MENOPAUSE / COMPLEX CONTRACEPTION / MEDICAL GYNAECOLOGY CLINICAL SERVICES AT CHALMERS

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Donna Lester
5 years ago
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1 MENOPAUSE / COMPLEX CONTRACEPTION / MEDICAL GYNAECOLOGY CLINICAL SERVICES AT CHALMERS We welcome referrals of complex women and these should be for the attention of Dr Ailsa Gebbie. Details of receptor status if appropriate and pathology grade and staging within the letter would be very helpful. The clinics generally operate as a one stop service but with suitable follow up and open access for review appointments. Any routine HRT prescribing is generally through primary care. We can supply leaflets with information about HRT, vaginal symptoms and non hormonal alternatives. We recommend the Menopause Matters website as a reputable, balanced site for women and health professionals CLINICAL PROBLEM AGREED MANAGEMENT Women with BRCA 1&2 gene mutations Role of use of combined oral contraception (COC) for chemoprophylaxis against ovarian cancer Specialist referral to Chalmers to consider use of COC Suggested use under 30 years only and careful discussion of risks and benefits Women with breast cancer Use of contraception/hrt at time of diagnosis Treatment of systemic menopausal symptoms Usually advise to discontinue any hormonal treatment at time of diagnosis. Could consider copper IUD rather than Mirena. Some women with breast cancer and heavy menstrual bleeding can be counselled about having a Mirena inserted or continuing following diagnosis refer to Chalmers. Almost all women will avoid use of systemic HRT following diagnosis. A few women in remission with severe symptoms which affect quality of life may choose to take this following careful counselling. Alternatives to consider

2 include anti depressants, progestogens and gabapentin. Safety of herbal agents with potential oestrogenic activity is uncertain. Treatment of severe vulvovaginal atrophy Local vaginal oestrogens can be prescribed after careful discussion. Less clinical concern about this in women taking Tamoxifen in contrast to aromatase inhibitors. Less systemic absorption and short half life of oestriol preparations (Ovestin cream) but oestradiol preparations more convenient (Vagifem 10 mcg pessaries and Estring). Cervical, vulval and vaginal cancers and vulval melanoma Includes both squamous cell and adenocarcinoma of cervix Systemic HRT and vaginal oestrogens are not contraindicated Borderline ovarian cancer Systemic HRT and vaginal oestrogens are not contraindicated in stage 1 serous borderline disease or any mucinous borderline disease. Stage 2 and above serous borderline disease should be referred to Chalmers for further discussion of the risk/benefit balance based on disease free interval and severity of symptoms. Ovarian cancer Heterogeneous disease, of which a subset is responsive to oestrogen suppression. Oestrogen receptor status will, in general, guide the appropriate prescribing of HRT in women with severe vasomotor symptoms. If disease is advanced and prognosis poor Decision about HRT should be made on balance of quality of life versus

3 potential for disease progression (a decision that can be aided by knowledge of histotype and ER histoscore). If patients are asymptomatic and wish osteoporosis prophylaxis If patients are known to have residual endometriosis following surgery or clear cell tumours arising in background of endometriosis (bearing in mind that endometriosis is also associated with endometrioid ovarian cancer and these tumours are often ER positive). Atrophic vaginal symptoms Stage 1A or 1B serous or endometrioid Stage 1C or above serous or endometrioid (can take receptor status into account) In general, all women <45 years who have mucinous or clear cell tumours should be advised to take HRT. Women with higher risk tumours should be referred to Chalmers for further advice and alternative management. Combined HRT should be considered as long as primary tumour was not endometrioid or serous with an ER histoscore>150. Same criteria should be used as for systemic symptoms HRT use acceptable if surgical staging was complete HRT contraindicated unless considered on individual basis as a result of severe symptoms Mucinous and clear cell HRT acceptable Granulosa cell No HRT unless case made on individual basis as result of severe symptoms. Endometrial cancer HRT acceptable systemic and local vaginal

4 Low grade stage 1A there is no proven need to wait a year before starting HRT if symptoms are particularly troublesome (but in reality a year may well have passed by time other non HRT options are explored in full) Higher stage Avoid HRT systemic and local vaginal High dose progestogen is a management option although note potential VTE risk with norethisterone so alternative progestogens recommended (megestrol acetate or Provera) Papillary serous and endometrial stromal cell tumour Long terms remission and menopausal quality of life issues very problematic Avoid HRT Systemic or local HRT could be considered Post risk reduction BSO Women with strong FH of breast/ovarian cancers Breast cancer risk reduction after BSO is estimated to be approx 50% use of HRT does not abrogate this benefit even if the patient has not had mastectomy, and in general the benefits of HRT continue to outweigh the risks up till the age of natural menopause (51 years) Some of these women will consider referral for bilateral mastectomy following genetic counselling Which HRT regimen should be first line for women undergoing laparoscopic BSO at high risk of breast/ovarian cancers If acceptable, a Mirena should be fitted at the time of laparoscopy and lowdose transdermal oestrogen prescribed (eg Evorel patches 50mcg twice per week). This is a convenient regimen that minimises bleeding and offers the lowest possible exposure to progestogen. Women will need reminded to change a Mirena at 5 years if used in conjunction with oestrogen (product licence 4 years only but this is technical

5 licensing problem and 5 years is standard). Should women having risk reduction surgery be offered hysterectomy as well as BSO? Consider using until age of natural menopause (aged 50 years) then reassess Concurrent hysterectomy would mean women could use oestrogen only HRT with less effect on breast cancer risk (if any) and thrombosis. Laparoscopic hysterectomy is now funded in Lothian and would be considered if other gynaecological/personal factors. This option can be discussed in more detail and may not be applicable to all women. Hysterectomy may minimise risk/side effects from combined HRT. Use of testosterone Useful for management of decreased libido, low mood and lack of energy following surgical menopause. Some issues with licensing and pharmacy supply in Scotland Intrinsa patches licensed in UK but not approved by SMC because of cost. Treatment with testosterone gel is recommended Testogel or Testim for male use may be used off licence in women (eg one sachet/tube per week in divided dosages). Usual UK practice is to give testosterone in conjunction with oestrogen. Lack of evidence on safety in women who have had breast cancer. Some ovarian cancers may be androgen sensitive and similar caution with oestrogen should be applied to androgens after ovarian cancer. Last review: March 2014 Next review: May 2015

FAQ-Protocol 3. BRCA mutation carrier guidelines Frequently asked questions

FAQ-Protocol 3. BRCA mutation carrier guidelines Frequently asked questions ULast updated: 09/02/2015 Protocol 3 BRCA mutation carrier guidelines Frequently asked questions UQ: How accurate are the remaining lifetime and 5 year breast cancer risks in the table? These figures are