Hormone replacement therapy…timing is everything, right?

Posted by 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.


  1. 2-3-2011

    Great post! HRT has continually been in the news due to the alarming media portrayal. We also covered it here (http://womensvoicesforchange.org/hormone-therapy-and-breast-cancer-the-new-york-times-ends-the-week-with-more-bad-news.htm), but our takeaway is much the same: that “it is clear that each woman who chooses to use systemic hormone therapy must do so knowing that right now, the only certainty is that the medical and scientific community cannot even state how long a woman can use the lowest dose possible of systemic hormone therapy to control her symptoms without increasing her risk of breast cancer.”

  2. 2-19-2011

    I have been on HRT for 20 years. I had early onset of menopause just after the birth of my third child (I was 39). My symptoms were severe depression, instant irritability and irrational death-wishes. My blood tests showed I was not producing the hormones I required. Once I started HRT, I was liberated – actually never happier. (I have not had a hysterectomy.) My GPs have continued to monitor my state of health and I have regular mamograms – so far no problems.

    Two weeks ago, after several discussions over the years with doctors about the risks of HRT, I decided to stop the treatment and asked my GP to continue to monitor my condition. He suggested a reduction rather than ‘cold turkey’. I have been through one cycle and have noticed sleep pattern disturbance and night-flashes but nothing I can’t live with. My mental-emotional state seems also to be stable.

    My husband has encouraged me to research alternatives – he probably doesn’t want the return of ‘Medea-She-Devil’!

    • 2-20-2011

      Hey Ginny:

      Thanks for commenting. One of the challenges with HRT is that doctors don’t know how to stop it when patients decide that they want to go off. I wrote about this in May of last year. Meanwhile, now that you have stopped, what do you do? I highly recommend that you check out the posts on hot flashes, night sweats and sleep. You can do that by clicking on any of these terms in the tag cloud on the home page of Flashfree. Many women I know, myself included, have had great success with a standardized formulation of Black Cohosh called Remifemin; its readily available in drugstores and online. However, before starting herbs, it’s advisable to speak to a health practitioner or an acupuncturist with a specialty in herbal medicine so that you can figure out the best dosage and regimen for your individualized needs.

  3. 6-6-2011

    Just have come off HRT after 5 years doctor advised but hot flushes back with vengence
    And not feeling the same nothing else worked before took 1 year to decide after all the pros and cons. Flushes are so bad thinking I will have to continue to take HRT.

    • 6-6-2011

      Isabel, part of the problem with HRT is that doctors don’t have any guidelines for helping women wean off of them. If you stopped abruptly, it’s no wonder that your flashes have returned in full force. Have you considered speaking to an acupuncturist or Chinese medicine specialist before resuming hormones?


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