Post Reproductive Health

Ovarian thecoma: A very unusual cause of postmenopausal bleeding

We describe a 67-year-old woman with postmenopausal bleeding having ceased estrogen plus progestogen therapy nine months before. Transvaginal ultrasonography showed endometrial thickening with normal ovarian appearance. Hormonal studies revealed high estradiol and inhibin B levels but normal androgens and adrenal hormones. Magnetic resonance image demonstrated a 13-mm left ovarian tumour. Hysterectomy and bilateral salpingo-oophorectomy were performed, and the pathological study revealed an 8 mm ovarian thecoma. This case illustrates a very unusual cause of postmenopausal bleeding. We suggest a study protocol and discuss the differential diagnosis of this case.

Safety of hormone replacement therapy in women with a history of cervical adenocarcinoma

Objectives Studies investigating the safety of hormone replacement therapy in cervical cancer have predominantly included patients with squamous disease. Pathological studies have identified estrogen receptor positivity in cervical adenocarcinomas. A recent small case-control study suggested a trend towards reduced survival with hormone replacement therapy in cervical adenocarcinomas. Our objective was to determine if hormone replacement therapy use in patients treated for cervical adenocarcinomas is detrimental to survival. Study design A retrospective review of all women under the age of 50 with stage 1B-2B cervical adenocarcinomas diagnosed between 1 November 2000 and 24 September 2019. Women were categorised into three groups: ovaries conserved (OVCON); or iatrogenic menopause with (IM-HRT) or without (IM-NOHRT) hormone replacement therapy. Hormone replacement therapy use was defined on an intention to treat basis. Statistical analysis was performed using Kaplan-Meier and Cox proportional hazards methods. Main outcome measures Overall (OS), disease specific (DSS) and progression free (PFS) survival. Results A total of 58 women (mean age 38.5 ± 6.6) were included in the study of whom 25 (43.1%) had OVCON, 20 (34.4%) had IM-HRT and 13 (22.4%) had IM-NOHRT. No menopause-associated deaths occurred. Although five-year DSS was 73% in IM-NOHRT compared to 95% in IM-HRT and 95% in OVCON, these differences were not statistically significant. Five-year PFS was 68% in IM-NOHRT compared to 90% in IM-HRT and 81% in OVCON but again, these differences were not statistically significant. Conclusion In this small study, hormone replacement therapy does not appear to be detrimental to survival in cervical adenocarcinomas. There is a trend towards improved survival with hormone replacement therapy. Larger studies are required to substantiate these findings.

Diagnostic pitfalls in ovarian androgen-secreting tumors in postmenopausal women with rapidly progressed severe hyperandrogenism

Objective Sex cord-stromal neoplasms of the ovary are rare tumors and a very infrequent cause of androgen excess and virilization in women. We report two cases of postmenopausal women with rapidly progressive signs of virilization and negative or indeterminate imaging for pelvic masses. Methods Both patients underwent a complete hormone profile, inconclusive transvaginal ultrasound and contrast-enhanced abdominopelvic computed tomography. Results Serum hormone analysis revealed for both cases a marked increase in serum total testosterone (T). In the first woman, Δ-4 androstenedione (Δ-4 A), dehydroepiandrosterone-sulfate (DHEA-S) and cortisol levels were in a normal range for age. In the second, Δ-4 A and DHEA-S levels were below the reference range. For both women, an ovarian source of androgens was suspected and bilateral laparoscopic oophorectomy was performed. Ovarian histology demostrated bilateral Leydig cell tumor (LCT) in the first case and bilateral ovarian thecoma in the second. After surgery, total testosterone returned to normal levels and clinical symptoms subsided. Conclusions In cases of postmenopausal androgen excess, physicians must rule out relatively rare androgen-producing tumors originating from the adrenals or ovaries. Regardless of imaging evaluation, our report highlights the importance of prompt and careful clinical and hormonal evaluation to ensure appropriate and timely treatment for the patient.

British Gynaecological Cancer Society and British Menopause Society guidelines: Management of menopausal symptoms following treatment of gynaecological cancer

These guidelines have been developed jointly by the British Gynaecological Cancer Society and British Menopause Society to provide information for all healthcare professionals managing women treated for gynaecological cancer. Menopausal symptoms can have a significant impact on quality of life for women. Cancer therapies, including surgery, pelvic radiotherapy, chemotherapy and endocrine therapy, can all affect ovarian function. The benefits and risks of using hormone replacement therapy are considered by cancer type with guidance on the type of HRT and optimal time of commencement after cancer treatment. Vaginal estrogens can be very effective for improving urogenital symptoms and are safe for the majority of women, including those for whom systemic HRT is contraindicated with rare exceptions. Alternative options to HRT are reviewed including pharmacological and non-pharmacological approaches.

How hairfall saved the patient from cancer twice – A postmenopausal patient with synchronous endometrial and endocervical carcinomas presenting with endocrine symptoms

Ovarian stromal hyperthecosis is an uncommon nonneoplastic cause of ovarian hyperandrogenism mainly in postmenopausal women. Here, we present a case of a postmenopausal woman who presented with features of virilization like alopecia and hirsutism. During its workup, two malignancies were diagnosed at a very early stage. Microscopic focus of endometrial adenocarcinoma in a polyp and similar focus of endocervical adenocarcinoma in the subsequent hysterectomy specimen were noted. Presence of synchronous malignancies in the uterus is very rare and it being detected in a patient who presented with a non-related symptom of hairfall makes it an interesting case scenario.

Endometrial cancer rate in Hormone replacement therapy users with postmenopausal bleeding: Retrospective cohort study

Objective To establish the endometrial cancer detection rate in women using hormone replacement therapy presenting with postmenopausal bleeding. Study Design Retrospective cohort study. Setting and population Rapid access gynaecology clinic at a tertiary hospital. Women aged under 60 years referred with postmenopausal bleeding. Methods Retrospective study of referrals received between 1 January 2019 and 31 December 2020 including Hormone replacement therapy (HRT) use and histological diagnosis. Main outcome measures Histological diagnosis of endometrial cancer, borderline ovarian tumour or endometrial intraepithelial neoplasia. Statistical analysis Chi squared test Results 1363 women were included. 214 women were using HRT when they experienced PMB and only one of these had endometrial cancer at histology (cancer detection rate 0.47%). 25 of the 1124 women who were not using HRT were diagnosed with endometrial cancer on histology (cancer detection rate 2.18%). Chi squared statistical analysis confirmed this was statistically significant ( p value .0156). Conclusions The endometrial cancer detection rate in women aged under 60 years using HRT with PMB is very low. Referral on a two-week wait pathway for suspected cancer diagnosis induces stress and anxiety for the woman and may lead to more invasive initial investigation even though other diagnoses are far more likely. Women aged under 60 years with postmenopausal bleeding that have either commenced HRT or had a change to their preparation within the last 6 months should be seen on a less urgent referral pathway if necessary given the very low probability of endometrial cancer.

A case of congenital long QT syndrome and medically induced menopause

This is a case report of a 47-year-old woman with known Long QT Syndrome who was given GnRH analogues to induce menopause prior to hysterectomy for fibroids who suffered several episodes of ventricular fibrillation leading to Torsades de Pointes cardiac arrests. This paper discusses the case and the physiological backdrop of hormone influences on the QT interval in women, includes the patient perspective and makes recommendations.

Counselling of path_ BRCA carriers who are considering risk-reducing oophorectomy

path_ BRCA 1/2 increases a woman’s lifetime risk of breast and ovarian cancer. Interventions can be offered which manage cancer risk; annual breast screening from age 30, chemoprevention and, once a woman’s family is complete, risk-reducing surgery. The latter is the most effective method of reducing cancer in path_ BRCA carriers; salpingo-oophorectomy reduces breast and ovarian cancer, respectively, by up to 50% and 95%. Factors affecting a woman’s decision to undergo risk-reducing surgery are complex; dominant factors include risks of surgery, effect on cancer outcomes and menopausal sequelae. Specific information relating to hormone replacement and non-hormonal alternatives are an important consideration for women but, are often overlooked. Informative counselling is required to enable satisfaction with the chosen intervention whilst improving survival outcomes. This review paper outlines the current data pertaining to these decision-making factors and provides a proforma to enable effective counselling.