As menopause hormones gain favor, experts say ‘keep cancer in the conversation’

As more women turn to hormones to relieve menopausal symptoms like hot flashes and night sweats, some physicians and scientists say not enough attention is being paid to the small increase in breast cancer risk associated with certain systemic therapies.

The link between breast cancer and hormone therapy has been the subject of heated debate for decades. In 2002, panic ensued after a large study, called the Women’s Health Initiative, found that older women taking a combination hormone pill were developing breast cancer at higher rates. (There was no risk with estrogen-only treatment, used only after a hysterectomy.) Prescriptions for combination hormone therapy plummeted.

But in recent years, the pendulum has swung in the other direction. Federal health officials removed the drugs’ so-called black box warning emphasizing the risks, though they retained language saying the combination drug had been linked to breast cancer and to cardiovascular disease.

Still, there is a dearth of good data about long-term safety with regard to breast cancer.

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“We need to keep cancer in the conversation,” said Garnet Anderson, a scientist at the Fred Hutch Cancer Center who is a principal investigator of the WHI. “I’m not saying it should overshadow treating women who have severe menopausal symptoms, but it’s part of the risk-to-benefit balance that has to be weighed on an individual basis.”

Fewer than 4% of women use hormones. But Dr. Lisa Larkin, founder of Ms. Medicine, a concierge medicine organization, is also concerned about patients who have seen claims about hormone therapy’s benefits on social media but have heard nothing about risks. Some have a history of breast cancer or are at elevated risk of the disease, and doctors generally say they should avoid the drugs.

“The messaging has gone too far,” Larkin said. “We harmed women for so long by not providing hormones to the right patients, but now we may harm women by giving the wrong patients hormones.”

The WHI found a small increase in the risk of invasive breast cancer among women taking a pill that combined estrogen and progestin, compared to a placebo. There were about 4 cases of breast cancer per 1,000 women each year among women on the combination hormone therapy, compared to 3 cases each year per 1,000 women not taking hormones, said Dr. JoAnn Manson, one of the study’s lead investigators. That’s a 26% increase in relative risk.