Friday, May 1, 2009


I am going through a tough time again - similar to before deciding to have a double mastectomy.

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
  • fatigue
  • weight gain
  • urinary incontinence
  • accelerated ageing - I may age rapidly
  • more prone to osteoporosis
(There is more info in the article below).

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.

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Menopausal side effects

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
  • fatigue
  • 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.

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Types of hormone replacement

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.

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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.

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Bio-identical hormones

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.

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Commercial vs. compounded hormone preparations

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.

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Osteopenia and osteoporosis

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.

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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.

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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.

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Sleep disturbances

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 Cancer

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 Hormonal Therapy section you can learn more about hormonal therapy medicines used to lower the risk of the cancer coming back in premenopausal women.