Effect of long-term hormone replacement therapy on the bone in ovariectomized women with cancer

Comparing the treatment of endometriosis-related pain by excision of endometriosis or hysterectomy: A multicentre prospective cohort study

OBJECTIVE

To compare the effectiveness of endometriosis excision alone to excision plus hysterectomy, with and without bilateral oophorectomy, for endometriosis-related symptoms.

DESIGN

Multicentre prospective cohort.

SETTING

Eighty-six specialist endometriosis centres.

POPULATION

Women undergoing rectovaginal endometriosis surgery between 2009 and 2021.

METHODS

We performed multivariable regression with random effects for patient and centre, controlling for age, BMI, smoking, laparoscopic versus open approach and type of bowel surgery performed, with sensitivity analysis for loss to follow-up.

MAIN OUTCOME MEASURES

Pain scores, bowel symptoms and quality-of-life measures.

RESULTS

Compared to endometriosis excision alone, women undergoing hysterectomy with conservation of ovaries had greater improvement in non-cyclical pain (MD: 1.41/10, 95% CI: 1.03-1.78, p < 0.001), dyspareunia (MD: 1.12/10, 95% CI: 0.71-1.53, p < 0.001), back pain (MD: 1.29/10, 95% CI: 0.92-1.67, p < 0.001) and quality-of-life scores (MD: 8.77/100, 95% CI: 5.79-11.75, p < 0.001) at 24 months post-operatively. Women undergoing hysterectomy with bilateral oophorectomy also had greater improvement in non-cyclical pelvic pain (MD: 2.22/10, 95% CI: 1.80-2.63, p < 0.001), dyspareunia (MD: 1.05/10, 95% CI: 0.59-1.52, p < 0.001), back pain (MD: 1.18/10, 95% CI: 0.77-1.59, p < 0.001) and quality of life (MD: 12.41/100, 95% CI: 9.07-15.74, p < 0.001) at 24 months compared to endometriosis excision alone. Compared to hysterectomy with ovarian conservation, hysterectomy with bilateral oophorectomy was associated with greater improvement in non-cyclical pelvic pain (MD: 0.81/10, 95% CI: 0.32-1.30, p = 0.001) at 24 months and quality of life (MD: 3.74/100, 95% CI: 0.56-6.92, p = 0.021) at 12 months, although this result was sensitive to loss to follow-up.

CONCLUSIONS

Patients who undergo endometriosis excision plus hysterectomy experience greater improvement in pain and quality of life compared to those who have endometriosis excision alone. There are additional benefits of bilateral oophorectomy with hysterectomy, although its value is less clear due to loss of follow-up.

Excisional endometriosis surgery with hysterectomy and bilateral salpingo-oophorectomy versus excisional endometriosis surgery alone for pelvic pain associated with deep endometriosis

Background: There is no agreed consensus on the optimal surgical treatment for pain associated with endometriosis. Objectives: To compare improvement in symptoms and quality-of-life in patients undergoing excisional endometriosis surgery (EES) versus EES with hysterectomy and bilateral salpingo-oophorectomy (EES-HBSO). Methods: This study evaluated patients undergoing EES and EES-HBSO at a single endometriosis centre between 2009 and 2019. Data was obtained from the British Society for Gynaecological Endoscopy database. Adenomyosis was assessed by blinded re-analysis of imaging and/or histology data. Main outcome measures: Pain scores (numeric rating scale 0-10) and quality-of-life scores (EQ-VAS) before and after EES and EES-HBSO. Results: We included 120 patients undergoing EES and 100 patients undergoing EES-HBSO. After controlling for baseline characteristics and the presence of adenomyosis, there was greater post-op improvement in non-cyclical pelvic pain amongst patients undergoing EES-HBSO compared to EES alone.The baseline pain scores had improved in the EES-HBSO cohort by 2.106/10 at 6 months (95%CI 0.469-3.742, p=0.012), 2.642/10 at 12 months (95%CI 0.871-4.413, p=0.004), and 2.548/10 at 24 months (95%CI 0.681-4.414, p=0.008), when compared to the EES group. Greater improvement amongst EES-HBSO patients was also seen for dyspareunia, non-cyclical dyschaezia and bladder pain. Patients undergoing EES-HBSO had greater improvement in EQ-VAS, although this was no longer statistically significant after controlling for adenomyosis. Conclusion: EES-HBSO appears to provide greater benefit than EES alone for symptoms including non-cyclical pelvic pain as well as for quality-of-life. Further research is required to determine which patients benefit the most from EES-HBSO, and whether removal of the ovaries, uterus or both is the key to this additional benefit in symptom control.

Impact of Hormone Replacement Therapy on the Overall Survival and Progression Free Survival of Ovarian Cancer Patients: A Systematic Review and Meta-Analysis

Background: Frequently, patients treated for Ovarian Cancer (OC) undergo menopause with subsequent symptoms. This review scrutinised the impact of Hormone Replacement Therapy (HRT) on the Overall Survival (OS) and Progression-Free Survival (PFS) of patients diagnosed with OC. Methods: A systematic literature search was conducted in the most popular English databases. Inclusion and exclusion criteria were applied to select publications that evaluate OS and PFS in these patients. End-point analysis targeted values of log(HR) and its Standard Error (SE). Results: Up to 1 September 2022, 11 studies were included in the qualitative synthesis. Eight publications, totalling 4191 patients, were included in the meta-analyses. Eight studies were considered for the OS analysis and pooled an HR of 0.66 with respective 95% CI between 0.57 and 0.76, with a p-value < 0.00001 at a Z value of 5.7, in favour of the HRT group. Results for PFS showed an overall HR of 0.73 in favour of the HRT group; CI between 0.57 and 0.95, p = 0.02 at a Z value of 2.36. Further subgroup analyses highlighted the non-inferiority of this treatment. Conclusions: Patients treated for OC that receive HRT for menopausal symptoms after various treatments appeared to have better OS than never-users.

Hormone replacement therapy and cervical cancer: a systematic review of the literature

Gynecological tumor treatment, including cervical cancer (CC) treatment, often leads to iatrogenic premature menopause. This highlights the critical importance of investigating indications for hormone replacement therapy (HRT), as most patients, thanks to the improvement in diagnosis and treatment, have to deal with the sequelae of their cancer treatments for many years. This systematic review aims to provide an overview of the current knowledge regarding the risks of HRT and CC. In particular, we aim to investigate whether the use of HRT can increase CC incidence, and evaluate its risk in CC survivors. A systematic review, in agreement with PRISMA guidelines, of the English literature present in PubMed and SCOPUS has been performed. A total of 2805 articles have been screened, of which 10 were considered eligible. Several studies reported a significantly reduced risk of developing cervical squamous cell carcinoma in postmenopausal women treated with HRT, while a weak increase in the incidence of adenocarcinoma has been shown. No evidence reports a harmful effect of HRT on CC oncological outcome, while several benefits, in terms of reduced metabolic risk and increased quality of life, have been described, thus concluding that HRT should be offered to young CC survivors for the management of early menopause.

Compliance with estrogen hormone replacement therapy after oophorectomy: a prospective study

Objective

To quantify compliance with using estrogen-only hormone replacement therapy (HRT) up until the time of mean age of natural menopause in women undergoing either bilateral oophorectomy or removal of one remaining ovary at the time of hysterectomy for benign disease.

Design

Prospective study. Annual questionnaire follow-up for ten years of women undergoing hysterectomy and bilateral oophorectomy for benign disease aged 46 or less at the time of surgery.

Setting

Gloucestershire Royal Hospital.

Participants

Five hundred and twenty-one women recruited over a four-year period from 1994 to 1997.

Main outcome measures

Compliance with HRT use, changes in HRT preparations and reasons for discontinuation.

Results

The median age of women at the time of hysterectomy was 42 (range 22–46) years; 4.9% ( n = 24) stopped HRT within the first two years and 16.5% ( n = 86) by the end of the study. The majority of women were prescribed HRT tablets (253, 48%) and the next most common being patches. In total, there were 1271 episodes of changing HRT, with the range between 0 and 18 changes per woman over the ten-year period. In all, 32% of changes were to a different route of HRT, 19% were to a different preparation of the same route, 18% were to an increased dose of the same preparation and 7% were to a decreased dose of the same preparation.

Conclusions

Compliance with HRT use was high throughout the study, although responses decreased after five years. Change to HRT preparations was consistently high across all preparations. Women requiring HRT after surgical menopause need to be supported in finding the right preparation for them.

Guidance for the management of breast cancer treatment-induced bone loss: a consensus position statement from a UK Expert Group

In postmenopausal women, the use of aromatase inhibitors increases bone turnover and induces bone loss at sites rich in trabecular bone at an average rate of 1-3% per year leading to an increase in fracture incidence compared to that seen during tamoxifen use. The bone loss is much more marked in young women with treatment-induced ovarian suppression followed by aromatase inhibitor therapy (average 7-8% per annum). Pre-treatment with tamoxifen for 2-5 years may reduce the clinical significance of the adverse bone effects associated with aromatase inhibitors, particularly if this leads to a shortening in the duration of exposure to an aromatase inhibitor. However, skeletal status should still be assessed at the commencement of aromatase inhibitor therapy. The rate of bone loss in women who experience a premature menopause before the age of 45 or are receiving ovarian suppression therapy is accelerated by the concomitant use of aromatase inhibitors. These patients are considered to be at high risk of clinically important bone loss and should have a baseline dual energy X-ray absorptiometry (DXA) assessment of bone mineral density (BMD). Randomised clinical trials in postmenopausal women indicate that bisphosphonates prevent the bone loss and accelerated bone turnover associated with aromatase inhibitor therapy and are a promising strategy for the prevention and treatment of osteoporosis in this setting. Treatment initiation recommendations are based on a combination of risk factors for osteoporotic fracture and BMD levels. Bisphosphonates, along with a healthy lifestyle and adequate intake of calcium and vitamin D are the treatments of choice to prevent bone loss. Due to the rate of bone loss associated with breast cancer treatments, and uncertainties about the interaction between aromatase inhibitor use and BMD for fracture risk, the threshold for intervention has been set at a higher level than that generally recommended for postmenopausal osteoporosis. Management recommendations have been summarised in two algorithms, one for women experiencing a premature menopause and the other for postmenopausal women requiring adjuvant aromatase inhibitor therapy.

Ovarian cancer patients and hormone replacement therapy: a systematic review

OBJECTIVE

Although the majority of patients with ovarian cancer are menopausal, approximately one-third are premenopausal at the time of diagnosis. Little information is available concerning the impact of hormone replacement therapy (HRT) on the clinical outcomes of patients previously treated for ovarian cancer. The objective of this review is to determine whether there is any adverse impact on survival among women with ovarian cancer on HRT.

METHODS

A protocol was developed in advance of commencement of this systematic review. It detailed the plan for the search strategy, selection criteria for studies, and methods for data collection and analysis. No limitation of study design was made, and the details of the search strategy are described in the text of the review. Two reviewers independently evaluated the eligibility of all studies and abstracted the data.

RESULTS

One randomized trial and two observational studies are included. Due to methodological heterogeneity of the included studies, results have not been pooled in a meta-analysis. The randomized trial presented differences between the intervention and control groups on median overall survival (44 months vs. 34 months/HRT vs. No-HRT) and disease-free survival (34 months vs. 27 months/HRT vs. No-HRT) that were not significant. Similarly, there were nonsignificant differences in survival and recurrence rates in the two included cohort studies.

CONCLUSIONS

This is a comprehensive systematic review of the evidence concerning HRT in ovarian cancer patients. Until more evidence becomes available, it appears that HRT is acceptable for patients with ovarian cancer as part of supportive and symptomatic therapy.

Is use of hormone replacement therapy associated with increased detection of human papillomavirus and potential risk of HPV-related genital cancers?

Oral contraceptives (OC) are a risk factor for female genital cancers and in vivo studies have shown that progestins stimulate human papillomavirus (HPV) gene expression. A similar role for hormone replacement therapy (HRT) has received little evaluation. Cervical/vaginal specimens were obtained to detect HPV from postmenopausal women (n = 429) seeking annual gynaecologic care. HPV was detected in 14% of women and 4.4% had high-risk, oncogenic types. HPV prevalence was similar across current, past and never HRT users. After adjustment for HPV-related risk factors, current and past user status showed no increased viral detection compared with never users. HRT duration also did not elevate risk among current users. However, longer duration (adj. OR 1.5/year, 95% CI 1.0-2.3) and longer latency (adj. OR 1.2/year, 95% CI 0.9-1.7) among past users of oestrogen/progestin regimens were associated with greater risk. Overall use of HRTs was not associated with HPV detection or disease. However, past users of combination HRTs had significantly greater risk of HPV detection with longer HRT duration and latency, similar to OC-HPV findings. The recommendation that postmenopausal women continue HRTs long term may lead to an increased development of HPV-related diseases, of particular concern among those who discontinue HRTs and subsequent gynaecologic care for early cancer detection.