Fw: Subject Reference: Estrogen & Cancer Risk / Harvard Commentaries

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Subject: Subject Reference: Estrogen & Cancer Risk / Harvard Commentaries

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opinions from medical experts Harvard Commentaries

Harvard Commentary: Estrogen And Cancer RiskJanuary 22, 2001

In December 2000, a panel of federal scientific advisers recommended that steroidal estrogen - the type used in postmenopausal treatments and birth control pills - be added the nation's list of cancer-causing substances because of its association with endometrial cancer and, to a lesser extent, breast cancer. Another type of postmenopausal estrogen, conjugated estrogen (Premarin), is already on the list. To find out more about estrogen and the risk of cancer, InteliHealth contacted Caren , M.D., assistant professor at Harvard Medical School and associate director of Women's Health for Research.

Q: What is estrogen?

Dr. : Estrogen is a hormone that is made by the ovaries in premenopausal women and is integral to normal sexual development and reproductive function. It also has other important effects, such as keeping bones strong, and is thought to contribute to the low risk of heart disease in women before menopause. After menopause, a woman's production of estrogen drops dramatically. At this time, many women decide to take supplemental estrogen, in the form of a pill or patch. It helps with symptoms related to estrogen deficiency, such as hot flashes and vaginal dryness. It's also recognized to be good for bones, in that estrogen replacement can prevent or minimize the fall in bone density that is typically seen after menopause, and can even increase bone density.

Q: What are the risks of estrogen?

Dr. : One clear concern, and indeed a key factor in estrogen appearing on the list of cancer-causing substances, is that women who use postmenopausal hormone therapy have been reported in several studies to have an increased risk of breast cancer. In a report from the Nurses' Health Study, which involved very large numbers of postmenopausal women, those taking hormone replacement therapy for five or more years had a 40 percent greater risk of developing breast cancer than those not taking it. But when used for a short time (less than 5 years) - which is how it's typically used for menopausal symptoms - there wasn't any appreciable increase in risk. Also, estrogen used alone increases the risk of cancer of the lining of the uterus --- endometrial cancer. But that risk is minimized or eliminated by giving progestin, another female hormone, with the estrogen. Some other noncancer risks associated with estrogen replacement therapy should also be mentioned. This therapy increases the risk of developing a blood clot in the veins of the leg or lungs and also is associated with an increased risk of gallbladder disease.

Q: What exactly is this list?

Dr. : Every two years, the National Toxicology Program, a division of the National Institutes of Health, updates a federal list of proven and suspected cancer-causing substances. When a substance appears on the list, it does not mean that it has suddenly been recognized to be associated with cancer. For instance, ultraviolet radiation - sunburn-causing rays known to also cause cancer - was also just recommended for addition to the list.

Q: Does this mean women shouldn't consider taking supplemental estrogen?

Dr. : What's important to remember with estrogen is that these aren't new findings. So this shouldn't come as any kind of "panic statement." However, the Food and Drug Administration listing does reinforce that women should be aware of the association of estrogen therapy with breast and uterine cancer that has been reported in many studies. These and other risks need to be balanced against the potential benefits. For some women, it may be reasonable to take estrogen, and for others it may make no sense at all.

Q: So who should take estrogen?

Dr. : For women who are symptomatic (for example, having hot flashes, vaginal dryness, etc.) and who don't have any clear reason not to take it, estrogen is the most effective therapy by far for this problem. It significantly reduces hot flashes in most women and can improve other symptoms and the overall sense of well-being. Prevention and treatment of bone loss are also reasonable indications for hormone replacement therapy (HRT) although women should be aware that there are good alternatives now available (bisphosphonates, such as alendronate and residronate, and selective estrogen receptor modulators, such as raloxifene). The potential benefits and risks of these agents should be weighed against those of estrogen.

Women in whom estrogen is generally not recommended are those with a personal history of breast cancer or a premalignant breast lesion, a family history of breast cancer, a history of blood clots, unexplained vaginal bleeding or a history of endometrial cancer (although HRT is prescribed for some women who have had stage I endometrial cancer that was effectively treated). There are other relative contraindications, such as a history of fibroids, which can grow when you take estrogen, or gallstones.

Q: What about birth control pills?

Dr. : The data have been less clear for the risk with birth control pills. Some studies suggest there's a slightly increased risk of breast cancer, but other studies show no increase. A recent study looked at the risk of oral contraceptives in women with a family history of breast cancer and found there may be a higher risk, but this related to history of use of oral contraceptives with higher estrogen content than those typically used today. More data are needed to determine the magnitude of increased risk, if any, with use of current preparations.

It is also important to keep in mind that oral contraceptives have other benefits. In terms of cancer risk, they have been associated with a lower risk of ovarian cancer.

Caren G. , M.D. M.P.H., is an Assistant Professor of Medicine at Harvard Medical School, and is Associate Director for Research of Women's Health in the Department of Medicine at Brigham and Women's Hospital.

This interview is not intended to provide advice on personal medical matters, nor is it intended to be a substitute for consultation with a physician. ============================================================

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