Chronic anovulation may increase postmenopausal breast cancer risk

The female athlete triad

The opportunities for girls and women to play soccer has rapidly grown and gained acceptance in recent years. The benefits of involvement in soccer, both physically and psychologically, are overwhelmingly positive. Despite the benefits, girls and women involved in soccer are also at risk for medical problems as a result of their sports participation. Amenorrhea, disordered eating, and premature osteoporosis are entities known together as The Female Athlete Triad. The triad occurs in all sports and is associated with significant short- and long-term health consequences, and thus remains a concern for all involved in the care of the soccer athlete.

Menstrual patterns in women with congenital heart disease

To examine the extent to which congenital heart disease (CHD) influences ovarian function, 98 women (mean age 32.7 years) were asked to complete a mailed questionnaire regarding their menstrual patterns. Patients were divided into acyanotic (60%) and cyanotic (38.8%) groups. Cycle lengths, duration of menstrual cycle, regularity of menses, amount of flow, and breakthrough bleeding were compared in these two groups and against age-matched controls. The mean age of menarche for the sample (13.4 years) was significantly different (p < 0.004) when compared to their controls (12.5 years). With the exception of breakthrough bleeding, statistical differences were not found between the study population and the controls. When the menstrual histories of cyanotic women were compared with those of acyanotic women, differences were found for all categories of menstrual patterns with the exception of the amount of menstrual flow. Menstrual patterns of cyanotic women compared to controls were found to be significantly different for all categories with the exception of amount of flow. In general, women with CHD have menstrual patterns similar to those in the general population.

Sex steroids and cancer in older women

Menopause and hormone replacement therapy (HRT) continue to be controversial subjects. The main concern is the potential risk of prolonged HRT and the possible development of endometrial and breast carcinoma. There is no obvious evidence at present to suggest that HRT increases endometrial carcinoma provided the patient receives progestogen for a period of 10 or more days (usual period is 12 days) during each month. However the breast does not seem to enjoy this safety margin and there is some concern about possible increase in the incidence of breast cancer if the treatment period is longer than 5 years. The increase in the risk is higher after 15 years of estrogen use. There is no obvious adverse effect on the ovary or on the cervix following HRT.

Use of progestogen therapy

Estrogen therapy for postmenopausal women has received adverse publicity since the mid-1970s because several reports implicated estrogens with an increased risk of endometrial cancer. Other studies indicated that the risk of endometrial malignancy is reduced when a progestogen is added to the estrogen. Not all postmenopausal women need estrogen replacement, since many are symptom free because they continue to produce endogenous estrogens. Within this group may be the women at greatest risk for adenocarcinoma of the endometrium. The progestogen challenge test was devised to identify women at greatest risk for endometrial cancer. The number of endometrial malignancies declined at Wilford Hall U.S. Air Force Medical Center with increasing use of this test from 1975 through 1983. The lowest incidence of endometrial cancer was observed in the estrogen-progestogen users (49.0 per 100,000) and was significantly lower than that found in either the unopposed estrogen users (390.6 per 100,000; p less than or equal to 0.0001) or in the untreated women (245.5 per 100,000; p less than or equal to 0.005). The incidence of breast cancer was also significantly lower in the estrogen-progestogen users (66.8 per 100,000) than in the untreated group (343.5 per 100,000) and lower than that expected from two national cancer surveys (188.3 and 229.2 per 100,000; p less than or equal to 0.01). Progestogens should be added to estrogen replacement therapy in women who have undergone a hysterectomy, as well as in those with an intact uterus.

Plasma progesterone concentration in women with and without adenocarcinoma of the endometrium

In the search for the postulated but elusive "estrogenic bias" in patients developing endometrial cancer, several authors have suggested lack of progesterone as the common denominator. In this study 21 patients at the time of diagnosis of Stage I disease are compared to stringently matched healthy control subjects. No significant difference was found in plasma progesterone concentrations between the two groups. These results, in conjunction with other calculated estrogenic indices based on these patients, provide no evidence of lack of progesterone at the onset of clinical disease. However, the effects of long-term progesterone lack related to chronic anovulation are not excluded by these findings.

Endogenous estrogens and breast cancer a possible relationship between body fat distribution and estrogen availability

The growth of hormone-dependent human breast cancer is related to the activity of endogenous estrogens. The evidence for an etiological role of endogenous estrogens is still circumstantial. Life style and in particular dietary factors are held responsible for large geographic differences and time-trends in breast cancer incidence. The measurement of urinary estrogen metabolites and plasma estrogens has given no satisfactory explanation for the latter. The newly developed interest in the bioavailability of plasma sex steroids may offer a better understanding of the biology and epidemiology of breast cancer. Based on our observations on the relationship between plasma free fatty acids and estrogen-protein-binding and recently gained insight in the metabolic consequences of different types of body fat distribution we postulate that Western life style may act on breast cancer incidence through an influence on body fat distribution and resulting changes in sex steroid availability.

How I Manage Exercise-Related Menstrual Disturbances

In brief: All women who stop menstruating or menstruate irregularly should be examined. Amenorrhea and oligomenorrhea are often related to heavy exercise, but in athletes as well as nonathletes these conditions can signal a serious pathologic condition. Even athletes with regular periods can experience hormone alterations, short luteal phase, or anovulation. Anovulation and hypoestrogenism are the two major conditions experienced by women with oligomenorrhea and amenorrhea. Anovulation may lead to endometrial pathology and an increased risk of breast cancer, while hypoestrogenism increases the risk of developing osteoporosis. Tests to pinpoint the causes of menstrual dysfunctions and measure estrogen levels are listed, and treatments to establish a proper balance of estrogen and progesterone are described.

Proposal to decrease the risk and improve the prognosis of breast cancer

Of 256 patients with breast cancer diagnosed between 1972 and 1981, 102 have died (mortality, 39.8%). More hormone users had negative axillary nodes (57.1%) than did nonusers (41.8%). The mortality of the hormone users (22.2%) was significantly lower (p less than or equal to 0.01) than that of the nonusers (45.5%). In 162 patients whose diagnosis of breast cancer was made prior to 1979, the 5-year survival rate in hormone users was 76.2% compared to 48.1% in nonusers. During the prospective phase of the study from 1975 to 1981, the lowest incidence of breast carcinoma (67.3:100,000) was observed in the estrogen-progestogen users and was significantly lower than that of the untreated group (342.3:100,000) and lower than that expected from both the Third National Cancer Survey and the National Cancer Institute System for Electronic Evaluation and Retrieval (SEER) data (p less than or equal to 0.01). Estrogen therapy does not increase the risk of mammary malignancy, but added progestogen significantly decreases the risk.

Do hormones cause breast cancer?

The evidence that various endogenous and exogenous sex hormones play a role in the etiology of breast cancer is reviewed. It is hypothesized that prolonged exposure to normal levels of ovarian estrogens and cyclic progesterone resulting from early menarche and late menopause, and primarily willful nulliparity and late childbearing, act at an early stage in the development of breast cancer by promoting excessive proliferation of normal epithelial stem cells. Excess endogenous or exogenous estrogens can enhance risk by stimulating proliferation of epithelial cells that have undergone partial malignant transformation. The breast, however, is much less responsive to the tumor-promoting effects of estrogens than the endometrium, and estrogens probably play a less important role in the later stages of mammary than endometrial carcinogenesis.