Archive for October, 2010

The New York Times reported on Wednesday that the latest data from the Women’s Health Initiative (WHI) showed that hormones “not only increase the risk of breast cancer but also that the disease will be more advanced and deadly.” They are quoting the JAMA article that came out 10/20/10 by Chlebowski RT et al. which was a compilation of longer follow-up on the original group of subjects in the WHI. Later in the Times article, the reporter notes the increased risk is low, but interviews the lead author of the JAMA article, an oncologist who treats breast cancer patients at Harbor-UCLA in Torrance, California who acknowledges that we (as doctors) don’t really know how much or how long women can safely take hormones. The North American Menopause Society responded with this summary: There are 1 to 2 extra deaths from breast cancer per 10,000 women per year. Specifically, for every 10,000 women in the study who were randomized to placebo, there were 1.3 deaths from breast cancer per year. For every 10,000 women randomized to combined hormone therapy, there were 2.6 deaths from breast cancer per year. The WHI found no increase in breast cancer risk with estrogen alone among women who had had a hysterectomy.
Hormone therapy in menopause became commonly prescribed after a book by Robert Wilson called “Feminine Forever” was published (1968, Pocket Books, New York). Dr. Wilson proposed that estrogen would keep women feeling and looking younger and more vital. It was during this time frame that hysterectomy rates peaked in our country and many women had their ovaries removed surgically – sometimes well before menopause. Supporting these women with patentable estrogen-like drugs was proven to help prevent osteoporosis (thinning of the bones) and atherosclerosis (hardening of the arteries). As a medical community, it became the standard of care to offer hormone “replacement” therapy to every perimenopausal and menopausal woman – even if they still had their uterus. Now fast-forward twenty to thirty years and recognize that hysterectomy rates are lower – partly because of improved technology for surveillance (ultrasounds, MRI scans of the pelvis, smaller sampling instruments to biopsy tissue from inside the uterus) and partly because of improved technology for therapies (endometrial ablations that remove or burn the lining of the uterus, and improved surgical techniques that allow smaller incisions for same-day procedures like laparoscopy or hysteroscopy).
When estrogen alone was shown to cause uterine cancer in a small percentage of women, a synthetic progestin was added and shown to “protect” the uterus. More women were on hormones than ever before. New pharmaceutical products were hitting the market one after another and pharmaceutical companies were watching us aging baby boomers with joyful anticipation.
The next chapter of the hormone story begins abruptly with the first publication of the results of the Women’s Health Initiative (WHI) in the summer of 2002. This study has produced lots of data and papers – this weeks study is one of the follow up papers. Over ten thousand women were randomized to receive either Prempro® (a combination of Premarin – a mix of hormones synthesized from the urine of pregnant horses – and medroxy progesterone actetate – a synthetic progestin) if they had a uterus or Premarin® alone if they didn’t. Although death rates were no different between the groups, there was a statistically decreased rate of colon cancer and osteoporosis and an increased rate of breast cancer, blood clots and strokes in the hormone-using group. The study was stopped early because the researchers believed that the risks of Prempro® use out-weighed the benefits. There is still an on-going analysis of the data as we try to understand the issue. It seems that rather than answering questions we’re left with more questions to answer! What if different hormone preparations had been used? What if we had chosen topical application rather than oral hormones? What if rather than a broad-based population we had targeted younger symptomatic women in their late 40’s or early 50’s? What if we screened the population and only treated non-smokers? I’m amazed that there was no extensive data gathered on nutrition, life-pacing or stress management as part of the WHI. What if we compared hormone use to acupuncture, a modality that has been shown to effectively treat hot flashes and sleep disruptions? It’s unlikely that we’ll ever have this large a study population to explore these questions.

I read my expert colleague’s opinions and am left with an empty feeling. I’m convinced a thorough discussion of stress management, psychosocial support and nutrition should precede any and all prescription pad actions. But that’s not the way medicine is prescribed today…

I’m not going to use the “C” (as in cancer) word in this blog post. The focus will be on breast health and optimal balance. Partly because it’s October and pink ribbons are everywhere and on everything. And partly because I’d rather focus on optimal breast health and save the discussion on diseases of the breast for another day.

Optimal breast health includes a healthy loving attitude towards our bodies. We cannot do careful self-breast exams unless we are touching and looking at our breasts carefully and thoroughly. We know that before and after pregnancies and breast-feeding, our breasts respond to our cyclic hormones by increasing in size and gland complexity.  We learn quickly that the hormonal fluctuations in our cycles can result in full, tender breasts if we are out of balance from a nutrition or stress standpoint. We also know that, anatomically, our breasts are fairly straightforward. There is a web of connective tissue with blood vessels surrounding a network of glands. Body fat “fills in the gaps” and provides the contour and texture. The fat also serves as a “storage silo” for hormones and their metabolites.

Breasts serve the amazing function of milk production for our newborn child after birth. There is an elaborate dance of hormones that interweave after labor and suckling. A relaxed, unstressed and nourished new mother produces milk easily and bountifully for her relaxed and unstressed child. Nature allows a smaller volume, higher protein colostrum to serve as nourishment and “immune system booster” until regular breast milk is created within a few days after birth.

But sometimes we forget this mystical dance. There’s a cultural expectation that we should undergo enlargement with implants if our breast size is too small and reduction with surgery if our breast size is too big.  And because our breasts are situated anatomically right over our heart, they are a magnifying focus for negative emotional energy from heartbreak and loss.

Listen, I’m all for pink ribbons and awareness and screening…don’t get me wrong. I’m just asking that we START with an attitude of awe and wonder and appreciation for our breasts and what they’re designed to do.