180 Unconjugated oestrogen for treatment of haematuria in advanced bladder cancer, post radiotherapy; a case report

<h3>Introduction</h3> Refractory haematuria can be a challenging symptom to treat in advanced bladder cancer which has progressed through conventional lines of treatment. Conjugated oestrogen has previously been used in treating refractory haematuria^1–4, a recent report described two cases where unconjugated oestrogen had been successfully used⁵, we present a further case here. <h3>Case Presentation</h3> An 84-yr-old man was referred to the specialist palliative care team with a 10-month history of grade 3 invasive urothelial transitional cell carcinoma with retroperitoneal and peri-cardial lymphadenopathy. He was treated with TURBT, mini-TURP and 6 cycles of gemcitabine-cisplatin chemotherapy. Repeat imaging showed a partial response in the bladder but no change of his lymphadenopathy. He suffered from progressive grade 3 haematuria post chemotherapy, which was initially treated with bladder irrigation and palliative radiotherapy. This provided around 6–8 weeks of symptom control, but painful haematuria with 3–4 cm visible clots then recurred. He was felt to be too frail for intravesical treatments and further radiotherapy was not felt to be indicated. A trial of oral estrodiol 2mg tds was used, within 3 weeks the patient reported the clots shrinking in size and then stopping entirely. He had 8 weeks of stable symptoms without pain or passage of clots, he then had a further episode of visible haematuria, without clots. He had been globally deteriorating over this time, he died 5 days after the recurrence of haematuria. <h3>Conclusion</h3> The possibility of an oral treatment or even transdermal option is a useful adjunct in this clinical scenario, particularly in patients who may struggle with repeated hospital trips for intravesical treatments, radiotherapy or three-way catheters. Unconjugated oestrogen holds the benefit of lower rates of venous thromboembolism than conjugated oestrogen in the general population⁶, though the effect in the cancer population is not known. <h3>References</h3> Ordemann R, Naumann R, Geissler G, <i>et al.</i> Encouraging results in the treatment of haemorrrhagic cystitis with estrogen – report of 10 cases and review of the literature. <i>Bone Marrow Transplant</i> 2000;<b>25</b>:981–985. Liu YK, Harty JI, Steinbock GS, <i>et al.</i> Treatment of radiation or cyclophosphamide induced hemorrhagic cystitis using conjugated estrogen. <i>J Urol</i> 1990;<b>144</b>(1):41–43. Rodriguez Luna JM, Teruel JL, Vallejo JL, <i>et al.</i> Control of massive hematuria in idiopathic haemorrhagic cystitis after administration of conjugated oestrogen. <i>J Urol</i> 1992;<b>148</b>:1524–1525. Miller J, Burdfield GD, Moretti KL. Oral conjugated estrogen therapy for treatment of hemorrhagic cystitis. <i>J Urol</i> 1994;<b>151</b>:1348–1350. Gardner J, Husbands E. Medical management of refractory haematuria in palliative patients. <i>Journal of Pain and Symptom Management</i> 2024. Vinogradova Y, Coupland C, Hippisley-Cox J. Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QReseach and CPRD databases. <i>BMJ</i> 2019;<b>364</b>:k4810.