Dear Friends:

Without adequate information or a balanced perspective, the decision about whether or not to take hormone therapy (HT) can be confusing and difficult for any woman. For those who have been diagnosed with breast cancer, have a history of breast cancer in their family, or who have had an abnormal biopsy, the choice can seem even more discouraging. This discouragement comes from the controversy on the relationship between female hormones and breast cancer.

The fact that experts are divided on this issue leaves women in the middle, feeling anxious, wondering whom to believe, and unsure of what to do. WHA consulted leading researchers and practicing physicians for their views. While there are no clear-cut guidelines on whether women with or at high risk of breast cancer should take hormone therapy, this insight from experts in the field will provide help with steps toward that decision.

The Whole Picture

Although it would make life a lot easier if a choice about HT were a clear yes or no, the decision is "highly individualized," says Mary Laya, M.D., M.P.H., assistant professor of medicine at the University of Washington in Seattle. Women with breast cancer, weighing their HT options, need to consider the stage of the disease (how much it has advanced) and the amount of time that has passed since their diagnosis.

The use of HT in women with breast cancer was once off limits, but the thinking on this issue is gradually evolving. The American College of Obstetricians and Gynecologists (ACOG) has changed its position allowing that HT may be "an option" for breast cancer patients, although the decision must be jointly evaluated with a gynecologist and oncologist. This shift in attitude may reflect "increasing concern for the overall quality of life" for women, says Rowan T. Chlebowski, M.D., professor of medicine at the University of California at Los Angeles and author.

The Purpose of HT

As with any medical treatment or test, starting with a clear goal in mind helps. With HT, the goal may be short-term management of unpleasant symptoms such as hot flashes, vaginal dryness, sleeplessness, and mood swings. For other women, longer term prevention of aging issues such as osteoporosis is the primary concern. "These are two very separate issues," says Steven R. Goldstein, professor of obstetrics and gynecology at New York University.

Symptom management may be particularly important for women with breast cancer who have undergone chemotherapy that resulted in premature menopause, with sudden symptoms that make life miserable. "Hormone therapy's ability to improve that quality of a woman's life and to prevent disease outweighs its risks," says Joanne Mortimer, M.D., associate professor of medicine at Washington University School of Medicine in St. Louis. An oncologist, Dr. Mortimer believes there is "no evidence" that HT stimulates breast cancer. In addition to estrogen's protective effects on the heart and bone, she also notes the value of estrogen in increasing mental alertness and in decreasing incidence of dementia in women.

Natural Hormone Options for Breast Cancer

Low-dose estrogen, such as estriol, may be an option for managing menopausal symptoms in women with breast cancer. Although estriol has been widely used in Europe for decades, the medication is still relatively unknown in the U.S. European studies suggest that estriol does not stimulate breast or uterine tissue like the more potent estrogens.

Natural progesterone may have a protective effect on breast tissue, although this hormone does not alleviate menopausal symptoms such as hot flashes or vaginal dryness. Progesterone may also help to balance estrogen excess. Additionally progesterone is believed to play a role in bone health.

What Are My Alternatives Beyond HT?

Breast cancer patients or women concerned about higher than normal risk of the disease may want to consider other options, particularly to prevent osteoporosis and other aging issues. That's the advice Marisa Weiss, M.D., author of Living Beyond Breast Cancer gives to her patients. "My own personal feeling is that rather than HT, women with breast cancer should have a program of blood pressure control, cholesterol control, and weight control to prevent heart disease. To avoid osteoporosis, I recommend a program of exercise, calcium and vitamin D supplementation."

Dr. Weiss's view is shared by Lisa Jablon, M.D., a breast surgeon and director of the high risk program at Albert Einstein Medical Center in Philadelphia. "We do a very detailed risk assessment with women that includes a review of her family history, a session with a genetic counselor, blood tests, bone density testing, mammogram and a review of her diet. If a woman isn't at risk of heart disease, I tell her, there's no point in preventing a heart attack you'd never have anyway," says Dr. Jablon.

One Patient's Story

Judith Winston is a survivor in every sense of the word. In 1995, three years after undergoing chemotherapy for colon cancer, she felt a lump in her breast. The lump turned out to be cancerous. Now, for Judith, there was another round of treatment. This time the treatment included a lumpectomy, radiation, and tamoxifen.

A fine artist and the mother of three sons, Ms. Winston recently at age 53, began exploring another career, acting in commercials. "I look and feel young, I want to live accordingly," she said.

When diminished libido, hot flashes, and vaginal dryness began to make her feel "miserable," she started researching her options. Her gynecologist recommended against "any kind of estrogen" in view of her breast cancer diagnosis. With her internist, however, she made a decision she calls "a leap of faith." She started using natural, low-dose vaginal estrogen suppositories three times weekly to help with vaginal dryness.

In deciding to try low-dose estrogen suppositories, Ms. Winston balanced her wariness about stimulating breast cells with her desire to feel well. "My quality of life is important," says Ms. Winston. She views the low-dose natural hormone therapy as an appropriately cautious approach.

Conclusion

Making a decision whether or not hormone therapy is the right choice is highly individualized. As with other decisions, educating yourself and weighing your options is critical to attain the outcome your desire.

Next week we will share with you the stories that you sent in.

To your health,

Marla Ahlgrimm, R.Ph.
Founder and CEO, Women's Health America
1289 Deming Way
Madison, Wi 53717
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1-800-558-7046 toll free voice number
1-888-8987412 fax