Presentations of endometrial activity after curative radiotherapy for cervical cancer

The treatment of choice for patients with advanced stage cervical cancer is (chemo)radiotherapy. Gynaecologic side effects consist of loss of ovarian function and destruction of the endometrium, resulting in infertility and premature ovarian failure. In premenopausal patients estrogens are prescribed to prevent climacteric symptoms. In general, no progestagens are added to the hormone replacement therapy because of the assumption of complete destruction of the basal layer of the endometrium after pelvic radiotherapy. The aim of this report is to show the different presentations of endometrial activity after curative radiotherapy in patients with cervical cancer.

Presentation of four patients who developed symptoms of residual endometrial activity.

In two patients, proliferation of functional endometrium led to hematocolpos and hematometrum with abdominal pain. The third patient underwent ovarian transposition and developed regular periods 3 months after finishing the radiotherapy. The fourth patient underwent trachelectomy with radiotherapy because of narrow tumour free margins. She developed vaginal blood loss after starting estrogens.

These patients show that in premenopausal patients, curative radiotherapy until 80Gy, may lead to symptoms of residual functional endometrium, e.g. hematometrum, hematocolpos, (ir)regular vaginal blood loss. In our opinion patients should be advised to use estrogens in combination with a progestogen, instead of unopposed estrogens, to prevent stimulation of residual functional endometrium. Tibolone may be an appropriate alternative hormone replacement therapy especially with the advantage of low androgen effects which might support the sexual functions, and the decrease of breast density.