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Underkofler KA, Ring KL. Updates in gynecologic care for individuals with lynch syndrome. Front Oncol 2023; 13:1127683. [PMID: 36937421 PMCID: PMC10014618 DOI: 10.3389/fonc.2023.1127683] [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: 12/19/2022] [Accepted: 02/16/2023] [Indexed: 03/05/2023] Open
Abstract
Lynch syndrome is an autosomal dominant hereditary cancer syndrome caused by germline pathogenic variants (PVs) in DNA mismatch repair genes (MLH1, MSH2, PMS2, MSH6) or the EPCAM gene. It is estimated to affect 1 in 300 individuals and confers a lifetime risk of cancer of 10-90%, depending on the specific variant and type of cancer. Lynch syndrome is the most common cause of inherited colorectal cancer, but for women, endometrial cancer is more likely to be the sentinel cancer. There is also evidence that certain PVs causing Lynch syndrome confer an increased risk of ovarian cancer, while the risk of ovarian cancer in others is not well defined. Given this, it is essential for the practicing gynecologist and gynecologic oncologist to remain up to date on the latest techniques in identification and diagnosis of individuals with Lynch syndrome as well as evidence-based screening and risk reduction recommendations for those impacted. Furthermore, as the landscape of gynecologic cancer treatment shifts towards treatment based on molecular classification of tumors, knowledge of targeted therapies well-suited for mismatch repair deficient Lynch tumors will be crucial. The objective of this review is to highlight recent updates in the literature regarding identification and management of individuals with Lynch syndrome as it pertains to endometrial and ovarian cancers to allow gynecologic providers the opportunity to both prevent and identify Lynch-associated cancers earlier, thereby reducing the morbidity and mortality of the syndrome.
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Abstract
The objectives of this Clinical Expert Series on endometrial hyperplasia are to review the etiology and risk factors, histologic classification and subtypes, malignant progression risks, prevention options, and to outline both surgical and nonsurgical treatment options. Abnormal uterine and postmenopausal bleeding remain the hallmark of endometrial pathology, and up to 10-20% of postmenopausal bleeding will be either hyperplasia or cancer; thus, immediate evaluation of any abnormal bleeding with either tissue procurement for pathology or imaging should be undertaken. Although anyone with a uterus may develop atypical hyperplasia, also known as endometrial intraepithelial neoplasia (EIN), genetic predispositions (eg, Lynch syndrome), obesity, chronic anovulation, and polycystic ovarian syndrome all markedly increase these risks, whereas use of oral contraceptive pills or progesterone-containing intrauterine devices will decrease the risk. An EIN diagnosis carries a high risk of concomitant endometrial cancer or eventual progression to cancer in the absence of treatment. The definitive and curative treatment for EIN remains hysterectomy; however, the obesity epidemic, the potential desire for fertility-sparing treatments, the recognition of varying rates of malignant transformation, medical comorbidities, and an aging population all may factor into decisions to employ nonsurgical treatment modalities.
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Kuzel D, Lisa Z, Fanta M, Zizka Z, Boudova B, Cindrova-Davies T, Mara M. Hysteroscopic management of endometrial polyps and submucous leiomyomas in women using a levonorgestrel-releasing intrauterine system. MINIM INVASIV THER 2021; 31:615-619. [PMID: 33428484 DOI: 10.1080/13645706.2020.1870499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION This study was designed to evaluate the feasibility and effectiveness of hysteroscopy in the management of symptoms related to endometrial polyps and submucous leiomyomas in women using a levonorgestrel-releasing intrauterine system (LNG-IUS). MATERIAL AND METHODS Twenty-three LNG-IUS users presenting with endometrial polyps and/or submucous leiomyomas and irregular uterine bleeding were recruited for hysteroscopic examination and surgery. Intrauterine pathology was investigated and treated by hysteroscopic resection with the LNG-IUS in situ, and the effect of the procedure on symptoms was evaluated after three to six months. RESULTS Intrauterine pathology was successfully resected by hysteroscopy in 23 (100.0%) out of 23 cases. Following hysteroscopy, 18 (78.3%) women reported amenorrhea, one (4.3%) regular spotting, three (13.0%) irregular spotting and one (4.3%) patient resumed normal menstrual cycle. We conclude that 19 (82.6%) patients were postoperatively asymptomatic. All procedures were uncomplicated and 4 (17.4%) were carried out without general anesthesia as office procedures. CONCLUSION Endometrial polyps and submucous leiomyomas can develop in LNG-IUS users, and this can cause irregular uterine bleeding. Hysteroscopic resection of these pathologies is a feasible method in the clinical management of symptoms.
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Affiliation(s)
- David Kuzel
- Department of Obstetrics and Gynaecology, Charles University, First Faculty of Medicine and General Faculty Hospital in Prague, Prague, Czech Republic
| | - Zdenka Lisa
- Department of Obstetrics and Gynaecology, Charles University, First Faculty of Medicine and General Faculty Hospital in Prague, Prague, Czech Republic
| | - Michael Fanta
- Department of Obstetrics and Gynaecology, Charles University, First Faculty of Medicine and General Faculty Hospital in Prague, Prague, Czech Republic
| | - Zdenek Zizka
- Department of Obstetrics and Gynaecology, Charles University, First Faculty of Medicine and General Faculty Hospital in Prague, Prague, Czech Republic
| | - Barbora Boudova
- Department of Obstetrics and Gynaecology, Charles University, First Faculty of Medicine and General Faculty Hospital in Prague, Prague, Czech Republic
| | - Tereza Cindrova-Davies
- Department of Physiology, Development and Neuroscience, St John's College Teaching Associate, University of Cambridge, Centre for Trophoblast Research, Cambridge, UK
| | - Michal Mara
- Department of Obstetrics and Gynaecology, Charles University, First Faculty of Medicine and General Faculty Hospital in Prague, Prague, Czech Republic
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Derbyshire AE, Allen JL, Gittins M, Lakhiani B, Bolton J, Shaw J, Pemberton PW, Needham M, MacKintosh ML, Edmondson RJ, Kitchener HC, Crosbie EJ. PROgesterone Therapy for Endometrial Cancer Prevention in Obese Women (PROTEC) Trial: A Feasibility Study. Cancer Prev Res (Phila) 2020; 14:263-274. [PMID: 32998940 DOI: 10.1158/1940-6207.capr-20-0248] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/22/2020] [Accepted: 09/16/2020] [Indexed: 12/24/2022]
Abstract
Obesity is the major etiologic driver for endometrial cancer. The levonorgestrel intrauterine system (LNG-IUS) reduces the risk of endometrial cancer and its precursor, atypical hyperplasia. We assessed feasibility and uptake of the LNG-IUS for primary prevention of endometrial cancer in high-risk women and its impact on endometrial tissue biomarkers. Women with class-III obesity [body mass index (BMI) > 40 kg/m2] and histologically normal endometrium were invited to participate in a clinical trial of the LNG-IUS for endometrial protection. Recruitment, successful LNG-IUS insertion, and adherence to trial procedures were recorded. We measured impact of the LNG-IUS on circulating biomarkers of endometrial cancer risk, endometrial proliferation (Ki-67, pAKT, PTEN), endometrial hormone receptor status [estrogen receptor and progesterone receptor (PR)], mental wellbeing, and menstrual function. At 6 months, women chose to keep their LNG-IUS or have it removed. In total, 103 women were approached, 54 were offered a participant information sheet, 35 agreed to participate, and 25 received a LNG-IUS. Their median age and BMI were 54 years [interquartile range (IQR) 52-57] and 47 kg/m2 (IQR 44-51), respectively. Three women (3/35, 9%) were ineligible due to atypical hyperplasia/endometrial cancer on their baseline biopsy. The LNG-IUS was well tolerated and had a positive overall effect on bleeding patterns and mental wellbeing. The LNG-IUS was associated with endometrial morphologic change, reduced Ki-67, and PR expression, but circulating biomarkers of endometrial cancer risk were unchanged. All but one woman (96%) kept her LNG-IUS. The LNG-IUS appears to be acceptable to some women with class-III obesity for primary prevention of endometrial cancer, which could provide a strategy for a prevention trial.Prevention Relevance: Novel strategies are urgently needed to prevent the rise in endometrial cancer diagnoses predicted by escalating obesity rates. Here, we show that women with class III obesity are willing to engage in risk reduction with a levonorgestrel intrauterine system, which could provide a strategy for an endometrial cancer prevention trial.
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Affiliation(s)
- Abigail E Derbyshire
- Division of Gynaecology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Jennifer L Allen
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary's Hospital, Manchester, United Kingdom
| | - Matthew Gittins
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Bhavna Lakhiani
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary's Hospital, Manchester, United Kingdom
| | - James Bolton
- Department of Histopathology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Joseph Shaw
- Department of Histopathology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Philip W Pemberton
- Department of Clinical Biochemistry, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Michelle Needham
- Sleep Apnoea Service, Salford Royal Hospitals NHS Foundation Trust, Salford, United Kingdom
| | - Michelle L MacKintosh
- Division of Gynaecology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Richard J Edmondson
- Division of Gynaecology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary's Hospital, Manchester, United Kingdom
| | - Henry C Kitchener
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary's Hospital, Manchester, United Kingdom
| | - Emma J Crosbie
- Division of Gynaecology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom. .,Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary's Hospital, Manchester, United Kingdom
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Jewson M, Purohit P, Lumsden MA. Progesterone and abnormal uterine bleeding/menstrual disorders. Best Pract Res Clin Obstet Gynaecol 2020; 69:62-73. [PMID: 32698992 DOI: 10.1016/j.bpobgyn.2020.05.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/30/2020] [Accepted: 05/06/2020] [Indexed: 12/30/2022]
Abstract
This chapter explores the role of progesterone and progestogens in the management of abnormal uterine bleeding (AUB). Progestogens are used to regulate intermenstrual bleeding and decrease heavy menstrual bleeding (HMB) in women of reproductive age or who are perimenopausal. In menopausal women, progesterones and progestogens prevent endometrial hyperplasia and aim to reduce the development of endometrial cancer. We hope to make clear current best practice including preparation, specific benefits and risks. Progesterone also acts in concert with other hormones to affect breast, cardiovascular system, lipid profile and bone. We hope to explain how its unintended side effects may be used beneficially or may cause intended side effects.
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Affiliation(s)
- Michaela Jewson
- Obstetrics and Gynaecology, Greater Glasgow and Clyde, Glasgow, UK.
| | - Prashant Purohit
- Obstetrics & Gynaecology, Kings College Hospital NHS Foundation Trust, London, UK
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Sheng KK, Lyons SD. To treat or not to treat? An evidence-based practice guide for the management of endometrial polyps. Climacteric 2020; 23:336-342. [DOI: 10.1080/13697137.2020.1742107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- K. K. Sheng
- Department of Obstetrics and Gynaecology, Mater Clinic, Sydney, Australia
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, Sydney, Australia
- Faculty of Medicine, University of Sydney, Sydney, Australia
| | - S. D. Lyons
- Department of Obstetrics and Gynaecology, Mater Clinic, Sydney, Australia
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, Sydney, Australia
- Faculty of Medicine, University of Sydney, Sydney, Australia
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Sun C, Ren XY, Gao Y, Liang ZG, Mou M, Gu HF, Xiao YB. Clinical Efficacy and Safety of Major Uterine Wall Resection and Reconstruction of the Uterus Combined with LNG-IUS for the Treatment of Severe Adenomyosis. Geburtshilfe Frauenheilkd 2019; 80:300-306. [PMID: 32139919 PMCID: PMC7056398 DOI: 10.1055/a-0995-2200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 08/01/2019] [Accepted: 08/11/2019] [Indexed: 12/16/2022] Open
Abstract
Objective
Aim of the study was to evaluate the clinical efficacy and safety of major uterine wall resection and reconstruction of the uterus (MURU) combined with a levonorgestrel-releasing intrauterine system (LNG-IUS) for the treatment of adenomyosis.
Methods
Ninety patients diagnosed with adenomyosis were enrolled in this study. All participants were examined by transvaginal ultrasound (TVU) or magnetic resonance imaging (MRI). Serum levels of cancer antigen 125 (CA 125) were quantitatively measured. All patients underwent MURU in combination with LNG-IUS. The therapeutic safety of MURU was assessed during surgery and the patientsʼ stay in hospital. The clinical efficacy was evaluated by comparatively analyzing changes in dysmenorrhea, volume of menstrual blood, uterine volume and serum levels of CA 125 before, and at 3, 6 and 12 months following MURU.
Results
All 90 patients enrolled in the study were successfully treated with MURU combined with LNG-IUS. No significant complications were observed during surgery and hospital stay. The mean operation time, intraoperative blood loss and length of hospital stay were 82.4 ± 13.8 min, 53.3 ± 20.3 ml, and 4.3 ± 0.8 days, respectively. Dysmenorrhea completely disappeared in all patients. Uterine volume and serum levels of CA 125 were restored to normal ranges. No recurrence of adenomyosis was observed during postoperative follow-up.
Conclusion
MURU combined with LNG-IUS is an efficacious and safe treatment for severe adenomyosis. This combined technique is not only effective to manage severe adenomyosis but also preserves as much of the uterus as possible.
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Affiliation(s)
- Cui Sun
- Gynecology Department of Affiliate Hospital of Maternal and Child Health Care of Zunyi Medical University, Zunyi, China
| | - Xiao-Yan Ren
- Gynecology Department of Affiliate Hospital of Maternal and Child Health Care of Zunyi Medical University, Zunyi, China
| | - Yi Gao
- Gynecology Department of Affiliate Hospital of Maternal and Child Health Care of Zunyi Medical University, Zunyi, China
| | - Zhi-Gang Liang
- Gynecology Department of Affiliate Hospital of Maternal and Child Health Care of Zunyi Medical University, Zunyi, China
| | - Meng Mou
- Gynecology Department of Affiliate Hospital of Maternal and Child Health Care of Zunyi Medical University, Zunyi, China
| | - Heng-Fang Gu
- Gynecology Department of Affiliate Hospital of Maternal and Child Health Care of Zunyi Medical University, Zunyi, China
| | - Yan-Bing Xiao
- Gynecology Department of Affiliate Hospital of Maternal and Child Health Care of Zunyi Medical University, Zunyi, China
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Chowdary P, Maher P, Ma T, Newman M, Ellett L, Readman E. The Role of the Mirena Intrauterine Device in the Management of Endometrial Polyps: A Pilot Study. J Minim Invasive Gynecol 2019; 26:1297-1302. [DOI: 10.1016/j.jmig.2018.12.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 12/03/2018] [Accepted: 12/19/2018] [Indexed: 12/12/2022]
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Raglan O, Kalliala I, Markozannes G, Cividini S, Gunter MJ, Nautiyal J, Gabra H, Paraskevaidis E, Martin-Hirsch P, Tsilidis KK, Kyrgiou M. Risk factors for endometrial cancer: An umbrella review of the literature. Int J Cancer 2019; 145:1719-1730. [PMID: 30387875 DOI: 10.1002/ijc.31961] [Citation(s) in RCA: 262] [Impact Index Per Article: 52.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 10/19/2018] [Indexed: 03/25/2024]
Abstract
Although many risk factors could have causal association with endometrial cancer, they are also prone to residual confounding or other biases which could lead to over- or underestimation. This umbrella review evaluates the strength and validity of evidence pertaining risk factors for endometrial cancer. Systematic reviews or meta-analyses of observational studies evaluating the association between non-genetic risk factors and risk of developing or dying from endometrial cancer were identified from inception to April 2018 using PubMed, the Cochrane database and manual reference screening. Evidence was graded strong, highly suggestive, suggestive or weak based on statistical significance of random-effects summary estimate, largest study included, number of cases, between-study heterogeneity, 95% prediction intervals, small study effects, excess significance bias and sensitivity analysis with credibility ceilings. We identified 171 meta-analyses investigating associations between 53 risk factors and endometrial cancer incidence and mortality. Risk factors were categorised: anthropometric indices, dietary intake, physical activity, medical conditions, hormonal therapy use, biochemical markers, gynaecological history and smoking. Of 127 meta-analyses including cohort studies, three associations were graded with strong evidence. Body mass index and waist-to-hip ratio were associated with increased cancer risk in premenopausal women (RR per 5 kg/m2 1.49; CI 1.39-1.61) and for total endometrial cancer (RR per 0.1unit 1.21; CI 1.13-1.29), respectively. Parity reduced risk of disease (RR 0.66, CI 0.60-0.74). Of many proposed risk factors, only three had strong association without hints of bias. Identification of genuine risk factors associated with endometrial cancer may assist in developing targeted prevention strategies for women at high risk.
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Affiliation(s)
- Olivia Raglan
- Department of Surgery and Cancer, Institute of Reproductive and Developmental Biology, Faculty of Medicine, Imperial College London, London, United Kingdom
- Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ilkka Kalliala
- Department of Surgery and Cancer, Institute of Reproductive and Developmental Biology, Faculty of Medicine, Imperial College London, London, United Kingdom
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Georgios Markozannes
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
| | | | - Marc J Gunter
- Section of Nutrition and Metabolism, International Agency for Research on Cancer (IARC), Lyon, France
| | - Jaya Nautiyal
- Department of Surgery and Cancer, Institute of Reproductive and Developmental Biology, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Hani Gabra
- Department of Surgery and Cancer, Institute of Reproductive and Developmental Biology, Faculty of Medicine, Imperial College London, London, United Kingdom
- Early Clinical Development, IMED Biotech Unit, Cambridge, United Kingdom
| | | | - Pierre Martin-Hirsch
- Department of Gynaecologic Oncology, Lancashire Teaching Hospitals, Preston, United Kingdom
- Department of Biophysics, University of Lancaster, Lancaster, United Kingdom
| | - Kostas K Tsilidis
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom
| | - Maria Kyrgiou
- Department of Surgery and Cancer, Institute of Reproductive and Developmental Biology, Faculty of Medicine, Imperial College London, London, United Kingdom
- Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
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Kuzel D, Mara M, Zizka Z, Koliba P, Dundr P, Fanta M. Malignant endometrial polyp in woman with the levonorgestrel intrauterine system - a case report. Gynecol Endocrinol 2019; 35:112-114. [PMID: 30449212 DOI: 10.1080/09513590.2018.1491028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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
The levonorgestrel-releasing intrauterine system (LNG-IUS) is widely used and recommended as a reliable contraceptive. It also acts by opposing the effects of estrogen on the endometrium, thereby preventing development of endometrial hyperplasia and its possible malignant transformation. This case describes a 52-year-old multiparous amenorrhoeic patient who was seen in the gynecology outpatient department for a routine control 46 months after the insertion LNG-IUS as contraception. Hysteroscopy with a target biopsy following suspicious ultrasound scan confirmed well-differentiated endometrioid adenocarcinoma. Ultrasound scan prior to inserting LNG-IUS revealed normal 5 mm thin endometrium with the sharp edges. Uterine bleeding before the LNG-IUS insertion was regular and not excessive and the woman has remained amenorrhoeic after the LNG-IUS insertion. We present a case of the growth of a polyp-shaped endometrial carcinoma in a LNG-IUS asymptomatic user.
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Affiliation(s)
- David Kuzel
- a Department of Obstetrics and Gynecology , First Medical Faculty of Charles University and General Faculty Hospital , Praha , Czech Republic
| | - Michal Mara
- a Department of Obstetrics and Gynecology , First Medical Faculty of Charles University and General Faculty Hospital , Praha , Czech Republic
| | - Zdenek Zizka
- a Department of Obstetrics and Gynecology , First Medical Faculty of Charles University and General Faculty Hospital , Praha , Czech Republic
| | - Peter Koliba
- a Department of Obstetrics and Gynecology , First Medical Faculty of Charles University and General Faculty Hospital , Praha , Czech Republic
| | - Pavel Dundr
- b Institute of Pathology , First Medical Faculty of Charles University and General Faculty Hospital , Praha , Czech Republic
| | - Michael Fanta
- a Department of Obstetrics and Gynecology , First Medical Faculty of Charles University and General Faculty Hospital , Praha , Czech Republic
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Pragout D, Laurence V, Baffet H, Raccah-Tebeka B, Rousset-Jablonski C. [Contraception and cancer: CNGOF Contraception Guidelines]. ACTA ACUST UNITED AC 2018; 46:834-844. [PMID: 30385358 DOI: 10.1016/j.gofs.2018.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To synthesize knowledge on cancer risks related to hormonal contraception and to propose recommendations on contraception during treatment and after cancer. METHODS A systematic review of the literature about hormonal contraception and cancer was conducted on PubMed/Medline and the Cochrane Library. RESULTS Overall, there is no increase in cancer (all types together) incidence or mortality among hormonal contraceptive users. Estroprogestin combined contraceptive use is associated with an increased risk of breast cancer (during use), and with a reduced risk of endometrial, ovarian, lymphatic or hematopoietic cancers that persist after discontinuation, and a decreased risk of colorectal cancer. Information on cancer risk is part of the systematic information given to patients wishing contraception. However, these data will not influence its prescription, considering the positive risk/benefit balance in women without specific cancer risk factor. Contraception is required during and after cancer treatment in every non-menopausal woman at cancer diagnosis. Specific thromboembolic, immunologic or vomiting risks due to the oncological context should be taken into account before the contraceptive choice. All hormonal contraceptives are contra-indicated after breast cancer, regardless of the delay since treatment, hormone receptor status and histological subtype. There is no data in the literature to limit hormonal or non-hormonal contraceptive use after colorectal or thyroid cancer. There was insufficient data in the literature to propose recommendations on contraceptive choice after cervical cancer, melanoma, lung cancer, tumor of the central nervous system, or after thoracic irradiation. If an emergency contraception is needed in a woman previously treated for a hormone-sensitive cancer, a non-hormonal copper intrauterine device should be preferred. CONCLUSIONS Information on cancer risk is part of the patient's information but does not influence the prescription of contraception in the absence of any specific risk factor. Contraception should be proposed in every woman treated or previously treated for cancer. The whole context should be taken into account to choose a tailored contraception.
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Affiliation(s)
- D Pragout
- Service de gynécologie obstétrique, unité d'orthogénie, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours, France
| | - V Laurence
- Département d'oncologie médicale, Institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - H Baffet
- Service de gynécologie médicale, orthogénie et médecine du couple, hôpital Jeanne-de-Flandre, CHRU de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France
| | - B Raccah-Tebeka
- Service de gynécologie-obstétrique, hôpital Robert-Debré, AP-HP, 75019 Paris, France
| | - C Rousset-Jablonski
- Département de chirurgie, centre de lutte contre le cancer Léon Bérard, 28, rue Laënnec, 69008 Lyon, France; Service de chirurgie gynécologique et oncologique - obstétrique, centre hospitalier Lyon Sud, 165, chemin du grand Revoyet, 69310 Pierre Bénite, France.
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Kitson SJ, Evans DG, Crosbie EJ. Identifying High-Risk Women for Endometrial Cancer Prevention Strategies: Proposal of an Endometrial Cancer Risk Prediction Model. Cancer Prev Res (Phila) 2016; 10:1-13. [DOI: 10.1158/1940-6207.capr-16-0224] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 11/20/2016] [Accepted: 11/21/2016] [Indexed: 11/16/2022]
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Nelson AL, Massoudi N. New developments in intrauterine device use: focus on the US. Open Access J Contracept 2016; 7:127-141. [PMID: 29386944 PMCID: PMC5683151 DOI: 10.2147/oajc.s85755] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Many more women in the US today rely upon intrauterine devices (IUDs) than in the past. This increased utilization may have substantially contributed to the decline in the percentage of unintended pregnancies in the US. Evidence-based practices have increased the number of women who are medically eligible for IUDs and have enabled more rapid access to the methods. Many women enjoy freedom to use IUDs without cost, but for many the impact of the Affordable Care Act has yet to be realized. Currently, there are three hormonal IUDs and one copper IUD available in the US. Each IUD is extremely effective, convenient, and safe. The newer IUDs have been tested in populations not usually included in clinical trials and provide reassuring answers to older concerns about IUD use in these women, including information about expulsion, infection, and discontinuation. On the other hand, larger surveillance studies have provided new estimates about the risks of complications such as perforation, especially in postpartum and breastfeeding women. This article summarizes significant features of each IUD and provides a summary of the differences to aid clinicians in the US and other countries in advising women about IUD choices.
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Affiliation(s)
- Anita L Nelson
- Department of Obstetrics and Gynecology, Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, CA, USA
| | - Natasha Massoudi
- American University of the Caribbean School of Medicine, Cupecoy, Sint Maarten
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Godfrey EM, Zapata LB, Cox CM, Curtis KM, Marchbanks PA. Unintended pregnancy risk and contraceptive use among women 45-50 years old: Massachusetts, 2006, 2008, and 2010. Am J Obstet Gynecol 2016; 214:712.e1-8. [PMID: 26694134 PMCID: PMC10994517 DOI: 10.1016/j.ajog.2015.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 11/11/2015] [Accepted: 12/07/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Little is known about unintended pregnancy risk and current contraceptive use among women ≥45 years old in the United States. OBJECTIVES The purpose of this study was to describe the prevalence of women ages 45-50 years old at risk for unintended pregnancy and their current contraceptive use, and to compare these findings to those of women in younger age groups. STUDY DESIGN We analyzed 2006, 2008, and 2010 Massachusetts Behavioral Risk Factor Surveillance System data, the only state in the United States to collect contraceptive data routinely from women >44 years old. Women 18-50 years old (n = 4930) were considered to be at risk for unintended pregnancy unless they reported current pregnancy, hysterectomy, not being sexually active in the past year, having a same-sex partner, or wanting to become pregnant. Among women who were considered to be at risk (n = 3605), we estimated the prevalence of current contraceptive use by age group. Among women who were considered to be at risk and who were 45-50 years old (n = 940), we examined characteristics that were associated with current method use. Analyses were conducted on weighted data using SAS-callable SUDAAN (RTI International, Research Triangle Park, NC). RESULTS Among women who were 45-50 years old, 77.6% were at risk for unintended pregnancy, which was similar to other age groups. As age increased, hormonal contraceptive use (shots, pills, patch, or ring) decreased, and permanent contraception (tubal ligation or vasectomy) increased as did non-use of contraception. Of women who were 45-50 years old and at risk for unintended pregnancy, 66.9% reported using some contraceptive method; permanent contraception was the leading method reported by 44.0% and contraceptive non-use was reported by 16.8%. CONCLUSION A substantial proportion of women who were 45-50 years old were considered to be at risk for unintended pregnancy. Permanent contraception was most commonly used by women in this age group. Compared with other age groups, more women who were 45-50 years old were not using any contraception. Population-based surveillance efforts are needed to follow trends among this age group and better meet their family planning needs. Although expanding surveillance systems to include women through 50 years old requires additional resources, fertility trends that show increasingly delayed childbearing, uncertain end of fecundity, and potential adverse consequences of unplanned pregnancy in older age may justify these expenditures.
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Affiliation(s)
- Emily M Godfrey
- Department of Family Medicine, University of Washington, Seattle, WA; Division of Reproductive Health, Centers for Disease Control and Prevention, NCCDPHP/DRH/WHFB, Atlanta, GA.
| | - Lauren B Zapata
- Division of Reproductive Health, Centers for Disease Control and Prevention, NCCDPHP/DRH/WHFB, Atlanta, GA
| | - Carie M Cox
- Department of Public Health, St. Catherine University, St. Paul, MN
| | - Kathryn M Curtis
- Division of Reproductive Health, Centers for Disease Control and Prevention, NCCDPHP/DRH/WHFB, Atlanta, GA
| | - Polly A Marchbanks
- Division of Reproductive Health, Centers for Disease Control and Prevention, NCCDPHP/DRH/WHFB, Atlanta, GA
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Wise MR, Jordan V, Lagas A, Showell M, Wong N, Lensen S, Farquhar CM. Obesity and endometrial hyperplasia and cancer in premenopausal women: A systematic review. Am J Obstet Gynecol 2016; 214:689.e1-689.e17. [PMID: 26829507 DOI: 10.1016/j.ajog.2016.01.175] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/19/2016] [Accepted: 01/21/2016] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To systematically review the literature on the association between obesity and endometrial hyperplasia or cancer in premenopausal women. DATA SOURCES We searched the bibliographic databases MEDLINE, EMBASE, PubMed, and CINAHL (inception to May 5, 2015), and checked reference lists of included studies and systematic reviews. STUDY ELIGIBILITY CRITERIA Studies of more than 50 women with endometrial pathology diagnosed during premenopause that reported on obesity as a risk factor were eligible. STUDY APPRAISAL AND SYNTHESIS METHODS Study identification and data extraction were independently performed by 2 authors. Where possible, data were pooled in a generic inverse variance forest plot. Heterogeneity was reported using the I(2) statistic. RESULTS Nine case-control studies of moderate quality were included. Quantitative analysis of 5 studies showed a dose-response relationship of body mass index and increased risk of endometrial cancer. For studies of women with body mass index of ≥25, the pooled odds ratio was 3.85 (95% confidence interval 2.53-5.84); body mass index of ≥30 was 5.25 (4.00-6.90); and body mass index of ≥40 was 19.79 (11.18-35.03). CONCLUSION Body mass index is a consistent and leading risk factor for endometrial complex hyperplasia or cancer in premenopausal women. Body mass index should be considered when deciding to assess the endometrium in symptomatic premenopausal women.
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Abstract
Menstrual suppression--the use of hormones to delay or eliminate menses--is often used in adolescents to manage conditions associated with the menstrual cycle and to accommodate lifestyle preferences. Reducing the frequency of menstrual bleeding does not cause any known physiologic harm and has potential short-term and long-term advantages. Different methods used for menstrual suppression, however, have associated risks and side effects that need to be weighed against the benefits of controlling menses. This article reviews the advantages and disadvantages of menstrual suppression and the different methods available for adolescents.
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Abstract
Menopause is an inevitable component of ageing and encompasses the loss of ovarian reproductive function, either occurring spontaneously or secondary to other conditions. It is not yet possible to accurately predict the onset of menopause, especially early menopause, to give women improved control of their fertility. The decline in ovarian oestrogen production at menopause can cause physical symptoms that may be debilitating, including hot flushes and night sweats, urogenital atrophy, sexual dysfunction, mood changes, bone loss, and metabolic changes that predispose to cardiovascular disease and diabetes. The individual experience of the menopause transition varies widely. Important influential factors include the age at which menopause occurs, personal health and wellbeing, and each woman's environment and culture. Management options range from lifestyle assessment and intervention through to hormonal and non-hormonal pharmacotherapy, each of which has specific benefits and risks. Decisions about therapy for perimenopausal and postmenopausal women depend on symptomatology, health status, immediate and long-term health risks, personal life expectations, and the availability and cost of therapies. More effective and safe therapies for the management of menopausal symptoms need to be developed, particularly for women who have absolute contraindications to hormone therapy. For an illustrated summary of this Primer, visit: http://go.nature.com/BjvJVX.
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Prophylactic use of levonorgestrel-releasing intrauterine system in women with breast cancer treated with tamoxifen: a randomized controlled trial. Obstet Gynecol 2013; 121:943-950. [PMID: 23635729 DOI: 10.1097/aog.0b013e31828bf80c] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To estimate the rate of endometrial pathology with the prophylactic use of levonorgestrel-releasing intrauterine system in women with breast cancer treated with tamoxifen. METHODS This was a randomized contro-lled trial of 129 Chinese women who attended a university hospital in Hong Kong and required adjuvant tamoxifen for breast cancer after the completion of postoperative radiotherapy and chemotherapy. Women were randomized to treatment (prophylactic levonorgestrel-releasing intrauterine system insertion before the commencement of tamoxifen) or control group. The uterine cavity was examined by hysteroscopy and endometrial sampling before the commencement of tamoxifen and at 12, 24, 45, and 60 months afterward. Any endometrial polyps or submucosal fibroids were resected through hysteroscopy at each assessment and specimens were sent for histologic confirmation. RESULTS A total of 94 women completed 5-year follow-up. There was no significant difference in the occurrence of submucosal fibroids (1 [1.8%] compared with 2 [3.4%]) and endometrial hyperplasia (both 0) in the treatment and control groups, respectively. Levonorgestrel-releasing intrauterine system significantly reduced de novo endometrial polyps (hazard ratio 0.19, 95% confidence interval 0.07-0.48) over the course of 5 years on an intention-to-treat basis. There was no statistically significant increase in breast cancer recurrence rate (10 [17.2%] compared with 6 [10.0%]) or cancer-related deaths (6 [10.3%] compared with 5 [8.3%]) in the treatment group, but the study was underpowered in this regard. CONCLUSIONS Prophylactic levonorgestrel-releasing intrauterine system prevents de novo endometrial polyps in women using tamoxifen. However, its role in the prevention of endometrial hyperplasia and adenocarcinoma as well as its effect on risk of breast cancer recurrence remain uncertain. CLINICAL TRIAL REGISTRATION Chinese Clinical Trial Registry, http://www.chictr.org/en/, ChiCTR-TRC-09000625. LEVEL OF EVIDENCE I.
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Added health benefits of the levonorgestrel contraceptive intrauterine system and other hormonal contraceptive delivery systems. Contraception 2013; 87:273-9. [DOI: 10.1016/j.contraception.2012.08.039] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 08/29/2012] [Indexed: 11/22/2022]
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Morelli M, Di Cello A, Venturella R, Mocciaro R, D'Alessandro P, Zullo F. Efficacy of the levonorgestrel intrauterine system (LNG-IUS) in the prevention of the atypical endometrial hyperplasia and endometrial cancer: retrospective data from selected obese menopausal symptomatic women. Gynecol Endocrinol 2013; 29:156-9. [PMID: 23134558 DOI: 10.3109/09513590.2012.730579] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The aim of this retrospective study was to evaluate the efficacy of levonorgestrel intrauterine system-releasing (LNG-IUS) insertion in preventing atypical endometrial hyperplasia (AH) and endometrial cancer (EC) in symptomatic postmenopausal overweight/obese women. A total of 34 overweight/obese postmenopausal women, presenting abnormal uterine bleeding (AUB) and endometrial hyperplasia (EH), and who were submitted to LNG-IUS insertion, were identified from registry data. Endometrial histology at LNG-IUS insertion showed simple EH in 20 cases (58.8%), complex EH in 14 cases (41.2%). At 36 months, 91% of patients showed no recurrence of AUB and a significant reduction in the mean endometrial thickness (from 8.2 ± 2.2 to 3.2 ± 1.5 mm, p < 0.05) was observed. Histologic regression of EH was observed in 27 (79.4%) and 33 (97.5%) cases at 12 and 36 months, respectively. None of the women in which EH persisted, reported cellular atypia or cancer progression at 12 and 36 months of follow-up. LNG-IUS represents an effective treatment option to manage postmenopausal obese women affected by AUB and EH. The device seems to be able to prevent the onset of AH and EC in women at high risk. Further prospective controlled studies in a well selected group of women are needed.
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Affiliation(s)
- Michele Morelli
- Department of Obstetrics and Gynecology, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro 88100, Italy
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Lee WL, Lee FK, Su WH, Tsui KH, Kuo CD, Hsieh SLE, Wang PH. Hormone therapy for younger patients with endometrial cancer. Taiwan J Obstet Gynecol 2012; 51:495-505. [DOI: 10.1016/j.tjog.2012.09.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2012] [Indexed: 12/17/2022] Open
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Use of Levonorgestrel-Releasing Intrauterine System in the Prevention and Treatment of Endometrial Hyperplasia. Obstet Gynecol Surv 2012; 67:726-33. [DOI: 10.1097/ogx.0b013e318273570b] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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