Could someone answer a few hormone therapy questions?

I’ll address a couple of your concerns.

- Many of us have stopped bisphosphonates! I used an older drug, Aredia, for 3 years and stopped because my mo was concerned about spontaneous femur fractures. Not a high incidence se, but we moved to simply monitoring my bone health. That was seven years ago and my osteopenia has not progressed.

- Osteonecrosis of the jaw (ONJ) is also a low incident se. Most mo’s will ask you to have any invasive dental work done prior to starting an AI. If you have a problem that involves invasive dental work you may be asked to go off the AI for a period of time prior to the dental work. Not a fun side effect but not a common one either

Debbie,

I don't have a lot of time right now but I'll try to answer some of your questions.

1. Studies have shown the superiority of AI's relative to tamoxifen in overall survival in post-menopausal women. It is important to not lose track of the primary purpose of taking anti hormonal medication - to improve both progression free and overall survival. Now, if someone can absolutely not take any of the AI's, and there are many, then tamoxifen is the next choice. Tamoxifen comes with its own serious side effects so it also has to be evaluated with risk/benefits. Osteoporosis is a genetic disease as well as a side effect of reduced estrogen action on the bones due to taking AI's. So, if one already has osteoporosis, there needs to be a discussion of risk/benefits of taking a bisphosphonate or a monoclonal antibody like Denosumab. The results of your DEXA scan will guide you & your physician on when or if to start therapy. The very best way to avoid needing any pharmacologic treatment of osteopenia or osteoporosis is to exercise with emphasis on impact exercises on long bones - the ones in your legs. Walking, running, tennis, dancing, etc all help to maintain the integrity of bones. Exercises like swimming and yoga are great but they don't improve bones. Of course, taking calcium and vitamin D help as well particularly if you are deficient.

I need to go right now but I hope I've answered this first question. If not, I'll be happy to clarify further. I'll be back later to address the others.

Jane

Debbie,

I'm back & glad my info helped a bit. Now, let's talk about blood clots. Malignancy of any kind induces what is caused a hypercoaguable state or prothrombotic state. The tumor cells themselves interact with blood & vascular endothelium which causes a release of molecules that will initiate the clotting system. So, you don't have to do anything at all to have a greater chance of blood clots. You already do just because you have cancer.

Tamoxifen is a SERM or selective estrogen receptor modulator. This means it has mixed estrogenic and antiestrogenic activity, depending on the tissue. It has antiestrogenic activity in the breast but estrogenic activity in the uterus and liver (this is the reason why women on long term tamoxifen are at higher risk of endometrial cancer). The estrogenic effects on the liver (which makes clotting factors) are suspected to be the reason behind blood clots for women taking tamoxifen. Let's talk about the estrogenic effects on the uterus. The risk of endometrial cancer increases with duration of therapy. It appears to be 2% risk for 2-5 years and 7% for 5 years although those numbers may not be up to date.

So, you have your underlying prothrombotic state coupled with the estrogen effects on the liver and you have a higher risk of clotting. The estrogenic effects on the uterus may cause increase risk of cancer. You can see why this is not the first option for post menopausal women.

Debbie - does this explanation help on clotting & uterine cancer risk? If not, I will clarify more if you want.

Jane