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The use of levonorgestrel-releasing intrauterine system in prevention of endometrial pathology in women with breast cancer treated with tamoxifen Hassan Omar, Waleed Elkhayat, Mohamed Aboulkasem Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt INTRODUCTION
Objective
Tamoxifenanonsteroidaltriphenylethyleneisthe most commonly used hormonal treatment for breast To determine whether the use of levonorgestrel-releasing cancer. It is highly effective in lowering the risk of intrauterine system prevents endometrial pathology in recurrent or contralateral breast cancer regardless of women with breast cancer treated with tamoxifen or not.
Participants and methods
menopausal status or clinical stage of disease. Tamoxifen isnot a pure antioestrogen, since it has an oestrogenic effect in We did a randomized controlled trial on 121 women who skeletal muscles, in lipid metabolism and in various required adjuvant therapy with tamoxifen for breast cancer.
gynaecological tissues. This unopposed estrogenic effect The women were randomly assigned to either group A promotes occult uterine lesions to develop into polyps, (endometrial surveillance alone) or group B (endometrial fibroids and endometrial hyperplasia and causes a 2-3 fold surveillance before and after insertion of the levonorgestrel increase in endometrial cancer.1,2 The incidence of intrauterine system for two years). Endometrial surveillance endometrial polyps, hyperplasia and endometrial cancer has was done by outpatient hysteroscopy and endometrial biopsy been reported to be between 5 and 35%, 4.7-16% and 0.8-5% before and two years after the start of tamoxifen.
respectively.3-5 These lesions commonly cause bleeding episodes which although benign in most cases require The baseline assessment showed only benign uterine changes investigations to exclude malignant disease. These episodes in all women (n=121).Women in group B had a much lower compromise the quality of life of women taking tamoxifen and incidence of endometrial polyps than group A (1.8 % versus have big implications for health resources. Routine 16.1 % p value = 0.02). There was no statistical significant endometrial screening of women without symptoms on difference in the incidence of submucous fibroid between the tamoxifen has been suggested but would not be cost effective two groups (6.4% in group A, 3.3% in group B , P value = and would be unlikely to lower mortality from endometrial 1.1). There was a higher incidence of bleeding in group B but cancer.6 An alternative strategy to deal with tamoxifen this resolved to a baseline similar to that of group A.
–induced endometrial changes and the symptoms they cause is Conclusion
to render the uterine tissues unresponsive to estrogenic The levonorgestrel-releasing intrauterine system has a protective action against the endometrial pathology caused by progestagens although established in prevention of the tamoxifen therapy in women with breast cancer. It reduces endometrial neoplastic changes associated with oestrogen the occurrence of de novo endometrial polyps.
replacement therapy, unfortunately causes several unwantedside effects leading to poor compliance and discontinuation of Keywords:
the treatment . There is also some concern that high dose levonorgestrel-releasing intrauterine system, tamoxifen, breast systemic progestagens may blunt the efficacy of tamoxifen to prevent recurrence of breast cancer.7 In addition some authorsreported that systemic progestagens did not reverse thedevelopment of polyps, cysts and fibroids associated withtamoxifen.8 Levonorgestrel-releasing intrauterine systemdelivers a high dose of progestagens in the uterine tissues with Corresponding author: Waleed Elkhayat, M.D.,
5 Qura Ibn Shourik Street, Giza, 12211, Egypt
a low dose systemically thus decreasing the progestagenic side-

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