Thank you Sharon Gunser and Katherine Cail for your well-written article headlined “Breast cancer risk factors and treatment options” in last Sunday’s Monitor.
As the writers pointed out, survival rates have improved by identifying women at high risk, early detection, and better therapy. Today, five in six women survive their breast cancers.
Gunser and Cail listed 12 risk factors for developing breast cancer, the last of which was combination (estrogen/progesterone) hormone replacement therapy (HRT).
My only concern with the report is that readers might interpret this risk to exclude all hormone replacement.
Few women and even some caregivers are not aware that estrogen alone appears to reduce the risk of breast cancer. The Woman’s Health Initiative in 2002 reported a decrease of almost one case of breast cancer per 1,000 women per year in a group of women who received only estrogen replacement.
As noted in the article, there was an increase of almost one case of breast cancer per 1,000 women per year in the group of women using the combination of estrogen/progesterone HRT. Because of the slight increase in breast cancer in this combination HRT group, the WHI study was abruptly halted.
Headlines in the media gave the impression that all hormone therapy caused breast cancer. Women were not informed that estrogen replacement alone decreased the risk of breast cancer. Tragically, large numbers of menopausal women abandoned their hormone replacement and many new menopausal women have never started HRT.
Progesterone was added to estrogen replacement specifically for women who still have their uterus. Years before there were reports that a relatively benign uterine cancer occurred in a small number of patients receiving only estrogen. Adding progesterone to estrogen prevented this cancer.
In recent times, women who no longer have their uterus take estrogen alone with all its benefits, including a slight decrease risk of breast cancer. The standard of care for women with their uterus (if they choose HRT) is a combination HRT resulting in a slight increased risk of breast cancer.
As an OB/GYN for many years, I believe strongly that for menopausal women the benefits of hormone replacement far outweigh any risks. Immediately, post menopausal women on HRT experience marked relief of debilitating hot flashes (often lasting 10 years or more). Sleep remains more normal and short-term memory improves. Other important menopausal complaints are helped with estrogen therapy.
More important are the long-term benefits of hormone replacement. If estrogen therapy is started within 10 years of menopause, it prevents the formation of atherosclerosis in arteries.
We learned from the WHI, women who began HRT shortly after menopause had a 50% reduction in myocardial infarction (heart attacks). The anti-inflammatory properties of estrogen seems the primary effect providing this protection.
Research has also suggested a decreased incidence of Alzheimers disease and other dementias in women who have been on HRT. Countless studies have documented that HRT reduces the risk of osteoporosis in women. The incidence of hip fracture is significantly lower in menopausal women receiving hormone therapy.
Finally, the bottom line is that on average women live longer who have been on some form of estrogen replacement after menopause.
It is important to note that one absolute contraindication to HRT is previous thrombus (clot) formation. Women who have had thrombophlebitis or pulmonary emboli, should never take estrogen. Presently, a history of breast cancer stands as a contraindication to HRT, although studies have not convincingly revealed any increase risk of recurrent breast cancer with hormone therapy. A family history of breast cancer is not a contraindication to hormone replacement.
Hopefully, women have the opportunity to engage in a thoughtful discussion of hormone replacement with their caregivers at the onset of menopause. For most women the first sign of menopause is the cessation of menstrual periods, often accompanied by hot flashes.
The standard of care for these women is presently combination HRT (estrogen/progesterone), which provides the benefits of estrogen while eliminating the risk of uterine cancer with progesterone.
As Gunser and Cail wrote, there is a slightly higher risk of breast cancer with combination HRT.
For women who have had a hysterectomy (removal of the uterus), hot flashes will be the telling sign of declining ovarian function, resulting in decreasing estrogen levels (menopause). Estrogen replacement alone appears the best choice for these women as they experience the consequences of menopause. An added benefit will be a slightly lower risk of breast cancer.
Many ask how women got along without HRT in the past? The average length of life for a woman in 1900 was 50 years, a few years short of the average age of menopause.
Today women are living much longer, well past their menopause, and developing health problems associated with a lack of estrogen: heart disease, osteoporosis, and dementia.
Clearly there is no substitute for a healthy life style including good nutrition and physical exercise, but it seems that women can significantly benefit from estrogen replacement after menopause. Many will live better and longer.
(Dr. Oge Young, a retired obstetrician/gynecologist, is past president of the New Hampshire Medical Society. He lives in Concord.)