Effect of hormone replacement therapies and selective estrogen receptor modulators in postmenopausal women with uterine leiomyomas:a literature review

Uterine fibroids in menopause and perimenopause

Uterine fibroids (UFs) are benign tumors that arise from a single genetically altered mesenchymal stem cell under the influence of gonadal hormones. UFs are the most common benign gynecologic tumors in premenopausal women worldwide. It is estimated that nearly 70% to 80% of women will develop UFs at some point during their lifetime. UFs often present with abnormal uterine bleeding (AUB), pelvic fullness, and may have deleterious effects on fertility. The natural regression of UFs begins in menopause. This is, however, a generality as this pathology may still be present in this age group. Many clinicians are concerned about hormone therapy (HT) because of UFs regrowth; nevertheless, research of this subject remains inconclusive. If UFs are present in perimenopause or menopause, they typically manifest as AUB, which represents up to 70% of all gynecological consultations in perimenopausal and postmenopausal women. As AUB is a broad symptom and may not be specific to UFs, a thorough evaluation is required for correct diagnosis and proper treatment accordingly. Understanding the unique characteristics of the available treatment modalities is crucial in deciding the appropriate treatment approach. Decision on treatment modality should be made based on selection of the least morbidity and lowest risk for each patient. Multiple modalities are available; however, surgery remains the method of choice, with the best cure rates. Various attempts to create an inexpensive, safe, and effective drug for the treatments of UFs are still in the early stages of the clinical trials with some showing great promise. Treatment options include tibolone, aromatase inhibitors, selective estrogen receptor modulators, uterine artery embolization, and selective progesterone receptor modulators.

A high AR:ERα or PDEF:ERα ratio predicts a sub-optimal response to tamoxifen therapy in ERα-positive breast cancer

PURPOSE

Approximately 30% oestrogen receptor alpha (ERα)-positive breast cancer (BC) patients exhibit intrinsic or recurrent resistance to adjuvant endocrine therapy with tamoxifen. The androgen receptor (AR) is expressed in about 90% of ERα-positive patients, with particularly high expression in tamoxifen-resistant tumours. Prostate-derived Ets factor (PDEF), which is a co-regulator of AR, plays a role in tamoxifen resistance in ERα-positive BC. The purpose of this research was to analyse the potential roles of AR, PDEF and ERα levels in the response to tamoxifen resistance in ERα-positive BC.

METHODS

The nuclear AR:ERα and PDEF:ERα ratios were examined immunohistochemically in a cohort of 225 ERα-positive pre-menopausal BC patients who had received adjuvant tamoxifen therapy.

RESULTS

For both AR:ERα and PDEF:ERα ratios, the optimal cutoff value was 2.0. Patients receiving adjuvant tamoxifen treatment who had a high AR:ERα (≥ 2.0) (HR = 3.90) or PDEF:ERα ratio (≥ 2.0) (HR = 2.77) had a beyond twofold increased risk of failure. Both the AR:ERα ratio (P = 0.001) and PDEF:ERα ratio (P = 0.002) were independently associated with the risk of tamoxifen treatment failure. Furthermore, both a high ratio of AR:ERα (≥ 2.0) and PDEF:ERα (≥ 2.0) were associated with shorter disease-free survival (DFS) and shorter disease-specific survival (DSS). In addition, both the AR:ERα ratio and PDEF:ERα ratio were independent predictors of DFS (both P < 0.0001) and DSS (P = 0.001 and P < 0.0001, respectively).

CONCLUSIONS

AR:ERα and PDEF:ERα ratios are independent predictors of the response to conventional ERα-directed tamoxifen endocrine therapy.

HRT for women with premature ovarian insufficiency: a comprehensive review

BACKGROUND

Premature ovarian insufficiency (POI), often and misleadingly referred to as ‘premature menopause’, is defined as a loss of ovarian activity before the age of 40 years and is characterized by irregular or absent periods and reduced fertility. Symptoms include those associated with the natural menopause (night sweats and vaginal dryness), and with the long-term adverse effects of estrogen deficiency (osteoporosis and cardiovascular disease): the latter is believed to explain the shorter life expectancy associated with POI.

OBJECTIVE AND RATIONALE

The objective of the current review was to collect all relevant studies supporting recommendations on the indications, treatment options, and risks of hormone replacement therapy (HRT) (estrogen, progestogens and androgens) for women with POI.

SEARCH METHODS

The current review was written based on the best available evidence on the topic collected for the recently published ESHRE guideline on the management of women with POI. PUBMED/MEDLINE and the Cochrane library were searched in a stepwise approach. Relevant references were summarized in evidence tables, with assessment of the quality.

OUTCOMES

HRT is strongly recommended for women with POI, mainly for vasomotor and genito-urinary symptom relief. In addition, HRT has been shown to have a role in bone protection and probably also in primary prevention of cardiovascular disease. There is little evidence on the optimal type, regimen and dose of HRT; patient preference for route and method of administration of each component of HRT must be considered when prescribing, as should contraceptive needs. In women with POI, physiological replacement of estrogen (and progesterone) is essential for their health, and the controversies that surround the use of HRT in postmenopausal women do not apply.

LIMITATIONS, REASONS FOR CAUTION

N/A.

WIDER IMPLICATIONS

New areas of study on HRT for women with POI should focus on life expectancy, quality of life and neurological function. Furthermore, randomized controlled trials comparing transdermal estradiol with oral estrogens with regard to efficacy, patient satisfaction and side effects are urgently needed.

STUDY FUNDING/COMPETING INTERESTS

The authors received no funding for the review. The costs for the development of the ESHRE guideline were covered by ESHRE. The authors have no conflicts of interest to disclose.

Effects of obesity and hormone therapy on surgically-confirmed fibroids in postmenopausal women

To examine the association between body mass index (BMI), use of menopausal hormone therapy (HT), and incidence of uterine fibroids in postmenopausal women, 610,604 postmenopausal women without prior hysterectomy or diagnosis of fibroids were followed as part of a large United Kingdom prospective cohort study. We used Cox regression models to calculate adjusted relative risks (RRs) of surgically-confirmed fibroids (defined as a hospital admission with uterine fibroids as a primary diagnosis with a related surgical procedure), in relation to BMI and use of HT. During an average of 11.4 years of follow-up, 3561 women were admitted to hospital with surgically-confirmed fibroids. Five-year incidence rates decreased with age, from 0.50% (1 in 200 women) at age 50-54, to 0.11% (1 in 1000 women) at age 75-79. The 5-year rate in postmenopausal women aged 50-54 was about a quarter that seen in premenopausal women of the same age (1 in 200 vs. 1 in 50). Compared with normal weight women, obese women had a RR of surgically-detected fibroids of 1.46 (95% CI 1.33-1.59; p < 0.0001). HT use was associated with a RR of 2.33 (95% CI 2.18-2.49; p < 0.0001) in ever versus never users. When we analysed HT use and BMI together, obese vs. normal weight never users had a RR of 2.00 (95% CI 1.77-2.26): the highest risks were seen in women who were obese and had ever used HT, RR = 3.30 (95% CI 2.88-3.79). Uterine fibroids continue to occur in postmenopausal women; obesity and hormone therapy use are important modifiable risk factors.

Acupuncture for uterine fibroids

BACKGROUND

Uterine fibroids (UFs) are benign growths within the uterine muscle and are present in 30% of women during their reproductive years. With the exception of hysterectomy, there are no effective medical and surgical treatments for women with uterine fibroids . Acupuncture is an ancient Chinese method which has been used for both the prevention and treatment of diseases for over three thousand years. There are many types of acupuncture used to manage UFs, with body acupuncture being the most commonly used. The literature reporting the benefits or harms of acupuncture for the management of UFs has not yet been systematically reviewed.

OBJECTIVES

To assess the benefits and harms of acupuncture in women with uterine fibroids

SEARCH STRATEGY

The following electronic databases were searched 21st May 2009: the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; AMED; the Menstrual Disorders and Subfertility Group's Specialised Register of Trials; Chinese Biomedical Literature Database (CBM); Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS); Chinese Medical Current Contents (CMCC) and China National Knowledge Infrastructure(CNKI). Citation lists, experts in the field and grey literature were also referred to. No restrictions such as language were applied.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing acupuncture management with placebo acupuncture, no management, Chinese medication, Western medication or other managements of uterine fibroids were considered for inclusion. Acupuncture management included either traditional acupuncture or contemporary acupuncture, regardless of the source of stimulation (for example, body, electro, scalp, elongated, fire, hand, fine needle, moxibustion). Acupuncture management without needling was excluded.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial risk of bias according to our a priori criteria. No trials were included in this version of the review, therefore no data was collected.

MAIN RESULTS

No randomized double-blind controlled trials met the inclusion criteria .

AUTHORS' CONCLUSIONS

The effectiveness of acupuncture for the management of uterine fibroids remains uncertain. More evidence is required to establish the efficacy and safety of acupuncture for uterine fibroids.There is a continued need for well designed RCTs with long term follow up.