From the Guidelines
For a 44-year-old woman with a frontal lobe osteomeningioma potentially related to long-term progesterone use for heavy bleeding, I recommend discontinuing the progesterone medication and consulting with a neurosurgeon for evaluation and management of the meningioma. The patient should undergo a complete neurological assessment and MRI with contrast to determine the exact size, location, and characteristics of the tumor. Treatment options will depend on tumor size, symptoms, and growth rate, ranging from observation with regular MRI monitoring (every 6-12 months) to surgical resection if the tumor is causing symptoms or showing significant growth. Radiation therapy might be considered as an alternative or adjunct to surgery in certain cases. For the heavy menstrual bleeding that prompted the progesterone use, alternative treatments should be discussed with a gynecologist, including non-hormonal options like tranexamic acid (Lysteda) 1300 mg three times daily during menstruation, or levonorgestrel IUD (Mirena) which provides localized rather than systemic hormone exposure, as suggested by recent guidelines 1. The connection between progesterone and meningioma growth is based on the presence of progesterone receptors in many meningiomas, which can stimulate tumor growth when exposed to exogenous progesterone, and discontinuing the hormonal medication may slow or stabilize tumor growth in hormone-sensitive meningiomas. It's also important to consider the potential effects of other hormonal treatments on uterine fibroids and bleeding symptoms, as discussed in studies on uterine neoplasms and fibroid management 1. However, the primary concern in this case is the potential link between progesterone use and meningioma growth, and addressing this through discontinuation of the medication and appropriate neurological evaluation and management is the priority.
From the Research
Meningioma and Hormonal Influences
- Meningiomas are slow-growing benign brain tumors, and their etiology is largely unknown 2.
- The evidence suggests that gender-specific hormones, particularly progesterone, may be involved in the pathogenesis of meningioma 2, 3.
- About 70% of meningiomas express progesterone receptors, while fewer than 31% express estrogen receptors 2.
- A dose-dependent relationship between the incidence and growth of meningiomas and hormonal treatment with progestin has been established 3.
Progesterone Pill and Meningioma Risk
- The use of progestin treatments, such as cyproterone acetate, has been associated with an increased risk of meningiomas 3.
- A similar but lower risk of meningiomas has been reported with the use of chlormadinone acetate and nomegestrol acetate as progestin treatments 3.
- There is no statistical evidence of an increased risk of meningioma among users of oral contraceptives 4.
- Available data suggest an association between the use of hormone replacement therapy and increased meningioma risk, although the evidence is not definitive 4.
Management of Meningioma and Sex Hormone Therapy
- Cessation of progestin treatment leads to stabilization or regression of progestin-induced meningioma 5.
- Avoiding sex hormone therapy may be possible in the context of meningioma treatment, but hormonal treatment is not always easily replaceable 5.
- Consensual recommendations have been established regarding sex hormone therapies and meningioma, including withdrawal and monitoring of sex hormone therapies 5.
- A decision tree regarding meningioma and combined contraception, progestin contraception, menopause hormonal treatment, progestin, and gender-affirming therapy has been suggested 5.