European Menopause and Andropause Society (EMAS) and International Gynecologic Cancer Society (IGCS) position statement on managing the menopause after gynecological cancer: focus on menopausal symptoms and osteoporosis

Abstract

Worldwide, it is estimated that about 1.3 million new gynecological cancer cases are diagnosed each year. For 2018, the predicted annual totals were cervix uteri 569 847, corpus uteri 382 069, ovary 295 414, vulva 44 235, and va​gina 17 600. Treatments include hysterectomy with or without bilateral salpingo-oophorectomy, radiotherapy, and chemotherapy. These can result in loss of ovarian function and, in women under the age of 45 years, early menopause. The aim of this position statement is to set out an individualized approach to the management, with or without menopausal hormone therapy, of menopausal symptoms and the prevention and treatment of osteoporosis in women with gynecological cancer. Our methods comprised a literature review and consensus of expert opinion. The limited data suggest that women with low-grade, early-stage endometrial cancer may consider systemic or topical estrogens. However, menopausal hormone therapy may stimulate tumor growth in patients with more advanced disease, and non-hormonal approaches are recommended. Uterine sarcomas may be hormone dependent, and therefore estrogen and progesterone receptor testing should be undertaken to guide decisions as to whether menopausal hormone therapy or non-hormonal strategies should be used. The limited evidence available suggests that menopausal hormone therapy, either systemic or topical, does not appear to be associated with harm and does not decrease overall or disease-free survival in women with non-serous epithelial ovarian cancer and germ cell tumors. Caution is required with both systemic and topical menopausal hormone therapy in women with serous and granulosa cell tumors because of their hormone dependence, and non-hormonal options are recommended as initial therapy. There is no evidence to contraindicate the use of systemic or topical menopausal hormone therapy by women with cervical, vaginal, or vulvar cancer, as these tumors are not considered to be hormone dependent.

The use of menopausal hormone therapy in women survivors of gynecological cancer: safety report based on systematic reviews and meta-analysis

“…These long-term risks often overlap with those suffered by women with premature ovarian failure (POF), thus extending the suitability of HMT [8]. This report complements the recommendations contained in a recent position paper published by EMAS and IGCS [33].…”

Individual Benefits and Risks of Intravaginal Estrogen and Systemic Testosterone in the Management of Women in the Menopause, With a Discussion of Any Associated Risks for Cancer Development

“…Data on estrogen replacement in this group demonstrate it is safe 50 . There are no studies available for women with Lynch syndrome 51 …”

“…The majority of endometrial cancers are diagnosed at an early stage and have a good overall prognosis, with a 5-year survival rate of greater than 85% 51 . Treatment usually involves hysterectomy and bilateral oophorectomy 51 .…”

“…The majority of endometrial cancers are diagnosed at an early stage and have a good overall prognosis, with a 5-year survival rate of greater than 85% 51 . Treatment usually involves hysterectomy and bilateral oophorectomy 51 . The most common type is a low-grade endometrioid adenocarcinoma, which is considered an estrogen receptor–positive neoplasm 71 .…”

Menopausal hormonal therapy in gynaecological cancers: An evidence‐based approach for clinical management

“…A large retrospective study investigated 373 women under 50 years with EOC in the 1970s and 1980s who had undergone debulking surgery. NAMS) position statements report that while there is no evidence to suggest decreased OS with MHT use in nonserous EOC, caution should be taken for use in serous carcinomas due to their hormonal responsiveness and also in tumours containing oestrogen receptors 17,18. Advanced stage endometroid ovarian cancers should be treated similarly to advanced endometroid endometrial cancers in which MHT is not recommended.…”