Question 42 - Breast Cancer,TAH, and HRT
(Posted May 9, 2000)

Dr N,

I am 40 yrs. old, have a strong family history of breast cancer, and recently had a partial mastectomy for breast cancer, myself. No lymph nodes were affected. Before starting the recommended treatment of 6 chemotherapy treatments, then radiation therapy, I had a total abdomal hysterectomy, 6 wks. after the breast surgery.This was done for a combination of reasons, being uterine fibroids, family history of ovarian cancer ( my sister died of ovarian cancer at age 46, after breast cancer at age 32), and a newly discovered ovarian cyst. There was no cancer found there. My mother died of matastisized breast cancer, and my only other sister has also had a partial mastectomy due to breast cancer.

My question has to due with HRT. You can see why I am reluctant to receive the convention HRT treatment. Also, it is now 6 wks. after my TAH, and my symptoms are mild, so far. I have night sweats ( not too severe, and some hot flashes, also not too severe), and few mood swings. I have not yet resumed sexual activity, so I really don't know what other problems may still be ahead. I am interested in using natural herbal treatments for my symptoms, but don't know which ones, or if they actually would be of benefit. Can you recommend any natural supplements to help me for all possible problems that may occur?

Hi,

This is obviously a difficult situation and I know that you want to do what is best for yourself.

First, let's define the problem and relevant issues. You are a 40 year old woman without a uterus and ovaries with a history of treated previous early stage breast cancer without evidence of metastasis. You have expressed a fear of estrogen use because of a strong family history of breast cancer and a fear of a reoccurrence.

The choice is ultimately a personal one.

A few things to consider:

(1) Women who are hormonally deficient, especially those who have had their ovaries removed and are without the benefit of HRT are known to have higher rates of death from heart attacks, strokes and osteoporosis.

(2) The fear of a reoccurrence of breast cancer can be overwhelming and preclude any thought of using estrogen replacement.

(3) To the best of my knowledge there has never been a study that showed increased rates of reoccurrence of breast cancer associated with estrogen use in patients previously treated for early stage breast cancer.

(4) It is possible by using alternatives to estrogen such as tamoxifen(Nolvadex), raloxifene(Evista) and a bisphosphonate(Fosomax) and lifestyle changes, that the risk of these problems can be diminished.

(5) To the best of my knowledge there is no over the counter herbal preparation that is capable of preventing the long term negative health affects of hormone deprivation.

(6) Most physicians who are treating a woman with a history of treated eary stage non metastatic breast cancer will discourage them from considering HRT. This is due to either being unaware that there is no evidence that it increases reoccurrence or mortality and/or a fear of becoming a malpractice target if the disease should reoccur.

I would encourage you to read the section of the web page, Breast Cancer & HRT and question 35 in the Ask Dr N section, as they address your concerns. I have also included below a summary or abstract of a study published in the American Journal of Obstetrics and Gynecology and an excerpt of medical education communication by Dr Rogerio Lobo, a highly regarded physician who is an expert in menopause.

Please let me know if you have further questions.

Dr N

Estrogen replacement therapy in women with previous breast cancer.

Am J Obstet Gynecol 1999 Aug;181(2):288-95 (ISSN: 0002-9378) Natrajan PK; Soumakis K; Gambrell RD Jr [Find other articles with these Authors] Department of Physiology, Medical College of Georgia, Augusta, Georgia, USA.

OBJECTIVE: We sought to review the status of patients with breast cancer who were treated with estrogen replacement therapy and compare the results with those of nonestrogenic hormone users and women not treated with hormone replacement.

STUDY DESIGN: The study group consisted of 76 patients with breast cancer, including 50 using estrogen replacement for up to 32 years, 8 using nonestrogenic hormone replacement for up to 6 years and followed for up to 11 years,and 18 using no hormones for up to 10 years. In addition to estrogen use, 40 of the 50 hormone users were treated with androgens, usually in the form of implantation of testosterone pellets. Forty-five subjects were also given progestogens, usually megestrol acetate 20 to 40 mg for 10 to 25 days each month. The 8 nonestrogen hormone users were treated with various combinations of testosterone pellets, tamoxifen, and progestogens. Forty-two of the 50 estrogen users are still being treated in our clinic, as are 2 of the 8 subjects using nonestrogen hormone. Follow-up was done through the tumor registry at University Hospital, and those whose tumor records were not current were telephoned. RESULTS: Of the 50 estrogen users, 3 have died (a mortality rate of 6%), and the rest have been followed for 6 months to 32 years, with a mean duration of follow-up of 83.3 +/- 8.81 months. One of the 8 nonestrogen hormone users has died (a mortality rate of 12.5%), and the rest have been followed for 2 to 11 years, with a mean duration of follow-up of 72.0 +/- 5. 93 months. Six of the 18 women not using hormone replacement have died (a mortality rate of 33.3%), and the rest have been followed for 6 months to 10 years, with a mean duration of follow-up of 50.5 +/- 6.01months.

CONCLUSION: Estrogen replacement therapy apparently does not increase either recurrences or mortality rates. Adding progestogens may even decrease recurrences. Women with early breast cancer should be offered hormone replacement therapy after a full explanation of the benefits, risks, and controversies.

Women's Health Clinical Management - Volume 1
Menopause Management for the Millennium CME

Author: Rogerio A. Lobo, MD

HRT in the Context of Disease

An important issue is whether HRT can be prescribed for postmenopausal women who have been treated for cancers (eg, breast and gynecologic cancer) or who have autoimmune diseases (eg, systemic lupus erythematosus [SLE] and multiple sclerosis [MS]) or other diseases associated with aging (eg, osteoarthritis [OA] and Parkinson's disease [PD]) or other chronic conditions (eg, diabetes and epilepsy). No prospective studies with a large number of patients and a long treatment period have addressed this question.

Breast Cancer

It has been estimated that the number of breast cancer survivors in the United States may approach 2.5 million.[280] Moreover, because breast cancer is being detected at an earlier age and adjuvant chemotherapy can cause ovarian failure, the number of women becoming menopausal at a younger age after breast cancer treatment is increasing.[280] Given that the risk of suffering a recurrence will be low for a large percentage of these women, should they consider HRT? At least 1 prospective study of HRT after localized breast cancer indicates that HRT does not seem to increase breast cancer events.[281] However, the most reasonable course of action for women who have been treated for breast cancer and who have menopausal symptoms is to treat the symptoms with alternative therapies. Diet and exercise are effective for prevention of CVD; weight training and the addition of bisphosphonates or SERMs (eg, tamoxifen and raloxifene) can reduce the risk for osteoporosis. Certain dosages of progestins can alleviate hot flushes, although many oncologists believe that use of any sex steroids is contraindicated. Nevertheless, in those breast-cancer survivors who choose HRT,[282] the lowest effective doses should be used, and these women must be monitored carefully.