Clinical Cases- the Expert's Opinions Take 2!

Today’s patient cases come from the Ask the Expert session: A personalised approach to Menopausal Hormone Therapy: Discussion of clinical cases. Likened to speed dating for healthcare professionals, in this session we had Dr. Alessandra Graziottin and Dr. Mark Brincat pose two very different clinical cases, one based on a BRCA 1 carrier who recently had surgery and one based on an overweight women  visiting three years after surgery who is now suddenly experiencing negative symptoms.

Case 1

A 38 year old patient who is known to be a BRCA1 mutation carrier recently underwent a prophylactic risk reducing bilateral salpingoophorectomy. She is now experiencing severe vasomotor symptoms and poor sleep. Her primary care provider and her oncologist have strongly advised her against use of menopausal hormones but she wants another opinion.

Dr. Graziottin explained the key questions this case highlighted:

  • Are carriers of BRCA1 and BRCA2 at a higher risk of MHT related cancers (breast, endometrium, ovary, and melanoma?
  •  Is systemic MHT a contraindication in BRCA 1/2 mutation carriers?
  • Is vaginal estrogen a contraindication in BRCA 1/2 carriers?
  • How can quality of life be improved in BRCA 1/2 carriers anticipating/undergoing risk reduction surgical interventions?

As highlighted in many other EMAS sessions, there are gaps in data which play a part in how to deal with this case. Currently there is no prospective RCT data on safety of MHT. However available observational data shows that MHT used by healthy carriers of BRCA1 or BRCA 2 is not associated with increased risk of breast or ovarian or endometrial cancer.

Dr. Graziottin suggested starting pre-operatively with dialogue, not only with the patient but with her primary care provider and oncologist too. It should be explained to the patient that if and when symptoms occur doctors have a spectrum of tools that can be used to investigate and change treatment. The recommendation given was to suggest the patient start with MHT explaining the data available to prove it is not dangerous in her situation, but also to offer her other options if she does not feel comfortable taking MHT.  There are a plethora of non-hormonal options which are not as effective, but patients can start on this and build up to MHT if needed. Vaginal estrogen is completely safe in this case, as the population will become atrophic, doctors should pre-empt that the patient will lose bone mass and promote the use MHT to stabilise this.  

As she had already had children, our audience of HCPs questioned why the patient didn’t reduce her breast or remove the uterus? Dr. Graziottin explained that many patients in northern America chose not to take breasts out till later in life, but take ovaries out earlier. She also explained that she would not chose to start the patient on androgens but if her QOL improves and she suffers with low libido it would be considered as an additional treatment.  She would also consider keeping the patient on MHT till 51, the average age of natural menopause, even though this is longer than the “suggested” 5 year period.

 Case 2

A 60 year old postmenopausal woman developed late menopause at the age of 57. She has a BMI of 38 and is suffering from severe hot flushes, joint pain, anxiety and a lack of concentration after a hysterectomy and bilateral salpingoophorectomy for cystic endometrial hyperplasia.

Dr. Brincat left this case open to the audience, which immediately led to questions about her age. In the guidelines, she would fall under the category of within 10 years of the onset of menopause but has approached 60 so it is unclear where guidance stands on giving this patient MHT.  

With the patient having experienced a late menopause and a hysterectomy, none of the HCPs suggest prescribing her MHT straight away, with a higher BMI she also has a basal risk of cancer. Even though she has had hyperplasia Dr. Brincat suggested using estrogen to reduce hot flushes and sweats. Morning joint pains (which in this case are due to chronic inflammation not OA) can also respond to estrogen but progesterones should be avoided as they will increase risk of cardiovascular disease, diabetes and cancer. Androgens may also be considered, a low dose gel or patch would be suggested to relieve her immediate symptoms.

So estrogen addresses anxiety and joint pain, androgen can address libido, but what else can we recommend to improve health of this women? Aspirin could be used to reduce risk of breast cancer and stroke and vitamin D should also be prescribed.

Dr. Brincat re-iterated that the take home message from this case is that we need to target all of her individual conditions not just rely side effects of medication to improve her symptoms and that combined MHT should be avoided in this case.

Do you agree with the consensus in the room or would you give patients alternative treatments? Let us know in the comments below!