HRT

Wednesday Bubble: More on breast tenderness, hormone replacement and breast cancer

Posted by Liz on Nov 30, 2011 in breast cancer, HRT, menopause | 2 comments

More bad news on the hormone replacement front: if you are taking estrogen (conjugated equine estrogen) with progestin (medoxyprogesterone) for menopausal symptoms and experience breast tenderness, you may want to think twice.

Frankly, this news isn’t exactly new. Because back in 2009, UCLA researchers reported similar findings in the Archives of Internal Medicine. These newer data, provided by the same researchers at UCLA’s Jonsson Comprehensive Cancer Center and published online in Breast Cancer Research and Treatment only add to the hormone risk fodder.

The researchers say that in their research, they’ve consistently run across data that suggest that “estrogen plus progestin compared to estrogen alone, have a more marked effect on breast tissue,” possibly due to more growth, leading to greater density. According to the lead study author, Dr. Carolyn Crandall “higher breast density (has been shown to be) associated with a higher risk of breast cancer,” adding that “in women with extremely dense breasts, the cancer risk can be four to six times higher than for women whose breasts are not dense.”

In this update, Dr. Crandall and her colleagues reviewed data from the Women’s Health Initiative, specifically focusing on reports of new breast tenderness. At the study’s start, almost 12% of women taking estrogen alone or estrogen in combination with progestin reported having breast tenderness. However, by the first year, women in the combination hormone therapy group reporting onset of breast tenderness after starting hormones had a 33% greater risk of developing invasive breast cancer compared with their peers who did not have breast tenderness. And while estrogen alone also increased the risk for developing breast tenderness, the effect was less than that of the combined hormones, especially since it did not lead to an increased breast cancer risk.

So, what to make of these new data? If you are taking HRT and develop breast tenderness, you need to speak to your health practitioner, assess your risks and make a joint decision as to whether or not the benefit of fewer menopausal symptoms is worth the risk of possibly developing an invasive form of breast cancer. And if you are not yet using hormone therapy, you may just want to step back and think twice.

Buyer beware: hormone therapy is a slippery slope with bumps, bruises and perhaps serious disease. Is it worth it? Only you can decide.

Estrogen and urinary incontinence: is there a link?

Posted by Liz on Nov 4, 2011 in aging, estrogen, HRT, incontinence/bladder control, menopause | 0 comments

One of the most common and (and yet unspoken about) conditions in women is urinary incontinence (UI) or problems with bladder control. Defined as the involuntary loss of urine – either due to a weakening of the pelvic floor muscles and in association with pressure on the bladder (stress urinary incontinence) or due to unknown causes and associated with an uncontrollable urge to pass urine, frequency and nighttime awakening (urge urinary incontinence or overactive bladder) – urinary incontinence is most definitely associated with aging. In fact, roughly 15 million women in the U.S. have stress urinary incontinence and about 20 million, overactive bladder.

There are a multitudes of risk factors for urinary incontinence and they range from weight, vaginal deliveries and pelvic surgery to alcohol use and of course, as mentioned, growing older. However, why is menopausal status also a risk factor?

One word: estrogen.

Indeed, results from the infamous Women’s Health Initiative study demonstrated that women who were randomized to combination hormone therapy or estrogen only were at increased risk for worsening urinary incontinence symptoms or for developing urinary incontinence after only one year of use. However, like other data from this study, questions have been raised with regard to the findings, namely that they are not applicable to the general population. And yet, it is critical to learn if using hormone therapy increases urinary incontinence risk; these conditions significantly affect quality of life and at their severest, limit physical and social activities, limit intimacy and other relationships, limit work productivity and affect overall wellbeing.

Rather than generalize, however, it’s important to take a close look at ethnically diverse populations of women in the community and tease out if there are any specific factors related to estrogen use that increase incontinence risk. That is exactly what a group of researchers did recently, when they examined a group of 167 women in menopause who had been surveyed in 1993, found to have no urinary incontinence and then reinterviewed eleven years later in 2004. In this study, which was published in Menopause journal,the researchers specifically evaluated if the women had used estrogen and if so, for how long (i.e. less than five years or more than five years). The findings? Although none of the women reported having urinary incontinence issues at the first interview, just over a decade later, 28% reported that they had developed urinary incontinence and almost 19%, that they developed urinary incontinence that resulted impacted their ability to function (e.g. avoiding social gatherings, not visiting friends or going to church, or avoiding traveling, shopping or physical activities). What’s more, of the women surveyed who reported that they had used estrogen for more than five years, 15% developed new cases of  urinary incontinence with an associated loss of function.

According a related piece in Reuters, the study’s lead investigator says that they didn’t take into account how much estrogen the women were using or if they used it in conjunction with progesterone, so there are weaknesses in the study. Still, it does appear that taking estrogen for more than five years may significantly increase the risk for bladder control issues. The next piece of the puzzle is discovering why it affects bladder function in the first place.

Bladder control issues are serious business. Yet another reason to speak to your doctor before moving forward on hormone therapy. Your move – worth the risk?

Breathe. What you need to know about asthma and HRT

Posted by Liz on Sep 30, 2011 in asthma, HRT, menopause | 0 comments

If you suffer from asthma, you will want to take note: researchers presenting at this week’s European Respiratory Society AnnualConference have shown that female asthmatics have an increased risk of landing in the hospital if they take hormone replacement therapy (HRT). Yet another nail in the HRT coffin, once again demonstrating that the health risks of taking hormone replacement may outweigh the benefits.

Notably, studies have shown that asthma risk increases in women after puberty. Moreover, hormones, most specifically fluctuating estrogen levels, can impact airways as much as allergies and hay fever (fluctuating estrogen levels can produce an inflammatory response and exacerbate breathing difficulties). On average, asthma symptoms develop in about 21% of menopausal women and more than twice as many using hormone therapy.

In this study of over 23,000 Danish women with documented asthma, researchers looked specifically at hospitalizations for severe reactions. They also collected information on smoking, exposure to smoke, body mass index, level of physical activity, history of hysterectomy and use of HRT.  The findings? Using HRT increased the risk for hospitalization for severe asthma reactions by as much as 40% compared to not using hormone therapy. What’s more, the longer the women used HRT, the higher their risk of ending up in the hospital; for example, if they used it for less than 3 years, they have a 29% increased risk and if they used it for more than 10, a 51% increased risk. Even more troubling was the fact that women didn’t smoke appeared to have the highest risk for being hospitalized in association with their HRT use.

Although this isn’t a randomized trial, and more information is needed, the researchers still recommend that practitioners be made aware of these findings. They say that the relationship between asthma and female sex hormones is hardly new, but that their findings confirm the relationship and further our understanding of it by showing the extent of severe asthma reactions that occur when women take hormones. “If a patient develops asthma or has a severe worsening of symptoms after taking HRT, they may need to stop hormone therapy altogether,” they add.

Newsflash: International Menopause Society has issued updated guidelines on HRT

Posted by Liz on Jun 10, 2011 in HRT | 7 comments

Got news?

I sure do!

The International Menopause Society has issued updated recommendations on the use of hormone replacement therapy (HRT, a term that they use to refer to estrogen, progesterone, combined therapies, androgens and tibolone). They note that the current guidelines are similar to those issued in 2007 but “include additional clinical data where needed.” And while they claim that there are “no reasons to place mandatory limitations on how long HRT is used (which by the way, runs counter to current recommendations of several major national and international medical associations), they do emphasize that HRT “should not be recommended without a clear indication for use, i.e. significant symptoms or physical effects of estrogen deficiency.”

The following are some highlights of the updated report:

• HRT should be used at the lowest effective dose to effectively reduce symptoms and maintain life quality
• Women who enter early menopause either spontaneously or due to hysterectomy or other condition before age 45 and particularly before age 40 may be at increased risk for heart disease, osteoporosis, mental disorders or dementia. Notably, the evidence of reduction of this risk via HRT is limited but is nevertheless recommended to preserve bone and reduce symptoms, at least until they enter the average age for menopause (i.e. ~52)
• Progestogen should be added to estrogen in all women with an intact uterus to prevent endometrial malignancies and cancer (except for in the case of low-dose estrogen)
• HRT is recommended to preserve bone health although it should not be started after age 60 and loses its effectiveness once therapy is stopped.
• Despite the controversy as to whether or not HRT is heart protective, the IMS says that it has the potential to boost or improve one’s risk profile because of how it affects the vascular system, metabolism of blood sugar, blood pressure and cholesterol levels. However, this recommendation is also framed within the recommendation that women adopt major primary prevention measures, such as stopping smoking, regular exercise, weight control, blood pressure reduction, and control of diabetes and blood pressure.

So, what about the risks of HRT that I’ve long written about on this blog? The convened panel disputes the conclusion of the Women’s Health Initiative (due to average older age of participants and when they started HRT) as well as data that have come down the pike since 2002. In fact, they say that the link with breast cancer is controversial and that HRT doesn’t initiate cancer (but rather, promotes an existing tumour). They also concur that data are still lacking with regards to type of HRT, doses, and administration type and incidence of breast cancer. And, with regards to endometrial cancer or stroke? They write that women with a uterus should be certain to add a progesterone component to their hormones to counteract any undue stimulation of their endometrium, and that stroke risk is related to increasing age and obesity, noting that risks may be avoided by using an estrogen patch or stopping use of hormones after the age of 60.

In general, the conclusion of the panel is than “most menopausal women have little to fear from the adverse effects of HRT” and that the benefits of hormone therapy outweigh the risks. Still, they do suggest that the decision to take HRT should be discussed with a physician and reviewed annually.

Not surprisingly, alternative therapies are completely
discounted in the IMS guidelines and they do not support the use of any bioidentical hormones whatsoever. Moreover, they make a point to place blame on the media without providing clear examples of their claims for “superficial and uncritical evaluations” of HRT, as if all media were one and the same.

I am not quite sure what to make of these recommendations. On one hand, they claim to have reviewed all the data since WHI but this panel convened four years ago. And while they are sure to promote HRT within a cautious framework, menopause continues to be positioned as a disease requiring treatment.Indeed, one of the report authors, Dr. Roger Lobos (Columbia University, New York), says that “the bottom line is that most doctors nowadays should feel comfortable about prescribing HRT to most women going through the menopause [but] like most medicines, you need to look at individual circumstances before deciding to taken it.”

Notably, media are once again positioned as the big bad wolf that misconstrue findings and attack  pharmaceutical companies for their profit motivations.

Has anything really changed except the date of the report? Well, the good news is that the IMS acknowledges that there are risks associated with HRT, at least for some women. And yet, the report still appears lack objectivity.

Do yourself a favour. Speak to your practitioner. HRT will shut down your symptoms. Period. But you must ask yourself, at what cost? Do your research. Ask the hard questions. And then ask them again.

You may be sweating. But the issue is greater than the sum of all sweats.

Flaming the fires of HRT: what influences risk?

Posted by Liz on Mar 4, 2011 in heart disease, HRT | 6 comments

Let’s face it. Despite my doubts about hormone replacement therapy (HRT), just like the Energizer Bunny, it’s going to keep on going. So as any responsible journalist must do, I have to share the good along with the bad and ugly. The trouble is that data rarely agree, lending confusion to the growing controversy about health risks, appropriate timing, combination and use of HRT.

Last week, several of you sent me a link to a study in the current issue of Menopause that appears to further clarify use of HRT and heart disease risk. Quite honestly, I had seen the study but was hesitant to write about it for fear of simply fueling the fires. But you’ve asked so I’ve answered.

The investigators of this particular study note that experts suspect that timing of hormone replacement, i.e. age when it’s started or time since menopause has begun when it’s started, plays a role in some of the differences between previous reports on HRT and heart disease. For example, reanalysis of data from the Nurses Health Study demonstrates that any heart benefits of HRT rely on starting therapy within 10 years of menopause, while data from the Women’s Health Initiative show that younger age plays an important role as well.

In a quest to tease this out further, they examined information on deaths from ischemic heart disease, age at first and/or current use of HRT, prior use and duration of use in 71,237 postmenopausal women in the California Teachers Study over a period of approximately 9 years. The findings?

• Overall, current age while using HRT appears to influence risk of dying from any cause. This factor appears to be much more importan than age that HRT was started or years since menopause began. Indeed, women using HRT at the time of the study who were younger than 65 years were found to have a 45% reduced risk of death from any cause compared to women who had never used HRT.
• Similar findings were seen when the researchers examined death from heart disease, with HRT providing some protection in younger current users that virtually disappeared once they reached 75 years.

The upshot is that the health consequences and risks of HRT may be influenced most by age at current use, with younger women having the most benefits to gain. Any sort of protection starts to disappear as women grow older so the window of opportunity might be small.

Still, questions remain. These researchers were only trying to determine the most important influencer(s) of death from heart disease and not examining cancer or other risks that have been definitively demonstrated.  Do these data fan the controversial fires and serve to heat up the debate? I believe that they do.

As always, buyer beware. Nothing is ever as it seems. Especially when it comes to hormone replacement therapy.

Hormone replacement therapy…timing is everything, right?

Posted by Liz on Jan 31, 2011 in breast cancer, HRT | 5 comments

Hormone replacement therapy (HRT) continues to be a hot topic in the menopausal world. And no wonder! Because the deeper we dive into the controversies, the more information we seem to learn about its dangers.

If you search for hormone replacement or HRT on this blog, you’ll find that the dialogue has nothing but consistent. And while naysayers may try to accuse me of a personal vendetta against hormones, it’s actually not the case. I started Flashfree for several reasons, the most important being that I wanted to provide enough information about menopause and aging and treatment strategies to enable women to think on their feet, consider the facts and have intelligent dialogues with their peers and practitioners before making any decisions that could affect their health and wellbeing as they grow older. Moreover, although I am a strong proponent of alternative strategies to combat the unpleasantries of dwindling hormones, I still believe strongly in the benefits of certain Western approaches to treating illness. However, I also a strong believer in integrative strategies that combine the best of our knowledge in an individualized fashion; my mantra is ‘treat the individual, not the masses.’ Hence, when I read about the history of the menopause in general and HRT in particular, what I see is disease mongering at its finest, examples of fear and loathing and mostly, a disrespect of women. And I care too much about women’s health to remain silent.

Last Friday, several of my colleagues sent me a link to the following study:

“Breast cancer risk in relation to the interval between menopause and starting hormone therapy.”

This newly-published study in the Journal of the National Cancer Institute is one of the largest to date since the findings of the now infamous Women’s Health Initiative (WHI) study linking Preempro to breast cancer. In it, investigators used observational information culled from over a million postmenopausal women in the United Kingdom to determine how type and timing of hormone therapy might influence the risk of developing breast cancer.

A bit of context is necessary for those of you who are unfamiliar with the major criticisms of WHI, namely that that the women studied were not representative of the normal menopausal population, were older, started hormone therapy later in life (i.e. >5 years from when menopause started) when their risks for disease were greater, and that the type of hormone replacement, namely the progestin component, were not taken into consideration. WHI was also criticized for not focusing on the small percentage of women in the study who took estrogen-only and were not at greater risk for breast cancer. (If you want to read more about that particular issue, check out the write up on data presented at this past year’s San Antonio Breast Cancer Conference.)

In the UK study, the average age of participants was 56.6, considerably younger than the study population in WHI. More than half (55%) of participants reported having used hormones at some point and 35% were current users, and the rest, had never used hormone therapy. Study participants were matched by socioeconomic status, childbirth information, BMI, physical activity, alcohol consumption and smoking to insure that these factors did not influence the study findings.

Overall, 15,759 breast cancers developed and were diagnosed approximately a year and a half after the last point of contact:

• Despite contentions by some experts that starting combination hormonal therapy within 5 years of menopause is safe, women between the ages of 50 and 50 who began HRT less than 5 years after menopause had the highest rates per year of breast cancer — .61% per year — that twice that of women who had never used hormones (.31%).
• Current users of estrogen also demonstrated increased breast cancer rates (.43%) who started hormones within or less than 5 years after menopause started.
• The risk of developing breast cancer was roughly 1.5 times higher among women on combination hormone therapy who started within 5 years than women who started 5 year or more from menopause.
• The risk of developing breast cancer among past users of hormonal therapy tended to decline over time after use of hormones stopped, and within 14 years, were almost equivalent to never users.

Mind you, the study is not without fault and may be criticized on the basis of the fact that it relied on observational information rather than randomized controlled results. In other words, data were collected and then analyzed based on what they inferred.  The research might also be questioned due to the fact that information about use of hormones was reported over a year before cancer was diagnosed, thereby possibly leading to mischaracterization of hormone users/non users and estimates of the risk for developing breast cancer. Nevertheless, the researchers say that taking these factors into account, breast cancer risk among hormone users regardless of type, would have increased by a factor of at least 1.2.

The key take-away message from this new study is that it’s may be impossible to define the safest parameter for using hormone therapy. For certain women, HRT may never be safe. For others who are willing to risk life-threatening conditions for fewer hot flashes, HRT may be worth the gamble. As always, ask the hard questions.

Timing is everything, right? Maybe not when it comes to hormone replacement.