Hormone therapy and meningioma

This information leaflet provides information and guidance for patients and general practitioners on the role of hormonal therapy in patients diagnosed with meningioma based on current literature and research.

Meningiomas are among the most common types of brain tumours, with five out of every 100,000 people a year in the UK receiving this diagnosis. They grow from the lining of the brain, which is called the meninges. In the UK each year, about 1600 people with a meningioma have surgery to remove their tumour.

Meningiomas tend to be more common in females although the reasons for this are not completely understood. Sex hormones (oestrogen and progesterone) seem to play a role in the development of meningiomas with examples including meningioma growth during pregnancy and shrinkage after delivery, and the increased risk of meningioma in patients with breast cancer. Hormone receptors are also present in meningiomas.

Progestin therapy

There is evidence that meningiomas may be more common and grow faster when taking a particular type of hormonal treatment drug called cyproterone acetate (CPA), a synthetic progestin used for male-to-female gender-affirming hormone therapy, as well as treatment of hirsutism (excessive hair growth) and acne (with or without polycystic ovarian syndrome). CPA is also used in combination with ethinylestradiol, an oral contraceptive, although the combination medicine (co-cyprindiol) is not used for the purposes of contraception in the UK.

The Medicines and Healthcare products Regulatory Agency (MHRA) advises doctors to monitor people taking more than 25 mg of CPA daily for meningiomas and to permanently discontinue treatment if a patient is diagnosed with a meningioma. The British National Formulary (BNF) prohibits CPA use (including co-cyprindiol) in patients with meningioma or a history of meningioma.

Reassuringly though, there is some evidence that the risk may decrease after CPA treatment is discontinued. Finally, higher doses of CPA are associated with increased risks of multiple meningioma locations and operations.

There is a similar but lower risk of meningiomas with other progestin drugs called chlormadinone acetate and nomegestrol acetate, although only the latter is found in a single combined oral contraceptive pill in the UK (Estradiol with nomegestrol). We would not recommend continuing with this medication if you are diagnosed with a meningioma; you should consult your GP to find an alternative contraceptive method.

Hormonal replacement therapy

Hormonal replacement therapy (HRT) during the menopause seems to increase the risk of meningioma. It is important to know that there is conflicting evidence behind this statement, with some studies demonstrating small increased risks and others not. It is also unclear if certain types of HRT, for example, oestrogen only versus combined oestrogen-progesterone are higher risk, but most studies seem to indicate that the risk in using oestrogen-only preparations may be slightly higher.

Most studies of HRT and meningioma have investigated the risk of meningioma in those taking HRT; few have studied what happens to people who have a meningioma or have had it resected. One such study of tumour growth found similar to lower growth rates in those treated with oestrogen HRT. Due to the mixed scientific evidence and until further studies clarify this risk, it is recommended that you avoid HRT if you have a meningioma or have had it removed previously. If you experience distressing and/or uncomfortable menopausal symptoms, you should discuss these with your doctor as they may cause you more problems than your meningioma.

Oral contraceptive pills

Oral contraceptive pills other than those containing the drug CPA mentioned above do not seem to increase the risk of meningioma. Although one study has demonstrated an increased risk, a meta-analysis (that is, a combination of many study results) found no increased risk. Unfortunately, there is little evidence to guide what to do if you already have a meningioma and this should be discussed with your doctor.

Hormonal fertility treatment

There is not enough data to comment definitively on any increased risk of meningioma if you are undergoing hormonal fertility treatments. Two studies that included people receiving such treatments (in vitro fertilisation and clomiphene) either demonstrated no effect or found hormonal fertility treatments may be associated with the diagnosis of meningioma and multiple meningiomas at a younger age. Further scientific evidence is required to help answer this question.

Summary

CPA should be avoided if you have a meningioma or have had surgery to remove it. HRT should be avoided if possible if you have a meningioma, although menopausal symptoms may be more troubling than your meningioma and this should be discussed with your doctor. Oral contraceptive pills do not seem to increase the risk of you developing meningioma, but there is little evidence to guide what you should do if you already have a meningioma. It is unclear if taking hormonal fertility treatment increases the risk of meningioma, but it is important to discuss this with your doctor if you have already been diagnosed with a meningioma or had one previously removed.

Benefits

Providing information for patients and clinicians on the use of hormonal therapies in meningioma.

Risks

Potential growth in meningiomas in cases of inappropriate management of hormonal therapy.

Alternatives

Please discuss alternative medications or treatment with your doctor in order to balance the risks and benefits of the proposed treatments based on your individual circumstances.

Medication

Bring all of your medicines (including inhalers, injections, creams, eye drops or patches) and a current repeat prescription from your GP.

Please tell the ward staff about all of the medicines you use. During your stay If you wish to take your medication yourself (self-medicate) please speak with your nurse. Pharmacists visit the wards regularly and can help with any medicine queries.

MyChart

We strongly encourage you to sign up for MyChart. This is the electronic patient portal at Cambridge University Hospitals that enables patients to securely access parts of their health record held within the hospital’s electronic patient record system (Epic). It is available via your home computer or mobile device.

Contacts/further information

If you have any questions please contact the secretary team for the respective neurosurgery and oncology consultants.

For patients under the care of Dr Jefferies and Dr Duke please call 01223 586705 or email Carolyn Langham.

For patients under the care of Mr Guilfoyle please call Jenny Wallis (secretary) on 01223 216135 or email Jenny Wallis.

For patients under the care of Mr Helmy please call William Herring (secretary) on 01223 274873 or email William Herring.

For patients under the care of Mr Santarius please contact Maria Harrington (secretary) on 01223 586858 or email Maria Harrington (opens in a new tab).

For all other Neurosurgical enquiries, email the neurosurgery secretariat.

Alternatively, please contact the main switchboard on 01223 245151 and ask for a neurosurgery secretary.

References/sources of evidence

1. Lusis EA, Scheithauer BW, Yachnis AT, Fischer BR, Chicoine MR, Paulus W, et al. Meningiomas in Pregnancy: A Clinicopathologic Study of 17 Cases. Neurosurgery [Internet]. 2012;71(5). Available from: Meningiomas in Pregnancy A Clinicopathologic (opens in a new tab)
2. Lopez-Rivera V, Zhu P, Dono A, Lee S, Chen PR, Ballester LY, et al. Increased Risk of Subsequent Meningioma Among Women with Malignant Breast Cancer. World Neurosurgery. 2020 Jul;139:e271–85.
3. Miyagishima DF, Sundaresan V, Gutierrez AG, Barak T, Yeung J, Moliterno J, et al. A systematic review and individual participant data meta-analysis of gonadal steroid hormone receptors in meningioma. Journal of Neurosurgery. 2023 May 1;1–10.
4. Pravdenkova S, Husain M. Progesterone and estrogen receptors: opposing prognostic indicators in meningiomas. J Neurosurg. 2006;105.
5. Abdelzaher E, El-Gendi SM, Yehya A, Gowil AG. Recurrence of benign meningiomas: predictive value of proliferative index, BCL2, p53, hormonal receptors and HER2 expression. British Journal of Neurosurgery. 2011 Dec;25(6):707–13.
6. Hua L, Zhu H, Li J, Tang H, Kuang D, Wang Y, et al. Prognostic value of estrogen receptor in WHO Grade III meningioma: a long-term follow-up study from a single institution. Journal of Neurosurgery. 2018 Jun;128(6):1698–706.
7. Joint Formulary Committee. British National Formulary [Internet]. [cited 2023 May 30]. Available from: https://bnf.nice.org.uk/drugs/cyproterone-acetate/
8. Weill A, Nguyen P, Labidi M, Cadier B, Passeri T, Duranteau L, et al. Use of high dose cyproterone acetate and risk of intracranial meningioma in women: cohort study. BMJ. 2021 Feb 3;n37.
9. Champeaux-Depond C, Weller J, Froelich S, Sartor A. Cyproterone acetate and meningioma: a nationwide-wide population based study. J Neurooncol. 2021 Jan;151(2):331–8.
10. Hage M, Plesa O, Lemaire I, Raffin Sanson ML. Estrogen and Progesterone Therapy and Meningiomas. Endocrinology. 2022 Feb 1;163(2):bqab259.
11. Dresser L, Yuen CA, Wilmington A, Walker M, Vogel TJ, Merrell RT, et al. Estrogen hormone replacement therapy in incidental intracranial meningioma: a growth-rate analysis. Sci Rep. 2020 Oct 21;10(1):17960.
12. Michaud DS, Gallo V, Schlehofer B, Tjønneland A, Olsen A, Overvad K, et al. Reproductive Factors and Exogenous Hormone Use in Relation to Risk of Glioma and Meningioma in a Large European Cohort Study. Cancer Epidemiology, Biomarkers & Prevention. 2010 Oct 1;19(10):2562–9.
13. Yang X, Liu F, Zheng J, Cheng W, Zhao C, Di J. Relationship Between Oral Contraceptives and the Risk of Gliomas and Meningiomas: A Dose-Response Meta-Analysis and Systematic Review. World Neurosurgery. 2021 Mar;147:e148–62.
14. Korhonen K, Salminen T, Raitanen J, Auvinen A, Isola J, Haapasalo H. Female predominance in meningiomas can not be explained by differences in progesterone, estrogen, or androgen receptor expression. J Neurooncol. 2006 Sep 25;80(1):1–7.
15. Shahin MN, Magill ST, Dalle Ore CL, Viner JA, Peters PN, Solomon DA, et al. Fertility treatment is associated with multiple meningiomas and younger age at diagnosis. J Neurooncol. 2019 May;143(1):137–44.

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high-tech equipment and/or specialist one-to-one care is required.