Only two years ago the number of American women diagnosed with breast cancer was one in ten; now it is one in nine. The breast cancer phobia has now overtaken almost all other health issues surrounding menopause for many American women, particularly those who have had a brush with it anywhere in their family. As to why we focus more on women with breast cancer than those with heart disease, Dr. Trudy Bush notes that although two thirds of all breast cancers are postmenopausal, one third do occur in younger women, "so you're thinking of the tragic cases among women forty to fifty-two."

A woman I'll call Sarah was brutally widowed in her prime of a dashing, beloved, prominent husband. She was left with a lovely apartment and a terrace garden she let go to seed because she couldn't bear for several years to step out on it and be assaulted by painful memories evoked by the sun and beauty. Sarah was a free-lance commercial artist, and a very successful one. But in her misery she soon became blocked creatively and desperately lonely.

Then to top it off—hot flashes. Hearing about "vaginal dryness" from her friends, she wondered if she would lose interest in sex before she had it again. The whole terror of being identified as a menopausal woman overtook her. "And I'm single, so it matters."

Off to the plastic surgeon for a full face- and neck-lift. Then to the gynecologist for something to "take away the embarrassment of these drippy hot flashes at dinner parties." She had to keep herself shelf-fresh—not like some postdated yogurt—if she was going to keep hope alive for recovering her creativity and her zest for finding a new partner in life.

"But I have these dangerous breasts," she told me, stroking the unusually large, well-formed bosoms under her T-shirt, as if they had grown alien and were ready at any point to turn on her. "I have a history of breast cancer among the women in my family." So, before giving herself hormones, she consulted two other doctors, one a reproductive oncologist. Both said, "Take the hormones. It's worth the benefit."

"But I admit I did it—do it—with great trepidation. Are you on them? Why? Why don't you get off?" The feverish questioning revealed her frustration and suppressed fears. I talked about my primary concern being prevention of osteoporosis and heart disease—the major dangers for older women. Like most of my most educated and savvy friends, she didn't know heart disease was the number one killer.

"I also have osteoporosis in my family," she said miserably. "So what do I do? I've been on for five years. My doctor never mentioned any end point."

Doctors seldom do, I said.

"All I know is that once I started taking hormones, the flashes stopped and I had a feeling of well-being. And I looked okay. All that is important to me because I'm an older single woman. So my philosophy has been, If it's working, don't mess with it. But am I doing something to my body that I'll kick myself for later?"

She had a bone density test a couple years before and was told she was fine; the hormones were working. Now she has a new male partner, and she's brought her terrace garden back to life. It's a place of delight where we sat that June day, surrounded by sprouting shrubs and exquisite coral roses, birdsong, and cool breeze. "It gives me such a lift when I wake up to come out here," Sarah said. She's become a happy, healthy, fully functioning, attractive and sexual woman again. Hormones appear to be integral to her quality of life in her mid-fifties. What risk is she running by taking HRT?

Dr. Hiram Cody, the New York Hospital breast surgeon, stresses: "When you're doing a family history, keep in mind that only a first-degree relative—mother or sister—poses an added risk. If it's a grandmother, aunt, or cousin, it's not nearly the same added risk, if any risk at all." Also, to be relevant, one's mother had to have been under the age of fifty when she developed the breast cancer. "It's a premenopausal first-degree relative who contributes a significantly increased risk of breast cancer," affirms the leading researcher on menopause in Britain, Dr. Malcolm Whitehead. "Even with the worst possible family history," adds Dr. Cody, "a woman has no more than a fifty-fifty chance of getting breast cancer."

"What we do know is the one-in-nine figure," says Dr. Allen. Speaking as a responsible gynecologist, she recognizes that in prescribing estrogen to one hundred women, it means that eleven of them will be taking a potential growth stimulus to the breast cancer before it is discovered. "Whether this changes the long-term prognosis is not known."

Studies that attempt to document any causative link between HRT and breast cancer are doomed to be inconclusive because the usual dose of Premarin provides only one quarter of the estrogen that a woman's fertile ovaries would produce. But it can be said that the more cycles a woman has, naturally and synthetically, the more estrogen she has in her system over a lifetime.

The primates researcher Kim Wallen points out that for two thousand years most women cycled only two or three times before becoming pregnant, followed by several years of nursing, which again suppressed their periods; then they cycled again several times before the next pregnancies. Historically, then, a woman in her reproductive years may have had a total of forty or fifty ovarian cycles. The modern woman may have more than three hundred. "So human females today are getting a very different pattern of hormonal stimulation," he concludes. "Then, when they go through menopause, we are hitting them with another period of exposure to hormones that they never would have had in the past."

The general world consensus of medical opinion from the best studies is that no evidence suggests there is any danger of increasing the risk of breast cancer by taking HRT for up to five or six years. Quite a number of studies report no danger for possibly up to ten years. There is an increased risk of breast cancer after ten years of use, but exactly what numerical value to put on that increased risk has not been determined. It ranges from 10 to 30 percent. But although there is an increase in the diagnosis of breast cancer after ten years in women on HRT, there is no increase in death from breast cancer. Clinicians postulate it may be because such women are highly aware of their bodies and on a "wellness track," closely monitored by their physicians.

Another expert emphasizes high fat diets as the chief culprit in increasing breast cancer rates among American women. Dr. Caldwell Esselstyn, Jr., is a maverick surgeon who campaigns for health care "beyond surgery." As president of the American Association of Endocrine Surgeons, Dr. Esselstyn starts with the data that show nations which consume greater amounts of fat per person have the highest mortality rates of breast cancer. "And we know that rural Japanese women who still eat a low-fat diet of vegetables, rice, and a little fish experience far less breast cancer than Japanese women who have become urbanized and now like steak and french fries," he says. "If the lobules and ducts of the breast are constantly being overstimulated by a high fat intake, which leads to higher production of estrogen, it stands to reason they will be more likely to have cell changes leading to cancer."

Not only does a fatty diet add indirectly to the risk of breast cancer by increasing the estrogen level, but most recently basic scientists have demonstrated in the laboratory that fat also has a direct effect on tumor growth independent of estrogen. Dr. David Rose at the American Health Foundation in Valhalla, New York, injected human female breast cancer cells into two groups of mice. He gave one group a diet of 23 percent corn oil, the same type of fat found in popular margarines. This high-fat diet both increased and accelerated the growth and spread of tumors as compared with the low-fat group. Rose's results, published in the Journal of the National Cancer Institute (October 1991) provide a compelling argument against high-fat diets to protect a woman from both heart disease and breast cancer.

"Nobody is arguing against estrogen supplement for the short term—the first three to five years of perimenopause and menopause," says Dr. Kuller, the public health expert at the University of Pittsburgh. "But for the long term, meaning ten to fifteen years, estrogen is drug therapy and should only be prescribed for women predisposed to osteoporosis or heart disease, or both." Dr. Kathi Hanna, senior analyst for the Office of Technology Assessment, a research arm of Congress that has surveyed existing studies, agrees: "It's alarming that practitioners are talking about using hormone therapy idefinitely."

But here's the rub. The key to hormonal protection against heart disease in older women, according to the Nurses' Health Study, was that the healthy women were taking estrogen currently. The risks and benefits of estrogen therapy on eight separate health conditions were toted up in a thorough review by T. M. Mack at the University of Southern California. Stopping treatment with estrogen at the end of five years would produce a moderate reduction in the expected hospitalizations for breast cancer. But it would also virtually eliminate all the benefits of long-term health enhancement—a Hobson's choice!

But at least we have choices.

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Women’s health