To the Editor: With great interest we read the review ofWalshe et al on the beneficial prognostic effects of developing amenorrhea after chemotherapy for breast cancer in premenopausal women. In their summary of the literature about the influence of tamoxifen on chemotherapy-induced amenorrhea, five studies are cited that found higher rates of amenorrhea after the addition of tamoxifen after adjuvant chemotherapy. In evaluating the effect of amenorrhea on breast cancer survival in these retrospective studies, menopausal status and amenorrhea are not defined in a consistent manner, which may even be more erratic and deceiving during tamoxifen use. We would like to underscore this with the data from a study on ovarian function during tamoxifen in 114 young breast cancer patients (+< 56 years of age) by performing serial transvaginal ultrasonography and serum follicle stimulating hormone and estradiol. Menopausal status after chemotherapy was defined by serum estradiol levels of more than 0.10 nmoI/L and follicle stimulating hormone +< 30.0 U/L, irrespective of the presence or absence of menses. Patients treated with high-dose chemotherapy (n = 51) all developed amenorrhea and a post-menopausal hormone status. After standard-dose chemotherapy in 63 patients, 21 developed amenorrhea. In 27 patients with pre-menopausal hormone levels, 19 patients (70%) developed ovarian cysts, despite amenorrhea in 12. Patients with ovarian cysts had much higher serum estradiol levels (2.18 nmol/L; standard deviation, 1.31; P < .0001) than patients without cysts (0.15 nmol/L; standard deviation, 0.20). Women with ovarian cysts and high estradiol levels often reported a disappearance of hot flashes during amenorrhea, indicating an estrogenic effect overriding tamoxifen (unpublished data).
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