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Yuk JS. Relationship between menopausal hormone therapy and breast cancer: A nationwide population-based cohort study. Int J Gynaecol Obstet 2024. [PMID: 38469634 DOI: 10.1002/ijgo.15461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/21/2024] [Accepted: 02/25/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVE To explore the risk of breast cancer associated with menopausal hormone therapy (MHT), including the various progestogens used today. METHODS The study included postmenopausal women over 40 years from the National Health Insurance Database in South Korea (2011-2014) who either used MHT for over 6 months (MHT group) or never used MHT (non-MHT group) and were matched 1:1 based on several variables using propensity score matching. Both groups were followed until 2020. RESULTS The non-MHT and MHT groups comprised 153 736 women each. In Cox proportional hazard analysis with time-dependent covariates, MHT was associated with an increased risk of breast cancer (hazard ratio [HR] 1.22, 95% confidence interval [CI] 1.15-1.3). Tibolone, estradiol valerate (EV)/medroxyprogesterone acetate (MPA), EV/norethisterone acetate (NETA), conjugated equine estrogen (CEE), EV, estradiol hemihydrate (EH), CEE/micronized progesterone (MP), CEE/MPA, EV/MP, EV/MPA, and EH/MP did not increase the risk of breast cancer compared with the non-MHT group. However, EH/drospirenone (DRSP) (HR 1.51, 95% CI 1.38-1.66), EH/NETA (HR 1.66, 95% CI 1.34-2.06), EH/dydrogesterone (DYD) (HR 1.37, 95% CI 1.12-1.68), and EV/cyproterone acetate (CPA) (HR 1.74, 95% CI 1.54-1.96) increased the risk of breast cancer compared with the non-MHT group. CONCLUSIONS MHT was linked to increased breast cancer risk, but not all MHTs. Specific combined therapies (EH/DRSP, EH/DYD, EH/NETA, and EV/CPA) were associated with higher risk, whereas estrogen alone and tibolone were not.
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Affiliation(s)
- Jin-Sung Yuk
- Department of Obstetrics and Gynecology, Sanggye Paik Hospital, School of Medicine, Inje University, Seoul, Republic of Korea
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Louw-du Toit R, Simons M, Africander D. Progestins and breast cancer hallmarks: The role of the ERK1/2 and JNK pathways in estrogen receptor positive breast cancer cells. J Steroid Biochem Mol Biol 2024; 237:106440. [PMID: 38048919 DOI: 10.1016/j.jsbmb.2023.106440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 12/06/2023]
Abstract
Progestins used in hormonal contraceptives and menopausal hormone therapy (MHT) have been linked to increased breast cancer risk. Whether the association holds for all progestins is unclear and the underlying mechanisms remain poorly understood. We directly compared the effects of four progestins (medroxyprogesterone acetate (MPA), norethisterone acetate (NET-A), levonorgestrel (LNG) and drospirenone (DRSP)) to each other and the natural progestogen progesterone (P4) on selected cancer hallmarks. To provide mechanistic insight into these effects, we assessed the role of the progesterone receptor (PR), and the extracellular signal-related kinase (ERK1/2) and c-Jun N terminal (JNK) signaling pathways. We showed that the increased proliferation of the luminal T47D breast cancer cell line by P4 and all progestins, albeit to different extents, was inhibited by PR knockdown and inhibition of both the ERK1/2 and JNK pathways. While knockdown of the PR also blocked the upregulation of MKI67 and CCND1 mRNA expression by selected progestogens, only a role for the ERK1/2 pathway could be established in these effects. Similarly, only a role for the ERK1/2 pathway could be confirmed for progestogen-induced colony formation, whereas both the ERK1/2 and JNK pathways were required for cell migration in response to the three older progestins implicated in the etiology of breast cancer, MPA, NET-A and LNG. Together our results show that all the progestins elicit their effects on cell proliferation via a mechanism requiring the PR, ERK1/2 and JNK pathways. While the ERK1/2 and JNK pathways are also required for increased cell migration by the older progestins, only a role for the ERK1/2 pathway could be established in their effects on colony formation. Notably, the cytoplasmic PR was not needed for activation of the ERK1/2 pathway by the progestogens. Given that DRSP showed significantly lower proliferation than MPA and NET-A, and that it had no effect on breast cancer cell migration and colony formation, hormonal formulations containing the newer generation progestin DRSP may provide a better benefit/risk profile towards breast cancer than those containing the older generation progestins.
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Affiliation(s)
- Renate Louw-du Toit
- Department of Biochemistry, University of Stellenbosch, Private Bag X1, Matieland 7602, South Africa.
| | - Mishkah Simons
- Department of Biochemistry, University of Stellenbosch, Private Bag X1, Matieland 7602, South Africa.
| | - Donita Africander
- Department of Biochemistry, University of Stellenbosch, Private Bag X1, Matieland 7602, South Africa.
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Yuk JS, Kim T, Cho H, Gwak G. Breast cancer risk association with postmenopausal hormone therapy: Health Insurance Database in South Korea-based cohort study. Eur J Endocrinol 2024; 190:1-11. [PMID: 38128117 DOI: 10.1093/ejendo/lvad168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/22/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023]
Abstract
CONTEXT Although many physicians have been concerned that the menopausal hormones used currently in clinical practice may affect the risk of breast cancer, there are currently few informative updated studies about the associations between menopausal hormone therapy (MHT) and the risk of breast cancer. OBJECTIVE This study aims to evaluate the association between the risk of breast cancer and MHT using the National Health Insurance Database in South Korea (HISK) cohort between 2002 and 2019 retrospectively. METHODS Postmenopausal women over 40 years of age from 2003 to 2011 were selected as the subject population, and their follow-up data were collected until 2019. We analyzed the risk and mortality of breast cancer according to the type of MHT received, namely, tibolone, combined estrogen plus progestin by manufacturer (CEPM), oral estrogen, combined estrogen plus progestin by physician (CEPP), or topical estrogen. RESULTS The risk of breast cancer increased in the CEPM group [hazard ratio (HR) 1.439, 95% CI 1.374-1.507, P-value < .001] in comparison with the non-MHT group. However, no significant associations were found between the use of tibolone, oral estrogen, CEPP, or topical estrogen and breast cancer risk in comparison with the non-MHT group (HR 0.968, 95% CI 0.925-1.012; HR 1.002, 95% CI 0.929-1.081; HR 0.929, 95% CI 0.75-1.15; HR 1.139, 95% CI 0.809-1.603). The mortality rate from breast cancer is lower in the MHT group in comparison with the non-MHT group, indicating that significant associations were found for tibolone, CEPM, and oral estrogen (HR 0.504, 95% CI 0.432-0.588; HR 0.429, 95% CI 0.352-0.522; HR 0.453 95% CI 0.349-0.588, P-value < .001). CONCLUSIONS This study suggests that the risk of breast cancer is increased by drugs in the CEPM group but not by tibolone, oral estrogen, CEPP, or topical estrogen. The mortality rate from breast cancer is lower with MHT (tibolone, CEPM, oral estrogen) than without MHT.
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Affiliation(s)
- Jin-Sung Yuk
- Department of Obstetrics and Gynecology, Sanggye Paik Hospital, School of Medicine, Inje University, Seoul, Republic of Korea
| | - Taeran Kim
- Department of Obstetrics and Gynecology, Sanggye Paik Hospital, School of Medicine, Inje University, Seoul, Republic of Korea
| | - Hyunjin Cho
- Department of Surgery, Sanggye Paik Hospital, School of Medicine, Inje University, Seoul, Republic of Korea
| | - Geumhee Gwak
- Department of Surgery, Sanggye Paik Hospital, School of Medicine, Inje University, Seoul, Republic of Korea
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Lalitkumar PGL, Lundström E, Byström B, Ujvari D, Murkes D, Tani E, Söderqvist G. Effects of Estradiol/Micronized Progesterone vs. Conjugated Equine Estrogens/Medroxyprogesterone Acetate on Breast Cancer Gene Expression in Healthy Postmenopausal Women. Int J Mol Sci 2023; 24:ijms24044123. [PMID: 36835533 PMCID: PMC9959219 DOI: 10.3390/ijms24044123] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/08/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
Recent studies suggest estradiol (E2)/natural progesterone (P) confers less breast cancer risk compared with conjugated equine estrogens (CEE)/synthetic progestogens. We investigate if differences in the regulation of breast cancer-related gene expression could provide some explanation. This study is a subset of a monocentric, 2-way, open observer-blinded, phase 4 randomized controlled trial on healthy postmenopausal women with climacteric symptoms (ClinicalTrials.gov; EUCTR-2005/001016-51). Study medication was two 28-day cycles of sequential hormone treatment with oral 0.625 mg CEE and 5 mg of oral medroxyprogesterone acetate (MPA) or 1.5 mg E2 as percutaneous gel/day with the addition of 200 mg oral micronized P. MPA and P were added days 15-28/cycle. Material from two core-needle breast biopsies in 15 women in each group was subject to quantitative PCR (Q-PCR). The primary endpoint was a change in breast carcinoma development gene expression. In the first eight consecutive women, RNA was extracted at baseline and after two months of treatment and subjected to microarray for 28856 genes and Ingenuity Pathways Analysis (IPA) to identify risk factor genes. Microarray analysis showed 3272 genes regulated with a fold-change of >±1.4. IPA showed 225 genes belonging to mammary-tumor development function: 198 for CEE/MPA vs. 34 for E2/P. Sixteen genes involved in mammary tumor inclination were subject to Q-PCR, inclining the CEE/MPA group towards an increased risk for breast carcinoma compared to the E2/P group at a very high significance level (p = 3.1 × 10-8, z-score 1.94). The combination of E2/P affected breast cancer-related genes much less than CEE/MPA.
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Affiliation(s)
| | - Eva Lundström
- Division for Obstetrics and Gynecology, Department of Women’s and Children’s Health, Karolinska Institutet, SE 17176 Stockholm, Sweden
| | - Birgitta Byström
- Division for Obstetrics and Gynecology, Department of Women’s and Children’s Health, Karolinska Institutet, SE 17176 Stockholm, Sweden
| | - Dorina Ujvari
- Division for Obstetrics and Gynecology, Department of Women’s and Children’s Health, Karolinska Institutet, SE 17176 Stockholm, Sweden
| | - Daniel Murkes
- Division for Obstetrics and Gynecology, Department of Women’s and Children’s Health, Karolinska Institutet, SE 17176 Stockholm, Sweden
| | - Edneia Tani
- Department of Pathology, Cytology Karolinska Institutet, SE 17176 Stockholm, Sweden
| | - Gunnar Söderqvist
- Division for Obstetrics and Gynecology, Department of Women’s and Children’s Health, Karolinska Institutet, SE 17176 Stockholm, Sweden
- Correspondence:
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Maas AHEM, Rosano G, Cifkova R, Chieffo A, van Dijken D, Hamoda H, Kunadian V, Laan E, Lambrinoudaki I, Maclaran K, Panay N, Stevenson JC, van Trotsenburg M, Collins P. Cardiovascular health after menopause transition, pregnancy disorders, and other gynaecologic conditions: a consensus document from European cardiologists, gynaecologists, and endocrinologists. Eur Heart J 2021; 42:967-984. [PMID: 33495787 PMCID: PMC7947184 DOI: 10.1093/eurheartj/ehaa1044] [Citation(s) in RCA: 105] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/29/2020] [Accepted: 12/08/2020] [Indexed: 12/13/2022] Open
Abstract
Women undergo important changes in sex hormones throughout their lifetime that can impact cardiovascular disease risk. Whereas the traditional cardiovascular risk factors dominate in older age, there are several female-specific risk factors and inflammatory risk variables that influence a woman’s risk at younger and middle age. Hypertensive pregnancy disorders and gestational diabetes are associated with a higher risk in younger women. Menopause transition has an additional adverse effect to ageing that may demand specific attention to ensure optimal cardiovascular risk profile and quality of life. In this position paper, we provide an update of gynaecological and obstetric conditions that interact with cardiovascular risk in women. Practice points for clinical use are given according to the latest standards from various related disciplines (Figure 1).
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Affiliation(s)
- Angela H E M Maas
- Department of Cardiology, Director Women's Cardiac Health Program, Radboud University Medical Center, Geert Grooteplein-Zuid 10, Route 616, 6525GA Nijmegen, The Netherlands
| | - Giuseppe Rosano
- St George's Hospitals NHS Trust University of London, Cranmer Terrace, London SW17 0RE, UK.,Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, via della Pisana, 235 Rome, Italy
| | - Renata Cifkova
- Center for Cardiovascular Prevention, Charles University in Prague, First Faculty of Medicine and Thomayer Hospital, Vídeňská 800, 140 59 Prague 4, Czech Republic.,Department of Internal Cardiovascular Medicine, First Medical Faculty, Charles University in Prague and General University Hospital in Prague, U Nemocnice 2, 128 08 Prague 2, Czech Republic
| | - Alaide Chieffo
- Interventional Cardiology Unit, IRCCS San Raffaele Hospital, Olgettina Street, 60 - 20132 Milan (Milan), Italy
| | - Dorenda van Dijken
- Department of Obstetrics and Gynaecology, OLVG location West, Jan Tooropstraat 164, 1061 AE Amsterdam, The Netherlands
| | - Haitham Hamoda
- Department Gynaecology, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, M4:146 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
| | - Ellen Laan
- Department of Sexology and Psychosomatic Gynaecology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Irene Lambrinoudaki
- Menopause Clinic, 2nd Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Aretaieio Hospital, 30 Panepistimiou Str., 10679 Athens, Greece
| | - Kate Maclaran
- Department Gynaecology, Chelsea and Westminster Hospital, NHS Foundation Trust, 69 Fulham Road London SW10 9NH, UK
| | - Nick Panay
- Department of Gynaecology, Queen Charlotte's & Chelsea and Westminster Hospitals, Imperial College, Du Cane Road, London W12 0HS, UK
| | - John C Stevenson
- Department of Cardiology, National Heart & Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Mick van Trotsenburg
- Bureau Gender PRO Vienna and Department of Obstetrics and Gynaecology, University Hospital St. Poelten-Lilienfeld, Probst Führer Straße 4 · 3100 St. Pölten, Austria
| | - Peter Collins
- Department of Cardiology, National Heart & Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
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Lundström E, Virijevic I, Söderqvist G. Progestogen addition with low-dose levonorgestrel intrauterine system in menopausal hormone treatment gives less normal breast tissue proliferation than oral norethisterone acetate or medroxyprogesterone acetate. Horm Mol Biol Clin Investig 2020; 41:hmbci-2019-0051. [PMID: 32735552 DOI: 10.1515/hmbci-2019-0051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 03/05/2020] [Indexed: 11/15/2022]
Abstract
Background The impact of hormones on the development of breast cancer is despite extensive studies, incompletely understood. Combined estrogen-progestogen treatment augments the risk for breast cancer beyond that of estrogen alone, according to numerous studies. The role of breast cell proliferation as a promoter in the development and growth of breast cancer is well recognized. Materials and methods Seventy-nine patients from three randomised trials were subject to a re-analysis of breast cell proliferation: (1) 22 women received continuous combined treatment with oral estradiol (E2) 2 mg/norethisterone acetate (NETA) 1 mg once daily for 3 months. (2) Thirty-seven women received 2 months of sequential treatment with oral conjugated equine estrogens (CEE) 0.625 mg daily combined with medroxyprogesterone acetate (MPA) 5 mg for 14/28 days of each cycle. (3) Twenty women received oral estradiol-valerate (E2V) 2 mg daily combined with levonorgestrel (LNG) intrauterine system (IUS), 20 μg/24 h for 2 months. Fine needle aspiration (FNA) (studies 1 and 3) and core needle biopsy (CNB) (study 2) were used for the assessment of breast cell proliferation. Results There were no baseline proliferation differences, but at the end of treatment there was a highly significant between-group difference for E2V/LNG IUS versus the other two groups (p = 0.0025). E2/NETA and CEE treatments gave a 4-7-old increase in proliferation during treatment (p = 0.04) and (p = 0.007), respectively, which was absent in the E2V/LNG group, showing a significant correlation with insulin-like growth factor binding protein-3 (IGFBP-3) serum levels. Conclusion E2V in combination with very low serum concentrations of LNG in the IUS gives no increase in proliferation in the normal breast.
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Affiliation(s)
- Eva Lundström
- Division for Obstetrics and Gynecology, Department of Children's and Women's Health, Karolinska Institutet, Karolinska University Hospital, SE-171 76, Stockholm, Sweden
| | - Ivana Virijevic
- Department of Obstetrics and Gynecology, Västerås Hospital, Västerås, Sweden
| | - Gunnar Söderqvist
- Division for Obstetrics and Gynecology, Department of Children's and Women's Health, Karolinska Institutet, Karolinska University Hospital, SE-171 76, Stockholm, Sweden.,Division for Obstetrics and Gynecology, Department of Children's and Women's Health, Karolinska Institutet, SE-171 76 Stockholm, Sweden, Phone: +46 73 833 82 22
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