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Topic: HRT After DCIS

Forum: DCIS (Ductal Carcinoma In Situ) — Just diagnosed, in treatment, or finished treatment for DCIS.

Posted on: Aug 11, 2014 01:20PM

Alpineartist wrote:

Ladies, you are a rich source of information when you have it, and a great help for research when you don't yet have it. I'm so grateful you are here. I'd like to open up a can of worms. Not for the sake of it, heaven knows, but for the sake of menopausal DCIS patients such as myself in dire need of symptom relief and the sake of science in general.

Quick background. As noted on signature, Small, well-excised, low grade (ER+ PR+) DCIS lesion removed one year ago. No rads or endocrine therapy thus far. 6-and 12-month scans good. (Thankful).
My last period was also one year ago, the month before surgery. Menopause came, and hell came with her. Nearly all symptoms, severe in most cases. Debilitating arthralgia preventing exercise, even walking. Vaginal tissue remodeling with painful cyst development and severe dryness and infection. Severe flushing day/night, mood and sleep disturbances, you name it. 

On one hand, with an ER+ lesion, it was somewhat comforting to know that estrogen was so low. (-Bloodwork confirmed this). I "toughed out" the months as anyone on Tamox or AIs would do, gaining assurance that any remaining ER+ tissue in either breast was slowly starving. But after one year of it, I began to wear down. How long would this go on? I had tried non-hormonal therapies of numerous kinds, with some success but not enough to return to exercise in any meaningful, cancer-protective way. Even work (I play guitar and paint pictures) became a serious challenge as intricate hand movements required were no longer possible. This had become a significant quality of life issue and had to be addressed better, and soon.

Long story short, I began studying. And studying, And studying. What I found was not only surprising, but exciting. 
We all know that since the WHI and MWS (huge studies in the late 90's), history (even family history) of BC has been a contraindication to hormonal therapies, as exogenous estrogen is known to (if not mutate DNA and cause tumors) certainly proliferate those already there. But new studies are being done every day. And evidence is accumulating that may challenge this protocol. 

In the WHI, conjugated equine estrogens (CEE) were used, alongside synthetic progestins such as MPA for uterine protection in patients with uteri. These were the standard drugs of the day. The evidence was iron-clad that these compounds increased risk (though slight in absolute terms). However, since that time, compounds have been developed that present greatly improved safety profiles. I ignore celebrity endorsements, nomenclature such as "bioidentical" (though it may be valid), media articles and even certain high profile doctors. I don't care. Show me the numbers. Show me the science. Show me Pubmed, Medscape, etc.What are the relative risks for these compounds vs controls? What are the methods? Cohort sizes? Time of treatments? Time of follow up? 

A landscape began to emerge. Each time relative risk was more than 1 (elevated risk) it was (you guessed it) CEE/MPA or CEE/NEDA. Each time RR dropped below 1 it was something else, such as estradiol and progestERONE (not progestINS). Again, and again, and again. Sometimes the compound id was buried deep in the "methods" part of the study, but the trend was clear. Compounds, delivery (such as transdermal vs oral) and timing protocols (continuous vs sequential) all mattered when it came to safety. Risk appears to be going down. Even for BC (DCIS included) patients. There might be some hope here for those of us BC'ers who suffer due to estrogen deprivation symptoms, but we may need to dig for it. 


What I'm asking for is help with an open-minded look at this. If it doesn't pan out, I'll take my cohosh and try to move on. But some of the best researchers on the planet are here, and I can't move on until I know what some of you have to say. I have pages and pages of the studies I speak of and would be delighted to share them with anyone also curious enough to see if it is time to amend the old WHI guidelines. Here are just a few to start off. Thank you so much.

 France, B. de Ligneieres 2002

we were unable to detect an increase in the relative risk (RR) of breast cancer (RR 0.98, 95% confidence interval (CI): 0.65-1.5) in the HRT users. The RR of breast cancer per year of use of HRT was 1.005 (95% CI 0.97-1.05). These results do not justify early interruption of such a type of HRT, which is beneficial for quality of life, prevention of bone loss and cardiovascular risk profile, without the activation of coagulation and inflammatory protein synthesis measured in users of oral estrogens.

Fournier, et al, BCRT Jan 2008

The association of estrogen-progestagen combinations with breast cancer risk varied significantly according to the type of progestagen: the relative risk was 1.00 (0.83–1.22) for estrogen–progesterone, 1.16 (0.94–1.43) for estrogen–dydrogesterone, and 1.69 (1.50–1.91) for estrogen combined with other progestagens. 

France, Corvina-Duverger, 2013

We found that breast cancer risk differed by type of progestagen among current users of EP therapies. No increased risk was apparent among EP therapy users treated with natural micronized progesterone... These results do not justify early interruption of such a type of HRT, which is beneficial for quality of life, prevention of bone loss and cardiovascular risk profile, without the activation of coagulation and inflammatory protein synthesis measured in users of oral estrogens.

Progestins and progesterone in hormone replacement therapy and the risk of breast cancer, 2007 Carlo Campagnolia

We have seen on one hand, that the evidence adduced in favour of the ‘estrogen augmented by progesterone’ hypothesis is open to different interpretations, and on the other that the physiological production of progesterone during the menstrual cycle may be associated with a lower risk of BC. The lack of increase in BC risk with HRT regimens cyclically containing natural progesterone, found by the E3N-EPIC study is therefore biologically plausible. It is probable that the increase in BC risk found in other studies on HRT use is related to the continuous-combined regimen employed and/or to the fact that synthetic progestins rather than progesterone were used.

The balance of the in vivo evidence is that progesterone does not have a cancer-promoting effect on breast tissue. This provides a biological rationale for the finding that oral micronized progesterone added to estrogens in sequential or cyclic-combined regimens does not increase the risk of BC. The greater BC risk persistently related to the use of HRT preparations containing estrogen and synthetic progestins seems in all likelihood due to the regimen and/or to the kind of progestin used. The “non-physiological” continuous-combined regimen, could increase the risk because it does not allow sloughing of lobular duct epithelium (such as occurs when progesterone declines at the end of the normal menstrual cycle). More importantly, many of the progestins used have several non-progesterone like actions that potentiate the proliferative effect of estrogens on breast tissue and estrogensensitive cancer cells. We therefore suggest that when HRT is indicated, preparations containing progesterone and not a synthetic progestin should be used, according to a sequential or cyclic-combined regimen. In this way the risk of endometrial cancer is minimized without increasing the risk of BC.

ccc

Oncotype DX DCIS score:13, VNPI score: 5 Surgery 6/11/2013 Lumpectomy: Right Dx 6/12/2013, DCIS, Right, <1cm, Stage 0, Grade 1, 0/0 nodes, ER+/PR+ Dx 6/28/2015, DCIS, Right, 1cm, Stage 0, Grade 2, 0/3 nodes, ER+/PR- Surgery 8/17/2015 Prophylactic mastectomy: Left, Right; Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement
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May 13, 2015 10:19AM farmerjo wrote:

Bunkie -

I had to cold-turkey after 17 years of HRT. It took a good 2 months before the symptoms started to ease. Hang in there.

ATM gene mutation, Lynch Syndrome, On HRT for 17 years at dx. Oncotype 19, MammaPrint high-risk. Ki67 29.1% ER 90% PR 5% False-negative sentinel node biopsy Dx 1/26/2015, IDC, Left, 2cm, Stage IIA, Grade 2, 0/1 nodes, ER+/PR+, HER2- (FISH) Surgery 2/12/2015 Mastectomy: Left, Right; Reconstruction (left); Reconstruction (right) Dx 2/13/2015, DCIS, Left, <1cm, Stage 0, Grade 3, 0/1 nodes, ER+/PR+, HER2- (FISH) Hormonal Therapy 4/12/2015 Femara (letrozole) Dx 5/31/2016, IDC, Left, Stage IIB, Grade 2, 1/11 nodes, ER+/PR+, HER2- Surgery 6/17/2016 Lymph node removal: Left Chemotherapy 7/31/2016 AC + T (Taxol) Hormonal Therapy 12/20/2016 Aromasin (exemestane) Surgery 1/17/2017 Prophylactic ovary removal
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May 13, 2015 10:44AM Velouria wrote:

I had been on HRT for six years prior to my DCIS diagnosis (began getting full-on menopausal symptoms at 43, toughed it out for two years (miserably) then gave in at 45, felt great on HRT.). My BS was surprisingly equivocal about whether I could continue to take it or not after my excision and rads (I refused Tamoxifen and AI). He advised me to wean myself off it, but understood when I said I wanted to get clear of the rads and their side effects before I began to do this, for the sake of my head. He didn't advise cold turkey ("too brutal") so I am now two months in to the process of cutting down (slicing my tablets in half every morning.). He advised me to take "at least four months". He also advised that I should wait a while after that and see how I fare, but he acknowledged that "some people cannot live without HRT - it may be a risk, but living is risk." I was pretty surprised that he was so candid but I really appreciated his open-mindedness and acknowledgement that in some cases, the quality of life that is lost to menopausal symptoms has to be weighed up. My oncologist took a different view and said he would not support a resumption of HRT for me; my GP was somewhere in the middle as she has mixed feelings about DCIS overdiagnosis and overtreatment.

Thus far in, unfortunately, I'm back to some horribly familiar old symptoms including insomnia, night sweats, palpitations, dizziness, UTIs and flatline libido. I'm trying not to prejudge how I might feel in a few months when I'm clear, but am not hugely optimistic that I'll feel better than I do now. There's never been any invasive breast cancer in my family that I can locate, but there's a hell of a lot of cardio problems right down my mother's side. I was keen to maximise the cardio protection of HRT as I feel there is genuine risk in my case - I already have Reynaud's, which indicates less-than-great circulation. And I'd like to protect my bones for a while longer.

It all feels such an offset of one speculative risk against another...I share the confusion voiced here. Thanks for helping me feel less alone.

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Jul 10, 2015 03:55AM - edited Jul 10, 2015 04:09AM by sspc

Hi Bunkie10,

I find it interesting that you were diagnosed with DCIS yet you still took your HRT. The usual response for DCIS is to stop immediately if your DCIS is ER+ I'm curious how long you took your HRT and what is he status of your DCIS now?

Well I am researching taking Maca for my hot flashes. There are many website that say to stay away from it but there are equal number of site that say it's ok because Maca does not have phytoestrogens in it.

It's very confusing and there is not much help out there for women like us. We're left on our own to figure out what to do, it's depressing.

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Jul 10, 2015 01:42PM - edited Jul 10, 2015 01:43PM by CAMommy

I was on estrogen after my hysterectomy/BSO two years ago. Then I got this DCIS. Not a doubt in my mind the estrogen caused it to grow. I removed my patch the day I found out it was 95% positive for estrogen. I have had very few menopausal complaints. Go figure. I was 44 when I had my hysterectomy and 46 now. I expected quitting cold turkey to be hard. It wasn't for me. But I'm also on celexa which is known to help hot flashes and anxiety.

Dx at age 46. Have family history, mother dx at 32 and is doing great at 75 no recurrence, grandma dx at 57, no recurrence in her lifetime. Surgery 7/31/2013 Prophylactic ovary removal Dx 6/18/2015, DCIS, Right, 6cm+, Stage 0, Grade 3, ER+/PR- Surgery 7/26/2015 Lumpectomy: Right Radiation Therapy 8/13/2015 Whole-breast: Breast
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Jul 12, 2015 04:08PM farmerjo wrote:

I tapered my HRT at dx, after being on it 17 years. It wasn't as bad as I thought it would be, and I kick myself for not stopping it sooner.

ATM gene mutation, Lynch Syndrome, On HRT for 17 years at dx. Oncotype 19, MammaPrint high-risk. Ki67 29.1% ER 90% PR 5% False-negative sentinel node biopsy Dx 1/26/2015, IDC, Left, 2cm, Stage IIA, Grade 2, 0/1 nodes, ER+/PR+, HER2- (FISH) Surgery 2/12/2015 Mastectomy: Left, Right; Reconstruction (left); Reconstruction (right) Dx 2/13/2015, DCIS, Left, <1cm, Stage 0, Grade 3, 0/1 nodes, ER+/PR+, HER2- (FISH) Hormonal Therapy 4/12/2015 Femara (letrozole) Dx 5/31/2016, IDC, Left, Stage IIB, Grade 2, 1/11 nodes, ER+/PR+, HER2- Surgery 6/17/2016 Lymph node removal: Left Chemotherapy 7/31/2016 AC + T (Taxol) Hormonal Therapy 12/20/2016 Aromasin (exemestane) Surgery 1/17/2017 Prophylactic ovary removal
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Jul 18, 2015 09:16PM bratscher wrote:

What about straight progesterone (no estrogen)?

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Jul 19, 2015 06:29AM farmerjo wrote:

I have heard of physician's prescribing small amounts of progesterone but it's pretty rare. Worthy of a talk with your MO.

ATM gene mutation, Lynch Syndrome, On HRT for 17 years at dx. Oncotype 19, MammaPrint high-risk. Ki67 29.1% ER 90% PR 5% False-negative sentinel node biopsy Dx 1/26/2015, IDC, Left, 2cm, Stage IIA, Grade 2, 0/1 nodes, ER+/PR+, HER2- (FISH) Surgery 2/12/2015 Mastectomy: Left, Right; Reconstruction (left); Reconstruction (right) Dx 2/13/2015, DCIS, Left, <1cm, Stage 0, Grade 3, 0/1 nodes, ER+/PR+, HER2- (FISH) Hormonal Therapy 4/12/2015 Femara (letrozole) Dx 5/31/2016, IDC, Left, Stage IIB, Grade 2, 1/11 nodes, ER+/PR+, HER2- Surgery 6/17/2016 Lymph node removal: Left Chemotherapy 7/31/2016 AC + T (Taxol) Hormonal Therapy 12/20/2016 Aromasin (exemestane) Surgery 1/17/2017 Prophylactic ovary removal
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Jul 20, 2015 05:11PM CAMommy wrote:

progesterone can convert to estrogen if the body needs it too. Best to avoid it if you are Estrogen positive.

Dx at age 46. Have family history, mother dx at 32 and is doing great at 75 no recurrence, grandma dx at 57, no recurrence in her lifetime. Surgery 7/31/2013 Prophylactic ovary removal Dx 6/18/2015, DCIS, Right, 6cm+, Stage 0, Grade 3, ER+/PR- Surgery 7/26/2015 Lumpectomy: Right Radiation Therapy 8/13/2015 Whole-breast: Breast
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Oct 25, 2020 10:25AM izzy16 wrote:

Hi alpineartist,

I see you have not been active here for awhile but when i researched taking Duavee (CEE/BZA) on Bco your threads came up plus a post asking about clinical trials w CEE/BZA so perhaps you'll see this.

There is currently an 11 center NCI trial in the US using CEE/BZA in post menopausal DCIS patients undergoing surgery. I am not allowed to post the link but it's on cancer.gov and it's called Conjugated Estrogens / Bazedoxifene in treating patients with Ductal Carcinoma in Situ Undergoing Surgery.

There's one other trial in Kansas w CEE/BZA in cancer.gov called Conjugated Estrogens / Bazedoxifene in reducing benign breast tissue proliferation and menopausal symptoms in peri or post- menopausal patients at moderate risk for breast cancer.

Personally i just started taking Duavee w the approval of my medical team after suffering w severe menopausal symptoms that were triggered by my double mastectomy for high grade DCIS at 40.

As you and others pointed out it’s too bad BZA isn’t available by itself.

Hope your quality of life has improved and hope the trials have favorable results to help women going forward.

best,

izzy


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Oct 25, 2020 06:57PM MinusTwo wrote:

izzy - this is a thread that has been inactive since 2015 so it's unlikely you will get a response.

2/15/11 BMX-DCIS 2SNB clear-TEs; 9/15/11-410gummies; 3/20/13 recurrance-5.5cm,mets to lymphs, Stage IIIB IDC ER/PRneg,HER2+; TCH/Perjeta/Neulasta x6; ALND 9/24/13 1/18 nodes 4.5cm; AC chemo 10/30/13 x3; herceptin again; Rads Feb2014

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