Gynecologic Problems in Patients with Breast Cancer

Many patients with breast cancer experience gynecologic problems during or after breast cancer treatment.  Some of these problems are caused by chemotherapy or hormonal therapy;  others are caused by low estrogen levels resulting from chemotherapy, hormonal therapy, or prophylactic oophorectomy; and still others are unrelated to breast cancer or its treatment.

Women who receive myelosuppressive chemotherapy are more likely to suffer vulval and vaginal infections as such chemotherapy can affect ovarian function and thus alter the vaginal ecosystem. Dyspareunia in patients with breast cancer may be due to loss of secretion of the secondary sexual glands, spasm of muscles around the vagina, or aggravation of psychosexual problems that existed before the breast cancer diagnosis. 

Low estrogen levels resulting from oophorectomy or medications that suppress ovarian function can exacerbate urinary incontinence

Patients taking tamoxifen for breast cancer prevention are at increased risk for endometrial carcinoma and require careful monitoring.  The evaluation of abnormal vaginal bleeding,  uterine or vaginal prolapse,  and uterine or ovarian enlargement in breast cancer patients is similar to the evaluation of these problems in patients without breast cancer.

Vaginal sonography and hysteroscopy are useful diagnostic tools in patients with vaginal bleeding or other pelvic symptoms. More and more women are asking gynecologists about prophylactic oophorectomy. This surgery may be appropriate in women with a genetic predisposition to ovarian cancer.

Introduction
Many patients with breast cancer experience gynecologic problems during or after breast cancer treatment. Some of these problems result from the effects of cytotoxic or hormonal therapies; other problems are unrelated to breast cancer treatment but may require special management in patients with breast cancer or breast cancer survivors. It is hoped that this section will increase awareness of special gynecologic problems affecting patients with breast cancer among the physicians involved in the care of these patients.

In this section, we will discuss the diagnosis and management of clinical problems that are frequently seen among patients with breast cancer referred to the Gynecologic Oncology Center at M. D. Anderson Cancer Center.

Several of these problems, including infections of the vulva and vagina, vaginal bleeding, and dyspareunia, are related to estrogen deprivation resulting from chemotherapy,  hormonal therapy,  prophylactic oophorectomy, or the myelosuppressive effects of chemotherapy. We will also discuss uterine and vaginal prolapse, urinary incontinence, tamoxifen-related gynecologic problems, uterine and ovarian enlargement, and prophylactic oophorectomy. The use of vaginal sonography and hysteroscopy as aids for assessing gynecologic problems in breast cancer patients will also be discussed.

Elizabeth R. Keeler, Pedro T. Ramirez, and Ralph S. Freedman
Committee on Gynecological Practice, the American College of Obstetricians and Gynecologists. Obstet Gynecol 2007

References

  • ACOG committee opinion: tamoxifen and endometrial cancer. Number 232, April 2000. Committee on Gynecological Practice, the American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet 2001;73:77-79.
  • ACOG committee opinion: tamoxifen and uterine cancer. Number 336, June 2006. Committee on Gynecological Practice, the American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;107(6):1475-1478.
  • Aziz S, Kuperstein G, Rosen B, et al. A genetic epidemiological study of carcinoma of the fallopian tube. Gynecol Oncol 2001;80:341-345.
  • Boike G, Averette H, Hoskins W, et al. National survey of ovarian carcinoma. IV. Women with prior hysterectomy: a failure of prevention? Gynecol Oncol 1993;A22:112.
  • Bourne TH, Campbell S, Reynolds KM, et al. Screening for early familial ovarian cancer with transvaginal ultrasonography and colour blood flow imaging. BMJ 1993;306:1025-1029.
  • Boyd J. BRCA: the breast, ovarian, and other cancer genes. Gynecol Oncol 2001;80:337-340.
  • Chalas E, Costantino JP, Wickerham DL, et al. Benign gynecologic conditions among participants in the Breast Cancer Prevention Trial. Am J Obstet Gynecol 2005;192:1230-1237.
  • Cohen I, Beyth Y, Tepper R. The role of ultrasound in the detection of endometrial pathologies in asymptomatic postmenopausal breast cancer patients with tamoxifen treatment. Obstet Gynecol Surv 1998;53:429-438.
  • Cohen I, Rosen DJ, Tepper R, et al. Ultrasonographic evaluation of the endometrium and correlation with endometrial sampling in postmenopausal patients treated with tamoxifen. J Ultrasound Med 1993;12:275-280.
  • Exacoustos C, Zupi E, Cangi B, et al. Endometrial evaluation in postmenopausal breast cancer patients receiving tamoxifen: an ultrasound, color flow Doppler, hysteroscopic and histological study. Ultrasound Obstet Gynecol 1995;6:435-442.
  • Fisher B, Costantino JP, Wickerham L, et al. Tamoxifen for prevention of breast cancer: current status of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. J Natl Cancer Inst 2005;97:1652-1662.
  • Ford D, Easton DF, Bishop DT, et al. Risk of cancer in BRCA1-mutation carriers. Breast Cancer Linkage Consortium. Lancet 1994;343:692-695.
  • Goldstein SR, Scheele WH, Rajagopalan SK, et al. A 12-month comparative study of raloxifene, estrogen, and placebo on the postmenopausal endometrium. Obstet Gynecol 2000;95:95-103.
  • Ismail SM. Gynecological effects of tamoxifen. J Clin Pathol 1999;52:83-88.
  • Jaiyesimi IA, Buzdar AU, Decker DA, et al. Use of tamoxifen for breast cancer: twenty-eight years later. J Clin Oncol 1995;13:513-529.
  • Jishi MF, Itnyre JH, Oakley-Girvan IA, et al. Risks of cancer among members of families in the Gilda Radner Familial Ovarian Cancer Registry. Cancer 1995;76:1416-1421.
  • Kauff ND, Mitra N, Robson ME, et al. Risk of ovarian cancer in BRCA1 and BRCA2 mutation-negative hereditary breast cancer families. J Natl Cancer Inst 2005;97:1382-1384.
  • Land SR, Wickerham DL, Costantino JP, et al. Patient-reported symptoms and quality of life during treatment with tamoxifen or raloxifene for breast cancer prevention: the NSABP Study of Tamoxifen and Raloxifene (STAR) P-2 trial. JAMA 2006;295:2742-2751.
  • Levine MF, Argenta PA, Yee CJ, et al. Fallopian tube and primary peritoneal carcinomas associated with BRCA mutations. J Clin Oncol 2003;21:4222-4227.
  • Miller SM, Fang CY, Manne SL, et al. Decision making about prophylactic oophorectomy among at-risk women: psychological influences and implications. Gynecol Oncol 1999;75:406-412.
  • Modan B, Hartge P, Hirsh-Yechezkel G, et al. Parity, oral contraceptives, and the risk of ovarian cancer among carriers and noncarriers of a BRCA1 or BRCA2 mutation. N Engl J Med 2001;345:235-240.
  • Narod SA, Risch H, Moslehi R, et al. Oral contraceptives and the risk of hereditary ovarian cancer. Hereditary Ovarian Cancer Clinical Study Group. N Engl J Med 1998;339:424-428.
  • Pepper JM, Oyesanya OA, Dewart PJ, et al. Indices of differential endometrial: myometrial growth may be used to improve the reliability of detecting endometrial neoplasia in women on tamoxifen. Ultrasound Obstet Gynecol 1996;8:408-411.
  • Piver MS, Jishi MF, Tsukada Y, et al. Primary peritoneal carcinoma after prophylactic oophorectomy in women with a family history of ovarian cancer: a report of the Gilda Radner Familial Ovarian Cancer Registry. Cancer 1993;71:2751-2755.
  • Prat J, Ribe A, Gallardo A. Hereditary ovarian cancer. Hum Pathol 2005;36:861-870.
  • The reduction in risk of ovarian cancer associated with oral-contraceptive use. The Cancer and Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development. N Engl J Med 1987;316:650-655.
  • Struewing JP, Watson P, Easton DF, et al. Prophylactic oophorectomy in inherited breast/ovarian cancer families. J Natl Cancer Inst Monogr 1995;17:33-35.
  • Tepper R, Cohen I, Altaras M, et al. Doppler flow evaluation of pathologic endometrial conditions in postmenopausal breast cancer patients treated with tamoxifen. J Ultrasound Med 1994;13:635-640.
  • Tobacman JK, Greene MH, Tucker MA, et al. Intra-abdominal carcinomatosis after prophylactic oophorectomy in ovarian-cancer-prone families. Lancet 1982;2:795-797.

Provided by ArmMed Media