A cohort study of topical vaginal estrogen therapy in women previously treated for breast cancer.

OBJECTIVE: To estimate the risk of recurrence of breast cancer associated with the use of topical vaginal estrogen therapy in the management of vaginal atrophy in women previously treated for breast cancer. METHODS: The study group comprised 1472 women with histologically confirmed breast cancer. In 69 of these subjects (4.7%) their only bothersome menopausal problems were vaginal symptoms. In these women, poorly absorbed topical vaginal estrogen cream or tablets were used. The response of these patients was compared with that of the rest of the database. A Cox regression analysis was performed using sex hormone usage after diagnosis as a time-dependent covariate. Disease-free interval was the outcome measured. Results are expressed as a hazard ratio with 95% confidence intervals. The hazard rate is defined as the probability of disease recurrence or of a subject dying from breast cancer over the study period. A second analysis was performed adjusting for factors known to affect breast cancer prognosis. RESULTS: Hormone usage was entered as a time-dependent covariate with disease-free interval as the outcome. Subjects who used a topical estrogen alone for menopausal symptoms had an uncorrected hazard ratio of 0.30 (95% confidence interval (CI) 0.11-0.80, p = 0.02). The corrected hazard ratio was 0.57 (95% CI 0.20-1.58, p = 0.28). The hazard rate for a subject dying was not analyzed, as there were too few numbers. CONCLUSIONS: Although the small numbers of this study preclude a definitive result, topical estrogen usage does not appear to be associated with an increased risk of recurrence of breast cancer.

Tamoxifen, hormone receptors and hormone replacement therapy in women previously treated for breast cancer: a cohort study.

OBJECTIVE: To determine the risk of recurrence of breast cancer associated with the use of hormone replacement therapy (HRT) in the management of menopausal symptoms in women previously treated for breast cancer who were taking concurrent tamoxifen or who were estrogen receptor-positive. METHODS: The study group comprised 1472 women with histologically confirmed breast cancer, of whom 342 subjects (23.2%) elected to use hormonal therapy in the management of their menopausal symptoms. Women were not excluded from treatment with hormonal therapy if they were taking adjuvant tamoxifen or if they had receptor-positive breast cancer. The response of these patients was compared with that of the rest of the database. A Cox regression analysis was performed with sex hormone usage as time-dependent covariate. Disease-free interval was the outcome measured. RESULTS: Subjects who took concurrent tamoxifen with combined continuous estrogen-progestogen therapy had a hazard ratio of 0.67 (95% confidence interval (CI) 0.14-3.24, p = 0.62), while concurrent tamoxifen and topical vaginal estrogen users had a hazard ratio of 0.31 (95% CI 0.10-2.57, p = 0.28). The hazard ratio for the estrogen-progestogen users who were estrogen receptor-positive was 0.24 (95% CI 0.10-1.49, p = 0.14). CONCLUSIONS: The use of HRT was not associated with an increased risk of recurrence of breast cancer in women taking concurrent tamoxifen or who were estrogen receptor-positive.

The significance of pelvic ultrasound abnormalities detected on routine ultrasound scanning prior to assisted reproduction.

OBJECTIVE: To determine the benefit of screening patients with pelvic ultrasound before commencing treatment with in vitro fertilization or gamete intra-fallopian transfer, as well as before each subsequent treatment cycle was performed. SUBJECTS AND SETTING: Seven hundred and seventy-nine patients who were enrolled in the Royal Hospital for Women Fertility Group assisted reproduction program. METHOD: A retrospective analysis was performed. RESULTS: It was found that the majority of abnormalities were detected by the initial ultrasound. However, ultrasound contributed little to their diagnosis and management. CONCLUSION: As a result of this review of pelvic ultrasound examinations performed, the policy of screening prior to the initial cycle of treatment will be continued to exclude significant ovarian tumors and to identify patients with polycystic ovaries, who are more likely to be stimulated to levels at which there is a risk of ovarian hyperstimulation syndrome. The policy of screening before each subsequent treatment cycle has been discontinued, since few additional abnormalities were detected.

The influence of advanced age on the outcome of assisted reproduction.

PURPOSE: Our purpose was to determine the influence of age on the outcome of assisted reproduction, with particular interest in women aged 40 years or older. METHODS: A retrospective review of the 779 patients enrolled in the Royal Hospital for Women Fertility Group fertility program between 1987 and 1994 was performed. The results for women aged 40 years or older were compared with those for women between 36 and 39 years and those younger than 36 years. The main outcome measures were pregnancy rate, pregnancy outcome, fertilization rate, and ovarian response. RESULTS: Compared with those in younger women, pregnancy rate, pregnancy outcome, fertilization rate, and ovarian response to controlled ovarian stimulation were significantly worse in women aged 40 years or older. CONCLUSIONS: The outcome of assisted reproduction in women of 40 years of age or older was extremely poor. Compared with those in younger women, pregnancy outcome and ovarian response to controlled ovarian stimulation were significantly worse in women of 40 years or more.

The significance of mild squamous atypia on cytology.

Between January, 1991 and February, 1993 inclusive, 396 Papanicolaou smears were reported to show Mild Squamous Atypia with or without Human Papilloma Virus (MSA +/- HPV). All women with MSA +/- HPV smears were routinely recalled for colposcopy. To determine the significance of MSA +/- HPV on routine smear screening, the records of all patients were reviewed. Three hundred and thirty-seven women (85.1%) attended the colposcopy clinic and are the subjects analyzed for this report. The remaining 59 (14.9%) failed to attend. Intraepithelial neoplasia was found in 61 patients (18.1%), of whom 27 (8.0%) had a high grade lesion (CIN 2 or 3 or GIN 2). No patient had invasive cancer of the cervix. Only 1 of the 45 pregnant women had a significant lesion. It is concluded that all asymptomatic women with MSA +/- HPV on cervical smear may be managed in accordance with the current NH and MRC recommendations (1) and have a repeat smear in 6 months and colposcopy if the abnormality persists at 12 months.

Gynaecological complications of women treated with tamoxifen for breast cancer.

We present 6 cases illustrating some of the gynaecological complications associated with tamoxifen treatment of women with breast cancer. The first 2 represent cases of myometrial hypertrophy secondary to tamoxifen use, a postmenopausal woman and a premenopausal women with recurrent carcinoma of the breast. The third is a case of probable ovulation induction in a perimenopausal women with recurrent breast cancer who was commenced on tamoxifen 20 mg daily. The other 3 cases illustrate some of the endometrial effects associated with tamoxifen therapy in women with a history of breast cancer, namely cystic glandular hyperplasia, endometrial polyps and endometrial cancer.