Posts Tagged "estrogen"

Estrogen: Worth the risk?

Posted by Liz on Apr 6, 2011 in breast cancer, estrogen, heart disease, osteoporosis | 9 comments

Any regular reader of this blog knows that I am not a fan of hormone replacement therapy (HRT) nor the health risks associated with it. Nevertheless, although I espouse alternative strategies for dealing with menopause, I do feel that sharing news about HRT is important; accurate information leads to informed and shared decisionmaking.

So, do they (i.e. hormones) or don’t they (cause harm)? Undoubtedly, important variables come into play, including current age, how close to menopause hormones are started, current health status, whether or not a woman has had a hysterectomy, smoking history, etc. Also important is whether estrogen is used alone or in combination with progesterone. And yet despite these factors, many medical organizations continue to recommend that HRT be used for the shortest time period possible if at all.

Still, researchers continue to delve into data from the now infamous Women’s Health Initiative Study to tease out the bad, ugly and even the good.

This week,  they are reporting on over 7,600 women who had taken estrogen alone for approximately 6 years, had had prior hysterectomies and were followed for an average of 10 years after the trial ended. If you recall, there has been some controversy as to whether or not estrogen alone is safer than combined HRT and actually lowers the risk for breast cancer in particular, which is why these data are particularly intriguing.

The researchers report that age at the time that hormone therapy (in this case, estrogen alone) is started is important. In fact, women who started estrogen therapy in their 50s, an increased risk for stroke and embolism, which appeared while taking estrogen, actually disappeared in the years that followed. Unfortunately, so did protection against hip fracture. Moreover, earlier reports of a decline in breast cancer risk were upheld despite body mass indices. However, the researchers say that this finding in particular, runs contrary to the preponderance of evidence from the majority of observational studies which show that estrogen use increases the risk of breast cancer, especially in lean women and after a long time period of use.

In an accompanying editorial, also in JAMA, the authors point out that more than 80% of women who took estrogen as directed only used it for an average of 3.5 years. Their point is that the results don’t directly address the “balance of risk and benefits associated with longer term estrogen use.” They also point to a larger review of data that show duration is an important factor when it comes to breast cancer risk, especially among lean women. Additionally, they say that tamoxifen, which actually antagonizes estrogen, has been shown to reduce breast cancer by 50%, which has led the International Agency for Research on Cancer to “conclude that unopposed estrogen therapy and combination HRT are carcinogenic.”

Are you confused yet?

Both set of researchers say that the decision to use estrogen or not is one that should be made between a woman and her doctor. Don’t forget: study findings continue to contradict. They add that while “there may still be a role for short-term use of unopposed estrogen for treating some women with menopausal symptoms, this role may be vanishing as existing and emerging data continue to be better understood in terms” of patients.

My thoughts? Err on the side of caution. Always.

Looking through the window: depression and menopause

Posted by Liz on Dec 27, 2010 in depression | 2 comments

There’s a new term that’s being kicked around in medical circles: ‘windows of vulnerability.’

It appears that a growing body of evidence supports the fact that during times of hormonal flux or reproductive cycle “events,” women become increasingly vulnerable to mood swings, anxiety and depression. And while this is certainly not news for many women, it still requires some attention because among the many windows that women may go through, the menopausal transition is evidently one of the most complex. The reason? This is a time when hormones interact with aging, sexuality, life stressors, self-esteem and general health issues.

The subject of depression and menopause is not new to this blog, nor are statistics suggesting that as many as 20% to 40% of women are believed to suffer major depression or at the very least, depressive symptoms during the peri/postmenopausal years. Moreover, women may have as much as a two- to four-times increased risk of developing depression as they transition from pre- to perimenopausal status. Among the multiple factors at play, estrogen is one of the most important; estrogen has been shown to promote the amount of the mood neurotransmitter serotonin available to the body, thereby providing an important antidepressant effect. However, a recent review suggests that the role that hormones like estrogen play in depression is directly related to their wide fluctuations rather than the fact that they are becoming deficient.

So, why is this important? For one, it highlights that hormone replacement is not the only answer for depression during menopause but rather, that it’s critical to pay attention to timing, i.e. when preventive strategies, including exercise, behavioral therapy and antidepressants might yield the greatest long-term benefits. Yet, it also suggests that estrogen-based therapies may indeed have a role in depression during menopause. And, since estrogen alone therapy has been shown to up the risk for ovarian cancer except for in women who’ve had hysterectomies, it also helps supports the need to explore the role plant-based estrogens in treating menopausal depression; fortunately, S-equol has already shown promise in this regard.

Feeling the window of vulnerability? There’s no time like the present to insure that you aren’t simply looking through the window but actually seeing that there’s hope and help on the other side. There are a lot of resources and strategies available to address depression during this time of life. While depression may be a “menopause-associated risk,” like others, it can be successfully ameliorated.

Thank you to Dr. Claudio Soares from McMaster University for an excellent review of depression in menopause and the inspiring, succinct “windows of vulnerability” terminology.

Estrogen only? Fanning the flames of the HRT debate

Posted by Liz on Dec 13, 2010 in breast cancer | 6 comments

A study presented at the esteemed San Antonio Breast Cancer Symposium last week has fanned the flames about the benefits versus risks of hormone replacement for menopausal symptoms. In this study, which ironically was pulled from the site press release highlights after experts questioned its merit, researchers did a reanalysis of data from the Women’s Health Initiative trial, the infamous 2002 study that was halted after Preempro was shown to increase breast cancer risk. Their findings? That women who had participated in the estrogen only arm of the study, had had benign breast disease, had had hysterectomies and had family histories of no breast cancer actually had significant reductions in breast cancer incidence. What’s more, 75% of women who did not have benign breast disease at the study’s start also had a reduced risk of developing breast cancer.

So, this is good news, right?

Well, estrogen alone can only be used by women who have had hysterectomies; estrogen plus progestin is used in women with intact uteri in order to avoid uterine cancer. This means that only a subset of women with menopausal symptoms are eligible to use estrogen alone. Moreover, as a physician blogger points out, the findings run counter to most data that show that estrogen use is actually associated with an increased risk of breast cancer. He also notes that abstracts that are accepted as posters at major medical meetings often have flawed or spotty data; in fact, in my years as a medical writer, I’ve often run across abstracts that ultimately disagree with published works.

The bottom line here is that despite the news, using estrogen alone to treat menopausal symptoms might only be an option for a very small percentage of women and may still place them at risk for cancer. At the end of the day, prescribing hormone replacement therapy continues to challenge the Hippocratic Oath: first do no harm.

Wednesday Bubble: Playing Russian Roulette – Hormone Replacement & Ovarian Cancer

Posted by Liz on Nov 10, 2010 in HRT | 6 comments

Do we really need to burst another hormone therapy bubble? Or have you heard enough yet? If you are anything like me, I remain puzzled by those in the pro-HRT camp that keep on insisting that the data are incorrect and that hormone replacement therapy (HRT) is safe. Just last week I received a press release stating the following:

“Medical Experts Report Reduced Risk of Life-Threatening Diseases in Women Who Undergo Menopause Hormone Therapy…Menopause experts Drs. Lovera W. Miller and David C. Miller, claim in their new book, Womenopause: Stop Pausing and Start Living (O Books 2010), that Menopausal Hormone Therapy, or MHT, can help reduce the risk of serious health conditions such as heart disease, stroke, breast cancer, diabetes, and even depression and dementia. The Millers present new evidence that puts to rest the controversial statement by the Women’s Health Initiative (WHI) in 2002 that declared MHT (formerly known as Hormone Replacement Therapy, or HRT) was harmful and could lead to the same health risks that the doctors say it now helps prevent.”

The Miller present new evidence that puts to rest the contention that HRT is harmful. Really?!

Ironically, the very same day, I received word of data presented at the American Association for Cancer Research Frontiers in Cancer Prevention Research Conference this week demonstrating that both combination hormone replacement therapy (estrogen plus progestin) and estrogen-only hormone therapy increases the risk for developing ovarian cancer. Previous studies have linked the use of estrogen only hormone therapy to ovarian cancer so these findings are important.

This latest bit of information comes out of a European study of almost 127,000 women, 424 of whom developed ovarian cancer after 9 years of followup. Among current users of hormones during the start of the study, 69% used combination HRT and 18%, estrogen-only hormone therapy. Key findings included:

• Increasing duration of use of any hormones was linked to an increased risk for ovarian cancer; women who used hormone therapy for 5 years or more had a 45% increased risk compared to women who had never used any hormones.
• Current use of any types of hormones was associated with an overall 29% increased risk for ovarian cancer.
• Type of hormone (combination versus estrogen only, regimens, how administered, as well as body-mass-index, smoking, oral contraceptive use and pregnancy history did not significantly affect risk.

In an accompanying news release, the lead investigator is quoted as suggesting that the link to ovarian cancer is consistent with recommendations that if women are going to choose to take hormones, that they take them for the shortest period of time possible.

This study joins the evolving database of evidence demonstrating that hormone replacement therapy, whether it’s combination estrogen/progestin or estrogen-only, can be a risky proposition in certain women. Want to read more trigger pulling data?

• HRT & Breast Cancer…  more and even more and don’t forget
• HRT & Death from Lung Cancer…  and more
• HRT & Heart Disease… and more

I don’t know about you but this woman is staying clear of HRT, hot flashes or not.

Wednesday Bubble me this: end the ‘silent suffering’

Posted by Liz on Oct 20, 2010 in estrogen, sexual health, vaginal atrophy | 12 comments

Bubble me this. When you think “chronic health condition,” what do you think of? I think heart disease, diabetes, multiple sclerosis or cancer. I don’t automatically think vaginal atrophy. And yet, it’s what’s for World Menopause Day.

The International Menopause Society (IMS) joined forces this year with Novo Nordisk FemCare Ag (marketers of Activella®) to ‘end silent suffering’ and promote recommendations for the management of vaginal atrophy during the menopause. A key problem, they say, is that results of a phone survey show that women are not discussing vaginal atrophy with their practitioners, who in turn, are not openly asking questions about vaginal health.

Vaginal atrophy refers to the thinning of the vaginal and vulvovaginal tissues due to a decline in estrogen, and can lead to pain, burning and soreness during sexual intercourse. Recent estimates suggest that vaginal atrophy affects about 50% of menopausal women. Symptoms can be mild or  severe, and unquestionably, the more a woman feels pain, the more she is likely to be distressed during intercourse or lose interest in sex altogether. What’s more, according to survey results, the majority of postmenopausal women incorrectly attribute vaginal atrophy symptoms to urinary tract and yeast infections. More importantly, the report notes that roughly 63% of surveyed women did not realize that vaginal atrophy was “a chronic condition requiring ongoing treatment of the underlying cause.”

A chronic condition requiring treatment?

Granted, a chronic condition is defined as a health problem lasting three years or longer. And depending on how long a woman’s menopause lasts, well, vaginal atrophy theoretically fits into that category. But aren’t we being a bit alarmist about the ‘silent suffering’ of women with this chronic condition?

Mind you, I am not mocking or doubting the horrible impact that vaginal atrophy can have on a woman’s life. In fact, aging and its accompanying aches and pains aren’t fun. Neither are hot flashes, night sweats, mood swings or vaginal pain. And I am heartened to see that the IMS has published recommendations for recognizing and managing vaginal atrophy. They include:

• Greater collaboration and open discussion with postmenopausal women about their vaginal health
• Early detection of vaginal atrophy
• The value of estrogen therapy in treatment, including HRT or preferably, vaginal tablets, cream or rings

According to these recommendations, lubricants and moisturizers are not universally recommended for use by themselves because they can be irritating and offer only temporary relief of symptoms. However, as Dr. Diana Hoppe points out in her book, Healthy Sex Drive, Healthy You, “to get the vagina adequately lubricated, I initially recommend lubricants [e.g. Replense or Astroglide]. If lubricants do not work to make sex more comfortable, I prescribe vaginal estrogen therapy, which comes in different forms.” The point that she makes is that it is important to consider lubrication issues (and the resulting atrophy) as something that can be addressed in a step-wise fashion. Nor does she discuss atrophy and dryness as if they are symptoms of a chronic condition. In fact, like Dr. Christine Northrup, Dr. Hoppe emphasizes that women’s health issues, in particular desire, are multifaceted and emotionally and physically related. Toward that end, is it possible that by focusing solely on the physiological aspects of atrophy, practitioners might miss other important factors?

The IMS recommendations also fail to mention selective estrogen receptor modulators (SERMS), which mimic the action of estrogen in the body but theoretically, without associated risks and side effects. Most importantly, while ‘localized’ estrogen (i.e. topically or vaginally applied) may have a better safely profile than systemic estrogens (which directly enter the bloodstream after being ingested or injected) it is not without risks; according to its package insert, Activella is associated with pain, headache, nausea, vomiting, irregular bleeding and thickening of the vaginal wall and and also has a boxed warning about heart disease, stroke and blood clotting.

There’s an inherent lesson here, which is why this piece is featured on Wednesday: by all means, seek help for vaginal atrophy but ask questions about the therapy your doctor or practitioner recommends. If your symptoms are severe, well, you might want to skip the lubricants and go for the big guns. And be sure to consider factors other than estrogen depletion that might be contributing to a declining libido. If there’s one thing that appears to permeate all women’s health issues, it’s this: nothing is as cut and dry as it seems.

I hardly believe that we’re on the verge of an atrophy epidemic or that we need to dramatize the “silent suffering” of countless women across the globe.

Bursting this one? Yeah, you bet.