Tuesday, May 26, 2009
I am feeling very introspective and like something inside me is awakening. I need to block all outside chatter to listen very carefully. The whole of last year I ignored the little voice inside me that said: 'Be still, I need to tell you something'.
When something potentially life threatening is chasing you with a big stick, you sit down and listen!! Now I am doing exactly what my intuition tells me to.
So if I have not called you or made a plan to see you, please excuse me. I am not sure when next I will feel like seeing anyone.
I am seeing Patricia, the 'Soul Dr', once or twice a week. She is a sounding board for my own intuition and is helping me to trust what I am sensing. I am feeling very grounded, energised, and happy.
Patricia warned that I must not think I can just go back to the way was living just yet as I may become exhausted again (I don't think I will ever as I can see what exhaustion can result in).
I don't have any extra energy for anyone or anything. I feel irritated by the thought of seeing or doing anything so I am going to listen to this (Feels very strange I must add!!). I need all the energy I can muster to heal.
I do the body awareness technique every second day and I am slowly integrating energy held in my past back into present time. This process seems very slow indeed but I am getting better at it with each attempt.
Until next time,
Saturday, May 9, 2009
DR. JOHN R. LEE'S THREE RULES FOR HORMONE REPLACEMENT THERAPY
Use a sprinkle of common sense and a dash of logic.
by John R. Lee, M.D.
The recent Lancet publication of the Million Women Study (MWS) removes any lingering doubt that there’s something wrong with conventional HRT (see Million Woman Study in the UK, Published in The Lancet, Gives New Insight into HRT and Breast Cancer for details). Why would supplemental estrogen and a progestin (e.g. not real progesterone) increase a woman’s risk of breast cancer by 30 percent or more? Other studies found that these same synthetic HRT hormones increase one’s risk of heart disease and blood clots (strokes), and do nothing to prevent Alzheimer’s disease. When you pass through puberty and your sex hormones surge, they don’t make you sick—they cause your body to mature into adulthood and be healthy. But, the hormones used in conventional HRT are somehow not right—they are killing women by the tens of thousands.
The question is—where do we go from here? My answer is—we go back to the basics and find out where our mistake is. I have some ideas on that.
Over the years I have adopted a simple set of three rules covering hormone supplementation. When these rules are followed, women have a decreased risk of breast cancer, heart attacks, or strokes. They are much less likely to get fat, or have poor sleep, or short term memory loss, fibrocystic breasts, mood disorders or libido problems. And the rules are not complicated.
Rule 1. Give hormones only to those who are truly deficient in them.
The first rule is common sense. We don’t give insulin to someone unless we have good evidence that they need it. The same is true of thyroid, cortisol and all our hormones. Yet, conventional physicians routinely prescribe estrogen or other sex hormones without ever testing for hormone deficiency. Conventional medicine assumes that women after menopause are estrogen-deficient. This assumption is false. Twenty-five years ago I reviewed the literature on hormone levels before and after menopause, and all authorities agreed that over two-thirds (66 percent) of women up to age 80 continue to make all the estrogen they need. Since then, the evidence has become stronger. Even with ovaries removed, women make estrogen, primarily by an aromatase enzyme in body fat and breasts that converts an adrenal hormone, androstenedione, into estrone. Women with plenty of body fat may make more estrogen after menopause than skinny women make before menopause.
Breast cancer specialists are so concerned about all the estrogen women make after menopause that they now use drugs to block the aromatase enzyme. Consider the irony: some conventional physicians are prescribing estrogens to treat a presumed hormone deficiency in postmenopausal women, while others are prescribing drugs that block estrogen production in postmenopausal women.
How does one determine if estrogen deficiency exists? Any woman still having monthly periods has plenty of estrogen. Vaginal dryness and vaginal mucosal atrophy, on the other hand, are clear signs of estrogen deficiency. Lacking these signs, the best test is the saliva hormone assay. With new and better technology, saliva hormone testing has become accurate and reliable. As might be expected, we have learned that hormone levels differ between individuals; what is normal for one person is not necessarily normal for another. Further, one must be aware that hormones work within a complex network of other hormones and metabolic mediators, something like different musicians in an orchestra. To interpret a hormone’s level, one must consider not only its absolute level but also its relative ratios with other hormones that include not only estradiol, progesterone and testosterone, but cortisol and thyroid as well.
For example, in healthy women without breast cancer, we find that the saliva progesterone level routinely is 200 to 300 times greater than the saliva estradiol level. In women with breast cancer, the saliva progesterone/estradiol ratio is considerably less than 200 to 1. As more investigators become more familiar with saliva hormone tests, I believe these various ratios will become more and more useful in monitoring hormone supplements.
Serum or plasma blood tests for steroid hormones should be abandoned—the results so obtained are essentially irrelevant. Steroid hormones are extremely lipophilic (fat-loving) and are not soluble in serum. Steroid hormones carry their message to cells by leaving the blood flow at capillaries to enter cells where they bond with specific hormone receptors in order to convey their message to the cells. These are called “free” hormones. When eventually they circulate through the liver, they become protein-bound (enveloped by specific globulins or albumin), a process that not only seriously impedes their bioavailability but also makes them water soluble, thus facilitating their excretion in urine. Measuring the concentration of these non-bioavailable forms in urine or serum is irrelevant since it provides no clue as to the concentration of the more clinically significant “free“ (bioavailable) hormone in the blood stream.
When circulating through saliva glands, the “free” non–protein-bound steroid hormone diffuses easily from blood capillaries into the saliva gland and then into saliva. Protein-bound, non-bioavailable hormones do not pass into or through the saliva gland. Thus, saliva testing is far superior to serum or urine testing in measuring bioavailable hormone levels.
Serum testing is fine for glucose and proteins but not for measuring “free” steroid hormones. Fifty years of “blood” tests have led to the great confusion that now befuddles conventional medicine in regard to steroid hormone supplementation.
Rule 2. Use bioidentical hormones rather than synthetic hormones.
The second rule is also just common sense. The message of steroid hormones to target tissue cells requires bonding of the hormone with specific unique receptors in the cells. The bonding of a hormone to its receptor is determined by its molecular configuration, like a key is for a lock. Synthetic hormone molecules and molecules from different species (e.g. Premarin, which is from horses) differ in molecular configuration from endogenous (made in the body) hormones. From studies of petrochemical xenohormones, we learn that substitute synthetic hormones differ in their activity at the receptor level. In some cases, they will activate the receptor in a manner similar to the natural hormone, but in other cases the synthetic hormone will have no effect or will block the receptor completely. Thus, hormones that are not bioidentical do not provide the same total physiologic activity as the hormones they are intended to replace, and all will provoke undesirable side effects not found with the human hormone. Human insulin, for example, is preferable to pig insulin. Sex hormones identical to human (bioidentical) hormones have been available for over 50 years.
Pharmaceutical companies, however, prefer synthetic hormones. Synthetic hormones (not found in nature) can be patented, whereas real (natural, bioidentical) hormones can not. Patented drugs are more profitable than non-patented drugs. Sex hormone prescription sales have made billions of dollars for pharmaceutical companies Thus is women’s health sacrificed for commercial profit.
Rule 3. Use only in dosages that provide normal physiologic tissue levels.
The third rule is a bit more complicated. Everyone would agree, I think, that dosages of hormone supplements should restore normal physiologic levels. The question is—how do you define normal physiologic levels? Hormones do not work by just floating around in circulating blood; they work by slipping out of blood capillaries to enter cells that have the proper receptors in them. As explained above, protein-bound hormones are unable to leave blood vessels and bond with intracellular receptors. They are non-bioavailable. But they are water-soluble, and thus found in serum, whereas the “free” bioavailable hormone is lipophilic and not water soluble, thus not likely to be found in serum. Serum tests do not help you measure the “free,” bioavailable form of the hormone. The answer is saliva testing.
It is quite simple to measure the change in saliva hormone levels when hormone supplementation is given. If more physicians did that, they would find that their usual estrogen dosages create estrogen levels 8 to 10 times greater than found in normal healthy people, and that progesterone levels are not raised by giving supplements of synthetic progestin such as medroxyprogesterone acetate (MPA).
Further, saliva levels (and not serum levels) of progesterone will clearly demonstrate excellent absorption of progesterone from transdermal creams. Transdermal progesterone enters the bloodstream fully bioavailable (i.e., without being protein-bound). The progesterone increase is readily apparent in saliva testing, whereas serum will show little or no change. In fact, any rise of serum progesterone after transdermal progesterone dosing is most often a sign of excessive progesterone dosage. Saliva testing helps determine optimal dosages of supplemented steroid hormones, something that serum testing cannot do.
It is important to note that conventional HRT violates all three of these rules for rational use of supplemental steroid hormones.
A 10-year French study of HRT using a low-dose estradiol patch plus oral progesterone shows no increased risk of breast cancer, strokes or heart attacks. Hormone replacement therapy is a laudable goal, but it must be done correctly. HRT based on correcting hormone deficiency and restoring proper physiologic balanced tissue levels, is proposed as a more sane, successful and safe technique.
Hormone imbalance is not the only cause of breast cancer, strokes, and heart attacks. Other risk factors of importance include the following:
Men share these risks equally with women. Hormone imbalance and exposure to these risk factors in men leads to earlier heart attacks, lower sperm counts and higher prostate cancer risk.
Conventional hormone replacement therapy (HRT) composed of either estrone or estradiol, with or without progestins (excluding progesterone) carries an unacceptable risk of breast cancer, heart attacks and strokes. I propose a more rational HRT using bioidentical hormones in dosages based on true needs as determined by saliva testing. In addition to proper hormone balancing, other important risk factors are described, all of which are potentially correctable. Combining hormone balancing with correction of other environmental and lifestyle factors is our best hope for reducing the present risks of breast cancer, strokes and heart attacks.
A much broader discussion of all these factors can be found in the updated and revised edition of What Your Doctor May Not Tell You About Menopause and What Your Doctor May Not Tell You About Breast Cancer.
Thursday, May 7, 2009
I asked more about my progesterone receptor result that had come back ambivalant when the estrogen receptor status was initally done. I asked whether the test could be redone. He said yes, and ordered a re-run (results will be ready on Monday).
I gathered from Gareth that the medical world does not care as much about the progesterone receptor status because they don't have a method of dealing with it.
I went home and read some more of Dr John R Lee's book 'What your Dr may not tell you about Menopause' and in which he details how having progesterone positive receptors on breast cancer cells is a good thing as this allow the progesterone into the cells. This can also happen if the receptor results come back negative as there are always progesterone receptors on breast cells.
Estrogen causes immature breast cells to divide more rapidly, while Progesterone slows the breast cell division and encourages cells to mature.
I am now waiting for my saliva progesterone, estrogen, testosterone, DHEA-S, and cortisol levels. These tests are still quite new in this country so the lab is taking it's time. I am on them!
I need these results to determine what percentage of progesterone to have mixed into the cream, and also as a marker to see what my hormone levels are before and after treatment.
I would start taking Progesterone now if I could! I am very excited that bio-identical progesterone is the alternative to Tamoxifen I was looking for!
In Dr John R Lee's book's, he pulls together most of my symptoms as being due to low progesterone levels:
- the adrenal fatigue - progesterone is a precursor to cortisol, the body's stress hormone.
- the slightly under active thyroid - low cortisol suppresses thyroid function
- the weight gain after haivng both my children - estrogen dominence
- the impaired blood sugar levels for most of my 20's and early 30's- estrogen dominence
- the low sex drive- estrogen dominence
- the suppressed immune system (zinc boosts the immune system and low progesterone levels cause a loss of zinc and a rise in copper - this can also lead to infertility)- estrogen dominence
- low oxygen levels - cancer is believed to grow in an anaerobic (no oxygen), acidic inter- and intracellular environment. Estrogen dominence reduces oxgygen levels in cells while progesterone promotes cellular oxygenation- estrogen dominence.
- the risk of gall bladder disease - this was a strange one to find. Towards the end of my pregnancy with Lily, my 2nd child, I had very itchy, yellow palms of my hands and soles of my feet. After much reading online, I determined that I had cholestasis due to pregnancy. This is temporary and is caused by the pressure of the baby on the gall bladder which hinders the free flow of bile from the gall bladder into the intesttine. The result is the back up of bilirubin in the blood, hence the yellow colour and the itchy. I never thought much of it it then but I wonder whether that was linked to low progesterone levels back then already??
If you are a woman, I urge you again, to read the books by Dr John R Lee - in them, he answers so many questions we all have but that our doctors may not have answers for.
After a close read of Dr John R Lee's website, I realise he died in 2003 so I will not be able to to email him! www.johnleemd.com
Wednesday, May 6, 2009
The Psyche-K technique uses kinesiology to test whether or not my subconscious has a belief installed. If not, we install it. Over simplification for this technique but that I feel great afterwards!
Now that I have a bit of a breather from surgery etc, I want to pick up where we left off.
Before the mastectomy, we installed the following 2 beliefs in my subconscious:
- I am worthy
- I am Heidi
The person who mentioned this theory had commented on why I had had both breasts removed when I only needed to have one removed (I had done this to lessen chance of recurrence by haivng as much estrogen senstive breast tissue removed as possible, and from a better reconstruction point of view). He questioned whether I was trying to feel more like a male??
I cast my mind back to growing up and remember being very much a tomboy. I was always playing bikes and skateboards, was crawling in rivers and storm water drains with the boys from my neigbourhood (all the kids in our neighbourhood just happened to be boys except for a girl next door who I never got along with).
I always wore a sleeveless vest under my t-shirts as I didn't like my the feeling of just the t-shirt on my chest/maybe of my nipples sticking through.
I cringed at the thought of parting with my vests when it came time for a bra so my mom gave me one for Christmas!! Very traumatic!
I was also in denial when my periods started so told my mom it was just a runny tummy.
Through my teens and early 20's, I was still very boy-ish but never thought much about it.
When I asked my parents whether they had wanted a boy, my mom said 'no'. My dad said 'no' at first, but then added that it would have been nice to have had a boy first to be assured that the family name would be continued!
Remember, there were no scans in those days to show the sex of the baby so parents had 10 months to wonder and wish for the sex they wanted. Even though we have scans today, parents could still desire the opposite sex, or feel disappointed, even if they know.
After I was born, my dad fell head over heals in love with me and didn't want anymore children!
I hate unexplored stuff so off with the lid!! During my session with Dr Lecore, she asked my subconscious whether gender was a issue for me.
My subconscious said it was an issue, back was not the main issue. We had to install the following beliefs first:
- I can relax and be myself safely
- I am confident, and therefore believe in myself fully
I feel like getting breast cancer has given me the opportunity to unpack and question all learnt beliefs, behaviours, roles, and identities I have gathered until now.
I now get to clean my slate, and take only what I want to. I am working from the bottom up. This process is quite scary at times but very rewarding.
I still don't know where it will end up. I am consciously taking ownership of every aspect of myself and this feels so good.
I realise that 'growing up' and becoming adult, happens in tiny steps, never all at once.
Tuesday, May 5, 2009
I busy reading Dr John R Lee's books: 'What you Dr may not tell you about Breast Cancer' and 'What your Dr may not tell you about Menopause' - his points are below.
(Dr Lee has also written a book called 'What your Dr may not tell you about Premenopause' which I will buy next - although I am sure the info is all pretty much the same).
EVERY WOMAN NEEDS TO READ THESE BOOKS! DOCTORS DO NOT KNOW THIS INFO. EVEN IF YOU THINK YOU ARE NOT A CANDIDATE FOR BREAST CANCER. The bio-identical progesterone also helps treat various other female problems.
To date, Dr Lee's books have been the most useful, well researched, comprehensive, and hope providing. Finding a practitioner int his country who has successfully treated breast cancer for many years is a not proving easy.
The only thing is: my breast tissue results came back as estrogen positive and progesterone ambivalent - they could not determine whether or not the breast cancer was stimulated by progesterone.
If it was stimulated by progesterone, I am not sure whether or not I can use the progesterone cream. About to email Dr Lee now.
I am questioning whether women could start measuring their estrogen and progesterone levels from 20-25yrs, correct any imbalances with bio-identical hormones, and decrease the chance of getting breast cancer. Obviously, there are other contributing factors to breast cancer and all these need to be addressed.
......Back to the lab for more info on the breast tissue results
What Dr. Lee Said About Breast Cancerhttp://www.johnleemd.com/store/hbh-081001.html#about_breast_cancer
For more than 20 years, women and charitable organizations around the world have joined together each October to mark Breast Cancer Awareness Month. Over the last two decades, Breast Cancer Awareness Month has done much to raise money and awareness levels for the disease. In our opinion, however, the event has focused too much attention on promoting the early detection of breast cancer while devoting little energy to preventing women from getting the disease in the first place.
To prevent a disease, one must understand what causes it. This is the truth that Dr. Lee understood. It was Dr. Lee's desire to know the causes behind breast cancer that led him to write his book, What Your Doctor May Not Tell You About Breast Cancer. If you have not read this groundbreaking document, we encourage you to do so this October. Here is an overview of some of the central points he made in the book.
Despite billions of dollars spent on breast cancer research, a woman's chance of surviving a malignant breast tumor has changed little over the last 50 years. It may come as a shock, but a woman's chance of surviving a malignant breast tumor today is about one in three...roughly the same rate as five decades ago. Research studies on mortality rates have shown that radiation therapy, tamoxifen, and chemotherapy are not saving more lives. At best, they prolong some lives by a few months or years, but often at the expense of painful or even deadly side effects. Moreover, the number of breast cancer cases per thousand women is much higher today than it was 50 or even 30 years ago.
While breast cancer is rarely caused by a single factor, unopposed estrogens play a central role in the formation of the disease. For decades, researchers have known that excess estrogen (i.e., estrogen that is unopposed by adequate progesterone and other hormones) increases a woman's risk for endometrial cancer. Recent research has revealed that it also plays a key role in breast cancer formation. Unopposed estrogens can break down into quinone estrogens that react with and damage the DNA in breast cells. These damaged cells can become cancer cells if the body's various defense mechanisms do not recognize and destroy them. In addition, unopposed estrogen can activate the Bcl-2 gene that frequently induces cancer-causing cell proliferation.
Unfortunately, it has become common in developed countries for both women and men to have high levels of unopposed estrogens. This condition, which Dr. Lee called estrogen dominance, has been fueled by changes in our diets and lifestyles. Another cause is our growing exposure to the estrogen-like substances–known as xenoestrogens–found in plastics, fertilizers, pesticides, and other manmade products. Unless we address estrogen dominance, breast cancer risks are likely to remain elevated.
Progesterone plays a critical role in countering the negative effects of unopposed estrogens. In the body, progesterone neutralizes many of the effects of unopposed estrogen that can lead to breast cancer. It decreases the cell proliferation that is induced by estrogen. In addition, it down-regulates the cancer-causing Bcl-2 gene and up-regulates gene p53, a gene that promotes the death (known as apoptosis) of tumor cells.
Given these findings, having adequate progesterone can be critical to preventing breast cancer. Unfortunately, progesterone levels among many women in developed countries are below normal, healthy levels. This is especially the case among older women and those who use conventional hormone replacement therapies (HRT). This is why Dr. Lee recommended natural progesterone supplementation for women suffering from estrogen dominance, not to mention the avoidance of HRT.
Besides maintaining healthy progesterone levels and avoiding HRT, women should take steps to reduce other breast cancer risk factors. These include reducing our exposure to xenoestrogens, maintaining healthy levels of other hormones such as DHEA and melatonin, reducing our intake of sugars and unhealthy fats, and managing stress levels through exercise and adequate rest.
Throughout his career as a physician and researcher, Dr. Lee was passionate about finding the causes of breast cancer and the other cancers that women face. It is therefore fitting that What Your Doctor May Not Tell You About Breast Cancer was the last book that he completed before he passed away in 2003. The words with which he opens the book speak volumes about his commitment:
"The book is dedicated to all the women who have lost their lives to breast cancer, and to all women currently fighting breast cancer."
Friday, May 1, 2009
I see Dr Gareth Edwards, my plastic surgeon, every week for saline injections into the breast tissue expanders.
Each week, Gareth urges me to go on Tamoxifen (estrogen receptor site blocker) because my breast cancer was 66% stimulated by estrogen, because I am premenopausal/35 yrs, and because there was a small bit of invasive cancer. I also need to consider having the LHRH agonist (shuts off ovarian production of estrogen) injection every 3 months. This treatment will put my body into early menopause - joy!
At first I resisted it and thought I could do it naturally but I am beginning to think I should intergrate both natural and allopathic medicine for the best survival chance.
I am slowly coming around to the fact that I may need to take Tamoxifen, but I am debating whether to take the drug to shut down my ovarian estrogen production for the next however many years or just to surgically remove my ovaries.
And while I am am doing that, should I not remove my uterus as well?? One of the possible long term side effects of Tamoxifen is uterine cancer so a hysterectomy would negate this.
This decision is not as easy as just deciding to go for the op - there may be after effects like:
- hot flashes
- vaginal dryness
- decreased libido or other sexual side effects
- sleep disturbance
- memory changes - your brain uses estrogen to think - even in men!
- mood changes
- weight gain
- urinary incontinence
- accelerated ageing - I may age rapidly
- more prone to osteoporosis
I am 35 yrs old!!! The thought of these symptoms is not very appealing. And I would want to try and treat the side/after effects with bio-indentical hormones but am not sure whehther I can take those now that I have a greater risk for breast cancer recurrence.
But the thought of dying of breast cancer is even less appealing. I am just playing a game of priorities here!
I keep looking at Glenn and my kids and crying. I want to be around as long as I can for them but the cost is huge. I feel miserable but keep trying to focus on the present moment.
It would be easier for me to die and start again next lifetime but it is more of a challenge for me to push through and live this life as best I can.
I saw another engery healer (Patricia - The Soul Dr) this week. She said the universe told her I am going to be ok and that everything I needed to get me to this point, got me here; good and bad. I need to love and accept (this again) myself completely as I am a spark of the creator and I am therefore perfect.
Maybe my issue is not about me not being a good/natural mother but more about needing to love and nature myself more. Maybe I had low self love when my kids were born. Two babies born close together and a house that needed so much of my love, time, and energy then pushed me into a energy deficit in my love and nurturing chakra (heart /breast/chest) area which resulted in a cancer. Still questioning and focusing equally on the energy issues while I look into the physical medications etc.
The decision to undergo prophylactic removal of the ovaries and tubes to lower the risk for cancer is a difficult and personal one.
Women who undergo oophorectomy prior to natural menopause will experience menopause from the surgery. Menopausal symptoms and the experience varies from woman to woman. Further, some of the consequences of menopause are more serious than others. Some women find hormone supplementation alleviates their menopausal symptoms. However, research on hormone replacement is inconclusive regarding the benefits and risks to menopausal women. Because much of the research has been conducted on women who experienced natural menopause, the applicability to women experiencing early surgical menopause is uncertain. It is important for each woman to discuss menopausal symptoms with their doctor and to weigh the potential benefits and relief from hormone replacement vs. their individual risks from hormone replacement or other menopausal treatments.
Different women experience menopausal side-effects to differing degrees. Some of the side effects reported by women include:
- hot flashes
- vaginal dryness
- decreased libido or other sexual side effects
- sleep disturbance
- memory changes
- mood changes
- weight gain
- urinary incontinence
Some of these side effects can be alleviated or resolved with medications, or improved with supplements. It is important to note that medications and supplements can have their own risks and side effects. For some individuals, low-dose hormone therapy may be an option for addressing medical or quality-of-life issues not resolved any other way.
Research of hormone replacement therapy in premenopausal women with BRCA mutations who have not had breast cancer but had oophorectomy has been limited. One study which examined short-term hormone replacement after oophorectomy in BRCA carriers indicates that prophylactic oophorectomy prior to age 50 substantially lowers the risk for breast cancer. The breast cancer risk reduction was similar in women who took hormones for up to three years and women who did not take hormones post-oophorectomy. The long term effects of hormone replacement after oophorectomy are unclear at this time.
A woman’s body can make various types of estrogen, as well as progesterone, testosterone, and other hormones. Several hormone replacement options are available for women with surgical menopause containing varying amounts of these hormones.
Hormones may be categorized by the type of hormones contained in the preparation, how the hormones are delivered to the body, and how the preparation is made. For some women the choice of hormones depends on their symptoms, for example, a woman experiencing vaginal dryness, may find an estrogen-releasing device called a vaginal estrogen ring helpful. The ring works by providing estrogen to the vaginal walls and minimizing absorption into the body. For women who retain their uterus, preparations containing progesterone are chosen to protect against uterine cancer risk.
For high-risk women, oophorectomy brings two primary benefits when performed prior to menopause: reduction of ovarian cancer risk and reduction of breast cancer risk. It may seem contrary for high-risk women to receive hormones after removing their ovaries to lower their risk for breast cancer. However, hormone levels received through medication is generally less than what is normally produced by the ovaries during the premenopausal years. It isn't entirely clear what effect estrogen replacement therapy (ERT) or combined estrogen-progestin therapy (HRT) might have on cancer risk, particularly in high-risk women or breast cancer survivors. A recent study followed premenopausal women who carry a BRCA mutation for 3 1/2 years. Women who elected risk-reducing salpingo- oophorectomy (removal of ovaries and tubes) had a substantial decrease in breast cancer risk. Hormone replacement after oophorectomy didn't significantly change the breast cancer risk in the women in this study. It is important for women to discuss the risk of hormone replacement with their healthcare team to make an informed decision.
HRT are preparations of estrogen combined with progesterone. The progesterone protects against uterine cancer and is generally prescribed for women who are postmenopausal but still have their uterus. ERT are estrogen-only preparations appropriate for postmenopausal women who have had hysterectomies. Because they have no uterus, these women have no risk of uterine cancer and therefore don’t require progesterone.
The Women’s Health Initiative is a large, randomized study for hormone replacement after menopause. It reviewed women who took HRT, ERT or a placebo after natural menopause. It is important to remember that this study did not look at women with BRCA mutations or premenopausal women who experienced surgical menopause. The study demonstrated that HRT supplementation (estrogen plus progesterone) increased the risk for breast cancer in women who went through natural menopause. The study concluded, however, that ERT supplementation (estrogen alone) does not appear to raise the risk for breast cancer in this population. The study did not specifically consider women who underwent surgical menopause due to risk-reducing oophorectomy, so its applicability to the high-risk population who undergo early menopause is uncertain.
Some attention has been given to whether certain hormone preparations are safer or more effective than others. “Bio-identical” hormones are hormone replacement preparations that are chemically identical to the hormones produced in the body; whether they originate in animals, plants, or are synthetic, they cannot be distinguished from the body’s own hormones. There is currently no conclusive evidence that "bio-identical" hormones are safer than other preparations.
Some physicians describe specially-made hormone compounds prepared by pharmacists as “bio-identical.” Compounded hormone replacement is described in more detail below.
Certain hormone preparations, (including some bio-identical compounds), have been tested by the FDA and are available commercially by prescription. Other "compounded" hormone preparations contain individualized combinations of different hormones and are prepared on an individual basis by pharmacists. Some physicians feel these "compounded" hormones are safer than commercial preparations. However, this has not been demonstrated by scientific research. There may be risks associated with compounded hormones: they are neither tested nor approved by the FDA and are unregulated. Compounded preparation methods vary from one pharmacist to another, and from one pharmacy to another, so compounds may not be consistent. Some custom-compounded preparations are not covered by insurance plans. Custom-compounded hormones may provide certain benefits, allowing individualized doses and mixtures of different hormones unavailable in commercial products. Anecdotally, some women posting on the FORCE message board reported they found pharmacist-compounded hormone preparations relieved their menopausal symptoms more effectively than commercially available preparations. A list of hormone replacement therapy products was published in a 2001 International Journal of Pharmaceutical Compounding.
Some physicians follow patients who use these compounds by testing their saliva for hormone levels. However the reliability of these tests and optimal saliva hormone levels have not been established.
One study of previous research which compared hormone types determined the conclusions drawn were compromised because the research efforts were too small or had design flaws. The study's authors suggested there was not enough evidence to recommend bio-identical hormones over conventional hormones.
The North American Menopause Society (NAMS), a professional organization devoted to promoting women's health and quality of life through an understanding of menopause, published a position statement on compounded hormone replacement. The NAMS does not recommend custom-compounded products over well-tested, government-approved products for the majority of women. Nor does the Society recommend saliva testing to determine hormone levels.
It is important for women who have undergone surgical menopause or are considering prophylactic oophorectomy to discuss menopausal symptoms and management with their healthcare team. The menopause experience is individual. Response to hormone replacement appears to be individual as well.
Osteopenia refers to loss of bone density. Osteoporosis is a more serious loss of bone density which weakens the bones. Some degree of bone thinning occurs as a natural part of the aging process. Significant weakening of the bones, however, puts a person at increased risk for fractures (broken bones). Loss of estrogen through natural or surgical menopause can lead to increased weakening of the bones.
A bone density test can determine whether a person’s bones are weakened or are of normal density. Health care providers categorize a person’s bone density as “normal,” “osteopenia,” or “osteoporosis,” as compared to others of the same age and gender. Health care providers often recommend a baseline bone density test before prophylactic oophorectomy or soon after and then on an annual or semi-annual basis after menopause.
Hormonal and nonhormonal medications can lower the risk for fractures due to loss of bone density. These medications may have side effects. Some, like hormones, may raise the risk for other cancers. Women with osteopenia or osteoporosis associated with menopause should be followed by endocrinologists or other health care professionals who are trained in managing menopausal symptoms. It is important for each woman to weigh the potential benefits and relief from hormone replacement vs. their individual risk for cancer or other risks associated with hormone replacement.
Weight-bearing or resistance exercise may lower the risk for osteoporosis in post-menopausal women. However, it is important to discuss exercise with your physician before starting any exercise routine. It is worthwhile to consult with a licensed physical therapist to assure that your exercise routine is safe and appropriate. Experts recommend post-menopausal women receive 1200 milligrams of calcium per day, either through their diet or through supplementation.
Studies show hormones and certain non hormonal medications—antidepressants belonging to a class of drugs called selective seratonin reuptake inhibitors (SSRIs), for instance—may relieve some menopausal side effects such as hot flashes. One small randomized trial found venlafaxine (Effexor) alleviated hot flashes in postmenopausal women compared to a placebo. Another study found fluoxetine (Prozac) lowered the frequency of hot flashes more effectively than placebo in post menopausal women. Research on the effectiveness and safety of supplements such as soy or black cohosh has been inconclusive.
Products such as handheld fans and "chillows," which cool the body temperature, have been helpful for some women who experience hot-flashes.
Decreased libido is often associated with menopause. Hormonal and nonhormonal options are available for improving libido in women who are surgically menopausal. Some physicians recommend the addition of testosterone replacement for women who have loss of libido with menopause that isn't alleviated by ERT or HRT alone. One short randomized, prospective study found testosterone supplementation improves libido in women who experienced loss of libido due to oophorectomy. There is conflicting data, however, about the safety of testosterone and whether it may increase the risk for breast cancer.
A small preliminary study looked at the effects of the antidepressant bupropion (Welbutrin) on the libido of individuals who were not clinically depressed. The study suggested bupropion improved sexual arousal, overall sexual satisfaction, and satisfaction with intensity of orgasm when compared to placebo. However, this study was not specific to high-risk women who experienced surgical menopause.
Some women report disruption in sleep patterns associated with menopause. Sleep disturbances may also cause menopause-related fatigue. One small randomized study compared insomnia in peri- and postmenopausal women who used the sleep aid zolpidem (Ambien) compared with those who took a placebo. Women who took zolpidem reported improved sleep over those who took a placebo.
Specialized sleep disorder clinics can sometimes assist with sleep disruptions associated with menopause.
LHRH Agonists Show Promise for Early Breast Cancerhttp://www.ajog.org/article/PIIS0002937805002814/abstract
The study reviewed here found that after surgery and other treatments for hormone-receptor-positive early-stage breast cancer in premenopausal women, treatment with the hormonal therapy medicine Zoladex (chemical name: goserelin) can lower the risk of the cancer coming back (recurrence) and improve overall prognosis.
The ovaries of premenopausal women produce estrogen. Estrogen can make breast cancer cells grow and increase the risk of the cancer coming back. Stopping the ovaries from producing estrogen or blocking the effects of estrogen on breast cancer cells can be an effective part of a treatment plan for premenopausal women.
Removing the ovaries (called oophorectomy or surgical ablation) or destroying the ovaries with radiation therapy permanently stop the ovaries from producing estrogen. But some premenopausal women may want to temporarily stop the ovaries from producing estrogen so they have the option of having children after treatment. Medicines called LHRH (luteinizing hormone releasing hormone) agonists can be used to temporarily stop the ovaries from making estrogen. This is called medical ovarian shutdown. LHRH-agonist medicines include Zoladex and Lupron (chemical name: leuprolide).
Tamoxifen, another hormonal therapy medicine, also can lower the risk of early-stage hormone-receptor-positive breast cancer coming back in both pre- and postmenopausal women. Tamoxifen is a SERM (selective estrogen receptor modulator). Tamoxifen has different effects on different types of cells. In breast cells, tamoxifen blocks estrogen receptors. Blocking the estrogen receptors means that estrogen can't attach to the cell and so can't tell the cell to grow.
In the study reviewed here, the researchers reviewed the information from more than 14 other studies involving more than 12,000 premenopausal women. All of the women in these studies were diagnosed with early-stage breast cancer. Almost all of the cancers were hormone-receptor-positive. To reduce the risk of the cancer coming back, the women were divided into three broad groups:
- some got Zoladex alone
- some got tamoxifen alone
- some got Zoladex and tamoxifen together
Many of the women also got chemotherapy to lower the risk of the cancer coming back. Doctors use the term adjuvant chemotherapy to describe chemotherapy used to lower the risk of the cancer coming back.
The researchers found:
- Zoladex and tamoxifen combined seemed to do a better job of reducing the risk of the cancer coming back and improving prognosis compared to Zoladex alone or tamoxifen alone.
- Zoladex alone or tamoxifen alone also reduced the risk of the cancer coming back and improved prognosis, but it wasn't clear if one medicine was more effective than the other.
- There was no difference in the risk of the cancer coming back or prognosis in women who got either Zoladex alone or tamoxifen and Zoladex together compared to women who got adjuvant chemotherapy with no hormonal therapy medicine. Still, the adjuvant chemotherapy caused more troubling side effects.
- Women who got Zoladex (either alone or with tamoxifen) and adjuvant chemotherapy had a lower risk of the cancer coming back and a better prognosis compared to women who got adjuvant chemotherapy with no hormonal therapy.
If you're a premenopausal woman diagnosed with hormone-receptor-positive early-stage breast cancer, you and your doctor will consider a number of treatment options to reduce the risk of the cancer coming back after surgery. Hormonal therapy and medical ovarian shutdown may be options you consider. Based on this study, you might want to ask your doctor if the combination of tamoxifen and Zoladex makes sense for you, whether or not you get adjuvant chemotherapy.In the Breastcancer.org Hormonal Therapy section you can learn more about hormonal therapy medicines used to lower the risk of the cancer coming back in premenopausal women.