Birkhäuser M
Division of Gynaecological Endocrinology, University Clinic of Obstetrics and Gynaecology, Berne, Switzerland.
Int J Fertil Menopausal Stud. 1994;39 Suppl 2:99-114.
Until a few years ago, every treated breast cancer was an absolute contraindication to hormonal replacement therapy (HRT). However, the very high five-year survival rate in stage I breast cancer observed today brings more and more apparently healthy early postmenopausal women who have been treated for breast cancer in the past and who are suffering from heavy vasomotor symptoms due to estrogen deficiency to gynecological consultation. Usually well informed, the same group of women starts to worry about an increased risk of postmenopausal osteoporosis and of cardiovascular diseases. What attitude should be adopted today? Our approach should be differentiated and respect the staging, the estrogen-receptor status, and the presence or absence of axillary lymph-node metastasis of every patient. In estrogen receptor-negative women, there is no contraindication to continuous combined HRT by a fixed estrogen-progestin combination. In estrogen receptor-positive and lymph-node-negative patients, treatment by a nonaromatizable progestin, such as medrogestone or medroxyprogesterone acetate (MPA), can be introduced to relieve the patient from her postmenopausal syndrome. After 2-3 years of a favorable evolution of the treated cancer, the substitution might be shifted to a fixed-combined continuous HRT. Because estrogen receptor-positive and lymph-node-positive patients today are usually receiving adjuvant treatment with tamoxifen, they profit already from prophylaxis for postmenopausal osteoporosis and, very likely, from decreased cardiovascular risk. If women out of this group continue to suffer from heavy vasomotor symptoms, MPA might be added. However, it must be stressed that every administration of sexual steroids to women who have been treated for breast cancer has to be started only in full agreement with the treating oncologist concerned with the case and only after having obtained the informed consent of the patient. The new ethical dilemma will be our attitude to quality of life in relation to life prolongation.
直到几年前，每一例接受过治疗的乳腺癌都是激素替代疗法（HRT）的绝对禁忌证。然而，如今观察到的I期乳腺癌非常高的五年生存率，使得越来越多表面上健康的绝经后早期女性前来妇科咨询。这些女性过去曾接受过乳腺癌治疗，由于雌激素缺乏而患有严重的血管舒缩症状。这群通常了解情况的女性开始担心绝经后骨质疏松症和心血管疾病风险增加。如今应该采取什么态度呢？我们的方法应该有所区别，要考虑到每位患者的分期、雌激素受体状态以及腋窝淋巴结转移情况。对于雌激素受体阴性的女性，使用固定的雌激素 - 孕激素组合进行连续联合HRT没有禁忌证。对于雌激素受体阳性且淋巴结阴性的患者，可以采用不可芳香化的孕激素进行治疗，如甲地孕酮或醋酸甲羟孕酮（MPA），以缓解患者的绝经后综合征。在治疗的癌症病情平稳发展2 - 3年后，可以转而采用固定组合的连续HRT。由于如今雌激素受体阳性且淋巴结阳性的患者通常正在接受他莫昔芬辅助治疗，他们已经从绝经后骨质疏松症的预防中获益，而且很可能心血管风险也降低了。如果这群女性中仍有患者患有严重的血管舒缩症状，可以加用MPA。然而，必须强调的是，对于接受过乳腺癌治疗的女性，每一次性激素给药都必须在与负责该病例的肿瘤内科医生充分协商并获得患者知情同意后才能开始。新的伦理困境将是我们在延长生命与生活质量方面的态度。
