The prevalence of menopausal level of follicle-stimulating hormone in peri-menopausal breast cancer patients aged between 45 and 60 years

Dear Editor,

In this issue of the Asian Journal of Oncology, authors Chanyoot Bandidwattanagong et al's research brilliantly described levels of follicle-stimulating hormone (FSH) in peri-menopausal females and its relation to multiple breast cancer treatments like hormonal and chemotherapy.^[1] Breast cancer is the most common cancer diagnosed in females. Its types include invasive and noninvasive. Early signs include retracted nipple, dimpling, change in texture of skin over the breast, breast lumps, and nipple discharge. Treatment of breast cancer depends on the type of cancer and how much it has spread in the body.

A cross-sectional study was conducted by the authors among peri-menopausal breast cancer patients aged 45-60 years. Age, cancer stage, FSH levels, and history of systemic treatments, including chemotherapy and tamoxifen use, were recorded. Patients receiving AIs were excluded. Menstrual statuses were divided into 1) rare or absence of menstruation for the past 2 years and 2) rare or absence of menstruation for more than 2 years. The primary outcome was to determine the prevalence of menopausal levels of FSH among peri-menopausal breast cancer patients. The secondary outcome was to determine independent factors that would predict menopausal FSH levels.

Total 90 patients were included in study; 44 out of 90 were of age 45-50 years. Out of these 44 patients,25 had FSH levels below 40IU/L. Remaining 19 had levels greater than 40IU/L. Thirty patients were of age 50-55 years. Out of these 30 patients,19 had FSH levels greater than 40IU/L. Sixteen patients were aged 55-60 years. Of the 16, eight had FSH>40.

This demonstrates a link between age and FSH levels. Forty-two out of 90 patients had stage 1 breast cancer; 23 out of 42 had FSH <40 IU/L; 16 out of 24 with metastatic disease had FSH >40 IU/L. This shows that patients with early-stage cancer had fewer chances of having FSH above 40 IU/L.

Regarding the treatment regimen, 33 patients never used tamoxifen; 24 out of 33 had FSH >40 IU/L; 39 patients had used tamoxifen previously (29 had FSH <40 IU/L). Eighteen patients were now using tamoxifen (12 had FSH >40 IU/L). This describes the influence of tamoxifen on FSH levels. Around 79.8% patients had received chemotherapy. Among them, 2/3^rd had received more than eight cycles; 25 out of 60 patients (60 received more than eight cycles) had FSH >40, the remaining 35 had <40 IU/L. Research by authors states that only half of peri-menopausal patients had post-menopausal levels of FSH.

I would like to stress some important points regarding the relation between FSH and age, tamoxifen, chemotherapy, and metastatic breast cancer. According to Bandidwattanawong et al.^[1] research, mean FSH levels were higher among the age group of 45 to 49. In women over the age of 45 years with continuing regular menstrual cycles, the follicular phase FS level rises without an accompanying change in LH. A research by Kawak Zehra et al.^[2] stated a link between tamoxifen use and FSH. According to their research on post-menopausal patients, serum FSH and LH levels were significantly lower in tamoxifen users than non-users. Research conducted to check the hormonal effects of an anti-estrogen in men^[3] also demonstrated that tamoxifen treatment resulted in a significant increase in FS levels and a borderline significant increase in LH levels. Regarding the effect of chemotherapy on FSH levels, an article by M. Haider^[4] described a decrease in the circulating levels of FSH, LH following administration of therapy to post-menopausal patients. D.Y. Wang’s research^[5] on post-menopausal patients stated that in women with advanced breast cancer, the mean FSH concentration was statistically sub-normal, probably due to hormonal treatment.

This research highlights the need for further investigation in the field of breast cancer and FSH levels in peri-menopausal women. I look forward to seeing future studies that build upon this important work. Thank you for your consideration.