Hormone Replacement Therapy(HRT) is indicated in menopausal women to overcome the short-term and long-term consequences of estrogen deficiency.HRT can be administered orally( in pill form), vaginally( as a cream), or transdermally ( in patch form) because it replaces female hormones produced by the ovaries, hormone replacement therapy minimize menopause symptoms. It can be used before, during and after menopause.
Hormone Replacement Therapy(HRT) is indicated in menopausal women to overcome the short-term and long-term consequences of estrogen deficiency.HRT can be administered orally( in pill form), vaginally( as a cream), or transdermally ( in patch form) because it replaces female hormones produced by the ovaries, hormone replacement therapy minimize menopause symptoms. It can be used before, during and after menopause.
The effect of Metformin on endometrial tumor-regulatory genes and systemic metabolic parameters in polycystic ovarian syndrome – a proof-of-concept study
A 38 slide power-point presentation for medical students years 4 or 5. The idea to familiarize with classification, clinical features, diagnosis and management.
Menopause: how to balance your hormones and live vibrantlyVandna Jerath, MD
Vandna Jerath, MD discusses menopause, hormonal imbalance, how to balance hormones, and living vibrantly for a health seminar at Parker Adventist Hospital in Parker, CO. She outlines a number of treatment modalities including hormone replacement therapy (HRT), bioidentical hormone replacement therapy (BHRT), and alternative therapy. She reviews the latest women's health updates related to menopause and vulvovaginal atrophy as well as her current practice usage of BioTE hormone pellet therapy and MonaLisa Touch vaginal laser revitalization treatment.
Obesity has many deleterious effects for women of reproductive age.
In the first place, obese women are more likely to encounter problems becoming pregnant and they are more likely to miscarry
They are at greater risk of developing pregnancy complications and problems associated with labour and delivery.
Finally, obese women are more at risk of postpartum complications .
Taken all together, maternal mortality and morbidity is significantly elevated for obese women .
Maternal obesity is also dangerous for the fetus and the newborn.The management of obesity requires a multidisciplinary approach.
Stepwise programmes with realistic time-related goals are required, starting with modification of lifestyle, progressing to pharmacotherapy and ultimately obesity surgery.
Weight loss interventions do not appear to be common practice among fertility centres& pre-pregnancy clinics in spite of clear evidence as to the benefits.
Women should be referred to a nutritionist in cases where clinicians lack the knowledge and/or time to provide adequate counselling.
Obesity in pregnancy is now rampant and bringing about concern because of the associated morbidity and mortality both to the mother and child. All hands must be on deck to prevent and manage this condition and associated sequel.
menstrual manipulation for adolescents with disabilityMini Sood
A presentation of aspects of menstrual care in adolescents including those with disability. Slides for medical students who may encounter young patients who are unable to mange their menses efficiently
The effect of Metformin on endometrial tumor-regulatory genes and systemic metabolic parameters in polycystic ovarian syndrome – a proof-of-concept study
A 38 slide power-point presentation for medical students years 4 or 5. The idea to familiarize with classification, clinical features, diagnosis and management.
Menopause: how to balance your hormones and live vibrantlyVandna Jerath, MD
Vandna Jerath, MD discusses menopause, hormonal imbalance, how to balance hormones, and living vibrantly for a health seminar at Parker Adventist Hospital in Parker, CO. She outlines a number of treatment modalities including hormone replacement therapy (HRT), bioidentical hormone replacement therapy (BHRT), and alternative therapy. She reviews the latest women's health updates related to menopause and vulvovaginal atrophy as well as her current practice usage of BioTE hormone pellet therapy and MonaLisa Touch vaginal laser revitalization treatment.
Obesity has many deleterious effects for women of reproductive age.
In the first place, obese women are more likely to encounter problems becoming pregnant and they are more likely to miscarry
They are at greater risk of developing pregnancy complications and problems associated with labour and delivery.
Finally, obese women are more at risk of postpartum complications .
Taken all together, maternal mortality and morbidity is significantly elevated for obese women .
Maternal obesity is also dangerous for the fetus and the newborn.The management of obesity requires a multidisciplinary approach.
Stepwise programmes with realistic time-related goals are required, starting with modification of lifestyle, progressing to pharmacotherapy and ultimately obesity surgery.
Weight loss interventions do not appear to be common practice among fertility centres& pre-pregnancy clinics in spite of clear evidence as to the benefits.
Women should be referred to a nutritionist in cases where clinicians lack the knowledge and/or time to provide adequate counselling.
Obesity in pregnancy is now rampant and bringing about concern because of the associated morbidity and mortality both to the mother and child. All hands must be on deck to prevent and manage this condition and associated sequel.
menstrual manipulation for adolescents with disabilityMini Sood
A presentation of aspects of menstrual care in adolescents including those with disability. Slides for medical students who may encounter young patients who are unable to mange their menses efficiently
Bringing life course epidemiology to understanding etiology and implications for timing of prevention . Studies cited in slides, but also motivated by much of my resesrch summarized here:
Colditz GA, Frazier AL 1995 CEBP Models of breast cancer show risk is set by events of early life: prevention efforts must shift focus
Terry MB, Colditz GA 2023 Cold Spring Harb Perspective Med
Colditz G, AND Bohlke K 2015 NPJ Breast Cancer
Colditz, Bohlke, Berkey 2014 Breast Ca Res Treatment
Gain a deeper understanding of uterine and endometrial cancer symptoms, diagnosis, treatment options, and current research trends with Dr. Jason D. Wright, Division Chief of Gynecologic Oncology at New York-Presbyterian/Columbia University Medical Center. This webinar is a collaboration with the Foundation for Women's Cancer.
Public webinar presentation on breast cancer. This presentation gives an overview of breast cancer in Malaysia, the risk factors and ways to reduce risk of breast cancer, early detection and its importance on survivorship besides exploring treatment options.
Studies have shown that older women receive less aggressive screening and treatment for breast cancer. Geriatric Oncologist, Meghan Karuturi, of MD Anderson Cancer Center joins us in this webinar to discuss age bias and how it affects older patients.
For information of chronic disease
. very common these days and required early detection and cure.
for education purpose
.this is simplify version of very important but complex topic .
This is only prevented by early detection and cure .
By identifying red flags of disease first we can detect high group .by targeting high risk group we will be able to detect and treat disease with less resources.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
2. • Breast cancer is the most frequent cancer diagnosis in
women (lifetime risk 10%)
• There was a significant increase in incidence rates for
premenopausal and postmenopausal BC in around 20 of
44 populations over the last decade (1998-2012)
• The increase in premenopausal BC is largely in high
income countries
• 2018 BC incidence (/100,000) in high income countries
Premenopausal: 30.6
Postmenopausal: 256
2020
4. Breast Cancer Epidemiology
• Fig: Average annual
percentage change for
premenopausal and
postmenopausal breast
cancer, 1998–2012
5. 2020
Trends in premenopausal
and postmenopausal
breast cancer truncated
ASIRs, 1998–2012, for each
country
Premenopausal breast
cancer defined as age <50
years and postmenopausal
breast cancer defined as
age ≥50 years
ASIR: age-standardized
incidence rate
6. • BC risk is lower in women with
• Late menarche
• Early menopause
• Having children early
• Having more children
• Longer duration of breast feeding
Breast Cancer Epidemiology
Reproductive factors
7. Evidence on breast cancer and MHT
• RR for MHT (=E+P) > E only
• WHI EPT HR: 1.26 (1.01-1.59)
• WHI ET HR: 0.77 (0.62-0.95)
• Progesterone / dydrogesterone < synthetic P
• Continuous > sequential
• Duration effect
• Promoter effect (RR ceased following discontinuation)
• Increase: lobular > ductal
• Better differentiation
• No increase in mortality
8. After 20 years, no more increase in the
RR, no more deaths… Chlebowski, et al., 2020
8.2y
9. After 20 years, no more increase in the
RR, no more deaths… Chlebowski, et al., 2020
10. • WHI: 26,525 postmenopausal wopmen with a
hysterectomy, 50-79yrs. Follow-up 8.2yrs.
• WHI: No difference (CEE) low vs. standard dose (0.625 mg)
(HR: 0.99 (0.65-1.48))
• WHI: No difference (route): TD E2 vs CEE 0.625mg
(HR: 0.75 (0.47-1.19))
• E2 + progesterone / dydrogesterone;
Finnish registry: E2 + DYD; <5 yrs
RR=1.00
French case-ctrl study: E2 + P/DYD;
RR=0.80 (0.44-1.43)
Shufelt, et al., 2018
Lyytinen et al., 2016
BC - Difference in E / P
Cordina-Duverget et al., 2013
Shufelt, et al., 2018
11. BC: The level of risk (by Gail)
High risk (>4.00)
• BRCA mut., Family hx: 1st degree premenopausal
• Bx: atypical hyperplasia, LCIS, DCIS
• High breast density: BI-RADS D
• Thoracic radiation
Intermediate risk (≤2.00)
• Reproductive factors: obesity, young age at menarche, nulliparity
• Family hx at older age, Med. breast density: BI-RADS C
• DM, Obesity (post-menopausal)(x1.20-2.50); Alcohol (x1.05-1.40)
Lower risk (<1.00)
• Breast-feeding (>12 mo); Low breast density: BI-RADS A; B
• Multiparity? (≥5; 1st<25 y/o!), low BMI, low BMD, VMS (?SWAN)
• Exercise, Wt. loss at any age;
• Obesity receiving MHT: No increase
GAIL:
www.cancer.gov/bcrisktool
IBIS tool: www.ems-
trials.org/riskevaluator
14. Mastalgia as a risk factor for BC (WHI)
Crandall et al., 2011
15. Modifiable risk factors for BC
• Alcohol: dose dependent
• Inactivity: Exercise decreases the risk even in
women under MHT
• BMI: Weight loss
16. MHT and Mortality
Benkhadra et al., 2015
• MHT does not affect the risk of death from all
causes (43 RCTs)
• RCTs including women with
• mean age less than 60 and
• MHT started less than 10 years after menopause
showed a reduction of mortality
RR: 0.70 (0.52-0.95)
17. BC risk in premenopausal
LNG-IUS20 users
• Two newer high quality registry-based studies
including women aged 18-40 years (premenopausal)
observing >500,000 wy of use found a minimal but
significant risk increase for current users. RR: 1.27
• In the Finnish study an increase in risk was
significant only for a > 5-years-duration of use
• Absolute numbers
• Non-hormonal contraception 55 cases/100,000 wy
• LNG-IUS 70 cases/100,000 wy
+15 cases/100,000 wy
Morch, et al., 2017; Soini et al., 2016
Soini et al., 2016
18. BC risk in peri and postmenopausal
LNG-IUS20 users
19. Breast cancer risk and MHT
SUMMARY
BC risk is lower
• With E alone than with EP combination
• With E in combination with Progestorone / Didrogesterone
(DG) than in combination with other progestins (=synthetic)
20. Breast cancer risk and MHT
SUMMARY
BC risk is lower
• With E alone than with EP combination
• With E in combination with Progestorone / Didrogesterone
(DG) than in combination with other progestins (=synthetic)
Incidence of BC
• Increases with duration of use (Absolute numbers !!!)
• Decreases with time since last use
• Increases with increasing breast density
• Increases with breast tenderness (mastalgia) in EPT, not ET
• No increase in POF!!! No further increase in obese women
21. Breast cancer risk and MHT
SUMMARY
BC risk is lower
• With E alone than with EP combination
• With E in combination with Progestorone / Didrogesterone
(DG) than in combination with other progestins (=synthetic)
Incidence of BC
• Increases with duration of use (Absolute numbers !!!)
• Decreases with time since last use
• Increases with increasing breast density
• Increases with breast tenderness (mastalgia) in EPT, not ET
• No increase in POF!!! No further increase in obese women
MHT
• Does not cause BC, but has a promoter effect
• Important to stratify on the level of individual risk
• Reduces mortality from all causes (after menopause)
25. Breast cancer risk and MHT IMS, Keypoints
• The increased risk is primarily associated with the addition of a
synthetic progestogen to estrogen therapy and to duration of
use [B]
• The risk may be lower with micronized progesterone or
dydrogesterone [C]
• The MHT attributable risk is small and decreases when
treatment stops [B]
• There is a lack of safety data supporting MHT use in breast
cancer survivors
• Breast cancer risk should be evaluated before MHT prescription
[D]*
• Any possible increased risk associated with MHT may be
decreased by selecting women with lower baseline risk
including low breast density and by providing education on
preventive lifestyle measures (reducing weight, reducing
alcohol intake, increasing physical activity) [D]
Meta-analysis (51 studies) 1.35 1
NHS EPT 1.32 2
WHI EPT 1.26 3
WHI EPT 1.24 4
MWS EPT/ET 1.66 5
1 . Lancet 1997;350:1047
2 . Chen WY et al, Ann Intern Med
2002;137:798
3. Writing Group for WHI, JAMA
2002;288:321
Study RR
Hormone therapy is associated with a small but significant
risk of breast cancer
4. Chlebowski et al, JAMA
2003;289:3243
5. Beral V, Lancet 2003;362:419-27
26. Characteristics of HT regimen and breast cancer risk
A. Characteristics of HT regimen
B. Real impact of risk (attributable risk)
1. Estrogen monotherapy versus combined EPT
2. Duration of use
3. Mode (sequential versus continuous)
4. Route (oral versus transdermal)
5. Dose
6. Type of estrogen
7. Type of progestin
27. 1. Estrogen monotherapy versus combined EPT therapy
• EPIC study:
prospective
observational study
• 10 European
countries
• 134,000 women
• Mean follow-up: 8.6
years
Bakken K et al, Int J Cancer 2010
28. 2. Breast cancer risk increases with duration of HT use
EPIC Study, Bakken K et al, Int J Cancer 2010
29. WHI Study: women with no prior exposure to HT
had no increased risk of breast cancer
Anderson GL,
Maturitas
2006;55:103
30. 1,2
1,3
1,4
1,5
1,6
1,7
1,8
1,9
2
sequentialHT fixed continuous
RR
3. Continuous regimens may be associated with higher
risk compared to sequential regimens
EPIC Study, Bakken K et al,
Int J Cancer 2010
The cumulative exposure to
progestin is lower with the
sequential regimens
Lyytinen H et al, Int J Cancer 2010
• Finnish case-control study
• 10,000 cases and 30,000 controls
aged 50-62
31. 4. The route of HT does not modify the risk of breast
cancer
Oral HT
Transdermal HT
Lyytinen H et al, Int J Cancer 2010
RR
RR
Cases controls
Cases controls
Bakken K et al, Int J Cancer 2010
EPIC study: oral versus transdermal RR 1.13 (NS)
32. 5. Dose of estrogen in HT and breast cancer risk
• No RCT on the effect of different HT doses on
breast cancer risk
• Lower estrogen doses have less impact on breast
density1
• Breast density is a surrogate marker of breast
cancer
Martin LJ et al, Maturitas 2009;64:20-26
Stuedal A Climacteric 2009;12:248-58
Grady D Menopause 2007;14:391-6
33. Identical HT regimens differing only in E2 dose are
associated with different increases in breast density
Christodoulakos G, Lambrinoudaki I, Vourtsi A et al, Maturitas 2006;54:78
% of subjects with breast density increase
0
5
10
15
20
25
30
35
CEE/MPA low E2/NETA E2/NETA
p=0.6
p=0.04 p=0.04
34. 6. The type of estrogen in HT does not influence
breast cancer risk
• No RCT directly comparing CEE to E2
• EPIC study:
compound RR of breast cancer
estradiol 1.08 – 1.61
CEE 1.16 – 2.18
RR CEE versus E2: 1.15 NS
Bakken K et al, Int J Cancer 2010
35. • E3N Study (French component of EPIC)
• 80,391 postmenopausal teachers in France
• Mean follow-up: 8.1 years
Fournier A et al, J Clin Oncol 2008;26:1260
7. The type of progestin may modify breast cancer risk
36. 7. The type of progestin may modify breast cancer risk
• All Finnish women > 50 years (221,551 women)
• Follow – up 1994 – 2005
• 6,211 incident cases of breast cancer
Lyytinen H et al, Obstet Gynecol 2009;113:65
37. B. HT and absolute risk of breast cancer
• Baseline 5-year absolute risk: 1.1%
• HT related RR: 1.26 (WHI)
5-year risk of breast cancer attributable to
HT: 3 women in 1000
Among 50-year old women who use HT (CEE/MPA)
for 5 years, 14 out of 1000 will develop breast cancer
until the age of 55
38. Risk factors of breast cancer: comparative assessment
Risk factors
• ΒΜΙ (>29,7 Kg/m2) 1.26-2.52
• alcohol (20g /day x 5 years) 1.28
• Hormone Therapy (EPT / WHI) 1.26
• 1st delivery > 30 years 1.5
• Family history of breast cancer 1.5
• Benign breast disease - breast biopsy 1.6-2.8
• Increased breast density 2.0-4.0
RR
Shah NR, Exp Opin Pharmacotherapy 2006;7(18):2455-63
Pichard C et al, Maturitas 2008;60:19-30
39. Mammographic patterns according to BI-RADS system
I II III IV
< 25% dense > 75% dense
51-75% dense
25-50% dense
RR 1.0 2.03 2.95 4.03
Cummings SR, J Natl Cancer Institute 2009;101:384-389
40. Individual breast cancer risk assessment
• Age, age at menarche and menopause
• BMI, adult weight gain
• Family history of breast cancer (1st degree relative)
• Benign breast disease requiring FNA or biopsy
• Previous hormone therapy
• Nulliparity / 1st delivery > 30years
• Daily alcohol intake
• Breast density
Vogel VG et al, Menopause 2008; 15(4 Suppl):782
Santen RJ et al, Endocr Relat Cancer. 2007 Jun;14(2):169-87
41. Risk factor patient
age 52
menarche 12
1st delivery 27
1st degree relative with breast cancer NO
Breast biopsy NO
Race white
Individual breast cancer risk assessment
US National Institutes of Health, www.cancer.gov accessed April 2010
Patient 5-year risk: 1.2%
Average 5-year risk: 1.4%
National Cancer Institute breast cancer
risk assessment tool
• Breast density:
BI-RADS II
• BMI: 27
• Menopause: 51
42. Risk factor patient
age 52
menarche 12
1st delivery 34
1st degree relative with breast cancer YES
Breast biopsy YES
No of biopsies 1
Atypical hyperplasia NO
Race white
Individual breast cancer risk assessment
US National Institutes of Health, www.cancer.gov accessed April 2010
Patient 5-year risk: 2.5%
Average 5-year risk: 1.4%
US National Cancer Institute breast
cancer risk assessment tool
• Breast density:
BI-RADS III
• BMI: 27
• Menopause: 51
43. Summary
• Hormone therapy is associated with a small, but
statistically significant increase in breast cancer risk
• The risk is more apparent with continuous
combined HT regimens
• The risk increases with duration of use
• The risk may differ by the progestin in the HT
regimen
• The absolute risk is small and in most cases has
minor clinical relevance
• HT is acceptable, provided a thorough
assessment of individual risk is performed in each
woman
