The latest guidance on safe use of menopausal hormone therapy
Dr. Pinkerton is Professor, Department of Obstetrics and Gynecology, and Director, Division of Midlife Women’s Health, at the University of Virginia in Charlottesville. Dr. Pinkerton is a North American Menopause Society (NAMS) past president and certified menopause practitioner. She also serves on the OBG Management Board of Editors.
Dr. Simon is Clinical Professor, Department of Obstetrics and Gynecology, George Washington University, and Medical Director, Women’s Health & Research Consultants, Washington, DC. Dr. Simon is a NAMS past president, a certified menopause practitioner, and clinical densitometrist. He also serves on the OBG Management Board of Editors.
Dr. Pinkerton and Dr. Simon provided peer review and comments for Dr. Kaunitz’s case study.
Dr. Kaunitz reports that within the past 36 months, he has received or is currently receiving grant or research support from Bayer, Teva, and TherapeuticsMD, and has served or is currently serving as a consultant to Actavis, Bayer, and Teva.
Dr. Pinkerton reports that within the past 36 months, she has received or is currently receiving grant or research support from TherapeuticsMD and has served or is currently serving as a consultant to Noven, Inc., Pfizer, Shionogi, and TherapeuticsMD.
Dr. Simon reports that within the past 36 months, he has been a consultant to or served on the advisory boards of AbbVie, Actavis, Amgen, Amneal, Apotex, Ascend Therapeutics, BioSante, Depomed, Dr. Reddy Laboratories, Everett Laboratories, Intimina by Lelo, Lupin, Meda, Merck, Novartis, Noven, Novo Nordisk, Nuelle, Pfizer, Regeneron, Sanofi SA, Sermonix, Shionogi, Shippan Point Advisors, Sprout, Teva, TherapeuticsMD, Warner Chilcott, and Watson.
In the past 36 months, Dr. Simon has received grant/research support from AbbVie, Actavis, Agile Therapeutics, Bayer Healthcare, EndoCeutics, New England Research Institute, Novo Nordisk, Palatin Technologies, Teva, and TherapeuticsMD.
Within the past 36 months, Dr. Simon has also served on the speaker’s bureaus of Amgen, Eisai, Merck, Novartis, Noven, Novo Nordisk, Shionogi, Teva, and Warner Chilcott.
Dr. Simon served as Chief Medical Officer of Sprout Pharmaceuticals until April 1, 2013.
Data suggest that several years of systemic hormone therapy are safe in mutation carriers who have intact breasts and no personal history of breast cancer. If such mutation carriers have undergone risk-reducing bilateral mastectomy, systemic hormone therapy can be used without significantly elevating the risk of breast cancer.
Case: Disabling vasomotor symptoms in a BRCA1 mutation carrier
Christine is a 39-year-old mother of 2 who underwent risk-reducing, minimally invasive bilateral salpingo-oophorectomy with hysterectomy 4 months ago for a BRCA1 mutation (with benign findings on pathology). Eighteen months before that surgery, she had risk-reducing bilateral mastectomy with reconstruction (implants) and was advised by her surgeon that she no longer needs breast imaging.
Today she reports disabling hot flashes, insomnia, vaginal dryness, and painful sex. Her previous ObGyn, who performed the hysterectomy, was unwilling to prescribe hormone therapy (HT) due to safety concerns. Christine tried venlafaxine at 37 to 75 mg but noted little relief of her vasomotor symptoms.
In discussing her symptoms with you during this initial visit, Christine, a practicing accountant, also reveals that she does not feel as intellectually “sharp” as she did before her gynecologic surgery.
What can you offer for relief of her symptoms?
More BRCA mutation carriers are being identified and choosing to undergo risk-reducing salpingo-oophorectomy and bilateral mastectomy. Accordingly, clinicians are likely to face more questions about the use of systemic HT in this population. Because mutation carriers may worry about the safety of HT, given their BRCA status, some may delay or avoid salpingo-oophorectomy—a surgery that not only reduces the risk of ovarian, fallopian tube, and peritoneal cancer by 80% but also decreases the risk of breast cancer by 48%.1
Surgically menopausal women in their 30s or 40s who are not treated with HT appear to have an elevated risk for dementia and Parkinsonism.2 In addition, vasomotor symptoms are often more severe, and the risks for osteoporosis and, likely, cardiovascular disease are elevated in women with early menopause who are not treated with HT. For these reasons, systemic HT is recommended for women with early menopause, and generally should be continued at least until the normal age of menopause unless specific contraindications are present.3
Because Christine not only has had risk-reducing gynecologic surgery but also risk-reducing bilateral mastectomy, her current risk for breast cancer is very low whether or not she uses HT. Because she does not have a uterus, her symptoms can effectively and safely be treated with systemic estrogen-only therapy.
Among clinicians with special expertise in the management of BRCA mutation carriers, the use of systemic HT would be considered appropriate—and not controversial—in this setting.4
Angelina Jolie details her surgeries
In March 2015, 39-year-old Oscar-winning actress and filmmaker Angelina Jolie Pitt published an opinion piece in the New York Times detailing her recent laparoscopic salpingo-oophorectomy and initiation of HT.5 Ms. Jolie Pitt, who carries the BRCA1 mutation, lost her mother, grandmother, and aunt to hereditary breast/ovarian cancer. Two years earlier, Ms. Jolie Pitt made news by describing her decision to move ahead with risk-reducing bilateral mastectomy.
Following her risk-reducing salpingo-oophorectomy, she initiated systemic HT using transdermal estradiol and off-label use of a levonorgestrel-releasing intrauterine system for endometrial protection.
Her courageous decision to publicly describe her surgery and subsequent initiation of systemic HT will likely encourage women with ominous family histories to seek out genetic counseling and testing. Her decision to “go public” regarding surgery should help mutation carriers without a history of cancer (known in the BRCA community as “previvors”) who have completed their families to move forward with risk-reducing gynecologic surgery and, when appropriate, use of systemic HT.6
The outlook for previvors with intact breasts
Three studies address the risk of breast cancer with use of systemic HT among previvors with intact breasts. A 2005 study followed a cohort of BRCA1 and BRCA2 carriers with intact breasts, 155 of whom had undergone risk-reducing salpingo-oophorectomy, for a mean of 3.6 years. Of these women, 60% and 7%, respectively, of those who had and had not undergone salpingo-oophorectomy used HT. The authors noted that bilateral salpingo-oophorectomy reduced the risk of breast cancer by some 60%, whether or not women used HT.7
A 2008 case-control study focused on 472 menopausal BRCA1 carriers, half of whom had been diagnosed with breast cancer (cases); the other half had not received this diagnosis (controls). A 43% reduction in the risk of breast cancer was associated with prior use of HT.8
A 2011 presentation described a cohort study in which 1,299 BRCA1 and BRCA2 carriers with intact breasts who had undergone salpingo-oophorectomy were followed for a mean of 5.4 years postoperatively. In this population, use of HT was not associated with an increased risk of breast cancer. Among women with BRCA1 mutations, use of systemic HT was associated with a reduced risk of breast cancer.9
Viewed in aggregate, these studies reassure us that short-term use of systemic HT does not increase breast cancer risk in women with BRCA1 or BRCA2 mutations and intact breasts.
The latest guidance on safe use of menopausal hormone therapy
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