Is Menopausal Hormone Therapy (MHT) safe in patients with neutropenia and leukopenia?

Safety of Menopausal Hormone Therapy in Neutropenia and Leukopenia

Menopausal Hormone Therapy (MHT) is generally safe for patients with neutropenia (1.5) and leukopenia (2.8), as there is no evidence that MHT increases the risk of leukemia or worsens cytopenias.

Understanding Neutropenia and Leukopenia

Neutropenia is defined as an absolute neutrophil count (ANC) less than 1,500/mcL, and the patient's value of 1.5 (1,500/mcL) is at the borderline of this definition 1. The patient's white blood cell (WBC) count of 2.8 is below the normal range, indicating leukopenia.

Evidence on MHT and Hematologic Parameters

The relationship between MHT and hematologic parameters has been studied:

• A cohort study of 37,172 postmenopausal women followed for 16 years found that MHT was not associated with an increased risk of leukemia. Compared to never-users, current users (RR=1.09,95% CI=0.70-1.71) and former users (RR=0.82,95% CI=0.59-1.15) showed no increased risk 2.

• There is no evidence in the guidelines suggesting that MHT worsens neutropenia or leukopenia.

Management Considerations

When considering MHT in a patient with neutropenia and leukopenia:

1. Assess the underlying cause of cytopenias:

   • Determine if the neutropenia is transient or chronic
   • Consider bone marrow examination with cytogenetics if the cause is unknown 3
   • Rule out medication-induced causes 4

2. Monitor hematologic parameters:

   • Regular complete blood counts to track neutrophil and WBC levels
   • Watch for signs of infection

3. Infection prevention:

   • Take commonsense precautions to avoid infection
   • Be vigilant about aggressive treatment of bacterial or fungal infections if they occur 3

4. Consider supportive therapy:

   • For severe neutropenia (ANC <0.5 × 10^9/L), granulocyte colony-stimulating factor (G-CSF) may be considered 5
   • For symptomatic anemia, erythropoiesis-stimulating agents may be appropriate 6

Special Considerations

If the patient has underlying myelodysplastic syndrome (MDS) causing the cytopenias:

• For lower-risk MDS, erythropoiesis-stimulating agents with G-CSF may be appropriate 4
• For higher-risk MDS, hypomethylating agents (azacitidine or decitabine) should be considered 4

Conclusion

The available evidence does not suggest that MHT increases the risk of leukemia or worsens existing cytopenias 2. The patient's neutropenia is borderline (1.5), and while the leukopenia (2.8) requires monitoring, these values alone should not contraindicate MHT if it is otherwise indicated for menopausal symptom management.

Pitfalls and Caveats

• Always investigate the underlying cause of neutropenia and leukopenia before initiating MHT
• If the patient has hormone-responsive cancer (particularly breast cancer), MHT is strongly discouraged regardless of blood counts 6
• Regular monitoring of blood counts is essential after initiating MHT
• If neutropenia worsens to severe levels (ANC <0.5 × 10^9/L), reassess the appropriateness of continuing MHT