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HRT and Ovarian Cancer
I have stage 1C ovarian cancer. I had a hysterectomy and staging surgery on November 15, 2007, and am currently undergoing chemotherapy. I am 46 years old, and had normal levels of hormones prior to diagnosis. Following the surgery, my doctor put me on estrogen patches (HRT). It is his belief that the benefits of estrogen outweigh the risks at my age.
My pathology report showed that my ovarian cancer was estrogen receptive/reactive. So why is HRT okay? My local gyno-oncologist and my gyno-oncologist at the Fred Hutchinson Center in Seattle both indicated it was okay. I like being on estrogen, but I am concerned because it seems risky. What is your opinion?
My pathology report showed that my ovarian cancer was estrogen receptive/reactive. So why is HRT okay? My local gyno-oncologist and my gyno-oncologist at the Fred Hutchinson Center in Seattle both indicated it was okay. I like being on estrogen, but I am concerned because it seems risky. What is your opinion?
MEDICAL PROFESSIONAL
Hi Rubyellen,
It is really tough! You are almost half way there! We tend to avoid estrogen when a ovarian cancer has an endometrioid subtype or is present in the setting of endometriosis.
The classic thinking is that estrogen replacement therapy does not stimulate the growth of most ovarian cancers. There is mixed information in the literature. Most recently, the women's health initiative (WHI) study does suggest that ERT may be associated with an increased risk of ovarian cancer (note this is estrogen plus progesterone, there is no reported increase with estrogen by itself in WHI study). Plus remember tha there have been no studies looking at estrogen increasing ovarian cancer recurrence in women with a known ovarian cancer.
So you are left with the option of just not taking estrogen because of a theoretical risk versus taking it because of the known benefits of sexual function, strong bones, improved quality of life.
I have pasted the WHI summary below:
Findings Summary
Gynecologic cancers are cancers of female organs other than the breast. We do not know much about the factors that affect these diseases, in part because they are not very common. Many years ago, a link between estrogen alone and endometrial cancer was found. Observational studies suggested that using estrogens combined with progestins would protect the uterus from this risk. Based on this information, physicians began to give combined hormones to women with a uterus.
In the October 1 issue of the Journal of the American Medical Association, the WHI investigators report that women randomized to combined estrogen plus progestin (E+P) experienced:
A 19% decrease in endometrial cancer rates
A 58% increase in ovarian cancer rates
Thus, women taking E+P have a risk of endometrial cancer that is similar to or slightly less than women taking placebo. Progestin appears to cancel the harmful effect of estrogen in the uterus, as previous studies showed. However, E+P does not completely prevent endometrial cancer, so the bleeding problems that women often have with this therapy must still be monitored. This monitoring usually includes doing an endometrial biopsy. In the WHI study, E+P use was associated with a 5-fold increase in the number of women needing endometrial biopsies.
The increase in ovarian cancer is consistent with reports from observational studies of estrogen alone and some other forms of combined hormones. However, the number of ovarian cancers in WHI was small (only 32), so it is possible that this was just a chance finding. No other study has linked this particular hormone combination with an increased risk of ovarian cancer. It is also helpful to think about these findings in another way. In women taking placebo, the rate of ovarian cancer would be 27 cancers per 100,000 women per year. In women taking E+P, the rate would be 42 cancers per 100,000 women per year, an increase of 15. Even if this effect of E+P is real and not a chance finding, ovarian cancer remains a rare disease in women taking these hormones.
The numbers of other gynecologic cancers (cancers of the cervix, fallopian tube, and peritoneum) were very small. Therefore, it is not possible to make conclusions about the effects of combined hormone use on these cancers.
Gynecologic cancers are rare diseases, so these estimates are not precise. Nevertheless, these results support current recommendations to use the lowest dose of E+P for the shortest duration needed to treat menopausal symptoms.
It is really tough! You are almost half way there! We tend to avoid estrogen when a ovarian cancer has an endometrioid subtype or is present in the setting of endometriosis.
The classic thinking is that estrogen replacement therapy does not stimulate the growth of most ovarian cancers. There is mixed information in the literature. Most recently, the women's health initiative (WHI) study does suggest that ERT may be associated with an increased risk of ovarian cancer (note this is estrogen plus progesterone, there is no reported increase with estrogen by itself in WHI study). Plus remember tha there have been no studies looking at estrogen increasing ovarian cancer recurrence in women with a known ovarian cancer.
So you are left with the option of just not taking estrogen because of a theoretical risk versus taking it because of the known benefits of sexual function, strong bones, improved quality of life.
I have pasted the WHI summary below:
Findings Summary
Gynecologic cancers are cancers of female organs other than the breast. We do not know much about the factors that affect these diseases, in part because they are not very common. Many years ago, a link between estrogen alone and endometrial cancer was found. Observational studies suggested that using estrogens combined with progestins would protect the uterus from this risk. Based on this information, physicians began to give combined hormones to women with a uterus.
In the October 1 issue of the Journal of the American Medical Association, the WHI investigators report that women randomized to combined estrogen plus progestin (E+P) experienced:
A 19% decrease in endometrial cancer rates
A 58% increase in ovarian cancer rates
Thus, women taking E+P have a risk of endometrial cancer that is similar to or slightly less than women taking placebo. Progestin appears to cancel the harmful effect of estrogen in the uterus, as previous studies showed. However, E+P does not completely prevent endometrial cancer, so the bleeding problems that women often have with this therapy must still be monitored. This monitoring usually includes doing an endometrial biopsy. In the WHI study, E+P use was associated with a 5-fold increase in the number of women needing endometrial biopsies.
The increase in ovarian cancer is consistent with reports from observational studies of estrogen alone and some other forms of combined hormones. However, the number of ovarian cancers in WHI was small (only 32), so it is possible that this was just a chance finding. No other study has linked this particular hormone combination with an increased risk of ovarian cancer. It is also helpful to think about these findings in another way. In women taking placebo, the rate of ovarian cancer would be 27 cancers per 100,000 women per year. In women taking E+P, the rate would be 42 cancers per 100,000 women per year, an increase of 15. Even if this effect of E+P is real and not a chance finding, ovarian cancer remains a rare disease in women taking these hormones.
The numbers of other gynecologic cancers (cancers of the cervix, fallopian tube, and peritoneum) were very small. Therefore, it is not possible to make conclusions about the effects of combined hormone use on these cancers.
Gynecologic cancers are rare diseases, so these estimates are not precise. Nevertheless, these results support current recommendations to use the lowest dose of E+P for the shortest duration needed to treat menopausal symptoms.
The ovarian cancer is grade 2-3 (depending on which pathology report you accept). Local pathologist says grade 2, and pathologist as Mass General (Dr. Robert Young) says grade 3. Cancer is papillary serous adenocarcinoma according to local pathologist, and transitional adenocarcinoma with serous component according to Dr. Young.
By normal levels of estrogen, I mean I had not started entering menopause.
I have had 2 chemotherapy appointments, and have 3 to go. Local gyno-oncologist recommended 6 chemotherapy treatments, and Fred Hutchinson recommended 3 chemotherapy treatments. I have decided to do 5. Due to my age, I am concerned about secondary cancers. You were right--this is a rough road! But I am doing it! I will be cured!
By normal levels of estrogen, I mean I had not started entering menopause.
I have had 2 chemotherapy appointments, and have 3 to go. Local gyno-oncologist recommended 6 chemotherapy treatments, and Fred Hutchinson recommended 3 chemotherapy treatments. I have decided to do 5. Due to my age, I am concerned about secondary cancers. You were right--this is a rough road! But I am doing it! I will be cured!
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