Expert Discusses Estrogen Use in Women With BRCA Mutations

Mache Seibel discusses the benefits of taking estrogen supplements for women who harbor the BRCA genetic mutation.
Many women who find out that they are positive for the BRCA gene mutation, therefore at higher risk for cancers such as breast and ovarian, will often opt for an oophorectomy, which is the removal of one or both of the ovaries to decrease cancer risk. However, this procedure will often cause early-onset menopause, bringing about a whole new class of risks and possible effects.
CURE spoke with Mache Seibel, M.D., a national expert in helping women in and around menopause improve their symptoms, about these risks, and how taking estrogen may be able to decrease the severity and mitigate some of the side effects that follow preventative surgery.

Can you give an overview of estrogen use for BRCA-positive women?

Women who have the BRCA mutation have an increased risk of breast and ovarian cancer. If you remove the ovaries and the fallopian tubes, it lowers the risk of the ovarian cancer by about 90 percent and it lowers the risk of breast cancer by about 50 percent. 
However, there is some confusion about hormones. Only about half of the women eligible, which would be nearly all of them, are taking estrogen. The issue is that they are being thrown into menopause at this very early age – typically before age 40 – because most of these women are going to have surgery between 35 and 40 years old, and the mean age of menopause is 51. 

What are some of the risks, and what should people be aware of when thinking about early-onset menopause? 

Well, the reason that they have the surgery is to lower the risk. But what they often don't realize is that the women who go into menopause before age 45, and absolutely those who go into it before age 40, are a different set of people than the women who go into menopause at the natural age. They face a different set of conditions by going early. What ends up happening is that they end up facing a much greater increased risk of fatal heart attack, not to mention non-fatal heart attacks, too, by not taking estrogen. Studies have shown that there is somewhere between a 23 to 67 percent increased risk of fatal heart attack if they don't take estrogen and they go into early menopause. This is a big issue for these women. 
One study from this year, published in the Journal of Clinical Endocrinology, showed that these women have a 47 percent lower risk of death by fatal cardiac disease if they take estrogen. The sooner they start it the better. Most recently, a study from JAMA Cardiology, published in September, showed a 23 percent increased risk of fatal heart attack for women who don't take estrogen. Heart disease alone is something that many women, and even their providers, often don't realize is such a major issue. 
When you move organ systems and then you look at conditions of the brain, you start looking at early menopause, again, as a whole different subset of problems. They have an increased risk of depression, increased risk of anxiety and some women may become suicidal. There's a tremendous – 50 percent or so – increase in cognitive impairment and the risk of Alzheimer's, can go up as much as 70 percent if they don't get treated with estrogen. So we're talking about major life consequences.  

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