Among the many unanswered questions about hormones prescribed for menopause is whether a woman’s health risks change after she stops taking the pills. A new study shows that virtually all the benefits disappear but that a slightly higher risk for breast and other cancers persists for at least three years after stopping the drugs.
The data come from a major study by the Women’s Health Initiative that looked at more than 16,000 women who used the estrogen and progestin combination drug Prempro, made by Wyeth. Reporting in The Journal of the American Medical Association, the study’s investigators urge caution in interpreting the results, noting that a woman’s individual risk remains small. The excess cancer risk among former hormone users translates to an added annual risk of 0.3 percent for an individual woman, or three additional cases of breast or other cancers a year among 1,000 women.
The findings don’t change current recommendations for hormone use, which advise that women consider using hormones only if they have moderate to severe hot flashes and other symptoms, and only at the lowest dose and for the shortest possible time.
“What we found in the study is quite consistent with the current guidelines,” said Gerardo Heiss, the report’s lead author and a professor of epidemiology from the University of North Carolina, Chapel Hill. “There is no reason for alarm. The absolute risk is of small magnitude.”
One of the biggest benefits of hormone drugs, an improvement in bone health, all but disappeared during the three years after women stopped taking the drugs. But other risks, like blood clots, stroke and heart attacks originally seen among older hormone users in the study, also quickly dropped back to normal rates once the women stopped taking the drugs.
The research was halted in mid-2002 because older women in the study who were long past menopause were at higher risk for heart attacks if they began using hormones. The findings changed the medical community’s views on hormone therapy, which was once used as a treatment to prevent chronic disease. Today, menopause hormones are advised only for the treatment of moderate to severe hot flashes and other menopause symptoms, and doctors typically prescribe far lower doses of the drugs and in a form different from those used in the study.
The report focuses on the three years following the end of the study, comparing the health of women who took hormones with that of participants who took placebos.
The Women’s Health Initiative investigators haven’t yet analyzed the part of the study concerning women with hysterectomies who used only estrogen. (Progestin is taken only if a woman still has a uterus to protect her from endometrial cancer.) In that group, overall breast cancer rates were lower among hormone users, although the data failed to reach statistical significance.
Future papers will provide additional analysis of the cancer trends in the study, the investigators said. During the three years women stopped taking hormones, there was some suggestion that their breast cancer risk began to drop from peak levels, but the overall risk remained about the same. The breast cancer data weren’t statistically significant, suggesting chance could play a role, but researchers say the trends are credible because they are consistent with previous research.
Other data on cancer risk also failed to reach statistical significance. For instance, there was a troubling suggestion that lung cancer risk was slightly higher among former hormone users, but that trend could also be due to chance.
It was only after researchers combined all the data from various types of cancers that they were able to show a statistically significant difference between the former hormone users and those who had used placebos during the study.
“I think the findings provide further support for recommendations to not use hormone therapy for chronic disease prevention,” said Dr. JoAnn Manson, a Women’s Health Initiative investigator and chief of preventive medicine at Brigham and Women’s Hospital in Boston. “Younger recently menopausal women have very low rates of adverse events related to hormone therapy, so if they’re getting symptom and quality of life benefits, those benefits are still likely to outweigh the risks.”
Wyeth said the data don’t change the fact that women should consult their doctors when making a decision about hormone therapy.
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23 Comments
Hormones used in WHI study were conjugated (horse) estrogens and progestins, not progesterone. The problem with conjugated estrogens is inability of our body to get rid of them properky. Natural estrogens are metabolised via 2-OH pathway, which is ok. Conjugated estrogens are metabolised via 4-OH pathway which is not natural and may create cancerogenic substances. The solution of the problem might be use of hormones with the same molecular structure as our own.
— Sergey Kalitenko MDFrom TPP — These are theories that are not proven, however many people do agree that chemically identical estrogen and progesterone may have different effects.
During the three years after they stopped using hormones did the former hormone users undergo more cancer screenings than those who had taken placebos?
From TPP — Very good question. The researchers don’t know the answer but given that these women were told they might be at higher risk, having been on hormones, it’s quite possible that what we are seeing is increased vigilance about screening in the cancer group. So they are finding more cancer because they are looking more often. As i’m sure you are aware, whether this is effect is due to vigilance is something that will only become apparent over time.
— kalebergWhat are they doing about those of use who cannot stop therapy because of severe hot flashes. I have tgried three times to wean myself from HRT and my quality of life is awful. Hourly hot flashes and very bad sleep at 64 is not good quality of life. I’m taking 1/2 dose of HRT and trying to cut it even more.
From TPP — The data show pretty clearly that the benefits outweigh risk for women with severe symptoms. I don’t think you should worry about this.
— PhyllisMy Dr. had me on HRT for 5 years. When the first study came out linking HRT wi. a higher cancer risk, I stopped taking estrogen and progestin, even though he insisted there was no risk.
— HedyLast year I was diagnosed wi. stage 2 breast cancer, estrogen driven.
I totally believe that HRT was responsible for this.
I do not drink or smoke, eat whole foods, and get plenty of exercise. I have spent my entire life avoiding pesticides, herbicides, and meats known to have hormones in them.
What a rude awakening!
Hedy
My dear Doctor spent a lot of time sharing information in 1996, suggesting that there were benefits to hormone replacement therapy. I believe I tried his prescription for a week or two and disliked them, so stopped. It reminded me too much of how nasty I felt taking birth control pills (in the 1970s and on…got to the point of feeling nauseous before taking them). I have never regretted my intuitive response. Thank God for intuition! My prayers are with any suffering the aftereffects of HRT!
— WendyMy female doctor encouraged me to go HRT route because it was believed to be good for the heart and for preventing bone loss. I had quit taking HRT the year before study came out linking this therapy with breast cancer. I was diagnosed with stage 1 breast cancer in May 2002. I had a healthy lifestyle and their had been no history of breast cancer on either my paternal or maternal side. Neither my mother or my older sister ever went on any kind of HRT and I still believe it was the HRT that I did for four years that caused the breast cancer. I wound up having a mastectomy after a lumpectomy and two re-excisions were unable to give me clear margins. I had ductal carcinoma in situ type breast cancer, estrogen positive. I did not have any chemotherapy or did I go on any preventive medication to prevent reoccurrence. I have reached the 5-year mark still cancer free.
— Theresa HernandezI had a total hysterectomy 6 years ago. Because
— Carolmy mother had Breast Cancer at 65 I opted not to receive HRT! Today I am about to finish radiation
treatments after stage 2 Breast Cancer which first
included Chemo and a Radical Modified Mystectomy!
My cancer at 49 was Hormone Positive and I’m currently on AriMidex for 5 years inorder to remove
all estrogen from my body. I would say-Ladies, do
not put anymore Estrogen into your Body if you can
help it!
As Carol’s posting above suggests. family genetics for breast cancer likely explain these findings.
— MARK KLEIN, M.D.Wendy #5 posted a comment referencing the BCP. How is the Pill similar/ different to HRT? Do they work in the same way, have similar risks? Will the choice to use BCP now, in my 20s, affect my risks later in life when I face menopause and the choice to use HRT?
— MelissaThere doesn’t seem to be much balance in the way we do things. Also, we don’t ask the next questions when it comes to statistics, such as how many women do percentages actually translate into. The hysterical response to the WHI results continues even as findings morph and new findings emerge. Women get breast cancer. They get breast cancer whether or not they take HRT. But more women die of heart attacks and heart disease than of breast cancer. If starting HRT when you’re on the cusp of menopause provides some protective benefits, should that not be taken into consideration? Or shall we continue to scream and yell and rend our clothes over HRT and blame our physicians for prescribing what they truly believed was of great benefit. Let the buyer beware. And let the buyer actually investigate what statistics actually mean, and make informed decisions based on all the information available.
posted ny ES
— Evelyn SharenovWomen shouldn’t necessarily take the advice of the Wyeth pharmaceutical company to “consult their doctors when making a decision about hormone therapy.”
— Carol 2The medical community knew years before the Women’s Health Initiative that hormones raised the risk for breast cancer, but encouraged their use in the hopes of reducing heart disease and stroke. It didn’t matter that there was no solid evidence to prove that they did. And, of course, the Women’s Health Initiative proved they did not.
Despite the fact that I was at high risk for breast cancer and had no problem with menopausal symptoms, some doctors suggested I take hormones. One all but expressed sympathy that I would wither away without them.
That’s not to say that a woman shouldn’t take hormones if her symptoms interfere with her ability to function, but those with moderate symptoms may very well be better off waiting for them to pass.
Many women have trouble going off hormones because the menopausal symptoms come back with great intensity as the drug works its way out of their system. It can take months to get to a point where hormone levels stabilize and the symptoms dissipate.
#5 Theresa
I had the same breast CA in 1985 and I’m still going strong at the age of 66!
— MarleneTPP and anyone taking HRT for ’severe’ symptoms: please tell those who took HRT and now have cancers how it is that your hot flashes and sleeplessness are worse than breast, gyne and gastrointestinal cancers, their treatments, and merely postponed early death? (There is no cancer cure).
There is no point or age at which these drugs are NOT carcinogenic, and then suddenly, carcinogenic. There is no point after taking them that you are free of the risk.
Your physicians and pharma are off the hook if you insisted you had to have these drugs because your symptoms were severe.
Lose weight, quit eating useless carbs (eat whole grain limited), stop drinking soft drinks with caffeine, including coffee and tea, eat smaller, vegetable filled meals and eat small meals more frequently. Stop drinking alcohol and smoking. All those things play with your hormones, which include insulin and thyroid.
Exercise hard up to an hour everyday, on top of your daily schedule. If you can’t do that now, hire an exercise therapist to design a program for you to get you there.
I did all those things and had no problem with menopause. I don’t think it was a coincidence.
— NLI yield to no one in my enthusiasm for vigorous exercise; in fact, I become a bore on the subject of heavy weight lifting’s benefits for women of all ages. However, there exist a small number of women who can make every possible positive change in lifestyle and still suffer horrible, debilitating menopausal symptoms. Some of them may feel that a small - and it is small - additional risk of breast cancer is better than a life of horrific hot flashes, and insomnia.
— kalebergFor Phyllis (#3) and others in the same boat with persistent hot flashes, Jane Brody wrote a year or so ago of her good experience with gabapentin, an anti-seizure drug, as an alternative to HRT for hot flashes. Perhaps you could search for this article and explore this option with your doctor. I don’t have personal experience, but Ms. Brody’s article suggested that it might be a solution for some people.
— AnneEverybody knows that the WHI was not designed to study early menopausal symptomatic women.Thus,it has no external validity,i.e.its results cannot be extrapolated to other groups of women under different hormonal treatments.The lung cancer story is amazing,to say the least…What else will be squeezed out of the WHI to prove that millions of dollars were wisely spent? The WHI has no doubt caused already a lot of damage to women’s health. Only the ongoing KRONOS study designed to study HT’s in symptomatic early postmenopausal women will give the right answers.Preventing women from the benefits of correctly indicated and prescribed HT’s because of the fear of rare side effects is not satisfactory Medicine.
— manuel neves-e-castro,MDWhat would get me thru menopause is a couple of cartons of cigarettes. Just a few smokes every day, then I’ll quit, I promise. Surely the benefits — calmed nerves, clearer thinking, emotional stability — of this known carcinogen would outweigh the risks.
No dctor in her right mind would agree with that, but there are plenty of them who bizarrely think that hormones — known carcinogens — provide benefits that outweigh the risks.
What they don’t tell you is that HRT doesn’t fix the changes associated with the ‘Pause — it generally just postpones them, which is why women write in complaining of hot flashes after trying to get off HRT for ten years. The bothersome symptoms typically rebound the minute you stop the drug.
Just like they do with alcohol or tobacco.
And! Hot flashes are not a life-threatening condition. No one ever died from a hot flash. They come on — then they go away. Carrying a fan, and wearing adjustable clothing, is perhaps a more reasonable approach than ingesting known carcinogens.
And who’s to say that there aren’t benefits to hot flashes, perhaps an immune-boosting and/or microbicidal effect that’s never been studied?
The endless symtomatization of menopause is a larger problem in this culture. Why are so many women (and men) so ill-equipped to cope with the natural and inevitable changes of our aging? Are we somaticizing other issues — social, personal, political, sexual — that are still taboo, or perhaps even too big, to complain about? Are these bodily complaints — about ‘devastating’ hot flashes, disturbed sleep, or whatnot — a metaphoric chorus for other things that are really wrong?
A New England Journal study by Harvard expert Dr. JoAnn Manson showed that HRT, while alleviating hot flashes, had no absolutely positive effect on women’s quality of life, even after the flashes went away, suggesting that it’s not really hot flashes that are the problem.
Perhaps it’s quality of life, or the perception of that quality. It’s well-known that women around the world have widely different, culturally-based experiences around menstruation, birthing, and menopause.
Our obsesson with the woes of menopause will probably, someday, historically, look like the Victorians’ propensity for swooning in public: the socially-constructed, acceptable malaise of the age.
And why are men even in this discussion??
You do have to wonder what would happen if guys got hot flashes. It would be totally different: “Baby, you shoulda seen me today - I was sssmmmokin! I had to take it all off — jacket, tie, shirt — right there in the board room. I was sweating like a boar. The boss had to hose me down with her water bottle. It was hilarious…”
The best way to get thru the ‘Pause is to apply all the things you already know: Eat good food, not too much; exercise; stay connected to life; don’t obsess about your looks/weight/symptoms; say no to drugs, and yes to humor, work, and love.
— Katharine M. Hikel, MDThere is so much nonsense and distraction in this sort of study.
The entire study design and focus *suggests*–though it does not say outright, because it cannot, because it is not true–that HRT is the most salient factor leading to breast cancer risk.
This simply is not the case.
Poorly-publicized studies have shown that insulin levels, and patterns of insulin spiking, are extremely strong indicators both of breast cancer risk and of recurrence.
Wonder why this isn’t publicized. Maybe because insulin levels and spiking are linked to the junky food and high-carb diets most women eat.
There are no benefits I am aware of, to having high insulin levels and spiking. On the contrary, these are known to lead to type II diabetes in the susceptible.
Other under-researched factors: chemical exposure, dietary omega-3s vs. omega-6s and trans-fats, etc. But why focus on these? You can’t use those studies to sell a drug.
But if you can scare women into thinking their own estrogen–something that once was quite lovely but somehow now has become instantly evil, an awfully odd logical shift–is the most salient factor then you can get them to take Arimidex (shut down all your hormones and get depressed and never have sex again) and other estrogen-focused drugs.
OTOH, natural estrogen has many benefits. For women with significant mood disorder or other mental illness, for example, sx often worsen after estrogen levels drop. This is documented. Supplementation of all hormones in natural form can be stabilizing. Ditto for so many other aspects of health: skin, hair, gums, vaginal membranes, gut. My hygienist told me she could tell who of her patients are on HRT and who are not, just by looking at the state of their gums. What’s the difference, I said. She said, the gums of the women who take estrogen are pinker.
You don’t have to take commercial equine estrogens, you don’t have to take progestin (which is marketed as same as your own progesterone, and is decidedly not). You don’t have to do high levels.
— appleThe fatter a woman, the more endogenous estrogen. Back to square one: it’s the estrogen.
— NLIf you are having hot flashes get a fan. Carry a little folding one in your purse, have a portable one by your bed. Begin fanning as soon as you feel one starting and it will abort it. Really! And monitor your diet. See what brings on your hot flashes. I always got them with wine, cake, and red meat, (and, strangely, every evening as the sun went down). It took 10 years for them to finally stop, but I made it without HRT. It would have only postponed the symptoms. My 70 year old sister-in-law finally stopped the hormone therapy and is now suffering terrible hot flashes. I’m grateful to be done with it all.
— NancyNL, you are right about the fat. It’s a huge factor, underpublicized. But skinny women do get breast cancer, so that’s just not all of it.
And I agree about the hot flashes. Who cares. That’s minor compared to other stuff that estrogen deficiency causes. Oh, like osteoporosis. No, taking calcium pills is not enough. You need adequate estrogen AND vitamin D to absorb that calcium.
Just get hormone levels monitored. Most docs don’t do this. They just take a blanket line, give HRT or don’t. That’s crazy. It’s like saying, thyroid supplementation is bad or it’s good. No, of COURSE you monitor the patient and give supplementation up to the level you want to see.
Many healthy women do continue to produce low levels of endogenous estrogen after menopause. They may not need HRT. But many women don’t produce any more hormones–any of those needed for normal functioning (estrogen, progesterone, testosterone, DHEA), for various reasons. And they may be the ones who need supplementation most.
— appleI was curious to see that no one mentioned antidepressants as being helpful for menopausal symptoms.
When I was very close to menopause, my GYN asked me how I was sleeping and I said “Great”. Then she looked at my chart and said “Oh, of course you are, you’re on anti-depressants”.
Since this conversation, which took place about 2 years ago, I have since noticed an occasional snippet written about this very finding — that women on anti-depressants may not experience menopausal symptoms which they might otherwise experience were they not on an antidepressant.
I don’t know if this is strictly based on anecdotal information, or if there is any research behind this hypothesis. I don’t know either if the class of antidepressants matters — I am on an SSRI.
All I know is that I sleep wonderfully well and have no hot flashes.
From TPP — They work for some, but not all, women. I wrote about the issue HERE>
— New-PeaI mentioned in my previous post that I may be getting some protection from menopausal symptoms thanks to my antidepressant. My sole reason for now considering hormones — almost exactly one year since my last period — is the serious decline I have been experiencing in brain function.
For at least the past 5 years my memory has been severely eroding — both long term and short term memory. This is mostly annoying when I find myself having to strain to find common, everyday words; or, similarly, when I find myself substituting words which are not related but have some common meaning, e.g., in the kitchen, I might say, “put the roast in the trunk”. More disturbing is when I can’t remember that I have told a friend something, and I retell the story for a second time… and have absolutely no recall of having told them (relatively recently).
After reading the chapters in The Female Brain by Louann Brizendine regarding brain changes at menopause, I came away with two words that I have no trouble remembering: BRAIN ATROPHY!
I do occasionally wonder whether antidepressant use can be contributing to these memory problems. I know that when I was on a much higher dose of my SSRI, a good 7 years before menopause, I had the same symptoms which I am now attributing to Brain Atrophy. I fairly quickly attributed it to the high dose, reduced my dose, and the issues mostly resolved.
In any event, I’m wondering what is known about how well hormones work to help “rejuvenate” the brain. I am very tempted to try them to see if it restores my memory. My GYN tells me I need to do it sooner rather than later.
— New-Pea