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Risks and benefits of therapy with menopausal hormones versus selective estrogen-receptor modulators in peri- and postmenopausal women at increased breast cancer risk

Col, Nananda F. MD, MPP, MPH, FACP1; Chlebowski, Rowan T. MD, PhD2

doi: 10.1097/gme.0b013e31817e5cce
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Decision making about menopausal therapies is complex because of the number of clinical factors that must be considered. Menopausal hormone therapy can relieve the vasomotor symptoms of menopause, but the most common preparation, combination estrogen and progesterone, increases the risk of breast cancer. Both tamoxifen and raloxifene can reduce the risk of developing invasive breast cancer, but the adverse effects of these drugs differ substantially. Risk models have been built to identify women at high risk for developing breast cancer, but their application in clinical practice has been develop disappointingly low. We propose an approach for identifying and managing menopausal women at high risk for breast cancer that can be readily implemented in clinical practice. The first step is to identify women at sufficiently high risk for breast cancer to merit treatment. For women aged 45 or older, the presence of one or more first-degree relatives with breast cancer and one or more previous breast biopsies will identify those whose 5-year risk is 2% or higher. For women 55 years or older, the presence of either one of these risk factors is sufficient. Any woman with a family history of breast cancer should be assessed as to whether she is likely to carry a BRCA mutation and referred for genetic counseling and possible genetic testing. Decisions about treatment options should be based on the presence or absence of bothersome vasomotor symptoms, an intact uterus, and risk factors for cardiovascular disease. A simple algorithm is presented to streamline identification and management of menopausal women at high risk for breast cancer.

Risk models have been developed to help identify women who are at high risk for developing breast cancer, but their use in clinical practice has been disappointingly low. A simple algorithm is presented to streamline identification and management of high-risk menopausal women.

From the 1Center for Outcomes Research and Evaluation Maine Medical Center, Portland, ME and 2David Geffen School of Medicine at UCLA Los Angeles, CA.

Received February 4, 2008; revised and accepted April 29, 2008.

Financial disclosure: Dr. Chlebowski is a consultant for and receives research support from Eli Lilly.

Address correspondence to: Nananda Col, MD, MPP, MPH, FACP, Director, Center for Outcomes Research and Evaluation, Maine Medical Center, 39 Forest Avenue, Portland, ME 04101. E-mail: coln@mmc.org

©2008The North American Menopause Society