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Essay 343

Essay 343 Posted by PAUL A.

A healthy 34 year old woman has been referred to the gynaecology clinic because her mother and sister have developed breast and ovarian cancer respectively. (a) Discuss the factors that affect her risk of developing ovarian cancer. [8 marks] (b) She undergoes laparoscopic bilateral salpingo-oophrectomy at the age of 38 years. How will you counsel her with respect to hormone replacement therapy? [12 marks]

H H Posted by H H.

A healthy 34 year old woman has been referred to the gynaecology clinic because her mother and sister have developed breast and ovarian cancer respectively. (a) Discuss the factors that affect her risk of developing ovarian cancer. [8 marks] (b) She undergoes laparoscopic bilateral salpingo-oophrectomy at the age of 38 years. How will you counsel her with respect to hormone replacement therapy? [12 marks]

A) Her risk  of breast cancer is increased due to her family history and is further increased if proved via genetic tests to be carrier of BRCA 1 or 2 gene mutations ,which increase her risk by 80 – 90%. If she is carrier of these genes and has children ,her risk is further increased.

Her risk is increased if she had an early menarche and if she is nullipara, this may be related to estrogen effect.

Her risk is increased if she gets pregnant at such age(late age of first pregnancy), and the risk is further increased in first 3-4 years after delivery.

Breast feeding reduce her risk of breast cancer,though evidence still lacking.

The use of estrogen containing medications eg combined oral contraceptive pills increase risk up to 24%.

 

 

B) Will explain to her that she will develop acute menopausal symptoms as the ovaries were surgically removed , depriving her body from the normal estrogen supply.

Will take history including personal or family history of osteoporosis,personal or family history of venous thrombosis, personal or family history of stroke or cardiovascular disease, personal or family history of other cancers ,  her wish to have a period every month .and her attitude to taking medications.

Will tell her of the benfits of HRT including prevention of hot flushes,sweating,irritability palpitation and lack of sleep. Will keep mental wellbeing. Will prevent genito-urinary atrophy and so prevent vaginal dryness ,dyspareunia, and frequency of micturition .

HRT at her age will prevent her rapid development of osteoporosis and will be cardioprotective.

Will tell her about the risks of HRT, however these were taken from studies on women taking HRT at or after menopause, In women 50y of age( breast cancer risk 32/1000 women) taking HRT for 5 and10 y will increase risk to 38 and 51/1000 women respectively. The risk after 5 years of stoping the HRT is as those who never used it.

Will tell her that intake of HRT on continuous bases protect against cancer endometrium than sequential or estrogen only HRT.  

Will tell her that HRT increase risk of venous thromb embolism 2-3 folds.

Will tell her that she be replacing her usual hormone which she would require till the age of menopause around 50 years. Will tell her how to self examine her breast and the need for screening of breast cancer and follow up in breast clinic.

Will tell her of routes of taking HRT ,oral,patches, implant ,gel, vaginal ring or cream.

Will give her written information and follow up appointement.Will tell her of support group for breast cancer. 

Posted by Leila R.

Breast cancer in two first degree relatives strongly suggest familial cancer syndrome. These syndrome are associated with mutation in BRCA1 and BRCA2 genes. Women carriers of BRCA1 and BRCA2 are at increased risk of ovarian cancer and breast cancer than general population, however not all women with gene mutation will develop the disease, and this is due to variable penetrance. Nulliparity, infertility  and the use of ovulation stimulating agents increases the risk of ovarian cancer. Infertility and use of ovulation stimulating agents is associated with increased risk. Conditions which are associated with inhibition of ovulation such as pregnancy, breast feeding and use of hormonal contraceptive pills is associated with reduced risk.

Bilateral salphingo oopherectomy at the age of 38 predisposes her to the risk of premature menopause. HRT would be strongly recommended to reduce the risk of osteoporosis, vasomotor symptoms and urogenital atrophy, colorectal cancer, alzeheimers disease, cataract, macular degeneration and tooth loss.  However use of HRT in this  women is associated with increased risk of developing breast cancer at earlier age. Therefore alternative treatment to HRT should be recommended.

 SERMs such as Raloxifen is effective in prevention of bone loss, however it is not effective in the reliefe of vasomotor symptoms. Phytoestrogens such as soy beans and red clover is not advisable as the estrogens produced will have same effect as HRT. High dose progesterone such as megestrol acetate is associated with risk of VTE, and also some breast tumours have progesterone receptors. SSRI such as fluoxetin and and SNRI such as Venlafaxine are effective in the relief of vasomotor syndrome.  Oral clonidine is not effective, but trans dermal clonidine is effective in the reliefe of vasomotor symptoms.

There is no evidence in the efficacy of complementary therapy like ginseng, black cohosh in the relief of vasomotor syndrome. The later is associated with hepatotoxicity.

Vaginal lubricant such as K Y jel can be used for relief of vaginal dryness due to uro-genital atrophy. 

essay 343 sofia Posted by sofia  S.

 

Ansa: Number of factors affect  her risk of developing ovarian cancer, first  being the possibility of her carrying genetic mutation of familial breast ovarian cancer syndromes namely BRCA1 &  BRCA2.life time risk with BRCA1 is 30-60% and BRCA2 is 15-20% for ovarian cancer. This requires a pedigree analysis and testing for genetic mutations after counselling.. Risk is more if mother had breast cancer before the age of 45. if she is a carrier, prophylactic oopherectomy reduces her risk but does not totally eliminates it  (2% risk of primary peritoneal carcinomatosis)  .Secondly  familial clustering of cancer  might be just a chance occurrence  but in that case as well, one  first degree relative affected with ovarian cancer increases her risk  of ovarian cancer by 3.6 fold and premenopausal breast cancer increases her risk of ovarian cancer by 50%.

other factors that will increase her risk is nulliparity. Use  of ovulation inducing agents increases  her risk. Breastfeeding    gives 20% protection and having children reduces the risk by 40%. Use of combined contraceptive pill reduces her risk of ovarian cancer by 60%.

Ans b: I will tell her that due prophylactic  salpingo-oopherectomy at 38 yrs she requires to have HRT  till the age of 50 yrs to prevent her from menopausal symptoms and and long term adverse affect of premature menopause namely osteoporosis and cardiovascular risk.HRT  does not increases the risk of breast cancer when given in  women with premature menopause until the age of menopause i.e 50 yrs.  But  women who have family history of breast cancer use of HRT is associated with increased risk of breast cancer depending on type and duration of HRT.  But HRT does not reverse  the benefit of prophylactic oopherectomy on breast cancer risk in carriers of BRCA1 and BRCA2(50% reduction).  In absence of data on mutation carriers non hormonal alternative should be considered for symptom relief and prophylaxis for osteoporosis. however in absence of menopausal  symptoms  and availability of non hormonal alternatives for osteoporosis prophylaxis risk  of HRT  outweighs the benefit.

HRT may be required if symptoms are severe and in that case its use should retricted to shortest duration and lowest effective dose as possible. If HRT is prescribed to her she requires progesterone component as  she still retains her uterus, use of LNG IUS will reduce her serum progesterone level  as progesterone increases her risk of breast cancer, but still long term data on outcome is lacking.

I will advise her on the other benefit and risk associated with hrt. Benefit includes relief of hot flushes and night sweats, improvement in  urogenital symptoms  insomnia and mood . Also  it has protective affect against osteoporosis , colon cancer and alzhiemer ds. Risk other than the breast cancer risk, will be 2-3 fold increased risk of VTE and would be contraindicated in personal history of VTE. Also increases the risk  of stroke and coronary artery event specially in those with risk factors like hypertension and h/o coronary artery disease .estrogen  alone and sequential combined HRT increases risk of endometrial cancer. Systemic side effects of estrogen and progesterone would be breast tenderness, bloating , headache  and mood changes.. Also advice on  life style changes including weight bearing exercise, dietary advice and stopping alcohol and smoking. provide her with written information and support group.

 

Hbadran Posted by HAnaa B.

This patient should be informed that she may have one of the autosomal dominant mutations that increase her risk of  developing  ovarian cancer either Brca1 (her risk is increased by 90% )or Brca2 ( with increase in her risk of ovarian disease to 10%) ,Supported by the presence of breast and ovarian cancer in 2 of her family mother and sister.

She should be informed that ovarian cancer risk for her is 3-4 folds normal population after she got her mother with the disease.

She should also know that her risk of ovarian cancer is increased by infertility and being nullipara to 27 fold and the drug of infertility to 2.8 folds. Getting her menstruation at early age and late menopause will also increase her risk.

Her risk of ovarian cancer is decreased by0.5% by performing tubal ligation, and by 40% if she is using OCPs, smoking may hasten her menopause by one or 2 years, there is a theoretical reduction in her risk of ovarian cancer if she will do Oophrectomy.

Explanation of the risk will let her to make an informed life style descion.

B

On performing salpingoophrectomy in 38 years old , the patient will experience sever menopausal symptoms that will affect her quality of life , like sever vasomotor symptoms , mood swings , osteoporosis, urogenital atrophy.

HRT in her situation is very important and its use is not accompanied by increase in her risk of cancer, or cardiovascular disease.

She should also know that hormonal HRT will decrease the rate of her bone loss. Decrease her risk of colorectal cancer, may delay the Alzheimer disease manifestation and protect her from coronary disease at young age,

Hormonal HRT may be one hormone or 2 hormones E+ progesterone to protect her endometrial lining from the unopposed effect of Estrogen alone.

It is advised to use it Sequentional  type so she will get her menstruation regularly. Side effects of both hormones estrogen and progesterone should be explained (breast tenderness , bloating , increase weight, nausea, headacke, leg cramps).

Her medical and family history should be taken seriously when prescribing the type of hormonal HRT..

She should also know that her benefits from the HRT outweigh the risks accompanied by the drug use.

Risk of use of HRT in post menopausal may include increase risk of VTE, myocardial infarction, cancer breast, gallbladder disease. 

ans to 343 Posted by SARO K.

 

ANS TO 343:(Jsk)

(a)One family member with breast cancer and one with ovarian cancer strongly suggests Hereditary cancer syndrome which is autosomal dominant with variable penetrance.she has 3.6 fold increase in ovarian cancer compared to women without family history.  Family history of Premenopausal  breast cancer  is associated with 50 percent chance of developing ovarian cancer than postmenopausal which is usually sporadic.She should be offered counselling and genetic susceptibility testing.If found to be positive BRCA 1 /2  her risk of developing hereditary ovarian cancer is 90 percent ,and 5-10percent  respectively.Her cumulative risk of developing ovarian cancer in BRCA 1  by age 70 is 30 -60 percent   wheras in BRCA 2 is 15 to 20 percent. other factors includes parity- nulliparity increase the risk whreas multiparity decrease the risk.coc pill  use  decrease 40 percent reduction in ovarian cancer and its effect lasts for 10 yrs.Use of ovulation inducing agents favour ovarian cancer.Prophylactic Bilateral salphingoo-ophorectomy prevents ovarian cancer but still has 3-4 percent chance  of peritoneal carcinomatosis.Tubal ligation and hysterectomy also associated with significant reduction.

(b)BSO at the age of 38 yrs will put her under risk of premature menopause. I have to outweigh the benefits of HRT VS family history of breast cancer with intact uterus.I will get history about medical  comorbidities,preference towards monthly and compliance. I will plan least effective dose for  short period to prevent harmful effects and achieve maximum benefits till the age of expected menopause.I will inform her that combined HRT is not going to do much harm to the breast  till her expected menopause and not going to reverse effect of BSO. I will inform options combined(contin/sequential),estrogen only,progesterone supplementation with different routes available including oral,patch,implants,IUS,vaginal rings. Benefits of HRT includes relief of hotflushes,decrease rate of bone loss and osteoporotic fractures with beneficial effect on lipid profile.Risk includes increased cardiovascular and cerebrovascular disease ,VTE(4/1000 IN HERS trial),increased ca breast (WHI trial) ,increase ca endometrium(estonly ) Progesterone in the form of local prep like IUS to prevent harmful effect on the breast as well as uterus friendly. Alternative options includes Tibilone  and raloxifene. Tibilone is associated with increased ca breast while raloxifene does not relieve Hot flushes.Phytoestrogens also not advised as she has intact uterus. I will give advice abt  nonhormonal methods of managing vasomotor symptoms such venlafaxine,trandermal clonidine and osteoporosis such as lifestyle modification, weight bearing exercise,Bisphospanates.I will highlight the importance of continued surveillance  of symptoms,self breast examination(6monthly) screening mammography(annually) ,effect of HRT on mammography. . I will  give her informed choice and written information leaflet with support group.

 

 

ans to 343 Posted by SARO K.

 

ANS TO 343:(Jsk)

(a)One family member with breast cancer and one with ovarian cancer strongly suggests Hereditary cancer syndrome which is autosomal dominant with variable penetrance.she has 3.6 fold increase in ovarian cancer compared to women without family history.  Family history of Premenopausal  breast cancer  is associated with 50 percent chance of developing ovarian cancer than postmenopausal which is usually sporadic.She should be offered counselling and genetic susceptibility testing.If found to be positive BRCA 1 /2  her risk of developing hereditary ovarian cancer is 90 percent ,and 5-10percent  respectively.Her cumulative risk of developing ovarian cancer in BRCA 1  by age 70 is 30 -60 percent   wheras in BRCA 2 is 15 to 20 percent. other factors includes parity- nulliparity increase the risk whreas multiparity decrease the risk.coc pill  use  decrease 40 percent reduction in ovarian cancer and its effect lasts for 10 yrs.Use of ovulation inducing agents favour ovarian cancer.Prophylactic Bilateral salphingoo-ophorectomy prevents ovarian cancer but still has 3-4 percent chance  of peritoneal carcinomatosis.Tubal ligation and hysterectomy also associated with significant reduction.

(b)BSO at the age of 38 yrs will put her under risk of premature menopause. I have to outweigh the benefits of HRT VS family history of breast cancer with intact uterus.I will get history about medical  comorbidities,preference towards monthly and compliance. I will plan least effective dose for  short period to prevent harmful effects and achieve maximum benefits till the age of expected menopause.I will inform her that combined HRT is not going to do much harm to the breast  till her expected menopause and not going to reverse effect of BSO. I will inform options combined(contin/sequential),estrogen only,progesterone supplementation with different routes available including oral,patch,implants,IUS,vaginal rings. Benefits of HRT includes relief of hotflushes,decrease rate of bone loss and osteoporotic fractures with beneficial effect on lipid profile.Risk includes increased cardiovascular and cerebrovascular disease ,VTE(4/1000 IN HERS trial),increased ca breast (WHI trial) ,increase ca endometrium(estonly ) Progesterone in the form of local prep like IUS to prevent harmful effect on the breast as well as uterus friendly. Alternative options includes Tibilone  and raloxifene. Tibilone is associated with increased ca breast while raloxifene does not relieve Hot flushes.Phytoestrogens also not advised as she has intact uterus. I will give advice abt  nonhormonal methods of managing vasomotor symptoms such venlafaxine,trandermal clonidine and osteoporosis such as lifestyle modification, weight bearing exercise,Bisphospanates.I will highlight the importance of continued surveillance  of symptoms,self breast examination(6monthly) screening mammography(annually) ,effect of HRT on mammography. . I will  give her informed choice and written information leaflet with support group.

 

 

ans to 343 Posted by SARO K.

 

ANS TO 343:(Jsk)

(a)One family member with breast cancer and one with ovarian cancer strongly suggests Hereditary cancer syndrome which is autosomal dominant with variable penetrance.she has 3.6 fold increase in ovarian cancer compared to women without family history.  Family history of Premenopausal  breast cancer  is associated with 50 percent chance of developing ovarian cancer than postmenopausal which is usually sporadic.She should be offered counselling and genetic susceptibility testing.If found to be positive BRCA 1 /2  her risk of developing hereditary ovarian cancer is 90 percent ,and 5-10percent  respectively.Her cumulative risk of developing ovarian cancer in BRCA 1  by age 70 is 30 -60 percent   wheras in BRCA 2 is 15 to 20 percent. other factors includes parity- nulliparity increase the risk whreas multiparity decrease the risk.coc pill  use  decrease 40 percent reduction in ovarian cancer and its effect lasts for 10 yrs.Use of ovulation inducing agents favour ovarian cancer.Prophylactic Bilateral salphingoo-ophorectomy prevents ovarian cancer but still has 3-4 percent chance  of peritoneal carcinomatosis.Tubal ligation and hysterectomy also associated with significant reduction.

(b)BSO at the age of 38 yrs will put her under risk of premature menopause. I have to outweigh the benefits of HRT VS family history of breast cancer with intact uterus.I will get history about medical  comorbidities,preference towards monthly and compliance. I will plan least effective dose for  short period to prevent harmful effects and achieve maximum benefits till the age of expected menopause.I will inform her that combined HRT is not going to do much harm to the breast  till her expected menopause and not going to reverse effect of BSO. I will inform options combined(contin/sequential),estrogen only,progesterone supplementation with different routes available including oral,patch,implants,IUS,vaginal rings. Benefits of HRT includes relief of hotflushes,decrease rate of bone loss and osteoporotic fractures with beneficial effect on lipid profile.Risk includes increased cardiovascular and cerebrovascular disease ,VTE(4/1000 IN HERS trial),increased ca breast (WHI trial) ,increase ca endometrium(estonly ) Progesterone in the form of local prep like IUS to prevent harmful effect on the breast as well as uterus friendly. Alternative options includes Tibilone  and raloxifene. Tibilone is associated with increased ca breast while raloxifene does not relieve Hot flushes.Phytoestrogens also not advised as she has intact uterus. I will give advice abt  nonhormonal methods of managing vasomotor symptoms such venlafaxine,trandermal clonidine and osteoporosis such as lifestyle modification, weight bearing exercise,Bisphospanates.I will highlight the importance of continued surveillance  of symptoms,self breast examination(6monthly) screening mammography(annually) ,effect of HRT on mammography. . I will  give her informed choice and written information leaflet with support group.

 

 

Maclon Posted by maclonchandu C.
The back ground lifetime risk of ovarian cancer is 0.9%. Having mother and sister affected by breast and ovarian cancer, there is a possibility of a hereditary cancer syndrome such as BRCA 1 or BRCA 2 mutation. The lifetime risk of ovarian cancer is 30-60% with BRCA1 and 15-20% with BRCA2 mutation. she should be reffered to regional genetic centre for risk assessment. For risk assessment,a family tree till 3rd degree relative is built,taking into account age of affected relatives, type of cancer, age of unaffected relatives any h/o of male cancers-- prostate,pancreas, colon. Early menarche, nulliparity, subfertiliy, use of ovulation inducing drugs are associated with risk of developing ovarian cancer. Having children is associated with 60% reduction in risk of ovarian cancer. With a lesser degree, breast feeding reduces the risk of ovarian cancer by 20%. Use of COCP is associated with 40% reduction in the risk of ovarian cancer. Tubal ligation is associated with reduction of risk in general population. B) she should be informed that she will require HRT containing oestrogen ( as tablets,sprays,gels,or vaginal rings) and progestogens ( oral tablets or LNG IUS system)  The benefits of HRT are explained to her which include relief of vasomotor symptoms such as hot flushes and night sweats thereby improving quality of life. HRT use prevents osteoporosis and reduces vertebral fractures , but requires long term use. She should be told that HRT use delays the onset and progress of Alzheimer's disease. Oestrogen replacement also associated with a decreased risk of macular degeneration, cataract and tooth loss. She should be informed that topical estrogens improve mild urogenital symptoms but not incontinence. Information is given about the reduced risk fo colorectal cancer. She should be explained about the risks which include increased risk of Coronary heart disease associated with continuous combined HRT particularly during the first year of use. Regarding the risk of breast cancer, she should be given information that use of HRT for 5, 10 and 15 years would cause 2,6 and 12 extra breast cancers per 1000 women. Use of oestrogen replacement in women with a premature menopause is not associated with an increased risk of breast cancer - duration of oestrogen exposure is the risk factor. She should be informed that unopposed oestrogen therapy Sequential combined HRT (progestogen for 10 days per cycle) are associated with an increased risk of endometrial hyperplasia and carcinoma but not continuous combined HRT. Regrding ovarian cancer, she should be told that current use of HRT is associated with an increased risk of ovarian cancer. But data regarding HRT use after prophylactic oopherectomy are limited and show no adverse effect.  HRT is associated with a 2-3 fold increase in the risk of venous thrombo-embolism. Trans-dermal oestrogen containing HRT is safer than oral HRT with respect to VTE. Systemic side effects of HRT should be informed which include Oestrogen related (fluid retention, breast tenderness, nausea, headache, leg cramps )and Progestogen related (mood swings, depression, acne, fluid retention, breast tenderness). Alternate options for HRT should be explained consisting of life style changes ( exercise, reduced caffeine and alcohol intake), acupuncture and reflex therapy to improve symptoms. Progestogens for eg magesterol may help relief of symptoms but associated with risk of VTE and breast cancer. Selective Estrogen Receptor Modulator such as raloxifene has antiestrogenic effect on breast and endometrium causing reduction of risk of breast cancer and prevents osteoporosis but no effect in the relief of vasomotor symptoms. Written information is provided.
Posted by Bee Fong C.

 

(a)            Hereditary gynaecological cancer is inherited through autosomal dominat. Her family history needs to be understood better in order to counsel her. Referral to the clinical genetist may be required. The time of diagnosis of her mother and sister’s malignancies, the type of malignancy, the treatment required and whether the malignancies were bilateral need to asked. Other family members need to questioned as well as to any other form of malignancy ie colonic and uterine cancer. Her family members should be tested for BRCA1, BRCA2 and hereditary non polyposis colonic cancer. If found to be positive, she should be tested for it herself and attend annual screening if found positive.

            Other risk factors includes nulliparity with early menarche increases her risk. Any history of ovulation induction drugs increases her risk. Having polycystic ovaries protects her on the other hand. Pregnancy and breast feeding are thought to be protective. Any history of tubal ligation with hysterectomy is protective. Having prophylactic Oophorectomy is protective but does not eliminate the risk as she can still develop peritoneal cancer. The combined oral contraceptive method can be used to protect her from ovarian cancer.

            She also needs to understands that there is also a background overall risk of ovarian cancer without hereditary cancer.

 

(b)            Prescribing HRT need to be discussed with the patient with weighing the risks and benefits. HRT is protective against osteoporosis in women without oestrogen supply before menopausal age. If she takes after menopause for osteoporosis it is only protective for the duration of use. It is also used to relieve vasomotor symptoms which can be severe when a salpingo-oophorectomy suddenly cuts off the supply of oestrogen. It is also protective against developing colonic cancer.

            On the other hand, it can increases the risk of developing ischaemic heart disease and stroke. The evidence is controversial. She needs to be aware about the increase risk of breast cancer especially if there is a family history of it. If she does go on HRT, referral to the breast surgeon may be necessary with annual screening.

            It is better to have sequential combined HRT if she still has her uterus to reduce the risks and side effects of HRT. If she is taking it beyond the age of menopause she may have it continuously.

            There is also potential of developing thromboembolism with HRT. Signs and symptoms need to be educated to look for thromboembolism. Any family history of thrombophilia or thromboembolic event need to discussed prior to screening her .

            Any vaginal atrophy with urinary symptoms can be treated with local oetrogen to relieve symptoms. The HRT need to be reviewed at around 50-52 years old to discuss continuation of it. Other options of relieving symptoms of menopause need to be discussed with her besides HRT including osteoporosis treatment with calcium and bisphosphonates, tibolone and raloxifene for vasomotor symptoms. Lifestyle changes with weight bearing excercises, reducing smoking and weight will reduce her risk of osteoporosis and ischaemic heart disease.

            Overall, the benefits outweigh the risks in her case and should be prescribed with regular follow up.

ans essay 343 Posted by vaneeza K.

A.Life time risk of developing ovarian cancer is 1-2% and this risk increases to 5.2 % if first degree relative affected under age of 55 years.As this woman has two first degree relatives with ovarian and breast cancer ,there is possibility in her of carrying BRCA1 and BRCA 2 gene mutation.If she will be carrier of BRCA 1 risk of developing ovarian cancer is 28-44% and 27% with BRCA 2.Prophylactic oophorectomy ,after age of 35 will reduce but does not eliminate the risk of ca ovary as there is still 1-2% risk of primary peritoneal carcinomatosis.There is also 12% increase risk of ovarian cancer in  HNPCC carrier.

Other risk factors include nulliparity,27 fold increased risk.Infertility and ovulution  inducing drugs also associated with higher risk of ovarian cancer.Parity and breast feeding have protective affect as they reduce risk of ovarian cancer by 60% and 20%.Use of COCP  by 5 years reduces risk by 40%.ovarian irradiation also increases risk of developing ovarian cancer.

B. The main aim of counselling in a woman who have prophylactic oophorectomy is to remove her anxiety of developing breast and endmeterial  cancer as she has family history of breast ca and uterus  in situ.she will be counselled that firstly estrogen replaecment  with premature menupause is not associated with breast cancer however risk is increased with combined therapy.Secondly risk falls to general population after 5 years of stopping HRT. On other hand unopposed estrogen is associated with risk of having endometerial hyperplasia and cancer.Combine therapy with natural progesterone derived progesogens and dyhydrogesterone are associated with lower risk campared to synthetic progesterone.LNG-IUS is also have increased risk.

She should be told that woman who develop breast cancer while taking HRT will have bigger and advance tumour with high mortality.  HRT also reduces the accuracy of mammographic screening. Besides this HRT is associated with 2-3 fold increased risk of VTE especialy during first year of use,in obeese woman with family history of VTE.

She will be counselled that HRT will improve her vasomotor symptoms with in 4 weeks and maximum effect in 3 months.It will also improve her psychological wellbeing .HRT also reduce risk of colorectal cancer,osteoprosis.alzheimer,s disease and dimentia.Topical estrogen will improve her local vaginal symptoms but not the incontinence.

If she is concerned about potential risks of HRT she should be told that life style modification including regular exercise with reduction in alcohol and caffeine intake will reduce frequency and severity of menupausal symptoms.She can use vaginal bio -adhesive moisturiser to rehydrate vaginal tissue.Transdermal clonidine (alpha 2 agonist) is also effective in relieving her vasomotor symptoms.SSRI(fluoxetine&paroxetine) and SNRI (venlafaxine) are effective in treatment of hot fluhes.She also has a choice of complimentary therapies,acupuncture and reflexology tech.Written information will be provdied.

answer essay 343 by N Posted by Sherif N.

proper history taking from the patient to determine her risks for de\veloping breast cancer, this includes her parity, life style (smoking, drinking), previous use of hormonal contraceptives and duration of use, previous use of ovulation induction drugs.

her menstrual cycle history, age of menarche, pattern of cycle, whether regular, associated with dysmenorrhea, PMS, whether there is history of PCO or anovulatory cycles

if she has diabete, GIT or colonic troubles. examination for her BMI, also karyotyping as this patient most probably has BRCA1 or BRCA2 gene mutation, to give her the exact risk of developing ovarian cancer specially if she has BRCA1 gene mutation

 

patient had undergone bilateral salpingooopherectomy, which makes her at great risk of developing acute menopausal symptoms, specially hot flushes, osteoporosis, increased risk of venour thromboembolism and cardiovascular stokes, vaginal dryness....for this, use of HRT is recommended

as the petient has first degree relative who developed cancer breast, so there is risk of cancer breast with the use of HRT, so this should be explained to the patient, and regular follow up, breast self examination, breast ultrasound, then breast mammography later are required to ensure she can continue on HRT, otherwise it should be changed to other alternatives

SERMs as Raloxifen will control osteoporosis, and better to prevent breast cancer, but it doesn't control hot flushes, also it increases the risk of DVT

patient should be advised regarding the pattern of her life style, to stop smoking or alcohol consumption, practice regular daily exercises, focus on healthy food habits, and intake of soya products. also traditional medicine and acupuncture help to control menopausal symptoms specially hot flushes

 

Ali Naveed Haq Posted by Ali Naveed Haq H.

 

a) Ovarian cancer is a leading cause of mortality due to female genital tract malignancy. There is no reliable screening method and on the top its presentation is usually late with advanced disease which leads to higher mortality and poor prognosis even after treatment. A number of factors affect the development of ovarian cancer some increase the lifetime risk of developing and some reduce the risk of developing it. 

The factors that increase the risk are increasing age it is more often seen in women above 55 years although it may be seen at all ages. Nulliparity is associated with a higher risk of developing ovarian cancer, so is infertility. It is associated with increase in the number of menstrual cycles, and ovulation and therefore pregnancy and anovulation confer a protective effect so is the use of combined oral contraceptive pills. Infertility is associated with increase in the risk, there is also an association with the use of ovulation induction agents which either due to infertility or themselves may increase the risk. Obesity and use of high protein diet increase the chance of ovarian cancer. Use of oral contraceptive , pregnancy and multiparity is associated with a lower risk of developing ovarian cancer.

Familial predisposition is highly associated with 10% lifetime risk of developing ovarian cancer . A positive history of two first degree relatives affected with ovarian cancer , or two first degree relatives affected with ovarian cancer or breast cancer, early development of ovarian cancer or breast cancer, one first degree relative with ovarian cancer and two or more second degree relatives affected with ovarian cancer , breast cancer or colon cancer. In addition a positive association is found with BRCA 1 and BRCA 2 , MMR genes are associated with 40% risk  of development of ovarian , breast cancer in females and prostate and breast cancer in males. Affected male and female relatives and a history of cancer must be taken among all first degree relatives like sisters , brothers, father, mother, and first cousins to chalk out life time risk.  Lynch syndrome is also associated high risk of developing ovarain cancer this is also associated with familial non polyposis colon disease. Certain ethnic races like Ashaknazi Jews are strongly associated with BRCA1 and BRCA 2 genes which run in these families.  However BRCA genes are also found in Asian and African races.

b) Prophylactic bilateral salpingoophorectomy is associated with a 95% reduction in the risk of developing ovarian cancer. It must be informed to patient that there still may be a 2-4% risk of developing cancer of epithelial origin. It is a recommended procedure for prophylaxis in patients with positive family history as described above or in positive BRCA families. The standard procedure is to undertake peritoneal washings and omental biopsy , in some early disease can be found.  The removal of ovaries renders the lady who is young infertile and with surgical menopause.

She is at risk of immidiete menopuasal symptoms like vasomotor symptoms, hot flushes, urogenital symptoms, vaginal atrophy, dysparunea, dysuria, urgency , reduced libido. Frequency of micturation, breast atrophy. Skin sagging , depression, memory loss may or may not be there. Among the long term risks she is at risk of developing osteoporosis, cardiovascular risks. 

Hormone replacement therapy which can be offered includes non hormonal  clonidine for hotflushes, lifestyle adjustments with increase in excercize, calcium supplementation, Soya diet, isoflavones, black cohosh all have been shown to improve the postmenopausal symptoms. Bisphosphonates use reduces bone loss. 

The quality of life can be increased by prescribing hormone replacement therapy for short periods , preperations containing estrogen and progesterone can be prescribed after ruling out contraindications to their usage like thromboembolic disease, cardiovascular risks, liver dysfunction, arterial disease. Cyclic combined therapy confers protection to endometrium for developing endometrial cancer. Local hormone repalcement therapy can be prescribed for improving urogenital symptoms these are highly effective . Long term use of Hormone replacement therapy is associated with a high risk of developing breast cancer, increased cardiovascular disease, cva, therefore should not be recomended for more than 5 years to 10 years. 

 

Posted by anuradha N.

A healthy 34 year old woman has been referred to the gynaecology clinic because her mother and sister have developed breast and ovarian cancer respectively. (a) Discuss the factors that affect her risk of developing ovarian cancer. [8 marks] (b) She undergoes laparoscopic bilateral salpingo-oophrectomy at the age of 38 years. How will you counsel her with respect to hormone replacement therapy? [12 marks]

(a) An ashkanazi jewishheritage makes her 5-10times more likely of carrying BRCA mutations which are associated with increased risk of familian ovarian cancer. history of bilateral breast cancer in the mother also increases her chances of carrying a hereditory cancer syndrome. Family history of prostate cancer, pancreatic cancer,male breast cancer and melanoma are associated with increased risk. A personal history of infertility, use of fertility drugs and nulligravidity are associated with increase in the risk of ovarian cancer. Use of combined oral contraceptive(coc) pill reduces her risk of ovarian cancer. use of COC for  a period of 5 yrs reduces her chance of ovarian cancer by 40% and this protection is present even in BRCA carriers and lasts for 10 yrs after discontinuation of the pill, without an increase in the relative risk of breast cancer. If the  lady is a carrier of BRCA1 mutation the risk of ovarian cancer is about 30-60% and  BRCA2 mutation confers a risk of 15-20% of developing ovarian cancer.

(b) her counselling would include risks benefits and common side effects of HRT. i will tell her that there is good evidence to support that vasomotor symtoms like hot flushes and night sweats are releived with HRT  with maximum benefit by about 3 months of use. HRT is associated with improvement in the symptoms of urogenital atrophy like vaginal dryness and urinary frequency, dysperunia etc , hrt may delay or prevent alzhimers disease. decrease the incidence of colorectal cancer. HRT is also asscociated with improvement in psychological well being. HRT is also associated with decreased loss of bone density and hence prevents osteoporosis, however HRT use for this indication alone is not recommended. HRT is protective against cardiovascular disease however in women with established cardiovascular disease it is associated with an increased  incidence of cardiovascular events in the first year of use, hence it is not recommended for secondary prevention. continuous combined HRT is not associated with an increase in endometrial cancer. oestrogen replacement in women with premature menopause(surgical in this case) is not associated with an increased risk of breast cancer even in BRCA 1 and 2 mutation carriers, however the use should as short a period as possible and with lowest dose.  HRT is associated with 2-3 fold increased risk of venous thromboembolism and this is especially so in women with family and personal history of venous thromboembolism. i will counsel her that HRT may be associated with side effects like nausea, headache, breast tenderness and pain, mood swings etc which usually resolve with continued use.  

 

Posted by vanosch M.

a)   This patient has an increased risk to have ovarian cancer compared to generalpopulation. There are many factors that increase the probability of having such cancer, these may include; a positive family history, previous history of breast or ovarian cancer, if patient have had ovulation induction or if she is known case of PCOS. Therefore, taking a full history is a crucial in such cases.

Menstrual history is also important, as there is increased risk of ovarian cancer associated with early menarche. The patient also should be inquired about any recent changes in her appetite or weight. However, such changes might only be seen in advanced stage of cancer.

Number of pregnancies have an protective effect as ovarian cancer more common in nullipara.

Finally if patient has a suspicious pelvic mass, she has certainly an increased possibility to have ovarian cancer  

 

b)

As this patient still young, she will have sudden  post-menopausal symptoms after removal of her ovaries, which my include physical and psychological symptoms, such as hot flashes, dry vaginal, dyspauronea,  decreased breasts size in addition to mood disorders.

Patient should counseled about these short-term consequences of the removal of the ovaries in spite of long-term ones such as osteoporosis and infertility as well.

After taking good history and reviewing her old chart if possible and after ruling out any contraindication to HRT such as endometrial and/or breast cancer, active hepatic disease and any undiagnosed vaginal bleeding. This patient should offer HRT and all risks and benefits of such treatment have to be explained thoroughly. Leaflets should be provided too, and any question or inquiry must be replayed.

Other alternatives of HRT might be offered especially if patient do not prefer to have such medication, these may include herbal medications, osteoporosis prophylactic treatment  and symptomatic treatment for hot flashes and dyspauronea.

Risks of HRT include increase of cardiovascular disease specially in the first year of use, risk of CVA is also increased and more incidence of breast and endometrial cancer. However, the total risk is still small.

Benefits of HRT may include relief of hot flashes and other symptoms of ovarian hormones withdrawal. Other proven benefits, are the prophylactic effects of HRT on Osteoporosis and there are some reports that it may postpone Alzheimer disease.

Finally as this patient have her uterus intact, she should advised not to have oestrogen-only treatment as such treatment increased significantly the risk of endometrial cancer.   

Dr.Mohanad- essay 343 Posted by vanosch M.

This patient has an increased risk to have ovarian cancer compared to generalpopulation. There are many factors that increase the probability of having such cancer, these may include; a positive family history, previous history of breast or ovarian cancer, if patient have had ovulation induction or if she is known case of PCOS. Therefore, taking a full history is a crucial in such cases.

Menstrual history is also important, as there is increased risk of ovarian cancer associated with early menarche. The patient also should be inquired about any recent changes in her appetite or weight. However, such changes might only be seen in advanced stage of cancer.

Number of pregnancies have an protective effect as ovarian cancer more common in nullipara.

Finally if patient has a suspicious pelvic mass, she has certainly an increased possibility to have ovarian cancer  

 

b)

As this patient still young, she will have sudden  post-menopausal symptoms after removal of her ovaries, which my include physical and psychological symptoms, such as hot flashes, dry vaginal, dyspauronea,  decreased breasts size in addition to mood disorders.

Patient should counseled about these short-term consequences of the removal of the ovaries in spite of long-term ones such as osteoporosis and infertility as well.

After taking good history and reviewing her old chart if possible and after ruling out any contraindication to HRT such as endometrial and/or breast cancer, active hepatic disease and any undiagnosed vaginal bleeding. This patient should offer HRT and all risks and benefits of such treatment have to be explained thoroughly. Leaflets should be provided too, and any question or inquiry must be replayed.

Other alternatives of HRT might be offered especially if patient do not prefer to have such medication, these may include herbal medications, osteoporosis prophylactic treatment  and symptomatic treatment for hot flashes and dyspauronea.

Risks of HRT include increase of cardiovascular disease specially in the first year of use, risk of CVA is also increased and more incidence of breast and endometrial cancer. However, the total risk is still small.

Benefits of HRT may include relief of hot flashes and other symptoms of ovarian hormones withdrawal. Other proven benefits, are the prophylactic effects of HRT on Osteoporosis and there are some reports that it may postpone Alzheimer disease.

Finally as this patient have her uterus intact, she should advised not to have oestrogen-only treatment as such treatment increased significantly the risk of endometrial cancer.   

Posted by Yingjian C.

(a) This lady has a family history suggestive of a hereditary cancer syndrome such as BRCA 1 or 2 which is associated with significantly increased risks of developing breast and/ or ovarian cancer, especially if her family members are being affected at a younger age, if there are multiple members or bilaterality of breast cancer or synchronous cancers. Other factors will be the presence of other cancers that have been implicated in BRCA 1 such as colon cancer in male and female members of the family and prostate cancer, and male breast cancer in BRCA 2.

 

The other factors that would affect her risk of ovarian cancer would be her gynaecological/ obstetric history, as nulliparity and infertility with or without usage of fertility drugs, especially over a long period. Protective factors would be breastfeeding and tubal ligation. Her contraceptive history would be significant as well. If she had taken combined oral contraceptive pills at least for 5 years, it could confer a long term benefit of halving the risks of ovarian cancer.

 

b) I would inform her that after laparoscopic bilateral salphingo oophorectomy she would undergo surgical menopause, which means that her body will be deprived of female hormones. Symptoms of menopause such as vasomotor symptoms (hot flushes, night sweats), mood changes, urogenital changes (dryness, dyspareunia, urgency), loss of libido. There will be progressive bone loss which may lead to osteoporotic fractures in future. Hormone replacement therapy, in the form of estrogen and progesterone, as a continuous or sequential preparation is usually given. She may continue to have withdrawal bleeding with sequential preparations. Progesterone is required for endometrial protection as her uterus has been conserved.

 

Side effects of HRT can be related to estrogen, such as fluid retention, breast tenderness, nausea, headache, or progesterone, such as mood swings, depression, acne. These can be modified by changing the dosage, type of hormone or route of administration. There is a small associated risk of gall bladder disease and enlargement of fibroids/ reactivation of endometriosis with HRT usage. There is no evidence that HRT causes weight gain.

 

The significant risks of hormone replacement therapy are increased risks of venous thromboembolism, stroke and myocardial infarction. The risk of breast cancer is slightly increased but the magnitude of which usually follows the delayed age of menopause. She may also experience irregular bleeding, especially in the initial months of using hormone replacement therapy. Bleeding that persist may need further investigations.

 

In cases where surgical menopause occurs at a premature age (below age 51 which is the average age), it is reasonable to commence hormone replacement therapy if she is healthy and does not have a family or personal history of venous thromboembolism or factors which put her at increased risk of venous thromboembolism. This is mainly for bone protection. However addition of hormones may increase the risk of breast cancer especially in her case, as she may be a carrier of BRCA gene that puts her at significant risk of breast cancer. It is known that the growth of breast tumours can be enhanced in the presence of estrogens/ progestrogens. In such cases it is best to avoid HRT, and to treat any symptoms of menopause with alternative therapy, such as lifestyle changes or selective serotoninergic receptor inhibitors for vasomotor symptom. She can also be considered for agents such as raloxifene. Consideration would also be given to her personal risk of osteoporosis, and screening for osteoporosis keeping in view treatment in future.

Essay 343 Posted by Samira  K.

1-As her sister has ovarian cancer, her risks of developing ovarian cancer increases 3.6fold.

If mother develops breast cancer esp.before menopause and/or  it is in both breast than her risks of developing ovarian cancer increases around 50%.

If her gene mutation analysis or linkage analysis shows BRACA 1 mutation then her risk of developing ovarian cancer at 50 years of age is 50%.With BRACA 2mutation it is 15-20%.

If patient is Nullipara her risk will be increased 27 times.If she is infertile and using infertility drugs her risk will increase 2.8 times.Use of OCP's has risk reduction by 40%,which will continue upto 10 years of stopping.

With self breast examination upto 35 years and mammography from 35 years regularly (early detection)will modify her risk.Tubal ligation and hysterectomy significantly decreases the risk but may be not appropriate for this young lady.Prophylactic bilateral salpingoophrectomy can reduce the risk but will not alleviate it 100%.

2-women will be adviced that early menopause will confer some risks to her wellbeing including hot flushes,night sweats.Her bones will become thin and brittle(osteoporosis),will be vulnerable to fractures.Her vagina might become dry with pain during intercourse,she might develop leakage of urine on coughing or sneezing,She might start to forget things(Alzeimer)her libido  and energy will decrease .For all these reasons she needs to take HRT.HRT is a combination of two hormones estrogen and progestrone , 2 female hormones which after removing her ovaries will be needed as a supplement.It will protect from most of the  symptoms.There is no prove that stress incontinence can be improved by estrogen therapy

HRT will not increase her risk of developing breast cancer if started for premature menopause & stopped at 50 years of age.Women should be counselled about risks  of VTE which will increase2-3 fold. Transdermal patch will not increase the risks significantly.Sequential HRT might increase her risks of increasing endometrial cancer but continous combined HRT will not.HRT is protective for colorectal cancer.

She might develop sideeffects of estrogen like breast tenderness,bloating,headache,nausea and side effects of progestrone like Acne,Headahe,mood swings,breast tenderness.We can give progestogens for 14 days every 3 months to decrease these side effects.Her risks of coronary artery disease,stroke ,pulmonary embolism might increase slightly.We should discuss with her routes of administration Tablets form or gel,implants or transdermal patch.We should discuss with her alternatives of HRT if she wishes or having VTE in 1st degree relatives or because of side effects of HRT she might ask for alternative.Raloxifen which is SERM can be adviced for osteoporosis reduction but will not relieve vasomotor symptoms.It is associated with 76% of breast cancer risk reduction.

SSRI like paroxitin,SNRI like venaflaxin is effective for short term.Other herbals,redclover phytosoya,blackcohosh etc have no proven effect and carries undesirable sideeffects.Trandermal  clonodine might be of benefit.Others like acupuncture,homeopathy some herbs needs te evaluated .

essay 343 Posted by zaitouni L.

factors affecting her risk_ increase by     1.family hix   heredetary breast&ov.ca.syndrom _BRCA1 INCREASE by less than 5%   2. obesity  3. parity_ nulliparity_late age of firist pregnancy_ovulation induction

 

H H Posted by PAUL A.

A healthy 34 year old woman has been referred to the gynaecology clinic because her mother and sister have developed breast and ovarian cancer respectively. (a) Discuss the factors that affect her risk of developing ovarian cancer. [8 marks] (b) She undergoes laparoscopic bilateral salpingo-oophrectomy at the age of 38 years. How will you counsel her with respect to hormone replacement therapy? [12 marks]

A) Her risk  of breast cancer READ THE QUESTION!!! Why should you be asked about breast cancer???is increased due to her family history and is further increased if proved via genetic tests to be carrier of BRCA 1 or 2 gene mutations ,which increase her risk by 80 – 90%. If she is carrier of these genes and has children ,her risk is further increased.

Her risk is increased if she had an early menarche and if she is nullipara, this may be related to estrogen effect.

Her risk is increased if she gets pregnant at such age(late age of first pregnancy), and the risk is further increased in first 3-4 years after delivery.

Breast feeding reduce her risk of breast cancer,though evidence still lacking.

The use of estrogen containing medications eg combined oral contraceptive pills increase risk up to 24%.

B) Will explain to her that she will develop acute menopausal symptoms (1) as the ovaries were surgically removed , depriving her body from the normal estrogen supply.

Will take history including personal or family history of osteoporosis,personal or family history of venous thrombosis, personal or family history of stroke or cardiovascular disease, personal or family history of other cancers ,  her wish to have a period every month .and her attitude to taking medications.

Will tell her of the benfits of HRT including prevention of hot flushes,sweating,irritability palpitation and lack of sleep(1). Will keep mental wellbeing. Will prevent genito-urinary atrophy and so prevent vaginal dryness ,dyspareunia, and frequency of micturition .

HRT at her age will prevent her rapid development of osteoporosis and will be cardioprotective.

Will tell her about the risks of HRT, however these were taken from studies on women taking HRT at or after menopause, In women 50y of age( breast cancer risk 32/1000 women) taking HRT for 5 and10 y will increase risk to 38 and 51/1000 women respectively. The risk after 5 years of stoping the HRT is as those who never used it (? Relevance to a 38 year old???).

Will tell her that intake of HRT on continuous bases protect against cancer endometrium than sequential or estrogen only HRT (How can something that increases your risk protect you at the same time? Both are associated with increased risk, but one more so than the other).  

Will tell her that HRT increase risk of venous thromb embolism 2-3 folds (? Evidence in 38 year old).

Will tell her that she be replacing her usual hormone which she would require till the age of menopause around 50 years. Will tell her how to self examine her breast and the need for screening of breast cancer and follow up in breast clinic.

Will tell her of routes of taking HRT ,oral,patches, implant ,gel, vaginal ring or cream(1).

Will give her written information and follow up appointement.Will tell her of support group for breast cancer. 

(Alternatives to HRT)

Leila Posted by PAUL A.

Breast cancer in two first degree relatives (IS THIS WHAT THE QUESTION SAID???) strongly suggest familial cancer syndrome. These syndrome are associated with mutation in BRCA1 and BRCA2 genes. Women carriers of BRCA1 and BRCA2 are at increased risk of ovarian cancer (1) and breast cancer than general population, however not all women with gene mutation will develop the disease, and this is due to variable penetrance. Nulliparity (1), infertility  and the use of ovulation stimulating agents increases the risk of ovarian cancer (A). Infertility and use of ovulation stimulating agents is associated with increased risk (B)???? Repetition. Conditions which are associated with inhibition of ovulation such as pregnancy, breast feeding and use of hormonal contraceptive pills (including POP??) is associated with reduced risk (1) why address all these 3 things in the same sentence?.

Bilateral salphingo oopherectomy at the age of 38 predisposes her to the risk of premature menopause. HRT would be strongly recommended to reduce the risk of osteoporosis, vasomotor symptoms and urogenital atrophy(1), colorectal cancer, alzeheimers disease, cataract, macular degeneration and tooth loss.  However use of HRT in this  women is associated with increased risk of developing breast cancer at earlier age(No evidence for this). Therefore alternative treatment to HRT should be recommended.

 SERMs such as Raloxifen is effective in prevention of bone loss, however it is not effective in the reliefe of vasomotor symptoms(1). Phytoestrogens such as soy beans and red clover is not advisable as the estrogens produced will have same effect as HRT. High dose progesterone such as megestrol acetate is associated with risk of VTE, and also some breast tumours have progesterone receptors. SSRI such as fluoxetin and and SNRI such as Venlafaxine are effective in the relief of vasomotor syndrome.  Oral clonidine is not effective, but trans dermal clonidine is effective in the reliefe of vasomotor symptoms.(what will you do about osteoporosis / cardiovascular risk?)

There is no evidence in the efficacy of complementary therapy like ginseng, black cohosh in the relief of vasomotor syndrome. The later is associated with hepatotoxicity.

Vaginal lubricant such as K Y jel can be used for relief of vaginal dryness due to uro-genital atrophy.

Sofia Posted by PAUL A.

Ansa: Number of factors affect  her risk of developing ovarian cancer, first  being the possibility of her carrying genetic mutation of familial breast ovarian cancer syndromes namely BRCA1 &  BRCA2(1).life time risk with BRCA1 is 30-60% and BRCA2 is 15-20% for ovarian cancer. This requires a pedigree analysis and testing for genetic mutations after counselling.. Risk is more if mother had breast cancer before the age of 45. if she is a carrier, prophylactic oopherectomy reduces her risk but does not totally eliminates it  (2% risk of primary peritoneal carcinomatosis)  .Secondly  familial clustering of cancer  might be just a chance occurrence  but in that case as well, one  first degree relative affected with ovarian cancer increases her risk  of ovarian cancer by 3.6 fold and premenopausal breast cancer increases her risk of ovarian cancer by 50%. (FHx of other cancers such as pancreatic, BMI, Hx of benign ovarian cysts)

other factors that will increase her risk is nulliparity(1). Use  of ovulation inducing agents increases  her risk. Breastfeeding   (1) gives 20% protection and having children reduces the risk by 40%. Use of combined contraceptive pill reduces her risk of ovarian cancer by 60% (1).

Ans b: I will tell her that due prophylactic  salpingo-oopherectomy at 38 yrs she requires to have HRT  till the age of 50 yrs (1) to prevent her from menopausal symptoms and and long term adverse affect of premature menopause namely osteoporosis and cardiovascular risk(1).HRT  does not increases the risk of breast cancer when given in  women with premature menopause (1) until the age of menopause i.e 50 yrs.  But  women who have family history of breast cancer use of HRT is associated with increased risk of breast cancer depending on type and duration of HRT.  But HRT does not reverse  the benefit of prophylactic oopherectomy on breast cancer risk in carriers of BRCA1 and BRCA2(50% reduction).  In absence of data on mutation carriers non hormonal alternative should be considered for symptom relief and prophylaxis for osteoporosis. however in absence of menopausal  symptoms  and availability of non hormonal alternatives for osteoporosis prophylaxis risk  of HRT  outweighs the benefit. (? meaning)

HRT may be required if symptoms are severe and in that case its use should retricted to shortest duration (you said needed till age 50!!) and lowest effective dose as possible. If HRT is prescribed to her she requires progesterone component as  she still retains her uterus, use of LNG IUS will reduce her serum progesterone level  as progesterone increases her risk of breast cancer, but still long term data on outcome is lacking.

I will advise her on the other benefit and risk associated with hrt. Benefit includes relief of hot flushes and night sweats, improvement in  urogenital symptoms  insomnia and mood (already written). Also  it has protective affect against osteoporosis (already written)  , colon cancer and alzhiemer ds. Risk other than the breast cancer risk, will be 2-3 fold increased risk of VTE (? Evidence in 38 year old) and would be contraindicated in personal history of VTE. Also increases the risk  of stroke and coronary artery event specially in those with risk factors like hypertension and h/o coronary artery disease (to prevent her from menopausal symptoms and and long term adverse affect of premature menopause namely osteoporosis and cardiovascular risk) (That was written by you earlier in your answer. So HRT prevents cardiovascular risk but increases coronary artery disease????).estrogen  alone and sequential combined HRT increases risk of endometrial cancer. Systemic side effects of estrogen and progesterone would be breast tenderness, bloating , headache  and mood changes(1).. Also advice on  life style changes including weight bearing exercise(1), dietary advice and stopping alcohol and smoking. provide her with written information and support group.Calcium & vit. D, SERMS, Bisphosphonates

Hanaa Posted by PAUL A.

This patient should be informed (you were not asked to inform her)that she may have one of the autosomal dominant mutations that increase her risk of  developing  ovarian cancer either Brca1 (her risk is increased by 90% )or Brca2 ( with increase in her risk of ovarian disease to 10%) ,Supported by the presence of breast and ovarian cancer in 2 of her family mother and sister.

She should be informed that ovarian cancer risk for her is 3-4 folds normal population after she got her mother with the disease.

She should also know that her risk of ovarian cancer is increased by infertility and being nullipara to 27 (???? You sure???)fold and the drug of infertility to 2.8 folds. Getting her menstruation at early age and late menopause will also increase her risk.

Her risk of ovarian cancer is decreased by0.5% by performing tubal ligation, and by 40% if she is using OCPs (1), smoking may hasten her menopause by one or 2 years (? relevance), there is a theoretical reduction in her risk of ovarian cancer if she will do Oophrectomy (1).

Explanation of the risk will let her to make an informed life style descion.

B

On performing salpingoophrectomy in 38 years old , the patient will experience sever menopausal symptoms that will affect her quality of life , like sever vasomotor symptoms , mood swings , osteoporosis, urogenital atrophy(1).

HRT in her situation is very important and its use is not accompanied by increase in her risk of cancer, or cardiovascular disease(1).

She should also know that hormonal HRT will decrease the rate of her bone loss(1). Decrease her risk of colorectal cancer, may delay the Alzheimer disease manifestation and protect her from coronary disease at young age,

Hormonal HRT may be one hormone or 2 hormones E+ progesterone to protect her endometrial lining from the unopposed effect of Estrogen alone.

It is advised to use it Sequentional  type so she will get her menstruation regularly. Side effects of both hormones estrogen and progesterone should be explained (breast tenderness , bloating , increase weight, nausea, headacke, leg cramps)(1).

Her medical and family history should be taken seriously when prescribing the type of hormonal HRT..

She should also know that her benefits from the HRT outweigh the risks accompanied by the drug use.

Risk of use of HRT in post menopausal may include increase risk of VTE (? Evidence in 38 year old), myocardial infarction (you said risk not increased earlier), cancer breast (? Evidence in women with premature menopause), gallbladder disease.

SARO K Posted by PAUL A.

ANS TO 343:(Jsk)

(a)One family member with breast cancer and one with ovarian cancer strongly suggests Hereditary cancer syndrome which is autosomal dominant with variable penetrance.she has 3.6 fold increase in ovarian cancer compared to women without family history.  Family history of Premenopausal  breast cancer  is associated with 50 percent chance of developing ovarian cancer than postmenopausal which is usually sporadic.She should be offered counselling and genetic susceptibility testing (not answering the question).If found to be positive BRCA 1 /2  her risk of developing hereditary ovarian cancer is 90 percent ,and 5-10percent  respectively(1).Her cumulative risk of developing ovarian cancer in BRCA 1  by age 70 is 30 -60 percent   wheras in BRCA 2 is 15 to 20 percent. other factors includes parity- nulliparity increase the risk (1)whreas multiparity decrease the risk.coc pill  (1)use  decrease 40 percent reduction in ovarian cancer and its effect lasts for 10 yrs.Use of ovulation inducing agents favour ovarian cancer.Prophylactic Bilateral salphingoo-ophorectomy (1)prevents ovarian cancer but still has 3-4 percent chance  of peritoneal carcinomatosis.Tubal ligation and hysterectomy also associated with significant reduction.

(b)BSO at the age of 38 yrs will put her under risk of premature menopause. I have to outweigh the benefits of HRT VS family history of breast cancer with intact uterus (? meaning).I will get history about medical  comorbidities,preference towards monthly and compliance. I will plan least effective dose (is this really what you want? Is there a difference between least effective and lowest effective???)for  short period to prevent harmful effects and achieve maximum benefits till the age of expected menopause (that will be 12 years – is that a short period?).I will inform her that combined HRT is not going to do much harm to the breast  (? meaning)till her expected menopause and not going to reverse effect of BSO. I will inform options combined(contin/sequential),estrogen only (would you use oestrogen-only???),progesterone supplementation with different routes available including oral,patch,implants,IUS,vaginal rings(1). Benefits of HRT includes relief of hotflushes,decrease rate of bone loss and osteoporotic fractures (1)with beneficial effect on lipid profile.Risk includes increased cardiovascular and cerebrovascular disease (NO),VTE(4/1000 IN HERS trial (no – not in women with premature menopause)),increased ca breast (WHI trial) (NO – not in women with premature menopause),increase ca endometrium(estonly (NO – combined HRT also increases risk)) Progesterone in the form of local prep like IUS to prevent harmful effect on the breast (NO!!!)as well as uterus friendly. Alternative options includes Tibilone  and raloxifene. Tibilone is associated with increased ca breast while raloxifene does not relieve Hot flushes(1).Phytoestrogens also not advised as she has intact uterus. I will give advice abt  nonhormonal methods of managing vasomotor symptoms such venlafaxine,trandermal clonidine and osteoporosis such as lifestyle modification, weight bearing exercise (1),Bisphospanates (1).I will highlight the importance of continued surveillance  of symptoms,self breast examination(6monthly (???? If she is doing it herself, why wait till every 6 months??)) screening mammography(annually) ,effect of HRT on mammography (what is the effect?). . I will  give her informed choice and written information leaflet with support group.

maclonchandu Posted by PAUL A.

The back ground lifetime risk of ovarian cancer is 0.9%. Having mother and sister affected by breast and ovarian cancer, there is a possibility of a hereditary cancer syndrome such as BRCA 1 or BRCA 2 mutation(1). The lifetime risk of ovarian cancer is 30-60% with BRCA1 and 15-20% with BRCA2 mutation. she should be reffered to regional genetic centre for risk assessment. For risk assessment,a family tree till 3rd degree relative is built,taking into account age of affected relatives, type of cancer, age of unaffected relatives any h/o of male cancers-- prostate,pancreas, colon (do these not affect females?). Early menarche, nulliparity(1), subfertiliy, use of ovulation inducing drugs are associated with risk of developing ovarian cancer. Having children is associated with 60% reduction in risk of ovarian cancer. With a lesser degree, breast feeding reduces the risk of ovarian cancer by 20%(1). Use of COCP (1)is associated with 40% reduction in the risk of ovarian cancer. Tubal ligation is associated with reduction of risk in general population (? BSO / hysterectomy). B) she should be informed that she will require HRT containing oestrogen ( as tablets,sprays,gels,or vaginal rings) and progestogens ( oral tablets or LNG IUS system) (1) The benefits of HRT are explained to her which include relief of vasomotor symptoms such as hot flushes and night sweats thereby improving quality of life(1). HRT use prevents osteoporosis and reduces vertebral fractures , but requires long term use(1). She should be told that HRT use delays the onset and progress of Alzheimer's disease. Oestrogen replacement also associated with a decreased risk of macular degeneration, cataract and tooth loss. She should be informed that topical estrogens improve mild urogenital symptoms but not incontinence. Information is given about the reduced risk fo colorectal cancer. She should be explained about the risks which include increased risk of Coronary heart disease (NO – not in premature menopause) associated with continuous combined HRT particularly during the first year of use. Regarding the risk of breast cancer, she should be given information that use of HRT for 5, 10 and 15 years would cause 2,6 and 12 extra breast cancers per 1000 women (in a 38 year old????). Use of oestrogen replacement in women with a premature menopause is not associated with an increased risk of breast cancer (how is this consistent with your previous statement??)- duration of oestrogen exposure is the risk factor. She should be informed that unopposed oestrogen therapy Sequential combined HRT (progestogen for 10 days per cycle) are associated with an increased risk of endometrial hyperplasia and carcinoma but not continuous combined HRT. Regrding ovarian cancer, she should be told that current use of HRT is associated with an increased risk of ovarian cancer. But data regarding HRT use after prophylactic oopherectomy are limited and show no adverse effect (so why tell her that it increases risk in the first place?????).  HRT is associated with a 2-3 fold increase in the risk of venous thrombo-embolism (? Evidence in premature menopause). Trans-dermal oestrogen containing HRT is safer than oral HRT with respect to VTE. Systemic side effects of HRT should be informed which include Oestrogen related (fluid retention, breast tenderness, nausea, headache, leg cramps )and Progestogen related (mood swings, depression, acne, fluid retention, breast tenderness)(1). Alternate options for HRT should be explained consisting of life style changes ( exercise, reduced caffeine and alcohol intake)(1), acupuncture and reflex therapy to improve symptoms. Progestogens for eg magesterol may help relief of symptoms but associated with risk of VTE and breast cancer. Selective Estrogen Receptor Modulator such as raloxifene has antiestrogenic effect on breast and endometrium causing reduction of risk of breast cancer and prevents osteoporosis but no effect in the relief of vasomotor symptoms(1). Written information is provided.

Bee Fong Posted by PAUL A.

(a)            Hereditary gynaecological cancer is inherited through autosomal dominat. Her family history needs to be understood better in order to counsel her. Referral to the clinical genetist may be required. The time of diagnosis of her mother and sister’s malignancies, the type of malignancy, the treatment required and whether the malignancies were bilateral need to asked (NOT ANSWERING THE QUESTION). Other family members need to questioned as well as to any other form of malignancy ie colonic and uterine cancer. Her family members should be tested for BRCA1, BRCA2 and hereditary non polyposis colonic cancer. If found to be positive, she should be tested for it herself and attend annual screening if found positive.

            Other risk factors includes nulliparity (1)with early menarche increases her risk. Any history of ovulation induction drugs increases her risk. Having polycystic ovaries protects her on the other hand. Pregnancy and breast feeding (1)are thought to be protective. Any history of tubal ligation with hysterectomy is protective(1). Having prophylactic Oophorectomy is protective but does not eliminate the risk as she can still develop peritoneal cancer. The combined oral contraceptive (1)method can be used to protect her from ovarian cancer.

            She also needs to understands that there is also a background overall risk of ovarian cancer without hereditary cancer.

(b)            Prescribing HRT need to be discussed with the patient with weighing the risks and benefits. HRT is protective against osteoporosis (1)in women without oestrogen supply before menopausal age. If she takes after menopause for osteoporosis it is only protective for the duration of use. It is also used to relieve vasomotor symptoms (1)which can be severe when a salpingo-oophorectomy suddenly cuts off the supply of oestrogen. It is also protective against developing colonic cancer.

            On the other hand, it can increases the risk of developing ischaemic heart disease and stroke (no – not in women with premature menopause). The evidence is controversial. She needs to be aware about the increase risk of breast cancer (not in premature menopause) especially if there is a family history of it. If she does go on HRT, referral to the breast surgeon may be necessary with annual screening.

            It is better to have sequential combined HRT if she still has her uterus to reduce the risks and side effects of HRT. If she is taking it beyond the age of menopause she may have it continuously.

            There is also potential of developing thromboembolism with HRT (? Evidence for premature menopause). Signs and symptoms need to be educated to look for thromboembolism. Any family history of thrombophilia or thromboembolic event need to discussed prior to screening her .

            Any vaginal atrophy with urinary symptoms can be treated with local oetrogen to relieve symptoms. The HRT need to be reviewed at around 50-52 years old to discuss continuation of it. Other options of relieving symptoms of menopause need to be discussed with her besides HRT including osteoporosis treatment with calcium and bisphosphonates (do these treat menopausal symptoms??), tibolone and raloxifene for vasomotor symptoms (does raloxifene treat vasomotor symptoms???). Lifestyle changes with weight bearing excercises(1), reducing smoking and weight will reduce her risk of osteoporosis and ischaemic heart disease.

            Overall, the benefits outweigh the risks in her case and should be prescribed with regular follow up.

VANEEZA Posted by PAUL A.

A.Life time risk of developing ovarian cancer is 1-2% and this risk increases to 5.2 % if first degree relative affected under age of 55 years.As this woman has two first degree relatives with ovarian and breast cancer ,there is possibility in her of carrying BRCA1 and BRCA 2 gene mutation (1).If she will be carrier of BRCA 1 risk of developing ovarian cancer is 28-44% and 27% with BRCA 2.Prophylactic oophorectomy (1),after age of 35 will reduce but does not eliminate the risk of ca ovary as there is still 1-2% risk of primary peritoneal carcinomatosis.There is also 12% increase risk of ovarian cancer in  HNPCC carrier.

Other risk factors include nulliparity,27 fold (27 fold???)increased risk.Infertility and ovulution  inducing drugs also associated with higher risk of ovarian cancer.Parity and breast feeding (1)have protective affect as they reduce risk of ovarian cancer by 60% and 20%.Use of COCP (1)  by 5 years reduces risk by 40%.ovarian irradiation also increases risk of developing ovarian cancer.

B. The main aim of counselling in a woman who have prophylactic oophorectomy is to remove her anxiety of developing breast and endmeterial  cancer as she has family history of breast ca and uterus  in situ.she will be counselled that firstly estrogen replaecment  with premature menupause is not associated with breast cancer however risk is increased with combined therapy (??/ evidence??).Secondly risk falls to general population after 5 years of stopping HRT. On other hand unopposed estrogen is associated with risk of having endometerial hyperplasia and cancer.Combine therapy with natural progesterone derived progesogens and dyhydrogesterone are associated with lower risk campared to synthetic progesterone (where did you read this?).LNG-IUS is also have increased risk (of what? Endometrial hyperplasia???).

She should be told that woman who develop breast cancer while taking HRT will have bigger and advance tumour with high mortality.  HRT also reduces the accuracy of mammographic screening. Besides this HRT is associated with 2-3 fold increased risk of VTE (? In women with premature menopause?)especialy during first year of use,in obeese woman with family history of VTE.

She will be counselled that HRT will improve her vasomotor symptoms (1)with in 4 weeks and maximum effect in 3 months.It will also improve her psychological wellbeing .HRT also reduce risk of colorectal cancer,osteoprosis(1).alzheimer,s disease and dimentia.Topical estrogen will improve her local vaginal symptoms but not the incontinence.

If she is concerned about potential risks of HRT she should be told that life style modification including regular exercise with reduction in alcohol and caffeine intake will reduce frequency and severity of menupausal symptoms.She can use vaginal bio -adhesive moisturiser to rehydrate vaginal tissue.Transdermal clonidine (alpha 2 agonist) is also effective in relieving her vasomotor symptoms.SSRI(fluoxetine&paroxetine) and SNRI (venlafaxine) are effective in treatment of hot fluhes.She also has a choice of complimentary therapies,acupuncture and reflexology tech.Written information will be provdied.(you have not addressed osteoporosis or cardiovascular disease

Sherif N Posted by PAUL A.

proper history taking (You were not asked to take a Hx)from the patient to determine her risks for de\veloping breast cancer(YOU WERE ASKED ABOUT OVARIAN CANCER), this includes her parity, life style (smoking, drinking), previous use of hormonal contraceptives and duration of use, previous use of ovulation induction drugs.

her menstrual cycle history, age of menarche, pattern of cycle, whether regular, associated with dysmenorrhea, PMS, whether there is history of PCO or anovulatory cycles

if she has diabete, GIT or colonic troubles. examination for her BMI, also karyotyping as this patient most probably has BRCA1 or BRCA2 gene mutation (WILL KARYOTYPE IDENTIFY THIS??), to give her the exact risk of developing ovarian cancer specially if she has BRCA1 gene mutation

patient had undergone bilateral salpingooopherectomy, which makes her at great risk of developing acute menopausal symptoms, specially hot flushes, osteoporosis(1), increased risk of venour thromboembolism and cardiovascular stokes, vaginal dryness....(WHAT IS THIS??)for this, use of HRT is recommended

as the petient has first degree relative who developed cancer breast, so there is risk of cancer breast with the use of HRT (is there no risk of breast cancer if she did not have a family history?), so this should be explained to the patient, and regular follow up, breast self examination, breast ultrasound, then breast mammography later are required to ensure she can continue on HRT, otherwise it should be changed to other alternatives

SERMs as Raloxifen (1) will control osteoporosis, and better to prevent breast cancer, but it doesn't control hot flushes, also it increases the risk of DVT

patient should be advised regarding the pattern of her life style, to stop smoking or alcohol consumption, practice regular daily exercises, focus on healthy food habits, and intake of soya products. also traditional medicine and acupuncture help to control menopausal symptoms specially hot flushes

Ali Naveed Posted by PAUL A.

a) Ovarian cancer is a leading cause of mortality due to female genital tract malignancy. There is no reliable screening method and on the top its presentation is usually late with advanced disease which leads to higher mortality and poor prognosis even after treatment. (waste of time & space)A number of factors affect the development of ovarian cancer some increase the lifetime risk of developing and some reduce the risk of developing it (this is a complete waste of your time and space – you are yet to discuss a single factor and cannot expect to get any marks. What did you cann this in your answer plan???)

The factors that increase the risk are increasing age it is more often seen in women above 55 years although it may be seen at all ages. Nulliparity (1)is associated with a higher risk of developing ovarian cancer, so is infertility. It is associated with increase in the number of menstrual cycles, and ovulation and therefore pregnancy and anovulation confer a protective effect so is the use of combined oral contraceptive pills(1). Infertility is associated with increase in the risk (you have already written this), there is also an association with the use of ovulation induction agents which either due to infertility or themselves may increase the risk. Obesity (1)and use of high protein diet increase the chance of ovarian cancer. Use of oral contraceptive , pregnancy(?? You have already written this – you are wasting your time & space) and multiparity is associated with a lower risk of developing ovarian cancer.

Familial predisposition is highly associated with 10% lifetime risk of developing ovarian cancer (is it????). A positive history of two first degree relatives affected with ovarian cancer , or two first degree relatives affected with ovarian cancer or breast cancer, early development of ovarian cancer or breast cancer, one first degree relative with ovarian cancer and two or more second degree relatives affected with ovarian cancer , breast cancer or colon cancer. In addition a positive association is found with BRCA 1 and BRCA 2 (1), MMR genes are associated with 40% risk  of development of ovarian , breast cancer in females and prostate and breast cancer in males. Affected male and female relatives and a history of cancer must be taken among all first degree relatives like sisters , brothers, father, mother, and first cousins to chalk out life time risk.  Lynch syndrome is also associated high risk of developing ovarain cancer this is also associated with familial non polyposis colon disease. Certain ethnic races like Ashaknazi Jews are strongly associated with BRCA1 and BRCA 2 genes which run in these families.  However BRCA genes are also found in Asian and African races.

b) Prophylactic bilateral salpingoophorectomy is associated with a 95% reduction in the risk of developing ovarian cancer. It must be informed to patient that there still may be a 2-4% risk of developing cancer of epithelial origin (how does this answer the question about HRT???). It is a recommended procedure for prophylaxis in patients with positive family history as described above or in positive BRCA families. The standard procedure is to undertake peritoneal washings and omental biopsy , in some early disease can be found (? Relevance to the question).  The removal of ovaries renders the lady who is young infertile and with surgical menopause.

She is at risk of immidiete menopuasal symptoms like vasomotor symptoms, hot flushes, urogenital symptoms, vaginal atrophy, dysparunea, dysuria, urgency , reduced libido. Frequency of micturation, breast atrophy. Skin sagging , depression (not a feature of the menopause), memory loss may or may not be there. Among the long term risks she is at risk of developing osteoporosis, cardiovascular risks(1)

Hormone replacement therapy which can be offered includes non hormonal  clonidine for hotflushes, lifestyle adjustments with increase in excercize, calcium supplementation, Soya diet, isoflavones, black cohosh all have been shown to improve the postmenopausal symptoms (? Evidence??). Bisphosphonates (1)use reduces bone loss. 

The quality of life can be increased by prescribing hormone replacement therapy for short periods (is a short period appropriate for a 38 year old with premature menopause?), preperations containing estrogen and progesterone can be prescribed after ruling out contraindications to their usage like thromboembolic disease, cardiovascular risks, liver dysfunction, arterial disease. Cyclic combined therapy (1)confers protection to endometrium for developing endometrial cancer. Local hormone repalcement therapy can be prescribed for improving urogenital symptoms these are highly effective . Long term use of Hormone replacement therapy is associated with a high risk (NO IT IS NOT. What does high risk mean?)of developing breast cancer, increased cardiovascular disease, cva, therefore should not be recomended for more than 5 years to 10 years (This is not true in a 38 year old with premature menopause).

Anuradha Posted by PAUL A.

A healthy 34 year old woman has been referred to the gynaecology clinic because her mother and sister have developed breast and ovarian cancer respectively. (a) Discuss the factors that affect her risk of developing ovarian cancer. [8 marks] (b) She undergoes laparoscopic bilateral salpingo-oophrectomy at the age of 38 years. How will you counsel her with respect to hormone replacement therapy? [12 marks]

(a) An ashkanazi jewishheritage makes her 5-10times (is this the first thing that comes to your mind? If you had to write about one thing, will this be the one?)more likely of carrying BRCA mutations which are associated with increased risk of familian ovarian cancer. history of bilateral breast cancer in the mother also increases her chances of carrying a hereditory cancer syndrome. Family history of prostate cancer, pancreatic cancer,male breast cancer and melanoma are associated with increased risk (1). A personal history of infertility, use of fertility drugs and nulligravidity (1)are associated with increase in the risk of ovarian cancer. Use of combined oral contraceptive(coc) pill reduces her risk of ovarian cancer(1). use of COC for  a period of 5 yrs reduces her chance of ovarian cancer by 40% and this protection is present even in BRCA carriers and lasts for 10 yrs after discontinuation of the pill, without an increase in the relative risk of breast cancer. If the  lady is a carrier of BRCA1 mutation the risk of ovarian cancer is about 30-60% and  BRCA2 mutation confers a risk of 15-20% of developing ovarian cancer. (BMI, hysterection / oophrectomy)

(b) her counselling would include risks benefits and common side effects of HRT. i will tell her that there is good evidence to support that vasomotor symtoms like hot flushes and night sweats are releived (1)with HRT  with maximum benefit by about 3 months of use. HRT is associated with improvement in the symptoms of urogenital atrophy like vaginal dryness and urinary frequency, dysperunia etc , hrt may delay or prevent alzhimers disease. decrease the incidence of colorectal cancer. HRT is also asscociated with improvement in psychological well being. HRT is also associated with decreased loss of bone density and hence prevents osteoporosis(1), however HRT use for this indication alone is not recommended. HRT is protective against cardiovascular disease however in women with established cardiovascular disease it is associated with an increased  incidence of cardiovascular events in the first year of use (how does this apply to this woman specifically?), hence it is not recommended for secondary prevention. continuous combined HRT is not associated with an increase in endometrial cancer. oestrogen replacement in women with premature menopause(surgical in this case) is not associated with an increased risk of breast cancer (1)even in BRCA 1 and 2 mutation carriers, however the use should as short a period as possible (why? It will be 12 years before she reaches the average age of natural menopause)and with lowest dose.  HRT is associated with 2-3 fold increased risk of venous thromboembolism (? Evidence in premature menopause)and this is especially so in women with family and personal history of venous thromboembolism. i will counsel her that HRT may be associated with side effects like nausea, headache, breast tenderness and pain, mood swings (1)etc (there are no marks for etc so you should not waste your time)which usually resolve with continued use.

Bp Posted by BHAWANA  P.

Genetic predisposition is the single biggest risk factor for developing ovarian cancer. A pedigree chart should be formed to assess the risk as her mother and sister has breast and ovarian cancer respectively. Investigations should be done for BRCA1 and 2 genes. The risk of ovarian cancer with BRCA1 is 40-50% and with BRCA2 is 20-25%.Also history of other cancers in family like colon cancer( Lynch syndrome) may be helpful in further assessing the risk.

Nulliparity and use of ovulation induction drugs increases the risk of ovarian cancer while use hormonal contraception, pregnancy and breastfeeding decreases the risk.

B) She should be fully counselled regarding pros and cons of HRT which will help her in making informed decision. As she is very young,the benefits of using HRT may outweigh the risks.HRT is helpful in preventing osteoporosis and hence pathological fractures. It helps to releive vasomotor symptoms like hot flushes, sweating. It improves general well-being and hence improves mood disturbances. Also lack of libido can be a concern in a young women like her and HRT overall increases libido.There is also evidence that HRT is helpful in preventing onset of Alzeihmer's disease and tooth loss.Continuous combined HRT is also reduces risk of endometrial cancer.

The side-effects include increased risk of cardio-vascular events, breast cancer, stroke and thrombo-embolism.The risk of breast cancer increases with increased duration but returns back to baseline risk after stopping HRT for 5 years.She might need specialist advise as she also runs risk of breast cancer. Self-monitoring for palpation of breast lumps/mammography will be advised to her.

I will also discuss regarding types of HRT-continuous combined, sequential, oestrogen only. I will advise regarding mode of use of HRT-oral, patch and oral/mirena coil and sub-dermal implants.

REFERENCE Posted by vaneeza K.

1, BUSYSPR NOTES  -MENUPAUSE-HRT

2,TOG,2010,12 HORMONE REPLACEMENT THERAPY AND BREAST DISEASE

Posted by Dr Dyslexia V.

X

ESSAYS 343

a)      She has an increased risk of developing ovarian cancer and there is an association with the BRCAG gene which increases the risk of breast cancer in BRCA 1 to 65% and ovarian cancer to 40% and BRCA 2 the risk of breast cancer is 45% and ovarian cancer is 11%. The other risk factors also include being nulliparous or being pregnant at a later age also increases the risk of developing ovarian cancer. The use of combine oral contraceptive pills confers protection against ovarian cancer but however she should be informed in regards to the increase risk in breast cancer. Breast feeding also confers protection to the development of ovarian cancer as well as breast cancer. The prolonged use of fertility drugs such as clomiphene citrate also increases the risk of ovarian cancer. Sterilization using tubal ligation also confers decrease in risk of ovarian cancer. She could also opt for salphingoopherectomy to reduce risk of ovarian cancer however, there is still risk of primary peritoneal cancer.

 

b)      Hormone replacement therapy are excellent agents to relief vasomotor symptomsof menopause such as hotflushes and night sweats and vaginal atrophy. It’s use in surgical menopause such as this patient will be of benefit such as offers good protection against osteoporosis and decrease in fracture of the vertebrae and hip in later age. It’s use during the perimenopausal state increases the risk of vascular disease such as myocardial infarction and stroke but however this data is currently controversial. She should be informed that there is higher risk of VTE in the use of HRT. It will be advisable to screen for thrombophilia with patients with family history of VTE prior to starting HRT. HRT is also associated with gall bladder disease.  The most important risk which should be discussed in this patient would be the increase in breast cancer if especially associated with BRCA gene. HRT usage has shown that there is slight increase in breast cancer occurrence and she would be required for regular breast assessment while on HRT. The use of other mode of routes such as intravaginal ring patches, nasal spray are available apart from oral HRT. She should be informed in regards to alternatives to HRT such as clonidine, SSRI which has less risk compared to use of oral HRT for the vasomotor symtoms and the use of SERM such as raloxifen and biphosponates for osteoporosis protection. She should be given written information pamphlet and follow up appointment after starting the HRT. She also should be informed that the HRT can be discontinued after the normal age of menopause.

Posted by zaitouni L.

Factors affecting her risk of developing ovarian cancer include;

Her family history of first degree relative  as she has her mother and her sister affected by breast and ovarian cancer respectively.

Genetic testing : if she is carrier of BRCA1  as it confers30%risk of developing ovarian cancer up to age of 60. If she is carrier of BRCA2 mutation  as it confers27%  risk of developing ovarian cancer up to age of70. Also mismatch repair gene associated with hereditary non polyposis coli cofirs increase life time risk of developing ovarian cancer upto 9-12%.

Nulliparity ,historyof  use of induction of ovulation  also increase the risk. 

 

Posted by zaitouni L.

 

 

sorry I WILL COPLETE MY ASWER;

B)  COUNCELLING OF THE WOMAN REGARDING hrt :

Iwill infom her that she will have menopausal symtoms as hot flushes ,night sweetes psychological symtoms as irritability , insomnia , vaginal dryness and dysparaunia after salpingooophrectom y.

Personal and  family  history of osteoporoses ,cardiac disease or VTE shuold be taken .

Iwill inform her about the benefites of HRT . HRT will reliefe vasomotor symtoms as night sweets hot flushes . HRT will improve psychological wellbieng  and prevent vaginal drynes and sexual problemes asdysparaunia and difficult arousal.

HRT  WILL decrease the risk of osteoporoses as it increases bone density and reduce vertebral bone fracture later on her life. It will prevent or delay the onset of Alzahiemer . It also decreases colorectal carcinoma 

Iwill inform her about riskes of HRT as it increase her risk of endometrial cancer if she used E orsequential HRT . but risk will not increase by use of continouse combined HRT.

HRT will not reduse risk of cadiac disease and if she has history of cardiac desease HRT will increase risk of  coronary heart disaes ,stroke and pulmonry embolism.

If she is at high risk of VTE   HRT  should be avoided .

I will infom her that HRT has syestemic side effectes related to E as breast tendernes and fluid retention.

also side effects related to prog as mood swenges.

IWILL INFORM HER that HRT can be taken as oral fom ,patches  ingection and topical E for vaginal dryness.

I WILL INFOR HER ABOUT THE ALTERNATIVES    including life stile advise ; SERMS, CLONIDINE whitch relief vasomotor symptom but not menopausal symtos . I will inform her about complementary therpies  as gabapentine and Gensing.. .

EssaY Posted by j  .

j reply

1.Since two first degree relatives are affected ,her chances of getting ovarian cancer is increased.Her risk of developing ovarian cancer if found to be carrier of BRCA1,BRCA2 is increased.Nulligravidity,use of infertilty drugs also increase the risk,Having children reduses the risk by 60% and use of COCP reduces by 40% though there is increased risk of developing breast cancer with pills.Tubal ligation and hysterectomy has a protective effect.Bilateral oopherectomy significantly reduces the risk though not eliminating completely because of risk of developing peritoneal carcinamatosis.

2.Counselling is important  regarding hormone replacement therapy to allay her fears and anxiety.I will tell her  that short term use is beneficial in vaginal dryness ,hot flushes,moodchanges.Also is protective for dementia,tooth decay and colo rectal cancer.

There is an increased risk of endometrial cancer particularly with sequential HRT.Starting  therapy at 38 years  with premature menopause does not increase risk of coronory heart disease and breast cancer.However self breast examination and annual mammography can be done to detect any early occurence of breast cancer.I ill inform that hormone replacement therapy can be taken as ora[tablets],patches.cream.Few side effects due to estrogenic and progesteronic effects like headache,water retention,leg bramps and bloating sensation could occur.

I will also provide information regarding non hormonal alternatives like clonidine and non pharmacological alternatives and their efficacy.I will provide her a information leaflet. 

Essay 343 Posted by Reena G.

a)

The woman has family history of breast and ovarian cancer so there is possibility of hereditary cancer syndrome.I will tell her that 5-10% of ovarian and breast carcinoma are due to  autosomal dominant. With history of ovarian carcinoma in  her sister  the risk is 3.6 fold as compare to woman with no such family history, if her mother had premenopausal breast carcinoma then her risk will increase to 50% and if she is from askenazi jewish family  then her risk for ovarian cancer  is at any age ,Her risk can be assessed by drawing pedigree and verbal information should be supplemented by details from hospital records . She should be genitically tested for mutation for BRCA1 and BRCA2  as BRCA1 carrier  has 80-90% and BRCA2 has 5-10% risk of Ovarian cancer.If she is nulliparous her risk will increase to 2.8 times and if using ovulation inducing drugs her risk will increase to 27 times. Parity , breast feeding and tubal ligation reduces her risk and OCP reduces risk to 40% for ovarian cancer.

b)

I will tell her that after BSO she will develop menopausal symptoms  and so she needs HRT and for that I will ask her personel and family history of osteoporosis ,VTE, stroke, cardiovascular disease and her attitude towards taking medication and follow up. I will tell her about the benefits of HRT that it prevents hot flushes, irritability, sweating, lack of sleep, vaginal dryness, dyspareunia and frequency of micturition and provides mental well being, HRT at her age will prevent osteoporosis and will be cardioprotective.I will tell her about risks of HRT  although studies were taken on woman taking HRT at or after menopause. Risk of breast cancer at 50 yers age is 32/1000women, if HRT taken for 5 or 10 years then risk will increase to 38 and 51/1000 women, however risk after 5 years of stopping HRT will equal to those non users.I will tell her that continuous combined oral pills are protective than sequential or only oestrogen pills.HRT increses the risk of VTE to 2-3 folds. I will tell her the need of self breast examination and need for screening breast  and follow up  also I will tell her about different routes of HRT like oral, patch, gel, implant, vaginal ring and cream, will give her written information and follow up appointments and will tell her about support groups for breast carcinoma.

 

Vanosch Posted by PAUL A.

a)   This patient has an increased risk to have ovarian cancer compared to generalpopulation. There are many factors that increase the probability of having such cancer, these may include; a positive family history, previous history of breast or ovarian cancer, if patient have had ovulation induction or if she is known case of PCOS.(You were asked to discuss these factors, not list them) Therefore, taking a full history (you were not asked to take a Hx. You should not try and re-design the question as the examiner will not change the marking scheme for you)is a crucial in such cases.

Menstrual history is also important, as there is increased risk of ovarian cancer associated with early menarche. The patient also should be inquired about any recent changes in her appetite or weight. However, such changes might only be seen in advanced stage of cancer.

Number of pregnancies have an protective effect as ovarian cancer more common in nullipara(1) .

Finally if patient has a suspicious pelvic mass, she has certainly an increased possibility to have ovarian cancer  

b)                     

As this patient still young, she will have sudden  post-menopausal symptoms after removal of her ovaries, which my include physical and psychological symptoms, such as hot flashes, dry vaginal, dyspauronea,  decreased breasts size in addition to mood disorders.

Patient should counseled about these short-term consequences of the removal of the ovaries in spite of long-term ones such as osteoporosis and infertility as well (? Meaning?? Poor English).

After taking good history and reviewing her old chart if possible (which chart and what are you looking for?) and after ruling out any contraindication to HRT such as endometrial and/or breast cancer, active hepatic disease and any undiagnosed vaginal bleeding. This patient should offer HRT and all risks and benefits of such treatment have to be explained thoroughly (how does the examiner know that you know the risks and benefits to be explained?). Leaflets should be provided too, and any question or inquiry must be replayed.

Other alternatives of HRT might be offered especially if patient do not prefer to have such medication, these may include herbal medications, osteoporosis prophylactic treatment  (like what?) and symptomatic treatment for hot flashes and dyspauronea (like what? There is nothing specific in your answer).

Risks of HRT include increase of cardiovascular disease specially in the first year of use, risk of CVA is also increased and more incidence of breast (not in women with premature ovarian failure) and endometrial cancer. However, the total risk is still small (?? 1% or 10%? What does small mean?).

Benefits of HRT may include relief of hot flashes and other symptoms of ovarian hormones withdrawal (like what?). Other proven benefits, are the prophylactic effects of HRT on Osteoporosis (1) and there are some reports that it may postpone Alzheimer disease.

Finally as this patient have her uterus intact, she should advised not to have oestrogen-only treatment as such treatment increased significantly the risk of endometrial cancer.

Yingjian Posted by PAUL A.

(a) This lady has a family history suggestive of a hereditary cancer syndrome such as BRCA 1 or 2 (1)which is associated with significantly increased risks of developing breast and/ or ovarian cancer, especially if her family members are being affected at a younger age, if there are multiple members or bilaterality of breast cancer or synchronous cancers. Other factors will be the presence of other cancers that have been implicated in BRCA 1 such as colon cancer in male and female members of the family and prostate cancer, and male breast cancer in BRCA 2.

The other factors that would affect her risk of ovarian cancer would be her gynaecological/ obstetric history, as nulliparity (1)and infertility with or without usage of fertility drugs, especially over a long period. Protective factors would be breastfeeding (1)and tubal ligation. Her contraceptive history would be significant as well. If she had taken combined oral contraceptive pills (1)at least for 5 years, it could confer a long term benefit of halving the risks of ovarian cancer.

b) I would inform her that after laparoscopic bilateral salphingo oophorectomy she would undergo surgical menopause, which means that her body will be deprived of female hormones. Symptoms of menopause such as vasomotor symptoms (hot flushes, night sweats), mood changes, urogenital changes (dryness, dyspareunia, urgency), loss of libido. There will be progressive bone loss which may lead to osteoporotic fractures in future(1). Hormone replacement therapy, in the form of estrogen and progesterone (1), as a continuous or sequential preparation is usually given. She may continue to have withdrawal bleeding with sequential preparations. Progesterone is required for endometrial protection as her uterus has been conserved.

Side effects (1)of HRT can be related to estrogen, such as fluid retention, breast tenderness, nausea, headache, or progesterone, such as mood swings, depression, acne. These can be modified by changing the dosage, type of hormone or route of administration. There is a small associated risk of gall bladder disease and enlargement of fibroids/ reactivation of endometriosis with HRT usage. There is no evidence that HRT causes weight gain.

The significant risks of hormone replacement therapy are increased risks of venous thromboembolism, stroke and myocardial infarction (not in women with premature menopause). The risk of breast cancer is slightly increased but the magnitude of which usually follows the delayed age of menopause. She may also experience irregular bleeding, especially in the initial months of using hormone replacement therapy. Bleeding that persist may need further investigations.

In cases where surgical menopause occurs at a premature age (below age 51 which is the average age), it is reasonable to commence hormone replacement therapy if she is healthy and does not have a family or personal history of venous thromboembolism or factors which put her at increased risk of venous thromboembolism. This is mainly for bone protection. However addition of hormones may increase the risk of breast cancer especially in her case, as she may be a carrier of BRCA gene that puts her at significant risk of breast cancer. It is known that the growth of breast tumours can be enhanced in the presence of estrogens/ progestrogens. In such cases it is best to avoid HRT, and to treat any symptoms of menopause with alternative therapy, such as lifestyle changes (like what?)or selective serotoninergic receptor inhibitors for vasomotor symptom. She can also be considered for agents such as raloxifene (does this treat menopausal symptoms?). Consideration would also be given to her personal risk of osteoporosis, and screening for osteoporosis keeping in view treatment in future.

Samira Posted by PAUL A.

1-As her sister has ovarian cancer, her risks of developing ovarian cancer increases 3.6fold.

If mother develops breast cancer esp.before menopause and/or  it is in both breast than her risks of developing ovarian cancer increases around 50%.

If her gene mutation analysis or linkage analysis shows BRACA 1 (1)mutation then her risk of developing ovarian cancer at 50 years of age is 50%.With BRACA 2mutation it is 15-20%.

If patient is Nullipara her risk will be increased 27 times (27 times????).If she is infertile and using infertility drugs her risk will increase 2.8 times.Use of OCP's (does this include progestogen-only pills?) has risk reduction by 40%,which will continue upto 10 years of stopping.

With self breast examination upto 35 years and mammography from 35 years regularly (early detection)will modify her risk (you were asked about ovarian cancer).Tubal ligation and hysterectomy significantly decreases the risk (1)but may be not appropriate for this young lady.Prophylactic bilateral salpingoophrectomy can reduce the risk but will not alleviate it 100%.

2-women will be adviced that early menopause will confer some risks to her wellbeing including hot flushes,night sweats.Her bones will become thin and brittle(osteoporosis),will be vulnerable to fractures (1).Her vagina might become dry with pain during intercourse,she might develop leakage of urine on coughing or sneezing,She might start to forget things(Alzeimer)her libido  and energy will decrease .For all these reasons she needs to take HRT.HRT is a combination of two hormones estrogen and progestrone (1), 2 female hormones which after removing her ovaries will be needed as a supplement.It will protect from most of the  symptoms.There is no prove that stress incontinence can be improved by estrogen therapy

HRT will not increase her risk of developing breast cancer (1)if started for premature menopause & stopped at 50 years of age.Women should be counselled about risks  of VTE which will increase2-3 fold (? Evidence in premature menopause). Transdermal patch will not increase the risks significantly.Sequential HRT might increase her risks of increasing endometrial cancer but continous combined HRT will not.HRT is protective for colorectal cancer.

She might develop sideeffects (1)of estrogen like breast tenderness,bloating,headache,nausea and side effects of progestrone like Acne,Headahe,mood swings,breast tenderness.We can give progestogens for 14 days every 3 months to decrease these side effects.Her risks of coronary artery disease,stroke ,pulmonary embolism might increase slightly (? Evidence in premature menopause).We should discuss with her routes of administration Tablets form or gel,implants or transdermal patch (1).We should discuss with her alternatives of HRT if she wishes or having VTE in 1st degree relatives or because of side effects of HRT she might ask for alternative.Raloxifen (1)which is SERM can be adviced for osteoporosis reduction but will not relieve vasomotor symptoms.It is associated with 76% of breast cancer risk reduction.

SSRI like paroxitin,SNRI like venaflaxin is effective for short term.Other herbals,redclover phytosoya,blackcohosh etc have no proven effect and carries undesirable sideeffects.Trandermal  clonodine might be of benefit.Others like acupuncture,homeopathy some herbs needs te evaluated .

(exercise, bisphosphonates for osteoporosis)

Bahawana Posted by PAUL A.

 

Genetic predisposition is the single biggest risk factor for developing ovarian cancer. A pedigree chart should be formed to assess the risk as her mother and sister has breast and ovarian cancer respectively. Investigations should be done for BRCA1 and 2 genes(1). The risk of ovarian cancer with BRCA1 is 40-50% and with BRCA2 is 20-25%.Also history of other cancers in family like colon cancer(1) ( Lynch syndrome) may be helpful in further assessing the risk.

Nulliparity (1)and use of ovulation induction drugs increases the risk of ovarian cancer while use hormonal contraception (progestogen-only???), pregnancy and breastfeeding decreases the risk(1).

B) She should be fully counselled regarding pros and cons of HRT which will help her in making informed decision. As she is very young,the benefits of using HRT may outweigh the risks.HRT is helpful in preventing osteoporosis and hence pathological fractures. It helps to releive vasomotor symptoms like hot flushes, sweating(1). It improves general well-being and hence improves mood disturbances. Also lack of libido can be a concern in a young women like her and HRT overall increases libido.There is also evidence that HRT is helpful in preventing onset of Alzeihmer's disease and tooth loss.Continuous combined HRT is also reduces risk of endometrial cancer. (it does not. It does not increase the risk. This is not the same as reducing the risk)

The side-effects include increased risk of cardio-vascular events (? Evidence in premature menopause), breast cancer, stroke and thrombo-embolism (? Evidence in premature menopause).The risk of breast cancer increases with increased duration but returns back to baseline risk after stopping HRT for 5 years (not in women with premature menopause).She might need specialist advise as she also runs risk of breast cancer. Self-monitoring for palpation of breast lumps/mammography will be advised to her.

I will also discuss regarding types of HRT-continuous combined, sequential, oestrogen only (should not be offered). I will advise regarding mode of use of HRT-oral, patch and oral/mirena coil and sub-dermal implants(1).

X Posted by PAUL A.

a)      She has an increased risk of developing ovarian cancer and there is an association with the BRCAG gene which increases the risk of breast cancer in BRCA 1 to 65% and ovarian cancer to 40% and BRCA 2 (1) the risk of breast cancer is 45% and ovarian cancer is 11%. The other risk factors also include being nulliparous (1)or being pregnant at a later age also increases the risk of developing ovarian cancer. The use of combine oral contraceptive pills (1)confers protection against ovarian cancer but however she should be informed in regards to the increase risk in breast cancer. Breast feeding (1)also confers protection to the development of ovarian cancer as well as breast cancer. The prolonged use of fertility drugs such as clomiphene citrate also increases the risk of ovarian cancer. Sterilization using tubal ligation also confers decrease in risk of ovarian cancer. She could also opt for salphingoopherectomy (1)to reduce risk of ovarian cancer however, there is still risk of primary peritoneal cancer.

 

b)      Hormone replacement therapy are excellent agents to relief vasomotor symptomsof menopause such as hotflushes and night sweats and vaginal atrophy. It’s use in surgical menopause such as this patient will be of benefit such as offers good protection against osteoporosis and decrease in fracture of the vertebrae and hip in later age(1). It’s use during the perimenopausal state (is the woman in question perimenopausal???)increases the risk of vascular disease such as myocardial infarction and stroke but however this data is currently controversial. She should be informed that there is higher risk of VTE (? Evidence in women with premature menopause)in the use of HRT. It will be advisable to screen for thrombophilia with patients with family history of VTE prior to starting HRT. HRT is also associated with gall bladder disease.  The most important risk which should be discussed in this patient would be the increase in breast cancer (? Evidence in women with premature menopause)if especially associated with BRCA gene. HRT usage has shown that there is slight increase in breast cancer occurrence and she would be required for regular breast assessment while on HRT. The use of other mode of routes such as intravaginal ring patches, nasal spray are available apart from oral HRT(1). She should be informed in regards to alternatives to HRT such as clonidine, SSRI which has less risk compared to use of oral HRT for the vasomotor symtoms and the use of SERM such as raloxifen (1 does not treat menopausal symptoms)and biphosponates for osteoporosis protection(1). She should be given written information pamphlet and follow up appointment after starting the HRT. She also should be informed that the HRT can be discontinued after the normal age of menopause.

essay 343 NA Posted by naila A.

 

A)Her risk of breast or ovarian cancer is increased with positive family history for these cancers in 1st or 2nd degree relatives. A positive history of colon and extra colonic also cancers increase the risk of gynaecological cancers. Presence of genetic mutations increase the risk substantially .BRCA 1 mutation increase the risk of breast cancer to 70 to 80% and increase the risk of ovarian cancer to 30 to 60 %.Presence of BRCA 2 mutation increase the risk of breast cancer to 70 to 80 % and increase the risk of ovarian cancer to 15 to 30 %.Nulliparity increase the risk of developing ovarian cancer, infertility  with use of fertility drugs also increase the  risk .Use of OCPs decrease the risk to 40% and having children decrease the risk to 60%.Tubal ligation and hysterectomy also decrease the risk. Prophylactic oophrectomy decrease the risk of developing ovarian cancer but there is 2 to 4 % risk of developing peritoneal cancer. Age is an important factor as the risk is increased in mid thirties and it is important to have the family completed by this time. Screening does not decrease the risk of developing ovarian cancer but it has a role in early detection.

B)She has developed acute surgical menopause which can result in severe vasomotor symptoms which are hot flushes and night sweats that can affect her quality of life badly. She can suffer from vaginal dryness and dyspareunea which again affects the quality of life. She is at increase risk of developing urinary tract infections, urgency and incontinence. Long term effects of menopause are risk of developing coronary heart disease, stroke and osteoporosis. To prevent these short term and long term effects HRT will be required. It will relieve her vasomotor symptoms and it will decrease the risk of urogenital symptoms. Long term effects of premature menopause are also prevented. Her risk of developing cardiovascular disease is decreased .The risk of osteoporosis is also decreased. HRT will also prevent macular degeneration and delay the onset of Alzheimer’s disease. Also protective against colorectal cancer. She should be informed that she can continue to use HRT till the average age of menopause that is 50 years without an increased risk of breast cancer or stroke. Alternative to HRT are modifications in life style .Regular  sustained aerobic   exercise decrease the risk of vasomotor symptoms. Reduced use of alcohol and caffeine also decrease the risk. SERMS are tamoxifen Raloxifine and clomiphine citrate.Tamoxifen is protective against breast cancer but increase the risk of endometrial cancer. It is osteoprotective may decrease the risk of cardiovascular disease but increase the risk of stroke. Raloxifine decrease the risk of development of breast cancer and endometrial cancer. May decrease cardiovascular events but increase the risk of stroke. It is osteoprotective. Progestogens show modest benefit in reducing vasomotor symptoms. Transdermal clonidine is effective in relieving these symptoms .SSRIs and SNRIs both are effective in relieving hot flushes. Topical vaginal bio-adhesives can rehydrate vagina. Complementary therapies are phyoestrogens, their value is unproven. Acupuncture is effective but associated with cardiac tamponade and hepatitis. Black cohosh can relieve  hot flushes but concerns about hapatotoxicity. Saint jhons’s Wort can relieve mild depression but has seri

REFERENCE Posted by PAUL A.

1, BUSYSPR NOTES  -MENUPAUSE-HRT

2,TOG,2010,12 HORMONE REPLACEMENT THERAPY AND BREAST DISEASE

 

The Busyspr notes do not say this about HRT and endometrial cancer and what you have written is incorrect. This is what the notes say:

 

Endometrial cancer

1) Unopposed oestrogen therapy is associated with an increased risk of endometrial hyperplasia and carcinoma

2) Sequential combined HRT (progestogen for 10 days per cycle) is also associated with an increased risk of endometrial cancer

3) Minimum progestogen dose for endometrial protection are
Oral norethisterone - 1mg for 10-14 days/ month
Norethisterone patch - 170mcg for 14 days /month
Oral levonorgestrel - 75mcg for 10-14 days / month
Levonorgestrel patch - 20mcg for 14 days / month
Oral medroxyprogesterone acetate - 10mg for 14 days / month or 20mg for 14 days every 3 months

Continuous combined HRT
0.5mg Norethisterone / 170mcg norethisterone patch / 2.5mg medroxyprogesterone acetate / 5mg dydrogesterone

4) Continuous combined HRT is not associated with increased endometrial cancer risk

5) In women with treated endometrial cancer, current data do not show an increase in recurrence or mortality associated with HRT. There is controversy over the use of oestrogen-only or oestrogen + progesterone regimes or progesterone alone

 

There is nothing inthe notes about natural or synthetic progestogens.

ZAITOUNI Posted by PAUL A.

Factors affecting her risk of developing ovarian cancer include;

Her family history of first degree relative  as she has her mother and her sister affected by breast and ovarian cancer respectively.

Genetic testing : if she is carrier of BRCA1 (1)  as it confers30%risk of developing ovarian cancer up to age of 60. If she is carrier of BRCA2 mutation  as it confers27%  risk of developing ovarian cancer up to age of70. Also mismatch repair gene associated with hereditary non polyposis coli cofirs increase life time risk of developing ovarian cancer upto 9-12%.

Nulliparity (1)  ,historyof  use of induction of ovulation  also increase the risk. (are there factors associated with reduced risk? You were asked about factors that affect risk)  

B)  COUNCELLING OF THE WOMAN REGARDING hrt :

Iwill infom her that she will have menopausal symtoms as hot flushes ,night sweetes psychological symtoms as irritability , insomnia , vaginal dryness and dysparaunia after salpingooophrectom y.

Personal and  family  history of osteoporoses ,cardiac disease or VTE shuold be taken .

Iwill inform her about the benefites of HRT . HRT will reliefe vasomotor symtoms (1)  as night sweets hot flushes . HRT will improve psychological wellbieng  and prevent vaginal drynes and sexual problemes asdysparaunia and difficult arousal.

HRT  WILL decrease the risk of osteoporoses (1)  as it increases bone density and reduce vertebral bone fracture later on her life. It will prevent or delay the onset of Alzahiemer . It also decreases colorectal carcinoma 

Iwill inform her about riskes of HRT as it increase her risk of endometrial cancer if she used E orsequential HRT . but risk will not increase by use of continouse combined HRT.

HRT will not reduse risk of cadiac disease (? Does this apply to women with premature menopause?)  and if she has history of cardiac desease HRT will increase risk of  coronary heart disaes ,stroke and pulmonry embolism.

If she is at high risk of VTE   HRT  should be avoided .

I will infom her that HRT has syestemic side effectes related to E (????)  as breast tendernes and fluid retention.

also side effects related to prog (???)  as mood swenges.

IWILL INFORM HER that HRT can be taken as oral fom ,patches  ingection and topical E (????)  for vaginal dryness (1)  .

I WILL INFOR HER ABOUT THE ALTERNATIVES    including life stile advise (like what?)  ; SERMS (like??)  , CLONIDINE whitch relief vasomotor symptom but not menopausal symtos (do SERMs treat vasomotor symptoms???)  . I will inform her about complementary therpies  as gabapentine (is this a complementary therapy???)  and Gensing.. .

J Posted by PAUL A.

1.Since two first degree relatives are affected ,her chances of getting ovarian cancer is increased.Her risk of developing ovarian cancer if found to be carrier of BRCA1,BRCA2 (1)  is increased.Nulligravidity (1)  ,use of infertilty drugs also increase the risk,Having children reduses the risk by 60% and use of COCP (1)  reduces by 40% though there is increased risk of developing breast cancer with pills.Tubal ligation and hysterectomy (1)  has a protective effect.Bilateral oopherectomy significantly reduces the risk though not eliminating completely because of risk of developing peritoneal carcinamatosis.

2.Counselling is important  regarding hormone replacement therapy to allay her fears and anxiety.I will tell her  that short term (why only short term in a 38 year old???)  use is beneficial in vaginal dryness ,hot flushes,moodchanges.Also is protective for dementia,tooth decay and colo rectal cancer.

There is an increased risk of endometrial cancer particularly with sequential HRT.Starting  therapy at 38 years  with premature menopause does not increase risk of coronory heart disease (1)  and breast cancer (1)  .However self breast examination and annual mammography (? Evidence of value in a 38 year old)  can be done to detect any early occurence of breast cancer.I ill inform that hormone replacement therapy can be taken as ora[tablets],patches.cream (1)  .Few side effects due to estrogenic and progesteronic effects like headache,water retention,leg bramps and bloating sensation could occur(1)  .

I will also provide information regarding non hormonal alternatives like clonidine and non pharmacological alternatives (like what?)  and their efficacy.I will provide her a information leaflet.

Reena Posted by PAUL A.

a)

The woman has family history of breast and ovarian cancer so there is possibility of hereditary cancer syndrome.I will tell her that 5-10% of ovarian and breast carcinoma are due to  autosomal dominant. With history of ovarian carcinoma in  her sister  the risk is 3.6 fold as compare to woman with no such family history, if her mother had premenopausal breast carcinoma then her risk will increase to 50% (risk of ovarian cancer??)  and if she is from askenazi jewish family  then her risk for ovarian cancer  is at any age (? meaning)  ,Her risk can be assessed by drawing pedigree and verbal information should be supplemented by details from hospital records . She should be genitically tested for mutation for BRCA1 and BRCA2  (1)  as BRCA1 carrier  has 80-90% and BRCA2 has 5-10% risk of Ovarian cancer.If she is nulliparous (1)  her risk will increase to 2.8 times and if using ovulation inducing drugs her risk will increase to 27 times (these must be the most dangerous drugs in common use given the mortality rates associated with ovarian cancer!!)  . Parity (1)  , breast feeding and tubal ligation reduces her risk and OCP (does this include progestogen-only pills?)  reduces risk to 40% for ovarian cancer.

b)

I will tell her that after BSO she will develop menopausal symptoms  and so she needs HRT and for that I will ask her personel and family history of osteoporosis ,VTE, stroke, cardiovascular disease and her attitude towards taking medication and follow up. I will tell her about the benefits (1)  of HRT that it prevents hot flushes, irritability, sweating, lack of sleep, vaginal dryness, dyspareunia and frequency of micturition and provides mental well being, HRT at her age will prevent osteoporosis(1)   and will be cardioprotective (1)  .I will tell her about risks of HRT  although studies were taken on woman taking HRT at or after menopause. Risk of breast cancer at 50 yers (how is this useful to a 38 year old? Surely doctors know the risk of breast cancer in 38 year old women)  age is 32/1000women, if HRT taken for 5 or 10 years then risk will increase to 38 and 51/1000 women, however risk after 5 years of stopping HRT will equal to those non users.I will tell her that continuous combined oral pills are protective than sequential or only oestrogen pills (of breast cancer???)  .HRT increses the risk of VTE to 2-3 folds (? Evidence in premature menopause)  . I will tell her the need of self breast examination and need for screening breast  and follow up  also I will tell her about different routes of HRT like oral, patch, gel, implant, vaginal ring and cream(1)  , will give her written information and follow up appointments and will tell her about support groups for breast carcinoma (why? She does not have breast cancer)  .

Naila Posted by PAUL A.

A)Her risk of breast or ovarian cancer is increased with positive family history for these cancers in 1st or 2nd degree relatives. A positive history of colon and extra colonic (like what? skin cancer??)also cancers increase the risk of gynaecological cancers. Presence of genetic mutations increase the risk substantially .BRCA 1 mutation increase the risk of breast cancer to 70 to 80% and increase the risk of ovarian cancer to 30 to 60 %.Presence of BRCA 2 (1)mutation increase the risk of breast cancer to 70 to 80 % and increase the risk of ovarian cancer to 15 to 30 %.Nulliparity (1)increase the risk of developing ovarian cancer, infertility  with use of fertility drugs also increase the  risk .Use of OCPs (does this include progestogen-only pills?)decrease the risk to 40% and having children decrease the risk to 60%.Tubal ligation and hysterectomy (1)also decrease the risk. Prophylactic oophrectomy decrease the risk of developing ovarian cancer but there is 2 to 4 % risk of developing peritoneal cancer. Age is an important factor as the risk is increased in mid thirties and it is important to have the family completed by this time. Screening does not decrease the risk of developing ovarian cancer but it has a role in early detection.

B)She has developed acute surgical menopause which can result in severe vasomotor symptoms which are hot flushes and night sweats that can affect her quality of life badly. She can suffer from vaginal dryness and dyspareunea which again affects the quality of life. She is at increase risk of developing urinary tract infections, urgency and incontinence. Long term effects of menopause are risk of developing coronary heart disease, stroke and osteoporosis (1). To prevent these short term and long term effects HRT will be required. It will relieve her vasomotor symptoms (1)and it will decrease the risk of urogenital symptoms. Long term effects of premature menopause are also prevented. Her risk of developing cardiovascular disease is decreased (1).The risk of osteoporosis is also decreased(1). HRT will also prevent macular degeneration and delay the onset of Alzheimer’s disease. Also protective against colorectal cancer. She should be informed that she can continue to use HRT till the average age of menopause that is 50 years without an increased risk of breast cancer (1)or stroke. Alternative to HRT are modifications in life style .Regular  sustained aerobic   exercise decrease the risk of vasomotor symptoms. Reduced use of alcohol and caffeine also decrease the risk. SERMS are tamoxifen Raloxifine and clomiphine citrate.Tamoxifen is protective against breast cancer but increase the risk of endometrial cancer (will you offer it to this woman?). It is osteoprotective may decrease the risk of cardiovascular disease but increase the risk of stroke (is stroke not a cardiovascular disease???). Raloxifine decrease the risk of development of breast cancer and endometrial cancer(1 ? menopausal symptoms). May decrease cardiovascular events but increase the risk of stroke. It is osteoprotective. Progestogens show modest benefit in reducing vasomotor symptoms. Transdermal clonidine is effective in relieving these symptoms .SSRIs and SNRIs both are effective in relieving hot flushes. Topical vaginal bio-adhesives can rehydrate vagina. Complementary therapies are phyoestrogens, their value is unproven. Acupuncture is effective but associated with cardiac tamponade and hepatitis (is it???). Black cohosh can relieve  hot flushes but concerns about hapatotoxicity. Saint jhons’s Wort can relieve mild depression but has seri

Answer Posted by PAUL A.

Answer plan

(a)

Increased risk

  • FHx
  • Mutations
  • Nulliparity
  • BMI
  • Smoking
  • Benign ovarian cysts

Decreased risk

  • COCP
  • Breastfeeding
  • TAH / TAH + BSO / BTL

(b)

Risks of prem. Menopause

-symptoms

-osteoporosis

-cvs

-cognitive decline

-increased mortality

Types of HRT

Oestrogen + progestogen; duration, routes

Benefits of HRT

-symptoms

-osteoporosis

-cvs

Risks /side-effects of HRT

-no breast ca / cvs / vte / endometrial ca

Drug SE

Alternatives to HRT

-calcium / vitamin D / lifestyle

-bisphosphonates

-SERMS

 

A good answer should include the following

(a)

Increased risk

Family history

  • Positive Hx  diagnosed before 50 years increases risk. Also history of colorectal / stomach / pancreatic cancer (1 mark)
  • Known carrier of mutations such as BRCA 1& 2 (1 mark)

Nulliparity (1 mark)

High BMI / smoking (1 mark)

Hx of benign ovarian cysts / endometriomas (1 mark)

 

Decreased risk

Use of COCP (1 mark)

Breastfeeding (1 mark)

TAH / TAH + BSO or BTL (1 mark)

(b)

Explain consequences of untreated premature menopause: symptoms, osteoporosis, cardiovascular disease, cognitive decline, increased mortality (2 marks)

Know need for oestrogen + progestogen until average age of menopause ~51 years (1 mark)

Discuss delivery systems (1 mark)

Discuss sequential or continuous combined / tibolone (1 mark)

Discuss benefits especially prevention of osteoporosis and management of symptoms (1 mark)

No evidence that risk of cardiovascular disease is increased (1 mark)

No evidence that risk of breast cancer is increased (1 mark)

No evidence that risk of VTE / endometrial cancer increased (1 mark)

Discuss drug side-effects (1 mark)

Discuss alternatives

-Calcium & vitamin D supplementation + weight-bearing exercise (1 mark)

- Bisphosphonates – will not treat menopausal symptoms (1 mark)

-SERMs such as raloxifene – reduce risk of osteoporosis and breast cancer but will not treat menopausal symptoms (1 mark)

essay 343 Posted by zaitouni L.

Please Pual   I WANT   THE refrence for your answer to help me in studing the subject