Hormone replacement therapy after gynaecological cancer

Premenopausal women who need their ovaries removed for their cancer treatment will become menopausal. This is called surgical menopause.

Menopausal side effects can severely reduce quality of life for some women. Symptoms from surgical menopause in young women may be more intense than natural menopause due to its sudden onset after surgery.  Hormone Replacement Therapy (HRT) is used for management of menopausal symptoms such as hot flashes, dry skin and vulvovaginal atrophy.

menopausal woman experiencing a hot flushAfter surgical menopause, women who still have a uterus will require a combination of estrogen and progestin therapy. The estrogen is required to treat the menopausal symptoms and the progestin will protect the uterus from developing endometrial cancer. If the women would only receive estrogen, the risk of developing endometrial cancer would be very high. Women who had a hysterectomy (the uterus is removed) do not require the progestin and will benefit from estrogen only.

HRT will reduce symptoms of menopause and also lower the risk of developing heart disease, cognitive impairment and prevent osteoporosis from bone density loss. 

Side effects of HRT

All medication can have side effects and patients prescribed HRT may experience some of them; including breast tenderness, bloating, nausea, indigestion, headaches, vaginal bleeding or leg cramps. These side effects are more likely to be present at the start of treatment and often pass after a few weeks or months. Others may experience no side effects.

In a small proportion of patients, HRT can also have more serious side effects and is associated with an increased risk of deep vein thrombosis (DVT), which in some cases can lead to blood clots in the lungs (Pulmonary Emboli, PE).

Estrogen can be administered by oral tablets, dermal patches, creams or suppositories. Research suggests that the risk of DVT/PE is higher with oral tablets compared to transdermal administration (through the skin).

Hormone Replacement Therapy increases the risk of being diagnosed with breast cancer, and this risk is greater with combined HRT (estrogen and progestogen) than with estrogen only HRT. The longer you take HRT the greater the risks are, and the longer they may last. The risk of developing breast cancer by using estrogen patches is very low.

Taking HRT tablets is associated with a slight increase in the risk of stroke, however the risk for women under age 60 is very low.

If a patient is taking HRT and their ovaries have not been removed, both oestrogen-only and combined HRT slightly increase the risk of ovarian cancer. 

In summary, in my practice we prefer to use transdermal estrogen (used as a patch that is changed twice weekly; or used as a gel applied to the skin). This form of estrogen replacement has many advantages and is the safest way with the least side effects.

Is Hormone Replacement Therapy safe after gynaecological cancer?

A recent review found that there is unfortunately limited research conducted in the area of HRT after gynaecological cancer, and women and their doctors should make decisions based on the patients’ individual circumstances and symptoms.

I am not aware of a single high-quality study that has shown an adverse effect of Hormone Replacement Therapy in patients previously diagnosed with gynaecological cancer. Numerous studies have shown that estrogen only HRT can be safely offered to women with a history of almost all types of gynaecological cancer. HRT has been shown to have a favourable impact on overall survival for ovarian cancer patients, without increasing the risk of recurrence.

However, we need to individualise the treatment of those women. For example, an exception for offering HRT would be for patents with ovarian cancer that arose in the background of endometriosis (most of clear cell cancers do). We know that endometriosis is fuelled by estrogen, and I would be inclined to make alternatives to estrogen available for these very few patients. 

For all other gynaecological cancer types, we advocate for estrogen replacement therapy in young, menopausal women. It reduces the risk of menopausal symptoms, the risk of heart attacks, stroke and cognitive decline and it is also good for bone health. Topical estrogen can be administered vaginally (as a pessary) and reduce vaginal dryness.

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