Increasing numbers of women in their 50s and 60s are using hormone replacement therapy to alleviate menopausal symptoms. The effect of long term use of these agents in women aged over 50 on the front is lone immediately becoming apparent. Hormone substitution therapy given to perimenopausal women increases breast annoyance and nodularity, increases the frequency of benign cysts and fibroadenoma in the breast, and results in the growth of some already established benign lesions. 1 Breast concentration increases in 17 % to 73 % of women who use hormone refilling therapy depending on how breast concentration is assessed. No clear relation exists between duration of therapy and change in density on mammography. Combinations of estrogen and progestin increase front concentration more than estrogen alone. continuous use of combined preparations of estrogen and progestin increase density more than their consecutive use. 2 Hormone substitution therapy affects both the sensitivity and specificity of breast screening. This is because the efficacy of summit screening depends on the decreasing front concentration seen with age. In a late survey of 103 770 women from Australia the sensitivity of two year mammographic shield in women aged 50-69 was 64.3 % ( 95 % confidence time interval 57 to 72 ) in those given hormone substitution therapy compared with 79.8 % ( 76 to 84 ) in non-users. 3 There were besides more interval cancers, false negatives ( odds ratio 1.60 ( 1.04 to 2.21 ), and faithlessly positives ( 1.12 ( 1.04 to 1.19 ) and a meaning reduction in specificity in women taking hormone substitute therapy. In countries where hormone surrogate therapy is widely used this decrease in the sensitivity of mammography could undermine the capacity of population based mammographic screening programmes to reduce mortality due to breast cancer. 3 The unite analysis of studies of early hormone successor therapy reported an increased risk of breast cancer of 1.023 for each year of consumption, the risk being 1.35 ( 1.21 to1.49 ) for women who took hormone refilling therapy for five or more years. 4 There were besides few data to correlate type of hormone refilling therapy and risk. More recent studies have reported significantly higher levels of risk of breast cancer in women taking compound estrogen and progestin preparations compared with women taking estrogen alone. 5 – 9 The annual increased gamble varied from 4 % to 9 % for combine preparations compared with 1 % to 3.3 % for estrogen alone. excess gamble at five years was higher, ranging from 25 % to 40 % for estrogen and progestin combined compared with a range of 1 % to 17 % for estrogen alone. The relative hazard of developing breast cancer after 10 or more years ‘ habit of estrogen and progestin together was 2.43 ( 1.79 to 3.30 ) in one survey. 8
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continuous combined preparations containing a testosterone derived progestin besides appear to be associated with a significantly greater gamble than the use of consecutive estrogen and progestin. 8 such is the concern surrounding the use of combined estrogen and progestin preparations that it was recently stated that “ the burden of proof should nobelium long be on epidemiologists and other investigators to demonstrate that such agents increase the hazard of breast cancer ; rather it should shift to the proponents of their manipulation to demonstrate that they do not. ” 10 Most studies have found that breast cancers that develop in women on hormone substitution therapy are smaller, less clinically advanced, have a lower rate of node positivity, are well differentiated and are of more favorable histological type than cancers that develop in women who do not use hormone replacement therapy. reproducible with these findings, most studies have shown either a decrease or no significant consequence of hormone refilling therapy on mortality due to breast cancer. Studies published so far have been based on preparations many of which are no longer in common use, and in most follow up has been less than 10 years. One large study of 1 121 700 nurses recruited in 1976 reported after 18 years of follow up that there was excess deathrate due to breast cancer in women who had taken hormone surrogate therapy for five years or longer ( relative risk 1.45, 1.01 to 2.09 ). 11 It may be time to reassess the value of hormone refilling therapy. Some doubt that its benefits in reducing the risk of bone loss exceed its risk, 12 and evidence suggests that there is an increased gamble in the rate of coronary events with shortstop term hormone successor therapy and a decreased risk with lone long term use. 13 The current attest suggests that the effects of hormone replacement therapy on the summit, particularly the effects of combinations of estrogen and progestin on summit concentration and risk of breast cancer, besides need to be considered. The use of progestogens and their manner of delivery necessitate especial attention. One option is delivering progestin immediately to the uterus and combining this with systemic oestrogen—this should alleviate menopausal symptoms while limiting the risk of breast cancer. alternative agents to control menopausal symptoms, such as tibolone, a synthetic steroid with weak estrogen, androgenic, and progestogenic activeness but with few apparent ill effects on the breast, need to be considered for women with no remainder cyclic hormonal production. The evidence that hormone substitute therapy reduces the effectiveness of breast screen and causes breast cancer in women over the age of 50 is clear ; the challenge for clinicians is to control menopausal symptoms while limiting these unwanted effects .
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