Breast Cancer and HRT

Does Hormone Replacement Therapy increase the risk of breast cancer?  

Well … Does hormone therapy increase the risk of breast cancer?

It doesn’t seem so.

The belief that HRT increases the risk of breast cancer is without merit.  It is primarily based on misinformation communicated to the media and health professionals by a seemingly reliable source, the National Institutes of Health (NIH) sponsored Women’s Health Initiative (WHI).  The results of the WHI  Estrogen Plus Progestin (E Plus P) Trial was published in the July, 17, 2002 issue of the Journal of the American Medical Association (JAMA) The article stated that there was a substantial increase in the risk of breast cancer associated with the hormones used in the study.

It is clear that the writers group of the NIH-sponsored project misrepresented their study findings as the data collected in the study did not support this conclusion.   What their agenda was remains unknown.

If this is true why does my doctor tell me estrogen causes breast cancer?

Unfortunately, very few physicians actually bothered to read the WHI article and most received their information from the media or from colleagues who didn’t read it.  As a result how they advised and treated their patients was often sub optimal.  The WHI article including the conclusions and recommendations was written by twelve individuals, eight non-physicians and four physicians, known as The Writing Group for the Women’s Health Initiative Investigators.  Only two of the four physicians were practicing and none of them were known to have expertise in menopausal medicine.  Incredibly the conclusions of the writers group were accepted by most physicians and the media with a complete absence of professional skepticism.  Physicians who had prescribed HRT for years with good patient results without independent thought or analysis simply stopped writing prescriptions for HRT and told their patients they could no longer use it.

Dr. Jacque Rossouw, the physician who heads the WHI and was in charge of the study, did not believe the WHI study provided evidence that the hormones used in the study increased the risk of breast cancer.  He said the WHI E Plus P study lasted only a little over five years and that during that time a breast cancer initiated by the hormones could not have grown to a size large enough to have been detected by mammography or a physician examination.  Dr. Rossoux was clear in saying that the breast cancers discovered were there before the study began.   How would I know that Dr. Rossoux said this?  I have spoken to Dr. Rossoux several times, face to face and on the phone. He told me this directly and the wording he used was that the breast cancers pre-existed the study.  I would presume that if an investigative reporter took the time to call him at the NIH he would tell them the same thing.

Consider some comments from recognized authorities in menopausal medicine:

A recent article in the Journal of the International Menopause Society, Climacteric, The Journal of Adult Women’s Health and Medicine in June 2014 concluded:

“Over-interpretation and misrepresentation of the WHI findings have damaged the health and well-being of menopausal women by convincing them and their health professionals that the risks of HT outweigh the benefits.” 

An excerpt from an editorial published in a prior issue of the Climacteric, and was endorsed by seven members of the Board of the International Menopause Society concluded:

“On current assessment, the WHI trial the most important and the most ambitious project in menopause medicine, has done a great disservice to the well-being and health of adult women.”

In an issue in the Journal Menopause Management, James Simon, MD, clinical professor at George Washington University, President and Medical Director of Woman’s Health & Research Consultants, Washington, DC, and a Past president of the North American Menopause Society, wrote in a “Letter to the Editor:

“While I applaud those WHI investigators who are finally emerging to voice their concern and frustration with being excluded from the July 2002 media- grabbing media-distorting WHI publication, they now must find their own absolution and path to redemption.

An entire generation of women, their partners and their families suffer unnecessarily for their collective sins.”


The events that transpired following the WHI publication were and continue to be a tragedy for menopausal women.  The media did their job which is primarily to sell advertising by sensationalizing anything that is remotely possible to sensationalize. Physicians failed in their responsibility to their patients by responding to the WHI’s publication without independent thought or compassion for their patients. 

Dr. Jerry Nosanchuk is a practicing physician who has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan.  Appointments with Dr. Nosanchuk can be made by calling: (248) 644-7200 and speaking to Caroline Monday through Friday from 10AM to 6PM

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.

Progesterone, Progestins & Progesterone Cream

Our goal is for every one of our menopausal patients to be able to say … I’m Back to being me.

Dr. N provides bio-identical treatment regimens that will resolve your  hot flashes, sweats, sleep disturbances, headaches, fatigue, depression, give you back your sex life and keep you looking younger.


Do I need to take progesterone if  I am on HRT?

If you still have your your uterus it is important that your HRT regimen includes a progesterone. The reason for this is that one of the natural functions of estrogen is to stimulate lining of the lining of your uterus. Before you reach menopause during your natural menstrual cycle you produce progesterone to prevent the uterine lining from being over stimulated.

Unfortunately, some menopausal women experience unpleasant symptoms while using progesterone. The challenge becomes how to individualize a regimen, that allows menopausal women to receive the documented health and quality of life sustaining benefits of estrogen replacement, while both adequately protecting the uterus and avoiding any potential progestin-related side effects.

What exactly are progesterone and progestins?

Progesterone is a naturally occurring hormone produced by the ovary following ovulation in premenopausal women. Progestins, are synthetic products, which mimic the effects of progesterone. The term progestogen, is used to describe hormones that provide progesterone-like activity, and this includes both progesterone and progestins. Although it may seem a little confusing at first, when I am referring to both progesterone and progestins collectively, I will use the term progestogen.

What kind of side effects?

Many women are intolerant to progesterone and progestins experiencing unpleasant symptoms, ranging from mild, to severe and life altering. Other menopausal women object to the withdrawal bleeding that may accompany progesterone and progestin use.

In addition, there is evidence that some progesterone, or progestin regimens may interfere with the beneficial effects of estrogen.

Will I definitely have unpleasant symptoms while using a progestogen?

No, the majority of women may not experience significant symptoms while using a progestogen. However, those women who do are often discouraged from continuing their HRT program.

What unpleasant symptoms can accompany progestogen use?

Unpleasant symptoms may include irritability, fatigue, depression, diminished libido, emotional volatility, breast tenderness, muscle aches, fluid retention, constipation, uterine cramping, changes in appetite, headaches and insomnia. Some women may experience none of these symptoms while others may experience all of them.

What kind of problems can “unopposed” estrogen stimulation cause?

“Unopposed” estrogen administration may result in irregular and excessive vaginal bleeding and abnormal changes of the uterine lining, including estrogen-induced endometrial cancer. Progestogens downgrade the sensitivity of the estrogen receptors in the uterine lining and reduce the frequency of these problems. It is so effective in preventing excessive stimulation of the uterine lining, that appropriate administration of progestogen, lowers the incidence of endometrial cancer to below that of non-users of HRT.

How do I include a progestagen in my HRT regimen?

There are 2 basic regimens, along with some variations.

In the first the estrogen is given continuously and the progestogens are taken for 10-12 days each month. In this method, after finishing the progestogen, women using this regimen will usually have what is referred to as “scheduled withdrawal bleeding,” beginning 1-7 days after the final progestogen dose each month. This is referred to as “sequential therapy.” Some women find the bleeding unacceptable and are less likely to continue HRT.

In the second method, estrogen and a smaller dose of a progestogen are combined and taken daily. This is often referred to as “continuous-combined therapy.” The rationale for this regimen is to prevent any vaginal bleeding, but some women experience persistent spotting, or bleeding. This regimen is available in both oral and transdermal formulations. It is recommended by many experts and has gained wide patient and physician acceptance in the United States.

Which method do you recommend?

I almost always suggest sequential HRT regimens. On the surface it might seem more attractive to use continuous-combined therapy and avoid any withdrawal bleeding, but this method may be less optimal than using a progestogen for 10-12 days each month.


There are many women who are users of continuous combined-therapy and are happy with this regimen. They have good control of menopausal symptoms, are not bothered by the daily progestogen dose and are able to avoid any withdrawal bleeding. For women who consider scheduled vaginal bleeding unacceptable and would not use HRT if it necessitated bleeding, continuous combined therapy is likely the best option.

Nevertheless, there is preliminary research evidence that suggests that a commonly used oral continuous-combined HRT formulation containing conjugated equine estrogen and medroxyprogesterone may interfere with the cardioprotective benefits of estrogen.

In addition, studies funded by the National Cancer Institute demonstrated an increase in the incidence of lobular carcinoma, a relatively uncommon form of breast cancer in patients using this formulation. The over all increase in cancer risk appears to be small and further studies are needed to define the issue, however for the moment, it might be more prudent to use either sequential therapy, or a non oral formulation of continuous-combined therapy.

There are alternate oral continuous-combined formulations and the status of these preparations relative to the aforementioned studies will be addressed in ongoing and future research.

If a woman has had a hysterectomy does she need to take a progestogen?

If the uterus is not present, there is no need for a progestogen, natural, or synthetic. Some make the argument that progesterone should be used “for balance,” in women without a uterus, as it more closely resembles a woman’s natural cycle. I do not recommend this as a premenopausal woman’s progesterone level is for practical purposes nearly undetectable for most of the ovulatory cycle and there is no reason to unnecessarily expose her to any potential negative consequences of progestogen use.

There is one subset of women who have had a hysterectomy where progestogen replacement would be a consideration. Those women who have had a surgical menopause because of endometriosis and residual endometrial tissue is known, or suspected to remain in the body. There have been a few cases reported in the medical literature where residual endometrial tissue has undergone malignant transformation. This is rare, but if residual endometriosis is a consideration, 10-12 days of a progestogen at 1-3 month intervals would be reasonable.

I suffer from a number of the symptoms you mention while using a progestin, is there any way to lessen the problem?

In some, but not all cases, it is possible to diminish the impact of these problems by changing the type, dose, schedule, or route of administration of the progestogen, but ultimately the symptoms are a direct effect of the progestogen, whether synthetic or natural. Many women have fewer symptoms when using a product such as micronized progesterone, either from a compounding pharmacy, or from the local pharmacy, where it is sold under the name of Prometrium. Women who are allergic to peanuts should not use this compound, as it contains peanut oil. Some women find they experience fewer symptoms when using a progestogen by the vaginal route, either in suppositories, or in cream form.

One strategy that is useful is to increase the progesterone free interval to 2, 3, or 4 months taking care to monitor for signs of endometrial overstimulation. Some doctors have had good results with the use of a progestin-releasing intrauterine device, which some research indicates is capable providing endometrial protection. However, in some women it is virtually impossible to include a progestogen in their HRT regimen due to the severity of the negative effects. In this extreme situation, it may be necessary to leave the progestogen out of the program entirely. However, users of unopposed estrogen who have a uterus should be monitored carefully, without exception, for the development of abnormal changes of the uterine lining.

I have heard a lot about natural progesterone skin creams, including one that contains Yam progesterone. Is this a good thing for me to use?

I do not believe there is any benefit to using progesterone skin creams, as they do not provide any protection from the long-term negative health consequences of hormone deprivation. Yam and other plant progesterones, cannot be metabolized in the human body, unless they are modified pharmaceutically and any suggestion that they provide benefit, other than skin lubrication, is without basis. Progesterone skin creams that purport to be “natural,” often contain micronized progesterone as the active ingredient. There is one study that suggested that a progesterone skin cream was mildly beneficial in reducing the severity of hot flashes.

There are those that recommend the use of progesterone skin cream as it is “natural” and counteracts any “estrogen dominance.” However, the defining feature of menopause is ovarian failure and its accompanying estrogen deficiency. As such, by definition, all menopausal women are estrogen deficient and the concept that they are suffering from “estrogen dominance,” is not plausible. These products are very effectively marketed and I believe that careful scrutiny will reveal that a significant number of those who advocate their use profit by their sale.

Dr. Jerry Nosanchuk is a practicing physician who has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan.  Appointments with Dr. Nosanchuk can be made by calling: (248) 644-7200 and speaking to Caroline Monday through Friday from 10AM to 6PM

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.

Unpleasant Side Effects of HRT

Covid-19, the Menopausal Woman and Virtual Visits

During these challenging times Dr. N provides Televideo Virtual Visits for women who find it difficult to access a physician skilled in menopausal medicine. These virtual visits may be covered by your private insurer or Medicare. To schedule a virtual visit call (248) 644-7200 and speak to Caroline Monday-Thursday 10AM-4PM

Dr. N provides natural hormone regimens that will make your skin more youthful, restore your sex life, resolve your hot flashes, sweats, sleep disturbances, headaches, fatigue and depression.

Our goal is for every one of our menopausal patients to be able to say … I’m Back to being me.

Dr. N provides bio-identical treatment regimens that will resolve your  hot flashes, sweats, sleep disturbances, headaches, fatigue, depression, give you back your sex life and keep you looking younger.


Click the link below to see videos of Dr. N’s patients discussing their therapy

Menopause – Symptoms, Sex and Hormones – YouTube

Side effects … Why they occur and strategies to avoid them.

Most unpleasant side effects of HRT, are related to (1) the oral route of administration, (2) progesterone and progestins and (3) the physiologic action of the hormone on its target tissue.

Side Effects Related To The Oral Route Of Administration:

The most frequent unpleasant hrt side effects associated with the oral route of administration are nausea, vomiting and loss of appetite. These hrt symptoms can be due to either a direct effect of the hormone replacement on the lining of the stomach, or secondary to the affect of the rapidly rising hormone levels on the brain. In the latter case this is not unlike “morning sickness.” If the symptoms do not resolve after a few weeks a reduction in dose, or switching to another oral product may be in order. If this does not alleviate the symptoms a change to a non-oral route of administration will be likely be required.

When a hormone is taken orally it is absorbed by the gastrointestinal tract and transported “en masse,” or as a “bolus” to the liver. This is referred to as the “first-pass” affect. During this passage the absorbed hormone alters the normal production of liver proteins. While most women seem to be unaffected in some women the alteration in the blood levels of these substances have the potential to cause an elevation of blood pressure and/or an increase in the frequency of migraine headaches.

Side Effects Unrelated To The Oral Route Of Administration:

One problem that is not specific to the oral route and can occur with any route of administration is breast tenderness. It can be perfectly normal for a woman who has been hormonally deficient to have breast soreness beginning a few weeks after starting estrogen replacement. Low estrogen levels can result in an involution of breast tissue and when the breast tissue is stimulated by estrogen replacement the breast tissue can be sore and tender for 2-3 months as the breast tissue regenerates. Women who have been estrogen deficient may notice a reduction in breast size and then notice a return to their pre-deficient state after taking replacement estrogen. If a woman does not recognize the reason for the breast soreness, she may suspect the discomfort has a more serious origin, become frightened and stop her HRT. If the tenderness persists for more than 2-3 months, a reduction in dose may be required. Of course it would be prudent for her to discuss this with her physician and have an examination if it persists, or if the physician believes it is warranted.

It is also possible to experience allergic reactions to HRT preparations. Women who are allergic to peanuts need to be aware that some hormone replacement preparations including Prometrium contain peanut oil and are capable of producing serious allergic reactions in those who are susceptible. Many women are allergic to the adhesive in transdermal estradiol patches, or find that they are intolerant to the vehicle in the patch resevoir that contains the medication. In some instances this can be resolved by using another brand of transdermal estrogen patch.

One frequent reason given by women for not starting HRT, or discontinuing its use is the prospect of continued uterine bleeding. A woman who has an intact uterus and is an estrogen user requires the use of a natural, or synthetic progestin to prevent potential overstimulation and the development of abnormal changes of the uterine lining. Women who are on a program of sequential therapy in which the progestin is give for 10-12 days a month will experience an expected withdrawal bleeding. HRT preparations are available that contain a combination of estrogen and a smaller dose of progestin which have been designed to be taken daily and prevent any uterine bleeding. These preparations are widely used and are preferred by many physicians, but others have a concern about the affects of daily use of progestins. Most women tolerate this combination well, but others are intolerant to daily use of even a small dose of progestin and/or find that they continue to experience spotting, bleeding, or cramping while using it. The subject of progestin and progesterone intolerance will be addressed further in the next section.

Many women are concerned that weight gain may occur if they use HRT. The research evidence does not support this and suggests that women who are users of HRT are actually less likely than non-users to put on extra pounds. This is discussed in the section of the web page, Menopause & Weight Gain.

Dr. Jerry Nosanchuk is a practicing physician who has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan.  Appointments with Dr. Nosanchuk can be made by calling: (248) 644-7200 and speaking to Caroline Monday through Friday from 10AM to 6PM

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.

Bio-Identical Subcutaneous Hormone Pellet Implants

Look younger, avoid wrinkling, prevent hair loss and have a great sex life

Dr. N provides natural hormone regimens for both women and men including hormone pellet implants that keep you looking years younger, restore your sex life, resolve hot flashes, sweats, sleep disturbances, headaches, fatigue and depression. To schedule an office or virtual visit call (248) 644-7200

Dr. N chats with Amber and her treatment after her hysterectomy

Relief from Persistent Menopausal Symptoms And Sexual Dysfunction “…a wonderful hormone replacement option for my patients.” You will love getting back to being you.

Click link below to see videos of Dr. N’s patients discussing their menopause and their therapy

Menopause – Symptoms, Sex and Hormones – YouTube

For an appointment call (248) 644-7200 and speak to Caroline

I have tried several types of hormone replacement therapy and I still have severe menopausal symptoms. Is this just me or do other women have this problem?                                                                                                                             office-picture-suzanne

It’s not just you. While most menopausal women do well while using the routine methods of hormone replacement 10% to 20% experience persistent life-altering menopausal symptoms unresponsive to their prescribed therapy. This occurs with greater frequency in those women who have had a hysterectomy irrespective whether the ovaries have been removed. However it can and does occur following a natural menopause. Some hormone deficient women on the surface seem to have few symptoms, others may suffer from sleep deprivation, depressed mood, debilitating hot flashes, night sweats, body aches, irritability, loss of libido, decreased quality of sex and memory problems.

My desire for sex is completely gone and this is causing problems in my relationship with my partner. Is this because of my menopause, or is it a normal part of aging?

It is not due to aging but rather to the menopause associated fall in hormones and is reversible with a more optimum program of hormone replacement therapy.

I would really like to feel like myself again. Is there anything that can help?

Subcutaneous implantation of hormone pellets may be the treatment of choice for you. This hormone replacement option is almost always successful in relieving persistent menopausal symptoms and restoring, libido, sexuality, quality of life and sense of well being. The pellets used are derived from plant source and contain estradiol. This form of estrogen is biologically identical to the natural estrogen produced by the ovary. If the patient is testosterone deficient, a pellet containing testosterone can be implanted as well. Testosterone is a naturally occurring female hormone and is the hormone most closely related to sex drive, energy levels and the maintenance of muscle mass. This rarely fails to relieve even longstanding menopausal symptoms, or restore sexuality.

How is this done?

The procedure is performed in the physician’s office with a minimum of discomfort and takes only a few minutes. A small amount of local anesthesia is injected into the area where the hormone pellets are to be placed, usually the buttock. The hormone pellets are then inserted into the subcutaneous tissue through an instrument designed for this purpose. Pressure is applied to the site for 5-10 minutes. No sutures are required as the actual incision is very small. As with any other surgical procedure, postoperative infection, or bleeding is possible but uncommon. The pellets, which contain the biologically identical form of natural estrogen produced by the ovary are absorbed into the blood stream producing hormone levels that are physiologic and remain relatively constant day-to-day.  The hormones are absorbed slowly directly into the bloodstream and mimics natural ovarian secretion. Depending on the metabolism of the individual and the number of pellets implanted they last from 3-6 months and the procedure is repeated at that time.

I have never heard of this method of hormone replacement, is it something new?

Actually, it has been available in the United States and other countries for over 50 years. In general, it is offered by physicians who specialize in menopausal issues. This method of hormone replacement was developed by Dr. Robert B. Greenblatt, of the Medical College of Georgia, a pioneer in menopausal medicine and a founder of the International Menopause Society.

Have you used this method in your patients?

I have offered this method of hormone replacement to my patients for 30 years. I believe it is the most successful treatment for persistent menopausal symptoms and decreased sexuality even when the problems have existed for several years. It has been a wonderful hormone replacement option for my patients, capable of restoring them to a previous quality of life, sexuality and intimacy.

Dr. N has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan. For an appointment call: (248) 644-7200 and speaking to Caroline.

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.