WILLIAM HOSKINS, MD Dr. Castiel is head of general gynecology and director of the Barbara White Fishman Women’s Health Center, and Dr. Hoskins is deputy physician-in-chief, disease management teams; chief of the gynecology service in the department of surgery; and holds the Avon Chair for Clinical Research at Memorial Sloan-Kettering Cancer in New York City. He also serves on OBG Management’s board of editors.
As more Ob/Gyns provide follow-up care to patients who have survived cancer, there is an increased need for information on how to better care for these women with regard to menopause, risk for subsequent disease, and preventive care.
Selective serotonin reuptake inhibitors (SSRIs), clonidine hydrochloride, and megestrol alleviate hot flushes in women who opt not to take hormone replacement therapy (HRT) due to concerns about subsequent disease.
Local estrogen therapy in the form of an estradiol-releasing vaginal tablet or ring effectively improves vaginal atrophy and has a higher patient acceptability than vaginal cream.
Because a majority of women who have survived breast cancer have not been screened for BRCA1 and BRCA2 mutations, Ob/Gyns should screen survivors to identify those patients at risk for subsequent disease.
Approximately half of the women who survive breast or a gynecologic cancer report severe, long-lasting sexual problems.
As more is discovered about cancer, caring for the cancer patient has become even more complicated. Women who have survived cancer, even nongynecologic diseases, increasingly are being followed by general obstetrician/gynecologists or primary care physicians. To help Ob/Gyns provide better care, this review will summarize cancer patients’ special needs with regard to menopause and premature menopause, genetic screening techniques, and well-woman care.
Only about 15% of postmenopausal women use HRT.
In evaluating the needs of the cancer patient, an understanding of the type of cancer and the surgical and medical management the woman has undergone is key. This knowledge aids the management of sexual health, fertility, and menopause. Additionally, depending on the type of cancer she has had, the patient may be exposed to health risks not previously identified. In these cases, an understanding of the familial basis of some cancers and hereditary syndromes is essential, as it can help identify those who may be at risk for subsequent malignancies or conditions.
Finally, as with all well-woman care, preventive measures such as bone densitometry, mammography, colonoscopy, exercise, self-breast examination, and smoking cessation must be addressed and discussed.
Menopause
Many young women with a cancer diagnosis face premature menopause. In addition to the psychological issues stemming from premature ovarian failure such as those related to fertility, these women experience many of the typical menopausal symptoms and other health risks well before their healthy counterparts.
In the decades since hormone replacement therapy (HRT) was introduced, there has been increasing controversy and confusion among patients and physicians about its benefits and risks. In particular, because of the possible role of estrogen in the pathogenesis of breast cancer, its use for post-menopausal therapy has been challenged.1-3
Currently, only about 15% of post-menopausal women use HRT, in part due to the concerns about breast cancer. Other reasons include breast engorgement and tenderness and a resumption of vaginal bleeding.
Most health-care providers believe HRT is contraindicated for breast cancer survivors. However, withholding HRT from all postmenopausal women would be a disservice to many, as it would expose them to health risks that would outweigh the risk for breast cancer. One of the clinician’s roles is to identify patients who would benefit from HRT and to avoid exposing others to unreasonable risk. Fortunately, the available alternatives to HRT are rapidly increasing in response to the demand this controversy has generated.
BRCA 1 and BRCA 2 are responsible for most inherited ovarian carcinomas.
Hormone replacement therapy initially was intended for short-term use in the management of vasomotor symptoms. The health benefits that were subsequently identified supported a longer duration of use.4,5 These include improving hot flushes, protecting bone density, and combating urogenital atrophy, but more recently, the potential benefit that hormones may have on cardiac health has come under scrutiny.6-8
Vasomotor symptoms. Menopausal women often complain of debilitating vasomotor flushes. For women who take tamoxifen, e.g., those with a history of breast cancer, vasomotor symptoms may be potentiated.9,10 Traditional HRT regimens, either oral or transdermal, have been effective in treating vasomotor symptoms in 85% to 90% of women.11 Even so, increasing numbers of women are turning to an ever-growing array of nonestrogen agents in an effort to alleviate symptoms and minimize their perceived risk of breast cancer.
Agents that can be used to alleviate hot flushes include selective serotonin reuptake inhibitors (SSRIs) such as venlafaxine hydrochloride in small doses, e.g., 25 to 75 mg daily.12,13 Clonidine hydrochloride, an antihypertensive, also is effective, but its side effects limit its use.14 If the 0.1-mg patch is used, it should be changed weekly, and if the drug is administered orally, the dosage should not exceed 0.1 mg twice daily. Megestrol, a progestin, also has been shown to be effective.15
Recently, phytoestrogens have been sought as substitutes for traditional HRT. While there is some evidence they may improve vasomotor flushes and protect against bone cancer and cardiovascular disease, results have been inconsistent and definitive studies are lacking.16-21
