HRT (Hormone Replacement Therapy) e rischio cancro

Ultimo aggiornamento  2019-12-02     22:54:44

Per HRT si intende la somministrazione di ormoni (estrogeni e/o progestinici e talvolta androgeni) al fine di colmare il deficit degli stessi derivante dalla naturale sospensione dell’attività endocrina ovarica che coincide con l’entrata in menopausa. Si stima che almeno 20 milioni di donne dei paesi occidentali utilizzino  la terapia ormonale sostitutiva (HRT). Ripristinare l’equilibrio ormonale presente prima della menopausa può attenuare i sintomi della menopausa stessa (vampate di calore, sudorazione, secchezza vaginale, ansia, irritabilità), e -se protratto per un tempo sufficientemente lungo – proteggere la donna dall’aumentato rischio osteoporotico.

Numerosi studi epidemiologici hanno riportato una diretta correlazione tra HRT e rischio di cancro degli organi riproduttivi femminili: mammella, utero e ovaio. Le donne in postmenopausa e non isterectomizzate,  che utilizzano la terapia ormonale sostitutiva (HRT, Hormone Replacement Therapy) a base di soli estrogeni, sono ad aumentato rischio (+ 2-10 volte)  di iperplasia endometriale e cancro dell’endometrio. Per minimizzare questo rischio, molte donne che ricorrono a HRT e che non sono state sottoposte ad isterectomia impiegano preparazioni estro-progestiniche o il Tibolone (Livia^l®).  Il progestinico contrasta gli effetti indesiderati degli estrogeni sull’endometrio però produce un aumento (+ 0.6-1.5% dopo 5 anni di terapia) del rischio di cancro mammario. 

Anche la terapia con soli estrogeni potrebbe favorire l’insorgenza del ca. mammario, ma solo dopo una terapia prolungata per almeno 10 anni (2).

Secondo altri numerosi studi si dovrebbe ritenere che gli estrogeni non avrebbe un diretto ruolo oncogeno, dal momento che non sono mai stati evidenziati danneggiamenti del DNA correllati alla terapia con estrogeni. Quest  ultimi avrebbero un ruolo favorente l’azione di altri oncogeni nell’insorgenza e soprattutto nella progressione e crescita del tumore (2).

Nelle donne isterectomizzate,  la terapia ormonale sostitutiva si effettua in genere con soli estrogeni; in questa specifica circostanza l’HRT sembra addirittura esplicare un effetto protettivo nei confronti del cancro mammario.

Nutraceutica: è un neologismo sincratico da “nutrizione” e “farmaceutica” coniato da Stephen de Felice nel 1989. I nutraceutici possono essere estratti, sintetizzati e utilizzati per gli integratori alimentari, oppure addizionati negli alimenti. Più raro è trovarli negli alimenti in maniera naturale e in quantità sufficienti ad ottenere dei benefici. I prodotti a base di soia o sostanze similari proposti in alternativa egli estrogeni sono assolutamente controindicati nelle paz. con patologie mammarie ed inoltre riducono gli effetti del tamoxifene. Il resveratrolo e il polline rosso, facilmente reperibili in farmacia ed erboristeria, sono totalmente privi di effetti “estrogeno simili” pur esercitando un’azione eutrofizzante sull’apparato osteo-articolare, sistema nervoso centrale e cardiocircolatorio.

PREVENZIONE:

1. accurata anamnesi personale e familiare della paziente prima di iniziare la terapia
2. visita ginecologica
3. esame mammario ogni 6 mesi
4. controlli medici annuali
5. screening mammografico
6. PAP test ad intervalli regolariIn conclusione

• In conclusione, i rischi ed i benefici della terapia ormonale sostitutiva devono sempre essere attentamente valutati, considerando anche l’importanza di posologia e durata della HRT.  Gli ormoni devono essere prescritti alla dose minima efficace e per il minor tempo possibile.  Se condotta nel rispetto delle regole sopra-riportate, il rischio appare abbastanza contenuto. Il rischio per ca. mammario è simile o addirittura inferiore a quello correlato ad altri fattori, come la familiarità per la patologia, presenza di mutazione di BRCA1 e BRCA2, la menopausa tardiva ed il menarca precoce, la nulliparità, la gravidanza tardiva (> 35 anni), l’obesità ed il sovrappeso.

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