Menopause, Breast Cancer, and What Comes Next-a Conversation With Dr. Avrum Bluming

Some of the questions we get most often are about breast cancer. Is it safe to take Menopausal Hormone Treatment after having been treated for breast cancer? Why might oncologists be averse to estrogen? What are the risks, and what are the benefits?

It’s easy to see why we get so many of these questions. Cancer is scary. And there’s a lot of misinformation about breast cancer and hormone treatments. But, there’s also good information, and some of the best comes from Dr. Avrum Bluming. He’s a renowned breast oncologist and the author of Estrogen Matters: Why Taking Hormones in Menopause Can Improve Women's Well-Being and Lengthen Their Lives -- Without Raising the Risk of Breast Cancer. So, you probably get where this is going. Because we’ve said it before. But we’re going to keep saying it anyway.

We recently were lucky enough to sit down with Dr. Bluming for a webinar. He answered a TON of your questions on MHT and breast cancer, and we HIGHLY recommend watching the whole thing on our YouTube, because there’s absolutely no way to get everything we discussed into one blog post.

But, for the condensed version, we edited down the interview for clarity and length, and you can read it below. Thanks again to Dr. Bluming for joining us!

Monica Molenaar:

Hi, I’m Monica Molenaar, one of the founders of Alloy Women’s Health. Today we’re going to talk about navigating the waters of treating your menopausal symptoms after breast cancer or after a BRCA diagnosis. It’s a topic that’s near and dear to my heart since I’m BRCA positive. I haven’t had breast cancer myself, but I’ve been getting screened for it consistently for 25 years, and so I’ve become a sort of subject matter expert. I’m here moderating this discussion with one of our fantastic prescribing doctors, Dr. Corinne Menn, who is an OBGYN and a breast cancer survivor herself. 

We’re lucky enough to be joined today by Dr. Avrum Bluming, a breast oncologist and one of the authors of a book called Estrogen Matters. Thank you so much for joining us today. Could you tell us a little bit more about yourselves?

Dr. Corinne Menn:

I’m a board-certified OBGYN and a North American Menopause Society-certified menopause practitioner. I’m also a 22 year breast cancer survivor. I was diagnosed when I was 28 during the second year of my OBGYN residency, just a few weeks after my mom died of ovarian cancer. I later found out I do carry the BRCA-2 gene mutation. Due to cancer treatments, I went through menopause three times.

I found that I wasn’t really well educated on how to deal with menopause in general, but certainly not on how to deal with menopause and breast cancer. And none of my doctors knew how to help me. So, I struggled for years. Dr. Bluming’s book and research have changed my life professionally and personally, so I’m so grateful to have him here with us.

Dr. Avrum Bluming:

I'm delighted to be here. I'm a medical oncologist, though I’m now retired from active practice. When I was practicing, for over 40 years, 60% of my patients had breast cancer. I want to mention that today, newly diagnosed breast cancer carries about a 90% cure rate, and I think it’s important we keep that in mind throughout this discussion.

Anyway, I’ve treated lots of people with breast cancer, including premenopausal women. That meant that I often induced precipitous menopause, which included all kinds of symptoms. My reaction was always, “Well, there’s a great chance we’ve cured your breast cancer. Aren’t the symptoms worth it?” 

Then my wife got breast cancer at the age of 48. I treated her with chemotherapy. And then she started developing symptoms, like hot flashes, sleep disturbances, palpitations, and genitourinary symptoms. And she tolerated all of it without complaining. But, she is a voracious reader, and she started to notice that right after she finished reading a page, she didn’t recall what she had read. And that was devastating. And then I became much more invested in what happens to women as they go through the menopausal transition, especially women with a history of breast cancer. 

Dr. Corinne Menn:

Let’s start with the benefits of Estrogen Therapy, Hormone Replacement Therapy, or, as we call it, Menopausal Hormone Treatment. 

Dr. Avrum Bluming:

Let’s start by laying the groundwork. Hormone Replacement Therapy is primarily estrogen. As a woman goes through menopause, there is a precipitous fall in circulating estrogen levels in her body, which results in menopausal symptoms. So, in order to treat those symptoms, we use estrogen. 

In the 1970s, we found that using estrogen alone actually does increase the risk of uterine cancer. And then we also found that adding progesterone neutralizes that risk. So, if you have a uterus, you’ll use estrogen and progesterone, and if you don’t have a uterus, you’ll take estrogen alone. 

We now know that women who take estrogen have a median increase in longevity of about three and a half years, which is great, since one thing we all have in common is wanting to live as well as possible for as long as possible. In women who take MHT, there is a decrease in the instance of heart disease, osteoporosis, and cognitive decline. Plus, it gets rid of your symptoms.

Dr. Corinne Menn:

So, there are all of these amazing benefits, both for symptom relief and for preventative healthcare. So why is there so much misinformation and fear out there among the general public and physicians? Most women who come to me are very against or fearful of MHT. 

Dr. Avrum Bluming:

We are a risk-averse species. During the early part of the 2000s, about 44% of menopausal women in the United States were taking hormones. In July of 2002, there was a press release, and then an article published in the Journal of the American Medical Association that claimed that hormone replacement therapy did many, many bad things. Just about every one of those claims has now been walked back. But one of the claims was breast cancer, and even though at the time estrogen was not associated with any significant increased risk of breast cancer, that was the headline in the New York Times. And the rate of prescriptions for hormone replacement therapy fell to 5%, and it remains there today.

Dr. Corinne Menn:

So, so much fear from the almost over 20 year old study. Let’s talk about BRCA mutation carriers. And let’s also lump in women who have a higher risk of developing breast cancer due to, say, their family history, or dense, fibrocystic breasts. Women are often told that MHT raises their risk. Can you give some guidance on the science?

Dr. Avrum Bluming:

First of all, thanks for calling it guidance. These are just guidelines, and you should always discuss these kinds of things with your practitioner. But the best guideline is that the overwhelming majority of women would benefit from taking this treatment. 

Dr. Corinne Menn:

I think a lot of women would be surprised to hear that.

Monica Molenaar:

We have a lot of questions coming in about different types of breast cancer and different types of breast cancer treatments.

Dr. Corinne Menn:

We're gonna jump into that now. Dr. Bluming, can you explain estrogen receptor positive vs. estrogen receptor when it comes to breast cancer? Because estrogen receptor positive breast cancer makes it sound like estrogen feeds breast cancer.

Dr. Avrum Bluming:

There are now 26 studies in the medical literature that I could find in languages that I can understand, and I reviewed all of those studies. Of the 26 studies, 25 show no increased risk of recurrence of breast cancer among women who take hormone replacement therapy of any kind. And that’s independent of whether they had estrogen receptor positive or estrogen receptor negative breast cancer. The one study that suggested an increased risk of recurrence is a study that was done in Sweden called the HABITS Study. HABITS stands for Hormones After Breast Cancer: Is it Safe? And that study reported an increased risk of contra, or local breast cancer, not an increased risk of distant recurrence. And there was no increased risk of death from breast cancer. And the study has several problems, including that it did not mandate baseline mammograms for women going into the study, which you would need in order to know to know that a local recurrence wasn’t there before starting.

Dr. Corinne Menn:

Yeah. Big, big problem. Can you explain what estrogen receptor status actually means?

Dr. Avrum Bluming:

Sure. An estrogen receptor is a molecule that is present on the surface of about 60% of diagnosed breast cancers. That molecule allows estrogen to bind to the surface of those cells, and estrogen stimulates multiplication of those cells. It’s very easy to extrapolate, and say that if it stimulates multiplication of those cells, it increases the risk of breast cancer. And that’s understandable. But the data doesn't support that.

Dr. Corinne Menn:

Switching gears, I recently spoke to an audience of over 400 young breast cancer survivors, and many were dealing with severe genitourinary syndrome. And a lot of them were really suffering. And a lot of them said their oncologists don’t discuss vaginal estrogen with them. How come in the oncology community we see such an incredible resistance to even vaginal estrogen? 

Dr. Avrum Bluming:

I don't know the answer to that. I can't explain it and I certainly can't defend it. Nothing is my last word about anything, and I constantly review data, but I’m going to make a categorical announcement now: I know of no evidence that transvaginal estrogen compromises anyone’s health.

Monica Molenaar:

When it comes to menopause treatment and breast cancer, you hear a lot of “women can’t have this,” and “you’re not a candidate for this,” and it’s often without any discussion.

Dr. Corinne Menn:

Absolutely. And when we’re talking about hormone therapy after breast cancer, I always say this: A woman has to be treated for her primary breast cancer. And that’s very important. And then you also have to look forward into your future. 

Dr. Avrum Bluming:

Right. And that should be an ongoing discussion with your doctor, because, besides being cancer free, your interests are also important. And the only way for a doctor to be able to understand your best interests is if the discussion is open. 

There is SO much more where this came from, and it got pretty specific. To watch the whole webinar (again, strongly recommend this), head over to YouTube.  More questions about breast cancer? We got you.