Another article about breast cancer risk associated with the Women’s Health Initiative(WHI) Study was recently published in the JAMA(Journal of American Medical Association) July 20, 2010 publication. It now reports an increase in mortality related to the increased incidence of breast cancer in the study group who used both estrogen and progesterone (Premarin and Provera). Over the 11 years follow-up of these women, an increase of 1.3 extra deaths per 10,000 women per year were reported compared to those in the group on no hormones. This difference was statistically significant but in absolute numbers is obviously not very large. There was no increased incidence or mortality in the WHI group on estrogen alone.
As many of you have heard from me, my commitment to the patients and/or readers of this newsletter is to clarify and interpret the information that comes out in the media related to women’s issues. The purpose of this article is just that. I want to make it clear that this article by Chlebowski essentially adds no new meaningful information to the menopause world, despite the media attention. To understand this, we must return to some of the learnings and questions from the earlier published WHI articles:
How could estrogen be the problem when the study group on estrogen alone without progesterone showed no risk and the combined group showed the increased risks? If progesterone is a risk factor, wouldn’t it be wiser to use a lower dosage of progesterone also if possible, probably in a cyclic rather than the continuous pattern that Prempro uses?
The average age of women starting in the WHI study was 63, so it clearly has an older women bias compared to the average age woman who starts hormones in her 40’s or early 50’s.
Present day recommended hormone therapy should be, and is becoming, more natural, plant-based, and "bioidentical" than the animal derived, non-"bioidentical" Premarin, or the strong synthetic Provera used in the WHI study.
There is growing evidence that transdermal estrogen products have an increased safety profile compared to Premarin in the WHI, in respect to the incidence of blood clots and cardiovascular risk
The majority of previously published articles concerning the severity of breast cancer which was found in patients who took hormone therapy showed a less aggressive, less fatal type of breast cancer.
North American Menopause Society (NAMS) suggests that "clinicians can help women put breast cancer risk in perspective by informing them that the increased risk of breast cancer using estrogen plus progesterone for 5 years is very similar to the increased risk of breast cancer associated with having menopause 5 years later. This increased risk of breast cancer occurs with a woman’s own internal, natural estrogen and progesterone.
So, when trying to assess the risk/benefit considerations of hormone therapy, all the previously considered factors are still in place, and this new study does not, in my mind, change the decision conclusions significantly. The recommended strategy for HT usage which has been forwarded by the American College of Obstetrics and Gynecology which suggests lowest dosage of estrogen possible for as short of time as possible to treat menopausal symptoms still is appropriate. Even though the FDA stance continues to be that "all estrogens are the same", there is mounting evidence that transdermal estrogen and cyclic low dose natural progesterone is a better and safer regimen than studies in WHI.
Each woman, in consultation with her healthcare provider, needs to prioritize her midlife health concerns and determine whether hormone therapy is an acceptable choice for you. Please do not make healthcare decisions based on the media’s interpretation of medical studies, but instead allow us to help you in your decision-making.
Jon S Nielsen MD
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