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The 2022 NAMS Update

Twenty Years on the North American Menopause Society Changes some positions on hormone replacement...

Statistics grab headlines – like the oft quoted but inaccurate statistic 1 in 8 women will get breast cancer at some point in her life. But statistics is a weird world, and numbers often lie. As the famous quote goes, “there are lies, damned lies, and statistics!”

But, where does this particular statistic come from? Patricia Kelly explained in Assess Your True Risk of Breast Cancer:

  • A thirty year old woman has a risk of developing breast cancer in the next decade of 1 in 227
  • A forty year old woman has a decade risk of 1 in 68 (1.5%)
  • A fifty year old woman has a decade risk of 1 in 42 (2.4%)
  • A sixty year old woman has a decade risk of 1 in 28 (3.6%)
  • A woman over seventy has the highest risk, 1 in 26 (4%)

We don’t see 1 in 8 there. That 1 in 8 “statistic” comes from adding the percentages together - which is some nonsense statistics. The risk in any decade of life is never more than 1 in 26, and that’s in the 70+ range. And let’s remember that now detection is SO MUCH BETTER, 90% of women diagnosed with early breast cancer will survive without a mastectomy or chemotherapy.

A trip down memory lane (while we still have memories)

By the early 1990’s it was clear that hormone replacement therapy (HRT) (even if it was pharmaceutical) made a significant difference to women, reducing the risk of heart disease, hip fractures, colon cancer, Alzheimer’s and handling the symptoms related to changes in hormones around menopause.

Questions remained about the impact of HRT on women’s long term health, including breast cancer rates. Many studies concluded that estrogen does not cause breast cancer. Enter the Women’s Health Initiative in 1991 to do a long term, large scale evaluation of synthetic estrogen and progestogen replacement on women’s health. In 2002 a bombshell hit the media stating the study had been stopped early “due to an increased risk of invasive breast cancer.”

The press leapt upon this statement and the buzz was crazy. Close to 70% of women stopped taking their synthetic HRT. The big challenge was that although statistics can identify a possible increase in risk – that does not always translate into a medical increase in risk. Statistics is all about working with numbers to identify patterns, but a pattern can be identified with the cause being completely due to chance. Any potential relationship needs to reach a certain level of confidence that the pattern is NOT due to chance, and that was not the case with estrogen and breast cancer. Many of the statistical analyses from the Women’s Health Initiative were misinterpreted for years. In the meantime – the message kept pounding out “Estrogen causes cancer”. Let’s face it – that’s ridiculous because if estrogen caused cancer – women from puberty onwards would be dropping like flies. And they don’t.

What Makes A Good Headline?

After a while, the North American Menopause Society (NAMS) changed its recommendations on HRT to say – use it before menopause to help with symptoms like hot flashes and mood swings but get off it as soon as possible.

Patients in the WHI study continued to be followed for more years and nothing indicated any increased risk of developing breast cancer. This news did NOT make the headlines…and yes, you are right, it’s been a long time that the media has hyped bad news and ignored the good news.

Let’s just pause the story here and say that no huge long term study has ever been done on bioidentical hormones – basically because no one (such as a pharmaceutical company) will pay for it. Women have however, been using bioidentical estrogen, progesterone, testosterone, DHEA very successfully and very safely for decades. Studies do exist and, while not as large as some studies, are robust enough to demonstrate that when used in balance and dosed appropriately, millions of women benefit from Bioidentical Hormone Replacement.

The NAMS Review 2.0 (in 2017)

Fast forward another decade or so. In 2017, a review of the WHI was published. The author of the review wrote “ highly unusual circumstances prevailed when the WHI trial was stopped. The investigators most capable of correcting the critical misinterpretations of the data were actively excluded from the writing and dissemination activities.” Say what? The people who understood the statistics and how they were being interpreted wrongly - were silenced?

During all this time, many women have suffered needlessly as a result of the faulty message “estrogen causes cancer”. They have experienced bone loss, memory loss, mood swings, incontinence, vaginal atrophy, loss of function - which reduces their role in the workplace - and thus, loss of income.

Key Summary Points For 2022

In July of 2022, the NAMS updated its position statement on the use of hormone replacement. The following items were called out and we want to share some key areas with you:

  1. The WHI only looks at oral synthetic estrogen (from pregnant mare’s urine CEE) and one progestin – medroxyprogesterone acetate (MPA). It did not look at bioidentical hormones or topical, pellets, or sublingual hormones.
  2. Estrogen alone without being balanced by progesterone increases the risk for abnormal uterine bleeding and uterine cancer.
  3. Non oral use of hormones (e.g. vaginal, transdermal) may offer more advantages because the hormones are not first broken down by the liver.
  4. After 20 years of following the women who took part in the study, those who had the synthetic progestogen MPA (not bioidentical progesterone) showed an increased incidence of breast cancer.
  5. Low dose vaginal estrogen is very well indicated for women with vaginal dryness, atrophy, and incontinence.
  6. Estrogen and progesterone therapy is approved for severe hot flashes, osteoporosis, very low estrogen levels, and vulvovaginal symptoms.
  7. There is the belief that studies do not support use of bioidentical hormone replacement. While studies may be smaller in size, there are still significant studies that support its use. This whole topic is still a very political hot potato. While NAMS doesn’t outright say “don’t use bioidenticals” it states, “patient preference alone should not be used to justify use of compounded bioidentical hormones therapy” Essentially, we cannot choose for ourselves, which is another can of worms when it comes to female healthcare.
  8. Low dose vaginal estriol is safe to use for vaginal atrophy. For women with breast cancer or post breast cancer the decision to use estriol can be made in consultation with the oncologist. The benefits of resolving painful vaginas may well outweigh any slight risk of increased estrogen levels, especially if balanced by progesterone.
  9. Conjugated estrogens (CEE) and MPA use is linked to increased stress incontinence whereas vaginal estrogen use is linked to reduced stress incontinence and reduced UTI’s.
  10. Vaginal estrogen is better than oral estrogens for libido and arousal, because oral estrogens will increase sex hormone binding globulin which reduces the amounts of hormones available to be used a different receptor sites in the body.
  11. Micronized progesterone is really good for reducing hot flashes and night sweats and improves sleep.
  12. Hormone therapy prevents bone loss in healthy postmenopausal women. Given that we always want our bones to be healthy – this statement suggests that long term use of hormones is actually a good idea.
  13. Hormone replacement – especially progesterone, helps with glycemic control so someone with type 2 diabetes could benefit from hormone replacement.
  14. Micronized progesterone is more protective of the cardiovascular system than synthetic progestins.
  15. Oral CEEs are associated with increased risk of gallstones, whereas transdermal hormone therapy has a lower risk of gallstones.
  16. Oral CEE’s with MPA are associated with increased risk of all-cause dementia, there is no mention of bioidentical hormones protective effect on the brain.
  17. Risk of breast cancer with use of CEE plus MPA is slightly greater than drinking 1 glass of wine a day, less than 2 glasses of wine a day, and similar to the risk of obesity and low physical activity. The greatest risk for developing breast cancer comes from a combination of factors – low activity, high inflammation, two or more alcoholic drinks a day, carrying too much extra weight, and smoking. Lifestyle factors are the biggest influences on breast cancer risk.
  18. The effect of hormone therapy on breast cancer risk may depend on the type of hormone therapy [use topical rather than oral, and bioidentical rather than synthetic], duration of use, and individual characteristics.

Questions, Answers & More Questions…

While the message from NAMS still seems to lean towards recommending using synthetic hormone replacement for a limited period of time, it does not reconcile all the benefits that hormone replacement can provide with deciding to stop it. Women can live into their 90’s - if we cut them off from hormones at age 65 or 70, that’s still a lot of years without the benefits of estrogen, progesterone, and testosterone. There is one short statement of interest “when providing hormone therapy to older women, clinicians…[can consider]… switching from oral to transdermal hormone therapy, choice of progestogen, and lowering of dose.” Hmmm – why wait until women are older to do this? This question has yet to be answered thoroughly.

While this 2022 update from NAMS has some promising messages for women, the thread of the message still also seems to focus on the use of synthetic hormone replacement. Only passing reference is made to the use of topical bioidentical hormones. We think it’s important to finish with the statement that the early reports of estrogen causing cancer in healthy women were inaccurate and as a result, millions of women have suffered needlessly.