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Unfortunately, according to the statistics, one out of 8 women will develop
this terrible disease in her lifetime. This is irrespective of whether she uses HRT.
This is a terrifying prospect. It is the principle reason many women choose to deny themselves the benefits of
HRT. This may be true even when they are aware that HRT is instrumental in the protection of cardiovascular disease,
by far the most frequent cause of death in menopausal women.
I recently attended a Mayo Clinic conference that dealt with the topic of of problem solving in hormone replacement
therapy. The lecturer, an expert in the field and a staff physician at Mayo, related that although some studies
showed a slight increase in the rate of breast cancer associated with estrogen use, just as many studies showed
no relationship at all. His opinion was that estrogen did not cause breast cancer.
If this is so, why do some studies show even a slight increase?
One possible reason is what is called a "surveillance bias."
This refers to the fact that we seem to follow women who use HRT more closely than those who do not. In order to
obtain and continue HRT, a women is required to see a physician and return at regular intervals. Accordingly, women
on HRT are more likely to have mammograms, physician breast examinations and to be instructed in breast self examination.
Women who are not HRT users, may not see their physicians as frequently, are less likely to undergo regular mammography,
or be instructed in self breast examination.
It would be expected, given this increased surveillance that more cancers would be found in the HRT group. In addition,
women in this group in whom cancers are discovered tend to have smaller, less aggressive tumors and are more likely
to survive their disease.
If just as many studies show no increase in the rate of breast cancer, why don't
we hear about them?
The principle agenda of the media, both print and visual, is to sell advertising.
While we often hear that their purported purpose is to educate you, in almost all cases the profit motive prevails.
Stories that talk about increased rates of cancer are perceived as having the potential of attracting more readers
or viewers.
Given that I have this fear of breast cancer, should I use HRT?
Ultimately, this is a personal choice. The statistics show that women who
use HRT are more likely to live longer and have a better quality of life. This is especially true in those women
who have had an early menopause and/or had a hysterectomy. In addition, there is no consistent evidence that post
menopausal estrogen use causes breast cancer. However, the continued perception that estrogen use increases the
incidence of breast cancer precludes many women from using HRT. For these women this may be the right decision,
as to live every day in constant fear would be untenable.
A Summary Of Some Of The Issues:
(1) Women who are hormonally deficient, especially those who have had their
ovaries removed and are without the benefit of HRT are known to have higher rates of death from heart attacks,
strokes and osteoporosis.
(2) The fear of a reoccurrence of breast cancer can be overwhelming and preclude
any thought of using estrogen replacement.
(3) To the best of my knowledge there has never been a study that showed increased
rates of reoccurrence of breast cancer associated with estrogen use in patients previously treated for early stage
breast cancer.
(4) It is possible by using alternatives to estrogen such as tamoxifen(Nolvadex),
raloxifene(Evista) and a bisphosphonate(Fosomax) and lifestyle changes, that the risk of these problems can be
diminished.
(5) To the best of my knowledge there is no over the counter herbal preparation that is capable of preventing the
long term negative health affects of hormone deprivation.
(6) Most physicians who are treating a woman with a history of treated eary
stage non metastatic breast cancer will discourage them from considering HRT. This is due to either being unaware
that there is no evidence that it increases reoccurrence or mortality and/or a fear of becoming a malpractice target
if the disease should reoccur.
Included below is a summary, or abstract of a study published in the American Journal of Obstetrics and Gynecology
and an excerpt of medical education communication by Dr Rogerio Lobo, a physician, who is a highly regarded expert
in menopause.
Estrogen replacement therapy in women with previous breast cancer.
Am J Obstet Gynecol 1999 Aug;181(2):288-95 (ISSN: 0002-9378) Natrajan PK;
Soumakis K; Gambrell RD Jr [Find other articles with these Authors] Department of Physiology, Medical College of
Georgia, Augusta, Georgia, USA.
OBJECTIVE: We
sought to review the status of patients with breast cancer who were treated with estrogen replacement therapy and
compare the results with those of nonestrogenic hormone users and women not treated with hormone replacement.
STUDY DESIGN: The
study group consisted of 76 patients with breast cancer, including 50 using estrogen replacement for up to 32 years,
8 using nonestrogenic hormone replacement for up to 6 years and followed for up to 11 years,and 18 using no hormones
for up to 10 years. In addition to estrogen use, 40 of the 50 hormone users were treated with androgens, usually
in the form of implantation of testosterone pellets. Forty-five subjects were also given progestogens, usually
megestrol acetate 20 to 40 mg for 10 to 25 days each month. The 8 nonestrogen hormone users were treated with various
combinations of testosterone pellets, tamoxifen, and progestogens. Forty-two of the 50 estrogen users are still
being treated in our clinic, as are 2 of the 8 subjects using nonestrogen hormone. Follow-up was done through the
tumor registry at University Hospital, and those whose tumor records were not current were telephoned. RESULTS:
Of the 50 estrogen users, 3 have died (a mortality rate of 6%), and the rest have been followed for 6 months to
32 years, with a mean duration of follow-up of 83.3 +/- 8.81 months. One of the 8 nonestrogen hormone users has
died (a mortality rate of 12.5%), and the rest have been followed for 2 to 11 years, with a mean duration of follow-up
of 72.0 +/- 5. 93 months. Six of the 18 women not using hormone replacement have died (a mortality rate of 33.3%),
and the rest have been followed for 6 months to 10 years, with a mean duration of follow-up of 50.5 +/- 6.01months.
CONCLUSION: Estrogen replacement therapy apparently does not increase either recurrences
or mortality rates. Adding progestogens
may even decrease recurrences. Women with early breast cancer should be offered hormone replacement therapy after
a full explanation of the benefits, risks, and controversies.
Women's Health Clinical Management - Volume 1
Menopause Management for the Millennium CME
Author: Rogerio A. Lobo, MD
HRT in the Context of Disease
An important issue is whether HRT can be prescribed for postmenopausal women
who have been treated for cancers (eg, breast and gynecologic cancer) or who have autoimmune diseases (eg, systemic
lupus erythematosus [SLE] and multiple sclerosis [MS]) or other diseases associated with aging (eg, osteoarthritis
[OA] and Parkinson's disease [PD]) or other chronic conditions (eg, diabetes and epilepsy). No prospective studies
with a large number of patients and a long treatment period have addressed this question.
Breast Cancer
It has been estimated that the number of breast cancer survivors in the
United States may approach 2.5 million.[280] Moreover, because breast cancer is being detected at an earlier age
and adjuvant chemotherapy can cause ovarian failure, the number of women becoming menopausal at a younger age after
breast cancer treatment is increasing.[280] Given that the risk of suffering a recurrence will be low for a large percentage of these women,
should they consider HRT? At least 1 prospective study of HRT after localized breast cancer indicates that HRT
does not seem to increase breast cancer events.[281] However, the most reasonable course of action for women who
have been treated for breast cancer and who have menopausal symptoms is to treat the symptoms with alternative
therapies. Diet and exercise are effective for prevention of CVD; weight training and the addition of bisphosphonates
or SERMs (eg, tamoxifen and raloxifene) can reduce the risk for osteoporosis. Certain dosages of progestins can
alleviate hot flushes, although many oncologists believe that use of any sex steroids is contraindicated. Nevertheless,
in those breast-cancer survivors who choose HRT,[282] the lowest effective doses should be used, and these women
must be monitored carefully.
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Dr Nosanchuk is currently in practice in Southeastern Michigan
and is accepting new patients. His office is located in Bingham Farms, a suburb of the Detroit Metropolitan Area.
Dr N specializes in the care and treatment of menopausal women and has a special interest providing treatment to
women whose lives have been altered by their menopause, hysterectomy, or both. This includes strategies to restore
quality of life, by resolving problems, such as persistent symptoms, loss of libido and disturbances of sexual
function.
Appointments with Dr Nosanchuk can be scheduled by calling (248) 644-7200
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