woman getting a mammogram, overdiagnosis, breast cancer survivors, hormone replacement therapy

Before the results of the Women’s Health Initiative (WHI) were published in 2002, we would frequently hear from women who were worried that the use of hormone replacement therapy (HRT) might be linked to breast cancer. In many cases, their physicians reassured them that there was no connection and that HRT was not only safe but essential for bone strength and heart health.

Here is a letter we published in our newspaper column on October 26, 1998, years before the WHI data were released:

Q. I am debating hormone replacement therapy. My doctor is very enthusiastic about Prempro, and says it will prevent osteoporosis and heart disease. My grandmother was crippled by spinal fractures so this is of concern.

I do worry about side effects such as breast cancer. My doctor downplays the danger but I would like to know as much as possible about all my options, including herbs, diet and exercise.
Then there was this from an irate husband:

“My wife is so angry at her physician that she can barely bring herself to schedule a visit. For years she was told to take Premarin and Provera. When reports surfaced that there might be “a problem with breast cancer, she asked her doctor about this risk. He repeatedly reassured her that there was nothing to worry about. Hormones were so safe, he claimed, that his own wife was taking them.”

The Women’s Health Initiative was stopped prematurely 11 years ago because of evidence suggesting that the combination of estrogen and progestin not only increased the risk of breast cancer but also elevated the likelihood of heart attacks and strokes. Initially, the medical community greeted this news with a great deal of skepticism. Here is an example of what some women faced:

Doctor Fires Patient Over HRT

“I have been on hormone replacement therapy for ten years, and my doctor has always been a strong proponent of HRT. I have been uncomfortable taking this and have asked about its safety in the past. He maintained that the news media only picks out the negative results of studies and ignores the positives, and he has always convinced me to continue taking HRT.

“I called my doctor’s office to discuss the recent warnings and learned that he has not changed his position concerning the benefits of HRT. I informed the nurse that I was uncomfortable taking the hormones and was going to discontinue taking them. I was then shocked to receive a letter from my doctor saying he can no longer treat me since I don’t agree with his philosophy on these drugs.

“I’ve gone to this doctor for years, and he initially prescribed HRT for me ten years ago. I didn’t realize that if I opted to stop, he would refuse to treat me. I am in excellent health and have no medical reason to take hormones other than menopause. Is it acceptable for a doctor to respond in this manner, by ‘dumping’ a patient? I thought it was the patient’s choice whether or not to take HRT.”

Although initially many HRT proponents tried hard to poke holes in the data, most physicians eventually accepted that there was indeed an increased risk of cancer as well as cardiovascular disease associated with estrogen and progestin therapy.

But over the years the doubters began to gain ground. Last year some researchers described HRT concerns as “mass fear” and “hysteria.” These experts maintained that the benefits of hormone replacement therapy outweighed the risks. If there was an increased risk of breast cancer, they claimed, it was extremely small and may have only represented an earlier diagnosis rather than a true cancer increase. They also suggested that if HRT were linked to breast cancer, any tumors would be easier to treat and less dangerous than “normal” breast cancer.

The Latest Data:

A brand new analysis from the Women’s Health Initiative may silence these apologists once and for all. On March 29, 2013, a study was published in the Journal of the National Cancer Institute that establishes unequivocally that HRT is indeed linked to an increased risk of breast cancer. The authors concluded:

In summary, estrogen plus progestin use is associated with increased breast cancer incidence, especially when its use is initiated close to menopause. Because prognosis after a breast cancer diagnosis is similar for combined hormone therapy users and non-users, increased breast cancer mortality on a population basis can be expected.

In plain English, women who develop breast cancer after taking hormone replacement therapy are just as susceptible to bad outcomes from their breast cancer as women who did not take estrogen and progestin and developed breast cancer spontaneously. Hormone-induced cancers are neither easier to treat nor less dangerous.

What About Bio-Identical Hormones?

We know that millions of women believe that “natural” or “bio-identical” hormones pose no risk of cancer or cardiovascular disease. We wish we had data like the Women’s Health Initiative to support that belief. There has never been a study comparable to the WHI for natural estrogens and progesterone. Consequently, we can draw no conclusions one way or the other.

Susan Love, MD, one this country’s greatest breast cancer physicians told us candidly that she did not think there was any significant difference between natural and synthetic hormones. She pointed out that women who have naturally high levels of hormones are at greater risk for breast cancer. You can’t get any more “bio-identical” than your own hormones. Dr. Love commented that very little research has been done on such formulations, and there is no evidence that they are safer than other types of estrogen and progesterone.

A Doctor’s Dilemma:

One physician summarized the dilemma like this:

Q. I am a family physician. Back when we were prescribing hormone replacement therapy (HRT) regularly, I used to offer women the option of plant-based estrogens instead of synthetic hormones. Since we learned the results of the Women’s Health Initiative (WHI), though, I’ve viewed all estrogens as carrying similar risk until proven otherwise.

There are practitioners who are saying that bio-identical hormones are safer. They encourage women to use them as an alternative for menopausal symptoms. Is there any research that shows that the risks are lower for plant-based HRT than for synthetic?

A. There is no comparable study of plant-based estrogens, and there is not likely to be one. The Women’s Health Initiative was a very large, expensive study, funded by the National Institutes of Health. Women were randomly assigned to receive Prempro or placebo. The results showed that postmenopausal hormones increased the risk of breast cancer, heart attack and stroke.

Women’s health expert, Susan Love, MD, responded to a question like yours: “I think that it is very unlikely that bio-identical hormones, as they’re called, will be any safer than Prempro.”

We have summarized information on estrogen and natural treatments for hot flashes and other symptoms in our Guide to Menopause.

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  1. Eva

    Interesting article. I read a lot of literature on this topic. I want to check website of Wellness MGT corp. too.

  2. Bev

    I’m 74 years of age, and been on Estrogen for the last 38 years after having a full Hysterectomy, I look 55, and look great, and have a full sex life, feel wonderful, when I last visited my Dr. in January, he advise that he will no longer be supplying me with my Estrogen because they know for fact now that it causes Breast Cancer,Strokes and Heart attacks, I still have a 4month supply, and I’m still taking it, he said he will not be renewing my prescription, what I’m I suppose to do after taking it for so many years, without having any problems.

  3. Susan

    I have an aunt that has breast cancer and they told she got it because she didn’t have estrogen in her system. Now I stopped all the supplements because I didn’t want breast cancer now I’m hearing not having estrogen can cause it. So I’m totally confused. Please help

  4. M.K.

    I was one who thought I would breeze through menopause, like I did childbirth and other stages of my life. NOT! At age 51 it started, not with hot flashes (never had one) but with debilitating anxiety, insomnia, brain fog. One gyn told me “welcome to menopause” and put me on oral estrogen which helped not at all. Three months later I saw a partner in his group and learned about bio-identical hormone pellets. I first had the pellets inserted three years ago, with a sublingual dose of progesterone at bedtime, and within two weeks of insertion I was sleeping, thinking clearly and no more anxiety. I feel like I was cured from some disease! I thank God every day (and so does my husband!) for sending me along this path. I keep up with my tests and mammos yearly, and enjoy life like never before.

  5. Amy

    I have been on Elestrin since 2007 and I honestly think it has helped me to feel like myself again. I had endometrial cancer at age 21, which was hormone sensitive. Eight years after my surgery, my ovaries stopped producing the amounts to par for my age at that time, I was 32. I was suffering with menopause issues, again…
    I already had a chemical menopause while I was on my chemotherapy drug Megace at age 21. The thing is, I was diagnosed with something that older people are diagnosed with and I really feel that quality of life is much preferred to than suffering from hormone deficiencies, especially when you are young. There are risks with everything and no one gets out of here alive. Live your life and be happy, cause it is short either way you look at it.

  6. PG

    I was on Premarin for 20 years, from age 45 to 65, and did very well. My new doctor made me get a mammogram every year before she would give me the prescription for Premarin. I finally got sick of getting the yearly mammos and just quit taking Premarin. Since then, my osteoarthritis is worse, my neck is stiff, and I have a bad case of scoliosis and spondylosis. It came about 2 years after I quit Premarin. Don’t know if it was present but not causing problems before, but all hell broke loose after I quit Premarin. Wish I had stayed on it now!

  7. Harriet D

    At age 47, I had a total hysterectomy. At the time, I was just beginning menopause. My doctor initially put me on Premarin, but after 2 weeks on it, my mood swings were horrible. I attended a lecture & questionnaire by a pharmacist who promoted the bio-identical hormones. My physician agreed to change my prescription and within 48 hours, my moods were back on an even level.
    I have now taken the bio-identical hormones, of varying dosages, for 15 years. I do best on a tri-est (80-10-10 ratio)/progesterone combination troche. Yes, I have a mammogram every year, and yes, breast cancer is prevalent in my family. However, for me, these hormones are life-savers.
    As I have aged, my physician has slightly reduced my hormones, according to my symptoms. For me, the mood swings & hot flashes that leave me dripping in perspiration, are the indicators of whether or not my prescription is correct.

  8. nancy p.

    I have taken HRT for HRT for 25 years now. At first I used a pill but about 10 to 15 years ago I was switched to the estrogen patch, I have no uterus or cervix anymore.
    I will only stop taking it if someone drags my dose from my cold, dead hands. My side effects were agony. I could manage the hot flashes in the daytime but not when they began waking me up more than four times a night because I also suffer from increasing insomnia. My tissues were so dried out that even just a blot with toilet paper tore my skin enough to bleed. Sex was impossible.
    This June I will turn 70 years old, my bones are strong and my hot flashes are gone. My doctor gives me the same dose of sleeping meds that I was put on about 14 years ago with no increase in dosage.

  9. cbrano

    Oh my gosh, I did the same thing with my Dr. He was so pro, and I was so con, HRT that I didn’t want to argue with him. I took the prescription and when I’d seen him for my annual visits he’d ask how I was and I’d say great! It was deceptive but it was easier than arguing with him. I also felt it was my choice on only what Dr. I wanted to see and also what I wanted to put in my body. He has since retired and my new dr. is on the fence about HRT, which has made my visits easier.

  10. lmk

    I am on combination HRT. I had heard that hormones can help women w/ MS. My lady GYN strongly recommends to keep taking hormones since I have MS. Why do hormones seem to help women with MS?
    I am still not totally comfortable taking HRT, but Dr. said benefits outweigh risk.

  11. MK

    I wish people would not still use the Women’s Health Initiative and HRT together. As far as HRT is concerned the Women’s Health Initiative was flawed as so many women were well past the ‘hot flash’ age as well as menopause when they were first put on HRT.
    I stayed on HRT for several years after the first hu-ha about this and only stepped down and off much later and without side effects.
    Please note that I have breast cancer in my family and yet I don’t regret taking HRT for one minute.

  12. RMS

    The WHI estrogen/progestin trial was stopped primarily because of a 26% increased risk of breast cancer found in women taking hormone therapy. For every 10,000 women taking estrogen/progestin, 38 will develop invasive breast cancer; of 10,000 women not taking HRT, 30 will develop the disease.
    * N.B. “Risk” is 8 per 10,000 women. Benefit needs individualized assessment. Some women are quite symptomatic with significant problems with sleep disturbance and/or cognitive dysfunction. Menopausal symptoms are more than the discomfort and misery of hot flashes where a very few of the many promoted treatments actually do some good. Sometimes without too many side effects.
    The second component of the WHI study, which looked at estrogen alone in women who no longer have a uterus, did not find any increased risk of breast cancer.
    *”HRT” comes in more than one formulation. Data was based on women taking a combination of estrogen-progesterone in what we generally consider higher doses than are now used. Estrogen alone in women without a uterus may not confer significant risk.

  13. Joan

    I had a partial hysterectomy in my 20’s and in my 50’s took HRT in the form of estrogen only for approx 8 yrs and quit when heard the study results. I am still having hotflashes and extreme vaginal dryness 16 years later and a doctor sugggested either oral estrogen again or vaginal estrogen. Are these approaches also causing the possible breast cancer and/or heart attacks? Or is estrogen alone safe to use?

  14. CB

    My Doctor used to lecture me about the benefits of HRT. I argued with him for a few years and then decided to take the prescription and throw it away later. It was just easier since I liked him otherwise.

  15. J. S.

    I took Premerin for years, staving off hot flashes. When I broke out in hives all over my body [no doctor could tell me what caused them] I told myself to dream of the color green if the hives were caused by the Premerin, a green capsule. That night I dreamed of my air conditioning filter absolutely packed with the green capsules! I could not dispute that and went off the drug immediately. Four years later I still have 2 or 3 flashes a day.

  16. Barbara

    What about the use of vaginal applications of hormone therapy for post menopausal women? Is there an alternative that works?

  17. TS

    I too am on low dose prempro. but I started taking it approx 10 yrs after menopause. It has helped with my cholesterol numbers and with vaginal dryness. I don’t know that it has helped any with my osteoporosis numbers though. Since I started this well after menopause am I still at high risk for breast cancer?

  18. AR

    Thanks for the info.

  19. mp

    What about Prolia? Unfortunately because of Ostepenia (and a mother who had serious Osteoporosis) after menopause (I had no symptoms from that) a prior doctor insisted I be on hormones (and Prempro, once that came out) for more than 10 years (beginning 20 years ago). My current doctor now wants me to take the 2x/year Prolia shots…I don’t want to do this, but my DEXA results are progressively worse. I’m very active (including hiking and some weight lifting), eat a correct diet, and work summers at 70+ years. What do you think?

  20. er

    I share your concerns about the increased risk of cancer, although I do not know the exact numbers and that in itself is a concern. (going from one in 10,000 to two in 10,000 is doubling your risk, but relatively unimpressive).
    I rarely hear mention of HRT and arthritis, however. When the initial scary stats came out I stopped HRT. In short order, my arthritis worsened to the extent I felt I had aged 10 years. My orthopedist said he had many other women patients who also had a spike in arthritis symptoms. I resumed HRT and am still taking it. I am careful to have routine gyn exams.
    I would love to hear about women in your audience who have experienced arthritic worsening when coming off HRT. For me, it is a real quality of life issue.

  21. Judy Z

    The arrogant doctor who fired his patient should NEVER have become a medical practitioner! He should have said (like my doctor did) “It’s your body and your decision.” I had fired another doctor who looked at my list of supplements and asked, “Why do you take all this junk?” Remember, people, doctors are NOT gods.

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