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| Special
Topics: Breast Cancer |
EARLY MENOPAUSE, HRT
and BREAST CANCER RISKS:
Assessing the Risks for Younger Women
by Kathryn Petras
Breast cancer....it’s something that worries so many
women, particularly those on hormone replacement therapy. There have been several studies
linking estrogen and an increased risk of breast cancer, debates about the safety of HRT
and whether the benefits outweigh the risks, and continual coverage about this very
real—and worrisome–topic.
And the studies keep coming: looking at the effects of
long-term (and even short-term) HRT usage in post-menopausal women. In average
post-menopausal women....that is, women over age 50.
But what about those of us who are hormone replacement
therapy long before the "average" post-menopausal woman? Many of us will be on
HRT for many years before we even get close to age 50. What are our risks? Are we
putting ourselves in danger? How can we read between the lines of these studies and assess
the situation?
A Brief Overview
The first—and most important thing—to keep in
mind is that we are not the typical post-menopausal woman. The studies that have
been done focus on women in their 50s and older who are extending their exposure to
estrogen. In other words, they are supplementing their bodies with estrogen for a longer
time than naturally designed. It’s this prolonged exposure that appears to
increase the risk of breast cancer.
Younger women—women who have premature ovarian
failure, early menopause, or surgical menopause—are not dealing with the same
situation. We’re replacing hormones that we normally would have had until we reached
the average age of menopause. In other words, then, HRT is giving use the hormones our
body "expects" to have. (And, according to most studies looking at the amount of
estrogen our bodies get from HRT, in many cases, we’re actually exposing ourselves to
lower levels of estrogen than those of our peers who have average hormone levels.)
It’s also important to remember that if you’re
currently on HRT due to early menopause or POF, your cancer risks aren’t necessarily
increased to the levels that appear in the studies because, as a younger woman, you start
out with a much lower risk of breast cancer to begin with than that of the older women
involved in the studies. (To make a rough comparison of odds, the average 35 year old
woman has a 1 in 622 chance of developing breast cancer, while a 55 year old woman has a 1
in 33 risk -- quite a large difference.)
This is not to say that it’s wise to talk to your
doctor about your concerns—and to carefully weigh your personal risks. Breast cancer
is not something to be overlooked, to say the least. It’s the most common cancer
affecting Western women. By the age of 75, about one in every thirteen women will get
breast cancer, and it will affect one in every eight women if there is a family history of
this disease. And as more studies have been done on HRT and breast cancer, the more
indisputable it appears that there is a link.
The Estrogen-Breast Cancer Connection
The concerns about estrogen replacement being linked to
increased breast cancer risk began because certain cancerous tumors have estrogen-receptor
proteins. Scientists have hypothesized that this type of tumor may grow more rapidly
if you are taking estrogen. So one theory about the link between estrogen and breast
cancer isn’t as much that estrogen will cause normal cells to become cancerous, but
that it may cause cancer cells already in your breasts to grow much more aggressively.
Another theory hypothesizes that the link between estrogen and breast cancer is as
follows: estrogen causes breast tissue to grow rapidly; cancer more commonly emerges in
rapidly growing tissue; thus there’s an increased risk of cancer. And yet another
theory holds that it’s a matter of estrogen being broken down in the breast and then
binding to -- and damaging -- DNA. Frankly, no one is quite sure exactly what causes it.
But that there is a link seems more and more definitive.
A Closer Look at What the Risk Numbers Mean for a Woman in Early Menopause
Okay...so what does this mean for you?
Well, let’s put the increased risk into perspective. It’s one thing to hear
the numbers on the news, but another thing to actually understand what they really mean.
It actually sounds more threatening than it actually is. Put simply, if the studies
that show an increase in breast cancer after five or more years of HRT are correct, this
means that instead of one woman in 500 getting breast cancer, the risk rises to 1.3 or 2.
On an individual level, this means that one woman’s chances of cancer increase by
about 0.3 to 0.5.
Second, as mentioned before, it’s vital to remember that the studies that have
been done deal with women age 50 and over. So you have to extrapolate, read between the
lines to figure out what this increased risk means to you, not a woman in her 50s or 60s,
but one in her 20s, 30s or 40s. In other words, you have to determine just what you are
increasing your risk from.
You may have heard the frightening statistic that one in eight women is expected to
develop breast cancer in her lifetime. But that’s actually one in eight women up to
age 85. The actual risk of breast cancer for a woman age 20 to 40 -- that is, the
usual age of someone coping with early menopause or POF -- is much lower. A woman at age
25 has roughly a 1 in 19,608 chance of getting breast cancer. At 35, the risk increases a
great deal, but it’s still not as high as you’d think -- 1 in 622. By age 45,
the risk has increased even more -- to 1 in 93 and by age 55, 1 in 33. It’s a very
large jump from 1 in 19,608 or 1 in 622 to 1 in 33. As a younger woman, on average you
are at a much lower risk of breast cancer than the woman who have been studied.
And add to this that going through early menopause or premature ovarian failure
actually reduces your risk of breast cancer compared. Studies have shown that women
who go through menopause before the age of 51 have a lower risk of breast cancer
than their peers. (By the same token, women who keep having periods past age 51, the
average age of menopause, have been found to have a 2.3 percent increased risk of breast
cancer each year they remain non-menopausal compared to their peers.)
The general rule of thumb, then, is that taking estrogen if you’ve gone through
early menopause or POF does not increase your risk of breast cancer as it does for
the "average" post-menopausal women who have been studied. Instead what it does
is bring your risk back up to that of a woman your age who has normally functioning
ovaries and regular estrogen levels. So those studies linking length of time on HRT and
increased risk don’t apply. Even if you’ve been on HRT for ten years,
you’re still not in the same boat as the older women who’ve been on it.
You’ve been replacing your estrogen; you’ve been ostensibly recreating your body
as it would have been had your ovaries been acting like those of other women your age.
Finally, it’s vital to remember that women going through early menopause or
premature ovarian failure do have a much greater risk of bone loss and cardiovascular
problems because of low estrogen levels. So, in most cases, doctors agree that the
benefits of HRT (protecting bone density, etc.) far outweigh the cancer risks. It’s
generally recommended that you go on estrogen until you reach the age of
"normal" menopause -- age 50 or so -- and then reevaluate the situation, since
at that point you do fall into the age group that has been studied.
Making the Decision: Risk Factors to Keep in Mind
All this said, though, it’s important to weigh your own risks where breast cancer
is concerned when making the decision about HRT. The main risk is for women who have a
family history of breast cancer -- especially if relatives on your mother’s side got
breast cancer before menopause. To get a little technical, there are two major
breast cancer genes that have been identified (among others)-- BRCA-1 and BRCA-2. If you
have a mutated BRCA-1 gene -- and have a strong family history of breast cancer,
you have an 80 to 85 percent risk of developing breast cancer and a 50 percent of ovarian
cancer over your lifetime. (If breast cancer doesn’t run in your family, you’ve
possibly inherited a "blocking" gene as well that prevents the mutation from
causing the cancer.) About 1 in 200-400 American women probably carry a mutated BRCA-1
gene. If you have a mutated BRCA-2 gene, you also run an 80 percent rusk of breast cancer,
but not ovarian cancer. Overall, your risk increases two times if your mother had breast
cancer before the age of 60, and about one and a half times if she got breast cancer after
age 60.
As mentioned before, you’re also at a higher risk if you’ve been exposed to
estrogen for a long period of time -- your own estrogen, not HRT. This is one
instance where premature menopause is actually a positive thing: The older you are when
you start menopause, the higher your chances of getting breast cancer. It’s a similar
effect if you start your period at a very young age -- before you reach 12. If you have
your first child after age 30 -- or never had a child, you also increase your risks. The
key here is exposure to estrogen without the protective benefits of your natural
progesterone. A prolonged exposure to unopposed estrogen is associated with an increase in
breast cancer. Other risk factors for breast cancer may include: obesity, smoking,
high-fat-low fiber diet, and alcohol consumption.
These other risk factors -- genetic predisposition, exposure to estrogen, and so on --
are the ones that you have to take into account when weighing how much of a risk it is for
you to go on HRT. Is your risk of breast cancer so high already that adding to your odds
of getting it outweighs the very high risk of osteoporosis and heart disease that
premature menopause causes? Or do your risk factors of osteoporosis or heart disease
outweigh the possible increase in breast cancer?
Next, take into account that, according to several research studies, a woman has a much
greater risk of dying from heart disease because she isn’t on HRT than she has of
dying from breast cancer if she does take it. And when you’re in early menopause,
your risk of heart disease is much higher than the average woman.
A Few Final Words
So should a younger woman on HRT worry about the
increased risk of breast cancer? And should this possible risk be enough to keep
you off of it? Unfortunately, this is a situation where there is no definite black and
white -- and where your individual risk factors must be taken into account.
All in all, as with so many of the other aspects of HRT,
the risks probably aren’t high enough to counterbalance the positives in most cases
for women with premature ovarian failure or early menopause. Again, the key would be
taking HRT until you reach age 50, then reconsidering the positives and negatives. If,
however, you have a family history of breast cancer, you will need to think even more
carefully, study the facts, go through all the possible negatives, and discuss the issue
with your doctor.
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