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Guideline: gynecologic management in breast ca.


The American College of Obstetricians and Gynecologists advises that selective serotonin reuptake inhibitors, or SSRIs, can safely be used to treat hot flashes in some women with breast cancer. And women who are able to become pregnant following breast cancer treatment can do so without increasing the risk of disease recurrence, according to the college.

The advice, published online as Practice Bulletin No. 126, is part of the college's comprehensive new clinical guideline on the gynecological management of women who are being - or have been - treated for breast cancer (Obstet. Gynecol. 2012;119:666-82). The guideline, which cites evidence from 166 published sources, covers such diverse issues as vasomotor symptoms; vaginal atrophy; contraception and fertility; uterine evaluation; and the treatment and prevention of bone loss in the context of current treatment regimens, which may include chemotherapy, hormonal treatments, radiation, and surgery.

"More and more women are living with breast cancer," Dr. Mindy E. Goldman, lead author of the guideline, said in an interview. But its treatments, particularly the hormonal therapies, have gynecologic side effects. "Ob.gyns. need to be aware of how these drugs work," said Dr. Goldman, who is director of women's cancer care at the University of California, San Francisco.

For managing vasomotor symptoms such as hot flashes, the guideline recommends that - because hormonal therapy is generally contraindicated in women with hormone-positive breast cancer - an SSRI, an SNRI (serotonin norepinephrine reuptake inhibitor), or gabapentin be used instead. For women on tamoxifen, an SNRI is a better choice than an SSRI, because it avoids a potential interaction. None of these medicines is licensed in the United States for the treatment of hot flashes.

Because chemotherapy, ovarian suppression, and aromatase inhibitors contribute to bone loss and increase fracture risk, the guideline recommends that pharmacologic therapy with bisphosphonates be considered for women who have T scores between -1.5 and -2.0, and be strongly considered for women with T scores less than -2.0, or those who have a 10-year risk greater than 20% for a major fracture, or a 10-year hip fracture risk greater than 3%. Zoledronic acid was seen as a strong option among the bisphosphonates, and although raloxifene was generally well tolerated, vasomotor symptoms are among its reported adverse effects.

The guideline also recommends annual monitoring of women whose risks of bone loss significantly change as a result of treatment. And vitamin D levels should be checked in women with breast cancer.

Up to 40% of women with breast cancer have severe vaginal dryness, and the topical hormonal creams, suppositories, and vaginal rings commonly used to treat it have not been shown to be safe in women with breast cancer. Preference should be given to nonhormonal vaginal moisturizers, with hormonal treatments used on a short-term basis when nonhormonal options have failed. Testosterone supplementation, in patches or creams, remains without enough breast safety data to support it.

Contraceptives that are appropriate for women with breast cancer include barrier methods, the copper intrauterine device, and sterilization. Hormonal methods are contraindicated in women with breast cancer and are considered a risk even for women who have been cancer free for 5 or more years.

Pregnancy following breast cancer treatment has not been shown to increase the risk of recurrence or mortality, according to a recent meta-analysis cited in the guideline (Eur. J. Cancer 2011;47:74-83). But chemotherapy can compromise fertility, and 5-year use of tamoxifen may diminish a woman's ovarian reserve before she may safely conceive.

In vitro fertilization (IVF) with embryo cryopreservation is seen as a strong option for preserving the potential to have a child; however, there is concern that ovarian stimulation in IVF could cause proliferation of breast cancer cells, leading some practitioners to recommend natural cycle (nonstimulated) IVF.

It is not clear whether ovarian suppression during cancer treatment preserves fertility, according to the guideline. Tamoxifen as an ovarian stimulant has been investigated and has shown promise in treating women whose fertility has been compromised as a result of breast cancer treatment. Although the aromatase inhibitor letrozole cannot be used in premenopausal women as a breast cancer treatment, it may be used in combination with gonadotropins as a fertility agent following treatment.

Finally, routine endometrial biopsy and uterine ultrasonography are not recommended for postmenopausal women taking tamoxifen without evidence of vaginal bleeding, as ultrasound has been associated with a significant false-positive rate leading to unnecessary invasive diagnostic procedures.

However, for women on tamoxifen who experience vaginal bleeding, an endometrial evaluation - including biopsy and follow-up of possible uterine structural anomalies - is essential, the guideline states.

The members of the Committee on Practice Bulletins-Gynecology who wrote the guideline reported no relevant conflicts of interest.
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Title Annotation:GYNECOLOGY
Author:Smith, Jennie
Publication:OB GYN News
Article Type:Medical condition overview
Date:Mar 1, 2012
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