2490, Buenos Aires C1428ADN, Argentina
| | - Patricia V Elizalde
- Instituto de Biología y Medicina Experimental (IBYME), CONICET, Vuelta de Obligado 2490, Buenos Aires C1428ADN, Argentina
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Mitchell L, Lewin J, Dirks J, Wang K, Tam S, Katz A, McCann B, Lo K, Laurence V, Rousset-Jablonski C, Gupta AA. Sexual Health Issues for the Young Adult with Cancer: An International Symposium Held During the First Global Adolescents and Young Adults Cancer Congress (Edinburgh, United Kingdom). J Adolesc Young Adult Oncol 2018; 7:153-163. [DOI: 10.1089/jayao.2017.0067] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Laura Mitchell
- Adolescent and Young Adult Program, Princess Margaret Hospital, University of Toronto, Toronto, Canada
| | - Jeremy Lewin
- Division of Medical Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Canada
| | - Julia Dirks
- Adolescent and Young Adult Program, Princess Margaret Hospital, University of Toronto, Toronto, Canada
| | - Kate Wang
- Adolescent and Young Adult Program, Princess Margaret Hospital, University of Toronto, Toronto, Canada
| | - Seline Tam
- Adolescent and Young Adult Program, Princess Margaret Hospital, University of Toronto, Toronto, Canada
| | - Anne Katz
- CancerCare Manitoba, Winnipeg, Canada
| | - Beth McCann
- Young People's Cancer Service, University College Hospital, London, United Kingdom
| | - Kirk Lo
- Division of Urology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Valerie Laurence
- Leon Berard Cancer Center, Lyon, France
- EA 7425 HESPER- Health Services and Performance Research, Center Hospitalier Lyon Sud, University of Lyon, Lyon, France
| | - Christine Rousset-Jablonski
- Leon Berard Cancer Center, Lyon, France
- EA 7425 HESPER- Health Services and Performance Research, Center Hospitalier Lyon Sud, University of Lyon, Lyon, France
| | - Abha A. Gupta
- Adolescent and Young Adult Program, Princess Margaret Hospital, University of Toronto, Toronto, Canada
- Division of Medical Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Canada
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Abstract
Major advances in menopause hormone therapy (MHT) hold promise in the future of better and safer care for women at and after the menopause. The principal advances are: (1) the critical window or 'window of opportunity' in the 10 years or so after the menopause, during which the benefits of MHT in healthy women exceed any risks; (2) use of transdermal instead of oral administration of estrogen to reduce the risk of venous thromboembolism; (c) investigation of the use of oral micronized progesterone (MP) and vaginal MP to prevent endometrial hyperplasia and carcinoma without any increased risk of breast cancer and venous thromboembolism in postmenopausal women receiving estrogens; vaginal MP prevents endometrial proliferation in the short term but the long-term effects in MHT remain to be established; (4) investigation into the use of intrauterine levonorgestrel-releasing devices (LNG-IUDs), which are an attractive form of MHT in perimenopausal women, providing contraception and reducing uterine bleeding, although the risk of breast cancer with LNG-IUDs requires clarification. Women in the future can look forward to a symptom-free menopause and to safer and more beneficial MHT.
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Affiliation(s)
- D A Davey
- a Faculty of Health Sciences , University of Cape Town , Western Cape , South Africa
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29
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Doherty JA, Jensen A, Kelemen LE, Pearce CL, Poole E, Schildkraut JM, Terry KL, Tworoger SS, Webb PM, Wentzensen N. Current Gaps in Ovarian Cancer Epidemiology: The Need for New Population-Based Research. J Natl Cancer Inst 2017; 109:3847624. [PMID: 29117355 DOI: 10.1093/jnci/djx144] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 06/19/2017] [Indexed: 12/25/2022] Open
Abstract
With recent ovarian cancer screening studies showing no clinically significant mortality benefit, preventing this disease, identifying high-risk populations, and extending survival remain priorities. However, several challenges are impeding progress in ovarian cancer research. With most studies capturing exposure information from 10 or more years ago, evaluation of how changing patterns of exposures, such as new oral contraceptive formulations and increased intrauterine device use, might influence ovarian cancer risk and survival is difficult. Risk factors for ovarian cancer should be evaluated in the context of tumor histotypes, which have unique molecular features and cells of origin; this is a task that requires large collaborative studies to achieve meaningful sample sizes. Importantly, identification of novel modifiable risk factors, in addition to those currently known to reduce risk (eg, childbearing, tubal ligation, oral contraceptive use), is needed; this is not feasibly implemented at a population level. In this Commentary, we describe important gaps in knowledge and propose new approaches to advance epidemiologic research to improve ovarian cancer prevention and survival, including updated classification of tumors, collection of data on changing and novel exposures, longer follow-up on existing studies, evaluation of diverse populations, development of better risk prediction models, and collaborating prospectively with consortia to develop protocols for new studies that will allow seamless integration for future pooled analyses.
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Affiliation(s)
| | - Jennifer A Doherty
- Affiliations of authors: Huntsman Cancer Institute, Department of Population Health Sciences, University of Utah, Salt Lake City, UT (JAD); Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark (AJ); Department of Public Health Sciences and Hollings Cancer Center, Medical University of South Carolina, Charleston, SC (LEK); Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI (CLP); Department of Preventive Medicine, Keck School of Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA (CLP); Channing Division of Network Medicine (EP, SST) and Obstetrics and Gynecology Epidemiology Center (KLT), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (EP, SST, KLT); Department of Public Health Sciences, University of Virginia, Charlottesville, CA (JMS); Population Health Department, QIMR Berghofer Medical Research Institute, Herston, Australia (PMW); Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD (NW)
| | - Allan Jensen
- Affiliations of authors: Huntsman Cancer Institute, Department of Population Health Sciences, University of Utah, Salt Lake City, UT (JAD); Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark (AJ); Department of Public Health Sciences and Hollings Cancer Center, Medical University of South Carolina, Charleston, SC (LEK); Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI (CLP); Department of Preventive Medicine, Keck School of Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA (CLP); Channing Division of Network Medicine (EP, SST) and Obstetrics and Gynecology Epidemiology Center (KLT), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (EP, SST, KLT); Department of Public Health Sciences, University of Virginia, Charlottesville, CA (JMS); Population Health Department, QIMR Berghofer Medical Research Institute, Herston, Australia (PMW); Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD (NW)
| | - Linda E Kelemen
- Affiliations of authors: Huntsman Cancer Institute, Department of Population Health Sciences, University of Utah, Salt Lake City, UT (JAD); Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark (AJ); Department of Public Health Sciences and Hollings Cancer Center, Medical University of South Carolina, Charleston, SC (LEK); Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI (CLP); Department of Preventive Medicine, Keck School of Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA (CLP); Channing Division of Network Medicine (EP, SST) and Obstetrics and Gynecology Epidemiology Center (KLT), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (EP, SST, KLT); Department of Public Health Sciences, University of Virginia, Charlottesville, CA (JMS); Population Health Department, QIMR Berghofer Medical Research Institute, Herston, Australia (PMW); Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD (NW)
| | - Celeste L Pearce
- Affiliations of authors: Huntsman Cancer Institute, Department of Population Health Sciences, University of Utah, Salt Lake City, UT (JAD); Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark (AJ); Department of Public Health Sciences and Hollings Cancer Center, Medical University of South Carolina, Charleston, SC (LEK); Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI (CLP); Department of Preventive Medicine, Keck School of Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA (CLP); Channing Division of Network Medicine (EP, SST) and Obstetrics and Gynecology Epidemiology Center (KLT), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (EP, SST, KLT); Department of Public Health Sciences, University of Virginia, Charlottesville, CA (JMS); Population Health Department, QIMR Berghofer Medical Research Institute, Herston, Australia (PMW); Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD (NW)
| | - Elizabeth Poole
- Affiliations of authors: Huntsman Cancer Institute, Department of Population Health Sciences, University of Utah, Salt Lake City, UT (JAD); Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark (AJ); Department of Public Health Sciences and Hollings Cancer Center, Medical University of South Carolina, Charleston, SC (LEK); Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI (CLP); Department of Preventive Medicine, Keck School of Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA (CLP); Channing Division of Network Medicine (EP, SST) and Obstetrics and Gynecology Epidemiology Center (KLT), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (EP, SST, KLT); Department of Public Health Sciences, University of Virginia, Charlottesville, CA (JMS); Population Health Department, QIMR Berghofer Medical Research Institute, Herston, Australia (PMW); Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD (NW)
| | - Joellen M Schildkraut
- Affiliations of authors: Huntsman Cancer Institute, Department of Population Health Sciences, University of Utah, Salt Lake City, UT (JAD); Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark (AJ); Department of Public Health Sciences and Hollings Cancer Center, Medical University of South Carolina, Charleston, SC (LEK); Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI (CLP); Department of Preventive Medicine, Keck School of Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA (CLP); Channing Division of Network Medicine (EP, SST) and Obstetrics and Gynecology Epidemiology Center (KLT), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (EP, SST, KLT); Department of Public Health Sciences, University of Virginia, Charlottesville, CA (JMS); Population Health Department, QIMR Berghofer Medical Research Institute, Herston, Australia (PMW); Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD (NW)
| | - Kathryn L Terry
- Affiliations of authors: Huntsman Cancer Institute, Department of Population Health Sciences, University of Utah, Salt Lake City, UT (JAD); Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark (AJ); Department of Public Health Sciences and Hollings Cancer Center, Medical University of South Carolina, Charleston, SC (LEK); Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI (CLP); Department of Preventive Medicine, Keck School of Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA (CLP); Channing Division of Network Medicine (EP, SST) and Obstetrics and Gynecology Epidemiology Center (KLT), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (EP, SST, KLT); Department of Public Health Sciences, University of Virginia, Charlottesville, CA (JMS); Population Health Department, QIMR Berghofer Medical Research Institute, Herston, Australia (PMW); Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD (NW)
| | - Shelley S Tworoger
- Affiliations of authors: Huntsman Cancer Institute, Department of Population Health Sciences, University of Utah, Salt Lake City, UT (JAD); Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark (AJ); Department of Public Health Sciences and Hollings Cancer Center, Medical University of South Carolina, Charleston, SC (LEK); Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI (CLP); Department of Preventive Medicine, Keck School of Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA (CLP); Channing Division of Network Medicine (EP, SST) and Obstetrics and Gynecology Epidemiology Center (KLT), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (EP, SST, KLT); Department of Public Health Sciences, University of Virginia, Charlottesville, CA (JMS); Population Health Department, QIMR Berghofer Medical Research Institute, Herston, Australia (PMW); Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD (NW)
| | - Penelope M Webb
- Affiliations of authors: Huntsman Cancer Institute, Department of Population Health Sciences, University of Utah, Salt Lake City, UT (JAD); Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark (AJ); Department of Public Health Sciences and Hollings Cancer Center, Medical University of South Carolina, Charleston, SC (LEK); Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI (CLP); Department of Preventive Medicine, Keck School of Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA (CLP); Channing Division of Network Medicine (EP, SST) and Obstetrics and Gynecology Epidemiology Center (KLT), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (EP, SST, KLT); Department of Public Health Sciences, University of Virginia, Charlottesville, CA (JMS); Population Health Department, QIMR Berghofer Medical Research Institute, Herston, Australia (PMW); Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD (NW)
| | - Nicolas Wentzensen
- Affiliations of authors: Huntsman Cancer Institute, Department of Population Health Sciences, University of Utah, Salt Lake City, UT (JAD); Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark (AJ); Department of Public Health Sciences and Hollings Cancer Center, Medical University of South Carolina, Charleston, SC (LEK); Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI (CLP); Department of Preventive Medicine, Keck School of Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA (CLP); Channing Division of Network Medicine (EP, SST) and Obstetrics and Gynecology Epidemiology Center (KLT), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (EP, SST, KLT); Department of Public Health Sciences, University of Virginia, Charlottesville, CA (JMS); Population Health Department, QIMR Berghofer Medical Research Institute, Herston, Australia (PMW); Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD (NW)
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ASPECTOS REPRODUCTIVOS EN MUJERES PORTADORAS DE MUTACIONES GENÉTICAS BRCA. REVISTA MÉDICA CLÍNICA LAS CONDES 2017. [DOI: 10.1016/j.rmclc.2017.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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31
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Pickar JH, Archer DF, Kagan R, Pinkerton JV, Taylor HS. Safety and benefit considerations for menopausal hormone therapy. Expert Opin Drug Saf 2017; 16:941-954. [DOI: 10.1080/14740338.2017.1343298] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- James H Pickar
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, USA
| | - David F Archer
- Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Risa Kagan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco and East Bay Physicians Medical Group, Sutter East Bay Medical Foundation, Berkeley, CA, USA
| | - JoAnn V Pinkerton
- Department of Obstetrics and Gynecology, University of Virginia Health System, Charlottesville, VA, USA
| | - Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
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Abstract
Most women use hormonal contraception for more than 30 years and for many, this may involve exposure in their older reproductive years when baseline breast cancer risk rises steeply. Overall, the risk of breast cancer diagnosis with exposure to hormonal contraception is very small and outweighed by its contraceptive benefits but despite this, there are still outstanding questions for all methods used in clinical practice due to paucity of available evidence, lack of which should not be taken to imply safety. This is exemplified by the following assumptions: the progestogen-only pill and long-acting reversible contraceptives are 'breast-safe' options in peri-menopausal women, use of the levonorgestrel intrauterine system for the management of endometrial pathology in breast cancer survivors is less likely to promote disease recurrence and the benefit all hormonal contraceptive methods confer in reducing unplanned pregnancy in women at high familial risk outweigh the risk of breast cancer diagnosis. There is no data on risk with the concurrent prescription of hormone replacement therapy in women exhibiting climacteric symptoms who are still menstruating. Advice of GPs and Community Sexual & Reproductive Health specialists will inevitably be sought about some or all these issues and in the absence of conclusive evidence from clinical studies, caution should be applied and women counselled appropriately.
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Affiliation(s)
- Jo Marsden
- King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
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Yang Z, Hu Y, Zhang J, Xu L, Zeng R, Kang D. Estradiol therapy and breast cancer risk in perimenopausal and postmenopausal women: a systematic review and meta-analysis. Gynecol Endocrinol 2017; 33:87-92. [PMID: 27898258 DOI: 10.1080/09513590.2016.1248932] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To investigate the association between estradiol therapy and incidence of breast cancer, taking into consideration of different types of combined progestogen, the duration of exposure and the type of regimen. METHOD A systematic review and meta-analysis. RESULT A total of 14 studies were included in our study. In estradiol-only therapy analysis, meta-analysis resulted a pooled OR =0.90, 95% CI (0.40, 2.02) from the RCTs and pooled OR = 1.11, 95% CI (0.98, 1.27) from observational studies. However, in the analysis of estradiol-progestogen therapy, the risk of breast cancer varies according to the type of progestogen and the duration with more than five years (OR = 2.43, 95% CI (1.79, 3.29)) presented a higher risk than using less than five years (OR = 1.49, 95% CI (1.03, 2.15)). CONCLUSIONS Estradiol-only therapy carries no risk for breast cancer, while the breast cancer risk varies according to the type of progestogen. Estradiol therapy combined with medroxyprogesterone, norethisterone and levonorgestrel related to an increased risk of breast cancer, estradiol therapy combined with dydrogesterone and progesterone carries no risk. The breast cancer risk rise progressively by prolonged use, furthermore, comparing to sequential therapy, continuous therapy carries a higher risk.
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Affiliation(s)
- Zhilan Yang
- a Department of Obstetrics and Gynecology , West China Second University Hospital, Sichuan University , Chengdu , PR China and
| | - Ying Hu
- a Department of Obstetrics and Gynecology , West China Second University Hospital, Sichuan University , Chengdu , PR China and
| | - Jing Zhang
- a Department of Obstetrics and Gynecology , West China Second University Hospital, Sichuan University , Chengdu , PR China and
| | - Liangzhi Xu
- a Department of Obstetrics and Gynecology , West China Second University Hospital, Sichuan University , Chengdu , PR China and
| | - Rujun Zeng
- a Department of Obstetrics and Gynecology , West China Second University Hospital, Sichuan University , Chengdu , PR China and
| | - Deying Kang
- b Department of Epidemiology , Sichuan University , Chengdu , PR China
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Ellingjord-Dale M, Vos L, Tretli S, Hofvind S, Dos-Santos-Silva I, Ursin G. Parity, hormones and breast cancer subtypes - results from a large nested case-control study in a national screening program. Breast Cancer Res 2017; 19:10. [PMID: 28114999 PMCID: PMC5259848 DOI: 10.1186/s13058-016-0798-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 12/22/2016] [Indexed: 12/29/2022] Open
Abstract
Background Breast cancer comprises several molecular subtypes with different prognoses and possibly different etiology. Reproductive and hormonal factors are associated with breast cancer overall, and with luminal subtypes, but the associations with other subtypes are unclear. We used data from a national screening program to conduct a large nested case-control study. Methods We conducted a nested case-control study on participants in the Norwegian Breast Cancer Screening Program in 2006 − 2014. There was information on estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) for 4748 cases of breast cancer. Breast cancer subtypes were defined as luminal A-like (ER+ PR+ HER2-), luminal B-like (ER+ PR- HER2- or ER+ PR+/PR-HER2+), HER2-positive (ER- PR- HER2+) and triple-negative (ER- PR- HER2-). Conditional logistic regression was used to estimate odds ratios (ORs) of breast cancer associated with age at first birth, number of pregnancies, oral contraceptive use, intrauterine devices and menopausal hormone therapy. Analyses were adjusted for age, body mass index, education, age at menarche, number of pregnancies and menopausal status. Results Number of pregnancies was inversely associated with relative risk of luminal-like breast cancers (p-trend ≤0.02), and although not statistically significant, with HER2-positive (OR = 0.60, 95% CI 0.31–1.19) and triple-negative cancer (OR = 0.70, 95% CI 0.41–1.21). Women who had ≥4 pregnancies were at >40% lower risk of luminal-like and HER2-positive cancers than women who had never been pregnant. However, there was a larger discrepancy between tumor subtypes with menopausal hormone use. Women who used estrogen and progesterone therapy (EPT) had almost threefold increased risk of luminal A-like cancer (OR = 2.92, 95% CI 2.36–3.62) compared to never-users, but were not at elevated risk of HER2-positive (OR = 0.88, 95% CI 0.33–2.30) or triple-negative (OR = 0.92, 95% CI 0.43 − 1.98) subtypes. Conclusions Reproductive factors were to some extent associated with all subtypes; the strongest trends were with luminal-like subtypes. Hormone therapy use was strongly associated with risk of luminal-like breast cancer, and less so with risk of HER2-positive or triple-negative cancer. There are clearly some, but possibly limited, etiologic differences between subtypes, with the greatest contrast between luminal A-like and triple-negative subtypes. Trial registration Not applicable.
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Affiliation(s)
| | - Linda Vos
- Cancer Registry of Norway, Oslo, Norway
| | | | | | - Isabel Dos-Santos-Silva
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Giske Ursin
- Cancer Registry of Norway, Oslo, Norway. .,University of Oslo, Oslo, Norway. .,University of Southern California, Los Angeles, CA, USA.
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Carroll JS, Hickey TE, Tarulli GA, Williams M, Tilley WD. Deciphering the divergent roles of progestogens in breast cancer. Nat Rev Cancer 2017; 17:54-64. [PMID: 27885264 DOI: 10.1038/nrc.2016.116] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Most breast cancers are driven by oestrogen receptor-α. Anti-oestrogenic drugs are the standard treatment for these breast cancers; however, treatment resistance is common, necessitating new therapeutic strategies. Recent preclinical and historical clinical studies support the use of progestogens to activate the progesterone receptor (PR) in breast cancers. However, widespread controversy exists regarding the role of progestogens in this disease, hindering the clinical implementation of PR-targeted therapies. Herein, we present and discuss data at the root of this controversy and clarify the confusion and misinterpretations that have consequently arisen. We then present our view on how progestogens may be safely and effectively used in treating breast cancer.
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Affiliation(s)
- Jason S Carroll
- Cancer Research UK Cambridge Institute, University of Cambridge, Robinson Way, Cambridge CB2 0RE, UK
| | - Theresa E Hickey
- Dame Roma Mitchell Cancer Research Laboratories, Hanson Institute and School of Medicine, University of Adelaide, Adelaide SA 5005, Australia
| | - Gerard A Tarulli
- Dame Roma Mitchell Cancer Research Laboratories, Hanson Institute and School of Medicine, University of Adelaide, Adelaide SA 5005, Australia
| | - Michael Williams
- Division of Epidemiology, Department of Public Health and Preventive Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, Oregon 97239-3098, USA
| | - Wayne D Tilley
- Dame Roma Mitchell Cancer Research Laboratories, Hanson Institute and School of Medicine, University of Adelaide, Adelaide SA 5005, Australia
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Roberts H, Hickey M. Managing the menopause: An update. Maturitas 2016; 86:53-8. [DOI: 10.1016/j.maturitas.2016.01.007] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 01/12/2016] [Accepted: 01/13/2016] [Indexed: 02/07/2023]
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Black A, Guilbert E, Costescu D, Dunn S, Fisher W, Kives S, Mirosh M, Norman W, Pymar H, Reid R, Roy G, Varto H, Waddington A, Wagner MS, Whelan AM, Mansouri S. Canadian Contraception Consensus (Part 3 of 4): Chapter 7--Intrauterine Contraception. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:182-222. [PMID: 27032746 DOI: 10.1016/j.jogc.2015.12.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. OUTCOMES Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada. EVIDENCE Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). CHAPTER 7: INTRAUTERINE CONTRACEPTION: SUMMARY STATEMENTS 1. Intrauterine contraceptives are as effective as permanent contraception methods. (II-2) 2. The use of levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg by patients taking tamoxifen is not associated with recurrence of breast cancer. (I) 3. Intrauterine contraceptives have a number of noncontraceptive benefits. The levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg significantly decreases menstrual blood loss (I) and dysmenorrhea. (II-2) Both the copper intrauterine device and the LNG-IUS significantly decrease the risk of endometrial cancer. (II-2) 4. The risk of uterine perforation decreases with inserter experience but is higher in postpartum and breastfeeding women. (II-2) 5. The risk of pelvic inflammatory disease (PID) is increased slightly in the first month after intrauterine contraceptive (IUC) insertion, but the absolute risk is low. Exposure to sexually transmitted infections and not the IUC itself is responsible for PID occurring after the first month of use. (II-2) 6. Nulliparity is not associated with an increased risk of intrauterine contraceptive expulsion. (II-2) 7. Ectopic pregnancy with an intrauterine contraceptive (IUC) is rare, but when a pregnancy occurs with an IUC in situ, it is an ectopic pregnancy in 15% to 50% of the cases. (II-2) 8. In women who conceive with an intrauterine contraceptive (IUC) in place, early IUC removal improves outcomes but does not entirely eliminate risks. (II-2) 9. Intrauterine contraceptives do not increase the risk of infertility. (II-2) 10. Immediate insertion of an intrauterine contraceptive (10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher continuation rate compared with insertion at 6 weeks postpartum. (I) 11. Immediate insertion of an intrauterine contraceptive (IUC; 10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher risk of expulsion. (I) The benefit of inserting an IUC immediately postpartum or post-Caesarean section outweighs the disadvantages of increased risk of perforation and expulsion. (II-C) 12. Insertion of an intrauterine contraceptive in breastfeeding women is associated with a higher risk of uterine perforation in the first postpartum year. (II-2) 13. Immediate insertion of an intrauterine contraceptive (IUC) post-abortion significantly reduces the risk of repeat abortion (II-2) and increases IUC continuation rates at 6 months. (I) 14. Antibiotic prophylaxis for intrauterine contraceptive insertion does not significantly reduce postinsertion pelvic infection. (I) RECOMMENDATIONS: 1. Health care professionals should be careful not to restrict access to intrauterine contraceptives (IUC) owing to theoretical or unproven risks. (III-A) Health care professionals should offer IUCs as a first-line method of contraception to both nulliparous and multiparous women. (II-2A) 2. In women seeking intrauterine contraception (IUC) and presenting with heavy menstrual bleeding and/or dysmenorrhea, health care professionals should consider the use of the levonorgestrel intrauterine system 52 mg over other IUCs. (I-A) 3. Patients with breast cancer taking tamoxifen may consider a levonorgestrel-releasing intrauterine system 52 mg after consultation with their oncologist. (I-A) 4. Women requesting a levonorgestrel-releasing intrauterine system or a copper-intrauterine device should be counseled regarding changes in bleeding patterns, sexually transmitted infection risk, and duration of use. (III-A) 5. A health care professional should be reasonably certain that the woman is not pregnant prior to inserting an intrauterine contraceptive at any time during the menstrual cycle. (III-A) 6. Health care providers should consider inserting an intrauterine contraceptive immediately after an induced abortion rather than waiting for an interval insertion. (I-B) 7. In women who conceive with an intrauterine contraceptive (IUC) in place, the diagnosis of ectopic pregnancy should be excluded as arly as possible. (II-2A) Once an ectopic pregnancy has been excluded, the IUC should be removed without an invasive procedure. The IUC may be removed at the time of a surgical termination. (II-2B) 8. In the case of pelvic inflammatory disease, it is not necessary to remove the intrauterine contraceptive unless there is no clinical improvement after 48 to 72 hours of appropriate antibiotic treatment. (II-2B) 9. Routine antibiotic prophylaxis for intrauterine contraceptive (IUC) insertion is not indicated. (I-B) Health care providers should perform sexually transmitted infection (STI) testing in women at high risk of STI at the time of IUC insertion. If the test is positive for chlamydia and/or gonorrhea, the woman should be appropriately treated postinsertion and the IUC can remain in situ. (II-2B) 10. Unscheduled bleeding in intrauterine contraception users, when persistent or associated with pelvic pain, should be investigated to rule out infection, pregnancy, gynecological pathology, expulsion or malposition. (III-A)
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Heikkinen S, Koskenvuo M, Malila N, Sarkeala T, Pukkala E, Pitkäniemi J. Use of exogenous hormones and the risk of breast cancer: results from self-reported survey data with validity assessment. Cancer Causes Control 2015; 27:249-58. [PMID: 26667320 DOI: 10.1007/s10552-015-0702-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/26/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Main aim was to estimate the association between use of exogenous hormones and breast cancer (BC) risk in a large population-based survey, and to assess the representativeness and overall validity of the data. METHODS The survey 'Women's Health and Use of Hormones' was conducted in Finland in 2009, including 7,000 BC cases and 20,000 matched population controls. Conditional logistic regression was used to estimate odds ratios and their 95 % confidence interval. For validation, exposure prevalences were compared with population data from Statistics Finland and two large population-based surveys. RESULTS We found positive associations with BC risk and exclusive use of hormone-releasing intrauterine device (HR IUD) in postmenopausal women (1.48, 95 % CI 1.10-1.99), when compared to never-users of any hormonal contraceptive and considering only prediagnostic use in cases. Regarding use of other hormonal contraceptives (HC), a positive association between long HC use (≥2 years) and BC was observed in both groups, OR being 1.37 (95 % CI 1.12-1.68) for premenopausal and 1.11 (95 % CI 1.03-1.20) for postmenopausal women, when compared to never-users of other HC. CONCLUSIONS Observed association between HR IUD use and risk of BC in postmenopausal women is worrying and deserves further attention. Selection bias seemed not to explain this result. Considering the increasing popularity of HR IUD use in, e.g., USA, impact of possible adverse effects in public health could be significant.
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Affiliation(s)
- Sanna Heikkinen
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Unioninkatu 22, 00130, Helsinki, Finland.
| | - Markku Koskenvuo
- Department of Public Health, Hjelt Institute, University of Helsinki, Mannerheimintie 172, PO Box 41, 00014, Helsinki, Finland
| | - Nea Malila
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Unioninkatu 22, 00130, Helsinki, Finland.,School of Health Sciences, University of Tampere, 33014, Tampere, Finland
| | - Tytti Sarkeala
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Unioninkatu 22, 00130, Helsinki, Finland
| | - Eero Pukkala
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Unioninkatu 22, 00130, Helsinki, Finland.,School of Health Sciences, University of Tampere, 33014, Tampere, Finland
| | - Janne Pitkäniemi
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Unioninkatu 22, 00130, Helsinki, Finland.,Department of Public Health, Hjelt Institute, University of Helsinki, Mannerheimintie 172, PO Box 41, 00014, Helsinki, Finland
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Dominick S, Hickey M, Chin J, Su HI. Levonorgestrel intrauterine system for endometrial protection in women with breast cancer on adjuvant tamoxifen. Cochrane Database Syst Rev 2015; 2015:CD007245. [PMID: 26649916 PMCID: PMC6823262 DOI: 10.1002/14651858.cd007245.pub3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Adjuvant tamoxifen reduces the risk of breast cancer recurrence in women with oestrogen receptor-positive breast cancer. Tamoxifen also increases the risk of postmenopausal bleeding, endometrial polyps, hyperplasia, and endometrial cancer. The levonorgestrel-releasing intrauterine system (LNG-IUS) causes profound endometrial suppression. This systematic review considered the evidence that the LNG-IUS prevents the development of endometrial pathology in women taking tamoxifen as adjuvant endocrine therapy for breast cancer. OBJECTIVES To determine the effectiveness and safety of levonorgestrel intrauterine system (LNG-IUS) in pre- and postmenopausal women taking adjuvant tamoxifen following breast cancer for the outcomes of endometrial and uterine pathology including abnormal vaginal bleeding or spotting, and secondary breast cancer events. SEARCH METHODS We searched the following databases: Cochrane Menstrual Disorders and Subfertility Group Specialised Register (MDSG), Cochrane Breast Cancer Group Specialised Register (CBCG), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Abstracts of Reviews of Effects (DARE), The Cochrane Library, clinicaltrials.gov, The World Health Organisation International Trials Registry, ProQuest Dissertations & Theses, MEDLINE, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycINFO, Web of Science, OpenGrey, LILACS, PubMed, and Google. The final search was performed in October 2015. SELECTION CRITERIA Randomised controlled trials of women with breast cancer on adjuvant tamoxifen that compared endometrial surveillance alone (control condition) versus the LNG-IUS with endometrial surveillance (experimental condition) on the incidence of endometrial pathology. DATA COLLECTION AND ANALYSIS Study selection, risk of bias assessment and data extraction were performed independently by two review authors. The primary outcome measure was endometrial pathology (including polyps, endometrial hyperplasia, or endometrial cancer) diagnosed at hysteroscopy or endometrial biopsy. Secondary outcome measures included fibroids, abnormal vaginal bleeding or spotting, breast cancer recurrence, and breast cancer-related deaths. The overall quality of evidence was rated using GRADE methods. MAIN RESULTS Four randomised controlled trials involving 543 women were identified and are included in this review. In the included studies, the active treatment arm was the 20 μg/day levonorgestrel-releasing intrauterine system (LNG-IUS) plus endometrial surveillance; the control arm was endometrial surveillance alone. In tamoxifen users, the LNG-IUS led to a reduction in the incidence of endometrial polyps over both a 12-month period (Peto OR 0.22, 95% CI 0.08 to 0.64, 2 studies, n = 212, I² = 0%) and over a long-term follow-up period (24 to 60 months) (Peto OR 0.22, 95% CI 0.13 to 0.39, 4 studies, n = 417, I² = 0%, moderate quality evidence). Also the LNG-IUS led to a reduction in the incidence of endometrial hyperplasia over a long-term follow-up period (24 to 60 months) (Peto OR 0.13, 95% CI 0.03 to 0.67, four studies, n = 417, I² = 0%, moderate quality evidence). However, it should be noted that the number of events of endometrial hyperplasia was low (n = 6). None of the trials were sufficiently powered to detect whether LNG-IUS leads to significant changes in the incidence of endometrial cancer in tamoxifen users. At 12 months of follow-up abnormal vaginal bleeding or spotting was more common in the LNG-IUS treatment group (Peto OR 7.26, 95% CI 3.37 to 15.66, 3 studies, n = 376, I² = 0%, moderate quality evidence). By 24 months of follow-up, abnormal vaginal bleeding or spotting occurred less frequently compared to 12 months of follow-up in the LNG-IUS treatment group but was still more common than the control group (Peto OR 2.72, 95% CI 1.04 to 7.10, 2 studies, n = 233, I² = 0%, moderate quality evidence). By 60 months of follow-up, no cases of abnormal vaginal bleeding or spotting were reported in either group. The numbers of events for the following outcomes were low: fibroids (n = 13), breast cancer recurrence (n = 18), and breast cancer-related deaths (n = 16). There was no evidence of a difference between the LNG-IUS treatment group and controls for these outcomes. The quality of the evidence was judged as moderate, due to limited sample sizes and low event rates for the outcome comparisons. AUTHORS' CONCLUSIONS The LNG-IUS reduces the incidence of benign endometrial polyps and endometrial hyperplasia in women with breast cancer taking tamoxifen. At 12 and 24 months of follow-up, the LNG-IUS increased abnormal vaginal bleeding or spotting among women in the treatment group compared to those in the control. There is no clear evidence from the available randomised controlled trials that the LNG-IUS prevents endometrial cancer in these women. There is no clear evidence from the available randomised controlled trials that the LNG-IUS affects the risk of breast cancer recurrence or breast cancer-related deaths. Larger studies are necessary to assess the effects of the LNG-IUS on the incidence of endometrial cancer, and to determine whether the LNG-IUS might have an impact on the risk of secondary breast cancer events.
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Affiliation(s)
- Sally Dominick
- University of California, San DiegoMoores UCSD Cancer CenterLa JollaCaliforniaUSA92093
| | - Martha Hickey
- The Royal Women's HospitalThe University of MelbourneLevel 7, Research PrecinctMelbourneVictoriaAustraliaParkville 3052
| | - Jason Chin
- King Edward Memorial Hospital/SJOG Murdoch HospitalPerthWAAustraliaWA6008
| | - H Irene Su
- University of California, San DiegoDepartment of Reproductive MedicineLa JollaCaliforniaUSA92093
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Koskela-Niska V, Pukkala E, Lyytinen H, Ylikorkala O, Dyba T. Postmenopausal hormone therapy-also use of estradiol plus levonorgestrel-intrauterine system is associated with an increased risk of primary fallopian tube carcinoma. Int J Cancer 2015; 137:1947-52. [PMID: 25846583 DOI: 10.1002/ijc.29549] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 03/15/2015] [Accepted: 03/23/2015] [Indexed: 11/08/2022]
Abstract
Data on the possible impact of postmenopausal hormone therapy (HT) on the incidence of rare primary fallopian tube carcinoma (PFTC) are scarce. Therefore, we conducted a nationwide case-control study analyzing the association between the use of different HTs and PFTC. All women aged 50 years or older with an incident PFTC (n = 360) during 1995-2007 were identified from the Finnish Cancer Registry. For each case of PFTC, ten age- and place of residence-matched controls were selected from the Finnish National Population Register, which also provided information on parity. Data on HT purchases were received from the Prescription Register, and data on hysterectomies and sterilizations from the National Care Register. Controls with a salpingectomy before the PFTC diagnosis of the respective case were excluded. The PFTC risk in relation to different HTs was estimated with a conditional logistic regression model, adjusted for parity, age at last delivery, hysterectomy and sterilization. The use for five years or more of estradiol combined with levonorgestrel-releasing-intrauterine system (odds ratio 2.84, 95% confidence interval 1.10-7.38) and sequential estradiol-progestin therapy (EPT; 3.37; 2.23-5.08) were both linked with increases in the risk of PFTC, while the risk with use of estradiol-only therapy or continuous EPT was not statistically significantly increased. The OR for the use of tibolone for one year or more was 1.56 (0.55-4.41). The use of HT is related to an increased risk of PFTC, particularly when a progestin component is intrauterine or systemic progestin is given in sequential manner.
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Affiliation(s)
- Virpi Koskela-Niska
- Department of Obstetrics and Gynecology, Helsinki University Hospital, FI-00029 HUS, Finland
| | - Eero Pukkala
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Unioninkatu 20, Helsinki, FI-00130, Finland.,School of Health Sciences, FI-33014 University of Tampere, Finland
| | - Heli Lyytinen
- Department of Obstetrics and Gynecology, Helsinki University Hospital, FI-00029 HUS, Finland
| | - Olavi Ylikorkala
- Department of Obstetrics and Gynecology, Helsinki University Hospital, FI-00029 HUS, Finland
| | - Tadeusz Dyba
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Unioninkatu 20, Helsinki, FI-00130, Finland.,Public Health-Cancer Policy Support, European Commission DG Joint Research Centre, Institute for Health and Consumer Protection, Ispra, I-21027, Italy
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Soini T, Hurskainen R, Grénman S, Mäenpää J, Paavonen J, Joensuu H, Pukkala E. Levonorgestrel-releasing intrauterine system and the risk of breast cancer: A nationwide cohort study. Acta Oncol 2015; 55:188-92. [PMID: 26243443 DOI: 10.3109/0284186x.2015.1062538] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Prolonged steroid hormone therapy increases the risk of breast cancer, especially the risk of lobular cancer, but the effect of the levonorgestrel-releasing intrauterine system (LNG-IUS) use is controversial. In this study we aimed to test the hypothesis that risk for lobular breast cancer is elevated among LNG-IUS users. MATERIAL AND METHODS We identified from the national Medical Reimbursement Registry of Finland the women aged 30-49 who had used LNG-IUS for the treatment or prevention of menorrhagia in 1994-2007, and from the Finnish Cancer Registry breast cancers diagnosed before the age of 55 and by the end of 2012. RESULTS A total of 2015 women had breast cancer diagnosed in a cohort of 93 843 LNG-IUS users during follow-up consisting of 1 032 767 women-years. The LNG-IUS users had an increased risk for both ductal breast cancer [standardized incidence ratio (SIR) 1.20, 95% confidence interval (CI) 1.14-1.25] and for lobular breast cancer (SIR 1.33, 95% CI 1.20-1.46), as compared with the general female population. The highest risk was found in LNG-IUS users who purchased the device at least twice, whose SIR for lobular cancer was 1.73 (95% CI 1.37-2.15). CONCLUSIONS The results imply that intrauterine administration of levonorgestrel is not only related to an excess risk of lobular breast cancer but also, in contrary to previous assumptions, to an excess risk of ductal breast cancer.
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Affiliation(s)
- Tuuli Soini
- a Department of Obstetrics and Gynecology , Hyvinkää Hospital , Hyvinkää , Finland
| | - Ritva Hurskainen
- b Department of Obstetrics and Gynecology , Hyvinkää Hospital , Hyvinkää , Finland
| | - Seija Grénman
- c Department of Obstetrics and Gynecology , Turku University Hospital , Turku , Finland
- d University of Turku , Turku , Finland
| | - Johanna Mäenpää
- e School of Medicine, University of Tampere, University of Tampere , Finland
- f Department of Obstetrics and Gynecology , Tampere University Hospital , Tampere , Finland
| | - Jorma Paavonen
- g Department of Obstetrics and Gynecology , Helsinki University Hospital , Helsinki , Finland
- h University of Helsinki , Helsinki , Finland
| | - Heikki Joensuu
- i Department of Oncology , Comprehensive Cancer Center, Helsinki University Hospital , Helsinki , Finland
- j Department of Oncology , University of Helsinki , Helsinki , Finland
| | - Eero Pukkala
- k School of Health Sciences, University of Tampere, University of Tampere , Finland
- l Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research , Helsinki , Finland
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Affiliation(s)
- Risto Erkkola
- Professor Emeritus, Department of Obstetrics and Gynecology, University Central Hospital , Turku , Finland .
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Andersen L, Friis S, Hallas J, Ravn P, Kristensen BW, Gaist D. Hormonal contraceptive use and risk of glioma among younger women: a nationwide case-control study. Br J Clin Pharmacol 2015; 79:677-84. [PMID: 25345919 PMCID: PMC4386952 DOI: 10.1111/bcp.12535] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 10/20/2014] [Indexed: 11/30/2022] Open
Abstract
AIM Oral contraceptive use influences the risk for certain cancers. However, few studies have examined any link with risk of central nervous system tumours. We investigated the association between hormonal contraceptive use and glioma risk among premenopausal women in a population-based setting. METHODS Using national administrative and health registries in Denmark to conduct a nationwide case-control study, we identified all women ages 15 to 49 years with a first time diagnosis of histologically verified glioma between 2000 and 2009. Each case was age-matched to eight population controls using risk set sampling. Based on prescription data, exposure until 2 years prior to the index date was categorized according to hormonal contraceptive type, i.e. combined oestrogen-progestagen or progestagen only, and duration of use (<1, 1 to <5, ≥5 years). We used conditional logistic regression to compute odds ratios (ORs) with 95% confidence intervals (CIs) for glioma associated with hormonal contraceptive use, adjusting for potential confounders. RESULTS We identified 317 cases and 2126 controls. Ever use of hormonal contraceptive was associated with an OR of 1.5 (95% CI 1.2, 2.0) and the OR increased with duration of use (long term, ≥5 years: OR 1.9; 95% CI 1.2, 2.9). The association between long term hormonal contraceptive use and glioma risk was most pronounced for progestagen only therapy (OR 2.4; 95% CI 1.1, 5.1), especially when this regimen constituted the sole hormonal contraceptive therapy (OR 4.1; 95% CI 0.8, 20.8). CONCLUSION Long term hormonal contraceptive use may increase the risk of glioma.
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Affiliation(s)
- Lene Andersen
- Department of Neurology, Odense University HospitalSdr. Boulevard 29, 5000, Odense, Denmark
- Institute of Clinical Research, Faculty of Health Sciences, University of Southern DenmarkSdr. Boulevard 29, 5000, Odense, Denmark
| | - Søren Friis
- Danish Cancer Society Research CentreStrandboulevarden 49, 2100, Copenhagen, Denmark
- Department of Public Health, University of Copenhagen2100, Copenhagen, Denmark
- Institute of Clinical Medicine, Aarhus University Hospital8200, Aarhus N, Denmark
| | - Jesper Hallas
- Clinical Pharmacology, Institute of Public Health, University of Southern DenmarkJ.B. Winsløws Vej 19, 2.sal, 5000, Odense C, Denmark
| | - Pernille Ravn
- Department of Gynecology, Odense University HospitalSdr. Boulevard 29, 5000, Odense C, Denmark
- Institute of Clinical Research, Faculty of Health Sciences, University of Southern DenmarkSdr. Boulevard 29, 5000, Odense C, Denmark
| | - Bjarne W Kristensen
- Institute of Clinical Research, Faculty of Health Sciences, University of Southern DenmarkSdr. Boulevard 29, 5000, Odense C, Denmark
- Department of Pathology, Odense University HospitalSdr. Boulevard 29, 5000, Odense C, Denmark
| | - David Gaist
- Department of Neurology, Odense University HospitalSdr. Boulevard 29, 5000, Odense, Denmark
- Institute of Clinical Research, Faculty of Health Sciences, University of Southern DenmarkSdr. Boulevard 29, 5000, Odense, Denmark
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Abstract
Progesterone and progesterone receptors (PRs) are essential for the development and cyclical regulation of hormone-responsive tissues including the breast and reproductive tract. Altered functions of PR isoforms contribute to the pathogenesis of tumors that arise in these tissues. In the breast, progesterone acts in concert with estrogen to promote proliferative and pro-survival gene programs. In sharp contrast, progesterone inhibits estrogen-driven growth in the uterus and protects the ovary from neoplastic transformation. Progesterone-dependent actions and associated biology in diverse tissues and tumors are mediated by two PR isoforms, PR-A and PR-B. These isoforms are subject to altered transcriptional activity or expression levels, differential crosstalk with growth factor signaling pathways, and distinct post-translational modifications and cofactor-binding partners. Herein, we summarize and discuss the recent literature focused on progesterone and PR isoform-specific actions in breast, uterine, and ovarian cancers. Understanding the complexity of context-dependent PR actions in these tissues is critical to developing new models that will allow us to advance our knowledge base with the goal of revealing novel and efficacious therapeutic regimens for these hormone-responsive diseases.
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Affiliation(s)
- Caroline H Diep
- HematologyOncology, and Transplantation DivisionDepartments of MedicinePharmacologyMasonic Cancer Center, University of Minnesota, Delivery Code 2812, Cancer Cardiology Research Building, 2231 6th Street SE, Minneapolis, Minnesota 55455, USADivision of Physiology and GrowthDepartment of Animal Science, University of Minnesota, Minneapolis, Minnesota 55108, USA
| | - Andrea R Daniel
- HematologyOncology, and Transplantation DivisionDepartments of MedicinePharmacologyMasonic Cancer Center, University of Minnesota, Delivery Code 2812, Cancer Cardiology Research Building, 2231 6th Street SE, Minneapolis, Minnesota 55455, USADivision of Physiology and GrowthDepartment of Animal Science, University of Minnesota, Minneapolis, Minnesota 55108, USA
| | - Laura J Mauro
- HematologyOncology, and Transplantation DivisionDepartments of MedicinePharmacologyMasonic Cancer Center, University of Minnesota, Delivery Code 2812, Cancer Cardiology Research Building, 2231 6th Street SE, Minneapolis, Minnesota 55455, USADivision of Physiology and GrowthDepartment of Animal Science, University of Minnesota, Minneapolis, Minnesota 55108, USA
| | - Todd P Knutson
- HematologyOncology, and Transplantation DivisionDepartments of MedicinePharmacologyMasonic Cancer Center, University of Minnesota, Delivery Code 2812, Cancer Cardiology Research Building, 2231 6th Street SE, Minneapolis, Minnesota 55455, USADivision of Physiology and GrowthDepartment of Animal Science, University of Minnesota, Minneapolis, Minnesota 55108, USA
| | - Carol A Lange
- HematologyOncology, and Transplantation DivisionDepartments of MedicinePharmacologyMasonic Cancer Center, University of Minnesota, Delivery Code 2812, Cancer Cardiology Research Building, 2231 6th Street SE, Minneapolis, Minnesota 55455, USADivision of Physiology and GrowthDepartment of Animal Science, University of Minnesota, Minneapolis, Minnesota 55108, USA HematologyOncology, and Transplantation DivisionDepartments of MedicinePharmacologyMasonic Cancer Center, University of Minnesota, Delivery Code 2812, Cancer Cardiology Research Building, 2231 6th Street SE, Minneapolis, Minnesota 55455, USADivision of Physiology and GrowthDepartment of Animal Science, University of Minnesota, Minneapolis, Minnesota 55108, USA
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Depypere H, Inki P. The levonorgestrel-releasing intrauterine system for endometrial protection during estrogen replacement therapy: a clinical review. Climacteric 2015; 18:470-82. [DOI: 10.3109/13697137.2014.991302] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Comhaire FH, Depypere HT. Hormones, herbal preparations and nutriceuticals for a better life after the menopause: part I. Climacteric 2015; 18:358-63. [DOI: 10.3109/13697137.2014.985645] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
OBJECTIVE To examine the association between premenopausal use of the levonorgestrel-releasing intrauterine system and cancer incidence in Finland with a special focus on endometrial adenocarcinoma. METHODS All Finnish women aged 30-49 years using a levonorgestrel-releasing intrauterine system for treatment of menorrhagia in 1994-2007 (n=93,843) were identified from the National Reimbursement Registry and linked to the Finnish Cancer Registry data. The incidence of cancers in levonorgestrel-releasing intrauterine system users was compared with that in the general population. RESULTS A total of 2,781 cancer cases were detected in levonorgestrel-releasing intrauterine system users during the follow-up of 855,324 women-years. The standardized incidence ratio (observed-to-expected ratio) for endometrial adenocarcinoma was 0.50 (95% confidence interval [CI] 0.35-0.70; 34 observed compared with 68 expected cases) after the first levonorgestrel-releasing intrauterine system purchase and 0.25 (95% CI 0.05-0.73; three observed compared with 12 expected cases) after two purchases. The standardized incidence ratio for ovarian cancer was 0.60 (95% CI 0.45-0.76; 59 observed compared with 99 expected cases), for pancreatic cancer 0.50 (95% CI 0.28-0.81; 15 observed compared with 30 expected cases), and for lung cancer 0.68 (95% CI 0.49-0.91; 43 observed compared with 63 expected cases). The standardized incidence ratio for breast cancer among all levonorgestrel-releasing intrauterine system users was 1.19 (95% CI 1.13-1.25; 1,542 observed compared with 1,292 expected cases). CONCLUSION The levonorgestrel-releasing intrauterine system may have a protective effect against endometrial malignant transformation. Using the levonorgestrel-releasing intrauterine system for treatment of menorrhagia during reproductive years was associated with a lower incidence of endometrial, ovarian, pancreatic, and lung cancers than expected. Levonorgestrel-releasing intrauterine system use was associated with a higher than expected incidence of breast cancer. LEVEL OF EVIDENCE II.
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Bao Q, Pan J, Qi H, Wang L, Qian H, Jiang F, Shao Z, Xu F, Tao Z, Ma Q, Nelson P, Hu X. Aging and age-related diseases--from endocrine therapy to target therapy. Mol Cell Endocrinol 2014; 394:115-8. [PMID: 25038521 DOI: 10.1016/j.mce.2014.07.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 06/30/2014] [Accepted: 07/03/2014] [Indexed: 10/25/2022]
Abstract
Aging represents an important health issue not only for the individual, but also for society in general. Burdens associated with aging are expanding as longevity increases. This has led to an enhanced focus on issues related to aging and age-related diseases. Until recently, anti-aging endocrine-therapy has been largely limited to hormone-replacement therapy (HRT) that is associated with multiple side effects, including an increased risk of cancer. This has greatly limited the application of HRT in anti-aging therapy. Recently, the focus of anti-aging research has expanded from endocrine signaling pathways to effects on regulatory gene networks. In this regard, the GHRH-GH-IGF-1/Insulin, TOR-S6K1,NAD(+)-Sirtuin, P53, Klotho and APOE pathways have been linked to processes associated with age-related diseases, including cancer, cardiovascular disease, diabetes, osteoporosis, and neurodegenerative diseases, all of which directly influence health in aging, and represent key targets in anti-aging therapy.
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Affiliation(s)
- Qi Bao
- Department of Plastic and Reconstructive Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Institute of Gastroenterology, Zhejiang University (IGZJU), China
| | - Jie Pan
- Department of Endocrinology and Metabolism, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Institute of Gastroenterology, Zhejiang University (IGZJU), China
| | - Hangfei Qi
- Department of Molecular and Medical Pharmacology, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA
| | - Lu Wang
- Department of Plastic and Reconstructive Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Huan Qian
- Department of Plastic and Reconstructive Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Fangzhen Jiang
- Department of Plastic and Reconstructive Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Zheren Shao
- Department of Plastic and Reconstructive Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Fengzhi Xu
- Department of Plastic and Reconstructive Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Zhiping Tao
- Department of Plastic and Reconstructive Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Qi Ma
- Department of Plastic and Reconstructive Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Peter Nelson
- Clinical Biochemistry Group, Medizinische Klinik und Poliklinik IV, University of Munich, Schillerstrasse 42, D-80336 Munich, Germany
| | - Xueqing Hu
- Department of Plastic and Reconstructive Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
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Progestogens in postmenopausal hormone therapy and the risk of breast cancer. Maturitas 2014; 77:311-7. [DOI: 10.1016/j.maturitas.2014.01.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 01/01/2014] [Indexed: 12/28/2022]
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