RHM Medical Experts Comment on WHI Follow Up Study

By: Red Hot Mamas

Published: October 14, 2010

What do the professionals say about the study? Read comments from RHM’s medical experts Mary Jane Minkin, MD, Jim Simon, MD, Michael Goodman, MD and more. Please note, these opinions do not necessarily depict RHM’s stance on the topic.

Mary Jane Minkin, MD

Any new updates from the Women’s Health Initiative can make my patients anxious, and the breast cancer update this past month was no exception. But what was new?

As all Red Hot Mamas members know, the Women’s Health Initiative part 1 studied women on continuous combined (estrogen plus progestin) therapy. They showed that women on this therapy after 5+ years showed an increased risk of breast cancer; that increased risk, after 5+ years, was about 8 per 10,000 women per year. What the WHI showed compared to other studies was that the tumors these women developed were slightly worse than those of the women in the control group; all other studies at that point had shown that the women on estrogen and progestin has less aggressive tumors.

What the latest analysis looked at was a follow up study, now several years later, of the same group of women. What this analysis showed was that indeed there were a few more deaths in the women in the estrogen plus progestin group, consistent with the higher rate of tumors, and those that looked more aggressive.

So should this paper change women’s thoughts about estrogen? Not really. Very few women take estrogen and progestin for long periods of time. We regularly reassess our patients’ hormonal use at each visit. We try to prescribe the lowest dose that works to control our patients’ symptoms. We tend to use significantly lower doses than used in the WHI study.

And although there was a higher incidence of breast cancer in the women in the WHI, there was also a lower incidence of osteoporosis and colon cancer, both very significant diseases for postmenopausal women. And the heart disease prevention data is still being looked at.

Indeed, as pointed out by the North American Menopause Society recently, and as I have told my patients for years, let’s look at a woman who goes through menopause at age 40, and doesn’t take hormone therapy. She definitely has a lower risk of getting breast cancer, compared to a woman who becomes menopausal at the average age of 51. However, she has a much higher risk of developing heart disease and osteoporosis. And women who go through menopause at age 60 have a higher risk of getting breast cancer, but a lower risk of heart disease and osteoporosis.

The mantra for HRT in 2002, when the WHI results were initially published, truly was the mantra of every good care provider before then, too: individualization of care. For most women who are really bothered by hot flashes, night sweats and insomnia, there is no more effective therapy available than hormone therapy. Short term therapy is quite safe, most reasonable care providers will agree. Longer term intervention must be discussed by the woman and her care provider; for many, the benefits will outweigh the risk-and the discussion should take place regularly.

Jim Simon, MD

The big problem with the primary data set first reported in 2002, and this publication as well is that the Estrogen + Progestogen treated group did not have an equal breast cancer risk to the placebo group at baseline (when they entered the study). When baseline risk for breast cancer is considered and adjusted for, the 5.6 years of E+P treatment did NOT show an increased risk of getting breast cancer. It isn’t clear whether the mortality increase in this manuscript can likewise be attributed to the differences in baseline breast cancer risk or not.

Read Dr. Simon’s full analysis on his website, www.menopausewise.com

Michael Goodman, MD

“Rerun” Study Data* States that Hormone Therapy Worsens Breast Cancer: What is the truth? And what does this mean for you?

Yet another re-run newsflash has emerged from that old, familiar Women’s Health Initiative (WHI) study. The same information was released in 2002, utilizing fear-tactics to scare the *#!!&%! out of women and doctors. Based on data from women who took “PremPro™” (an oral hormone mixture of relatively high-dose oral estrogen and the dangerous-if-given-long-term synthetic progestogen, Provera™), this “new” study purports to show that there was an increased death rate among women who took/take PremPro™ for signficant lengths of time.

It is important for you, dear reader, to understand that all hormones are not created equal, and to state that hormone therapy increases the risk of breast cancer” is flat wrong. Even worse, it is dishonest!

Read Dr. Goodman’s full analysis on his website, www.drmichaelgoodman.com

Mache Seibel, MD

On October 20, 2010 another article was reported in the medical journal JAMA about the risk of taking estrogen plus progestin on getting breast cancer. It’s a follow up study of the earlier Women’s Health Initiative Study from 2003. Over 16,000 postmenopausal women were studied and their ages ranged from 50 to 79. Some received conjugated equine estrogens, 0.625 mg/d plus medroxyprogesterone acetate 2.5 mg/d and others a placebo. As in the earlier study, this particular estrogen and progestin was associated with a slight but statistically significant increase in breast cancer over the placebo group. The cell type of cancer and the grade of the cancer was similar in both groups but the women who took this estrogen plus progestin (81 patients) were more likely to have breast cancer that had spread to the lymph nodes than the placebo group (43 patients). 51 women who took estrogen plus progestin died versus 31 deaths among those women who got the placebo.

What does it mean? Breast cancer and death from breast cancer can occur whether a woman takes estrogen plus progestin or not. But taking estrogen plus progestin continues to appear to be a medication that can increase a woman’s risk of breast cancer compared with not taking it. Does that mean women should not take estrogen plus progestin? Not necessarily. But it does mean that for each woman, it is important that she talk with her doctor to see if there is a particularly high risk of taking it for her and weigh the risks of taking it versus either trying alternatives or enduring the symptoms that she wants to take estrogen and progestin for. Women currently on estrogen plus progestin should continue to talk with their doctors annually and reevaluate if it is a good choice for them.

Learn more about Dr. Seibel’s work on his website, www.healthrock.com.