I’ve been wading through State of the Science of Endocrine Disrupting Chemicals – 2012. The 289-page report was prepared by a group of experts for the United Nations Environmental Programme and World Health Organization.
It is dense and complex, but what I’ve been looking for is any acknowledgement that hormonal contraceptives are endocrine disrupting chemicals (EDCs).
Hormonal contraceptives clearly act as EDCs according to the definition used in this report:
An endocrine disruptor is an exogenous substance or mixture that alters function(s) of the endocrine system and consequently causes adverse health effects in an intact organism, or its progeny, or (sub) populations. A potential endocrine disruptor is an exogenous substance or mixture that possesses properties that might be expressed to lead to endocrine disruption in an intact organism, or its progeny, or (sub) populations.
Adverse health effects would include, in this context, anything that disrupts the reproductive systems of humans (and wildlife) or contributes to other health problems such as hormone-related cancers, thyroid-related disorders, cardiovascular disease, bone disorders, metabolic disorders and immune function impairment. Hormonal contraceptives certainly disrupt the reproductive system and have been associated with increased risk of cardiovascular events, loss of bone density, decreased immune function and, in some studies, increased risk for breast cancer. Metabolic disorders? Recent research suggests that long-acting progestin-based birth control may increase risk in obese women for Type 2 diabetes.
The only mention I could find of specific contraceptive chemicals is in section 3.1: The EDCs of concern. In a table under the sub-heading Pesticides, pharmaceuticals and personal care product ingredients, two key components of hormonal contraceptives are listed: Ethinyl estradiol, the synthetic estrogen used in most oral contraceptive formulations, and Levonorgestrel, a synthetic progesterone used in combined oral contraceptive pills, emergency contraception, the Mirena IUD, and progestin-only birth control pills. Levonorgestrel is considered of “specific interest.”
The concern with these chemicals is not the effects they may have on women taking them, but on the possible reproductive impact on wildlife from the excretion of these chemicals into the aquatic environment. It seems ethinyl estradiol and levonorgestrel are considered safe contraceptive drugs when taken by choice to disrupt fertility, but EDCs worthy of concern when such disruption is unintended.
How would it change our perception of hormonal contraceptives if we acknowledged them as endocrine disrupting chemicals? Would we wonder why there is no discussion of how these EDCs might contribute to the health issues considered in the report? Would we ask why hormonal contraceptive EDCs are routinely used to “treat” (meaning only to alleviate symptoms of) endometriosis, fibroids and PCOS – conditions potentially caused by other EDCs?
Another relevant concern addressed in the report is the effect of “estrogenic agents, and their role in breast cancer.” The report states there “is good experimental evidence that estrogenic chemicals with diverse features can act together to produce substantial combination effects.” I have to wonder how hormonal contraceptive EDCs fit into this mix.
Here’s something to ponder. Last week news stories reported that the incidence of advanced breast cancer among young American women, ages 25 to 39, has risen steadily since 1976. Lead researcher Rebecca Johnson was quoted as saying, “We think it is a real trend and, in fact, it seems to be accelerating.” The increase is small in relative numbers, only 850 cases in 2009, but the “trend shows no evidence for abatement.”
Researchers can’t explain the increase. Lifestyle changes, obesity, sedentary lifestyle and toxic exposure to environmental chemicals are offered as possible factors. But what about the hormonal contraceptives many women of this generation have been taking since they were 15 or 16 years old? Surely these EDCs must be considered as potentially contributing factors.
Let me say up front that I have limited direct experience with adoption. Some members of my extended family have adopted children, another has given up an infant for adoption, and I have friends who have adopted children, and other friends who are adopted. It was one of those adopted friends who pointed me to this uncritical article from last fall about the practice of adoptive mothers ‘learning’ to breastfeed.
I’ve placed learning in scare quotes because this article isn’t about adoptive mothers developing a skill. It’s about taking high-risk drugs so that they can have the experience of breastfeeding their adopted children, even though they will be unable to produce enough breastmilk to nurse exclusively. But by taking combined oral contraceptives continuously for several months (which, contrary to the popular belief asserted in the article, does not “trick the body into thinking it’s pregnant”) and following up with domperidone, an antiemitic drug which sometimes has the side effect of causing lactation — even in men — some adoptive mothers are able to force their bodies to lactate.
What’s so terrible about this, you may be wondering. Domperidone isn’t approved by the FDA for use in the US, even for its intended purpose in treating nausea and vomiting, so it is usually purchased by ordering from other countries. The FDA, however, has not been silent about domperidone: The agency has issued multiple safety alerts, advising healthcare professionals and breastfeeding women NOT to use the drug. Although the amount bioavailable to the infant is small, domperidone is excreted in breastmilk.
The hormones in the birth control pill are also excreted in breast milk, and are suspected to promote growth of breast cancers, if not actually cause them. (And who can forget that immortal bit of testimony from the Nelson Pill hearings in 1970, “Estrogen is to cancer what fertilizer is to wheat”?)
I appreciate the desire of new moms to bond with their babies, I really do. But if you’re willing to take these kinds of risks with your own health and your baby’s, I have to wonder if your desire to breastfeed is really about the relationship with your child.
Three women who developed breast cancer after their use of combination hormone therapy have been initially awarded $72 million by a jury in Philadelphia, with further judgement about punitive damages still to come. The case concerns the use of PremPro, a combination of conjugated equine estrogen and medroxyprogesterone made by Wyeth. Wyeth has since been purchased by Pfizer. Women’s Health Initiative trial results released in 2002 found an increased risk of breast cancer in those randomized to estrogen + progestin compared with placebo. Earlier this year, Pfizer announced that it has set aside $772 million in its budget for settling PremPro lawsuits.
Prior to 2002, hormone replacement therapy was often recommended to otherwise healthy women as a health-enhancing preventative therapy. SMCR has long held that menopause is a natural stage in women’s lives, rather than a condition to be treated. Hormone therapy is no longer recommended for the prevention of disease in healthy women.
Every October it’s the same thing: Buy pink, think pink, drink the pink Kool-Aid. All in pursuit of (mostly) the cure for breast cancer.
Forget the cure. I’m much more interested in preventing the disease. As such, I’ve refused for years to walk or run for the cure to breast cancer. Not only am I concerned that too little of the money raised by such events is being spent on prevention research, I also don’t like what can only be called the commodification of breast cancer. For more on this check out thinkbeforeyoupink, a program of Breast Cancer Action.
In addition to these concerns, I find some of the breast-cancer fundraising and awareness-building activities being promoted this year to be nothing short of cringe-worthy.
I certainly won’t be attending boobyball 10 next month. This auspicious event is put on by Rethink Breast Cancer, a Canadian non-profit geared to building awareness in the under-40 crowd. Too bad Rethink’s booby fetish seems more appropriate for the under-12 set.
And I won’t be wearing an “I love boobies” bracelet anytime soon. Nor will students at a middle school in Kelowna, British Columbia, where the bracelets were recently banned because the message was deemed “offensive.” I’d ban the $3.99 over-priced plastic wristbands just for being silly.
The bracelets, along with other silly “I love boobies” promotional products, are sold by keep-a-breast.org, the mission of which “is to help eradicate breast cancer by exposing young people to methods of prevention, early detection and support.”
Although I’m sure both of these organizations mean well, I want to scream, “Enough already!” I know I don’t fit either org’s demographic, but still, enough already.
What I will attend, this evening, and with some hesitation, is the inaugural Read for the Cure event in Calgary. For $90 I’ll enjoy wine and nibbles, hear three Canadian female authors read from their work, and take home three books by these featured writers.
Read for the Cure is a Canadian endeavor launched in Toronto in 2006 by two women from the same book club who had recently completed treatment for cancer.
“Acknowledging the important role of reading in their lives, and the wonderful support they had received from their fellow members during their treatment, they saw an opportunity to harness the energy of enthusiastic book clubs and readers to raise funds for cancer research.”
I love books, I love my own book club, and I’m going to the event with a dear friend whose mother died of breast cancer.
While breaking my self-imposed boycott of cancer-related fundraising events, I plan to ask a few questions of my fellow attendees:
What’s your take on the mammography screening controversy?
Are you aware of the connection between healthy ovulatory menstruation and breast health?
What do you know about vitamin D and cancer prevention?
I’m also hoping to engage representatives from the Alberta Cancer Foundation and the Cancer Research Society — the two recipients of the event’s proceeds — in discussions about the current research projects they’re funding. Do they know about the Breast Cancer Prevention Study being conducted by Grassroots Health to explore the association between vitamin D levels and breast cancer?
Tonight, my drink of choice will be red wine. Here’s to a fun evening.
According to this article in the journal Radiology, menstrual timing affects how sensitive screening mammography is. The authors analysed the results of screening mammographies collected as part of the Breast Cancer Surveillance Consortium. They used menstrual timing (week of the menstrual cycle).
Overall, they found that there were no patterns, but when they subdivided by how recently women had had a mammogram, they found some interesting patterns. For women who had had a screening mammogram during the previous 2 years, they found that the mammography was more sensitive (correctly identified those with breast cancer as having breast cancer) during the first week of the cycle. For women having their first mammogram, the pattern was reversed, with screening during the first week tending to be less sensitive. And for women who had a prior mammogram more than 3 years previously, there was no pattern. The abstract says that menstrual timing did not affect the overall rate of detecting cancer. Other online coverage of this result quotes the author as saying that the difference between the first time detections and the detections in regularly screened women might be due to a difference in the size of tumours found – large tumours are picked up on first screenings, while subsequent screenings tend to find smaller tumours.
The study involved fairly large numbers (about 1200 cases of breast cancer in 380 000 mammograms), the results were found in subgroup analysis and the significance levels were around the 0.05 level. So it’s worth viewing these results with caution, and looking for confirmation in future studies.
In any case, those women with cyclic breast tenderness probably already know that mammograms are less painful if you time them appropriately, and it’s good that that coincides with the best sensitivity for women getting regular screening.
It’s October again: breast cancer awareness month. Women’s magazines are featuring stories about breast cancer, charitable events all over North America are raising money for breast cancer research, and retailers are urging you to shop to cure breast cancer.
Read those stories, run for the cure, but – at the behest of Breast Cancer Action - think before you pink. National chains and brand names aside, some of the more questionable vendors, hawking wares to consumers, leave one wondering how breast cancer became such ”big business”. Who will want a cure, or effective prevention strategies, if it will mean putting a lot of people out of work? Including manufacturers who make mammography machines, and pharmaceutical companies that focus on breast cancer drugs.
Breast Cancer Action positions itself as ”the watchdog of the breast cancer movement“. They are the only national breast cancer organization in the United States that does not accept money from any source that profits from breast cancer. Their position on shopping in support of breast cancer awareness is clear:
Think Before You Pink™, a project of Breast Cancer Action, launched in 2002 in response to the growing concern about the number of pink ribbon products on the market. The campaign calls for more transparency and accountability by companies that take part in breast cancer fundraising, and encourages consumers to ask critical questions about pink ribbon promotions.
This October, consider carefully how you will demonstrate your breast cancer awareness. “After all”, as Breast Cancer Action notes, “ if shopping could cure breast cancer, it would be cured by now.”
When the story that girls are reaching puberty earlier than ever began popping up everywhere this week, I did not doubt its veracity. It was no coincidence that I received an email from a friend yesterday, observing with mixed feelings that she had just purchased a first bra for her oldest daughter. Her daughter is 9.
News about girls reaching puberty earlier and earlier isn’t exactly new. We saw a flurry of stories in late 2009, when studies found an association between early menarche, late menopause and breast cancer. Additionally, the finding that African American girls often show signs of pubertal development earlier than other girls is well-established.
The study that triggered this new explosion of publicity, published this week in Pediatrics, assessed girls’ development by evaluating the size of breast buds (as breasts are called in early stages of development). The researchers evaluated an ethnically diverse population of 1,239 girls ages 6 to 8 across three research sites. They found that 10.4 percent of white, 23.4 percent of black and 14.9 percent of Hispanic 7-year-olds had reached “Sexual Maturation Stage 2.” Stage 2 is more typically reached at age 10, but may occur any time from age 8 to age 13. Menarche, the first menstrual period, occurs on average at age 12, in Stage 4, but it, too, varies, occurring as early as age 9 and as late as age 17.
The Pediatrics study does not, however, reveal what has caused the age of puberty to fall. Many are quick to blame the alleged obesity epidemic, as the study found that heavier girls were more likely to have more breast development. But Dr. Frank M. Biro, the first author of the study and the director of adolescent medicine at Cincinnati Children’s Hospital Medical Center, told the New York Times that it is unlikely that weight alone explains the findings. Instead, he speculates that environmental chemicals may influence early breast development, and he and his colleagues are presently running lab tests to assess the girls’ hormone levels and chemical exposure.
Fat is one of many factors affecting pubertal development. Others include:
- environmental toxins, including phthalates and Bisphenol A, commonly known as BPA, which can be found in nearly anything made of plastic: baby bottles, toys, plastic serving utensils, and more
- premature birth and low birth weight, which affect endocrine function
- psychosocial stressors, such as family dysfunction or abuse
- formula feeding, especially without breast feeding
- in-utero chemical exposure
- and, often neglected in these discussions, endocrine disruptors–the hormones used in raising beef and dairy cattle as well as chicken in this country. Almost all foods in a modern North American diet contains endocrine disruptors.
(For a more thorough analysis of causes of early puberty, see Sandra Steingraber’s report, The Falling Age of Puberty in U.S. Girls: What We Know, What We Need to Know, published in 2007 by the Breast Cancer Fund. Among other findings, Steingraber reports that new research has revealed that the amount of natural hormones a child’s body produces on its own is much lower than previously estimated; this means “safe levels” of exposure to synthetic hormones and endocrine disruptors must be recalibrated, and policy modified accordingly.)
Sadly, much of the public discussion of this research seems to be centering on the possible role of the alleged obesity crisis (or in fat activist Kate Harding’s preferred terminology, “the obesity crisis OOGA-BOOGA!”), despite a lack of concrete evidence. I’d hate to see this research lead to increased fat-shaming and body image issues for young girls, as there are far more serious consequences of a dramatic decline in age of puberty.
Why isn’t the focus on what can be done to help girls? Research published ten years ago by Girl Scouts, Inc., reported that 8- to 12-year-old girls are growing up in an increasingly stressful environment, as their cognitive and physical development occur at an accelerated pace, while emotional development does not. In other words, despite the budding breasts, a 10-year-old is still a 10-year-old psychologically. The resulting tension leads to young girls dealing with teen issues, such as sexuality and relationships, before they are ready.
Sandra Steingraber’s report for the Breast Cancer Action Fund lists numerous other possible outcomes of early puberty, including increased risk of mental illnesses such as depression, anxiety and eating disorders, as well as higher risk of PCOS and breast cancer later in life. Early puberty is also associated with greater risky behaviors in adolescence, such as smoking, drinking, drug use, and crime, as well as early and unprotected sex. Early-maturing girls also experience higher rates of violent victimization.
Guest Post by Barbara A. Brenner Executive Director, Breast Cancer Action
One of the saddest aspects of capitalism is that companies think they can and should own anything they get their hands on. Some time ago, they started obtaining patents on human genes, including two genes implicated in breast cancer: BRCA1 and BRCA2.
The company that obtained the patents on these genes is called Myriad Genetics. With the patents, Myriad controls both the tests given to women to see if they carry mutations on these genes that may predisposed them to breast and ovarian cancer, as well as all the research related to the genes.
How can anyone own our genes? Up until now, no court has been asked that question. But last week, in a ground breaking decision, a federal judge in New York declared that Myriad’s patents on the breast cancer genes are invalid because they patent a part of nature.
That may seem like an obvious thing to most of us, but the research community is up in arms about how their inability to patent genes will inhibit their ability to innovate new treatments. Sounds plausible, but don’t be fooled. These patents are more about making money than they are about taking care of people who are sick.
Breast Cancer Action, an education and advocacy organization that carries the voices of people affected by breast cancer, was a plaintiff in the lawsuit brought by the American Civil Liberties Union against Myriad over the patents. Because — unlike almost all other breast cancer organizations — we don’t accept funding from Myriad or other companies that profit from breast cancer, we could stand up for the interests of patients who either couldn’t afford the very expensive test, or who couldn’t learn what their “ambiguous” test results meant because the research wasn’t being done to find out.
Ambiguous gene test results are not uncommon, and they are most often found in women who are not white. So, once again, the worst impact of health policy – in this case, the policy to allow genes to be patented – fell on the people who were most likely to have the worst breast cancer outcomes.
Thanks to the ACLU, the Public Patent Foundation and a federal judge, the patents on the breast cancer genes are now invalid. That means that, once the decision becomes final, new tests will be on the market, and researchers will be able to pursue a greater understanding of what mutations on the genes mean.
Myriad will appeal. The case will probably eventually end up in the US Supreme Court. Myriad might get a stay of the trial court ruling pending that appeal. If they do, we’ll have to wait for our genes to be returned once again to their rightful owners – us.
Reprinted with permission.
This catalog showed up in my office mailbox today. Do I need to say any more than Think Before You Pink?
In other breast cancer news, Rachel at Our Bodies, Our Blog has a good summary (with lots of links) of the recently announced federal court decision to invalidate the patent on breast cancer genes.
Janice Horowitiz’ “Dueling Docs” feature at Huffington Post today is about the issue of girls reaching puberty at increasingly earlier ages than previous generations. Both Dr. Alisan Goldfarb and Dr. Stephen Safe talk about endocrine disruptors such as BPA (bisphenol-A, a carcinogenic component of some plastics found in some baby bottles and water containers) and pesticides. Certainly both types of chemicals are likely to be a factor in early menarche, but I find it surprising that those are the only factors mentioned. There’s no discussion of the roles of psychosocial stressors, low birth weight, or formula feeding. Neither physician gives serious consideration to the endocrine disruptors that are the hormones used in raising beef and dairy cattle as well as chicken in this country; Dr. Safe acknowledges that “[a]lmost all foods have endocrine disruptors”, but qualifies that statement with, “particularly fruits and vegetables.” (Do you suppose the beef and dairy lobby advertise at Huffington Post?)
For a more thorough, nuanced analysis of this issue, see Sandra Steingraber’s report, The Falling Age of Puberty in U.S. Girls: What We Know, What We Need to Know, published in 2007 by the Breast Cancer Fund. Among other findings, Steingraber reports that new research has revealed that the amount of natural hormones a child’s body produces on its own is much lower than previously estimated; this means “safe levels” of exposure to synthetic hormones and endocrine disruptors must be recalibrated, and policy modified accordingly.
You may have heard the news that 23 hormone replacement therapy lawsuits filed by women diagnosed with breast cancer were dismissed by a New York judge this week. Judge Martin Shulman granted Pfizer’s motion to dismiss for two reasons: the plaintiff’s delayed filing exceeded the the three-year statute of limitations in New York, and that “the potential risk of contracting breast cancer from taking HRT medication was well known at all times out there in the stream of public information.” Oddly, Judge Shulman simultaneously asserted “that the debate over HRT health problems has not yet been settled.”
I can’t argue about exceeding the statute of limitations, but it’s difficult for a judge to assert that breast cancer risk of hormone therapy is well known public information. The Lancet reported today that up to half of US adults have trouble interpreting medical information, displaying low levels of health literacy. Health literacy, according to The Lancet, is the ability to comprehend and use medical information that can affect access to and use of the health-care system. Health literacy is more than reading and comprehending news reports of medical issues (which are often of poor quality – see Health News Review for sharp analysis of health news); one must also know how to navigate the complexities of the health care system, including knowing how and when to question one’s physicians and pharmacists.
It’s also hard to argue that HT risks are well known when gynecologists, the primary prescribers of HT, refuse to believe the scientific evidence. In 2000 – well after 1990s publication of data from the Heart and Estrogen/Progestin Replacement Study (HERS), a prospective, randomized, double-blind study of 2,763 women with coronary disease which found no benefit of hormones in preventing heart disease – 94.6% of American gynecologists surveyed recommended HT during menopause. Denial continued even after the Women’s Health Initiative (WHI) study – a large, prospective, randomized placebo-controlled trial of estrogen (with and without progestin) in healthy menopausal women – was stopped early in July 2002, because the treated group experienced higher rates of breast cancer, cardiovascular disease, as well as other risks of harm.
WHI was a large, primary prevention trial that contained enough subjects (more than 27,000) to answer the research question; used a design widely acknowledged to be the standard in testing therapeutic efficacy; tested Prempro, the most popular hormone combination; and was monitored by a data safety monitoring board using pre-established criteria. Practitioners should have been satisfied that the question of estrogen as a health-protecting drug had been resolved. Instead, a storm of protest erupted from physicians who could not, or would not, believe the results. Objections to the WHI results (almost exclusively from gynecologists) were so widespread that the media characterized the WHI results as confusing and controversial.
In truth, there was no confusion about the data, which were monotonously consistent with HERS and other randomized controlled studies. [Fugh-Berman & Scialli, 2006]
Why do gynecologists, judges, and others still regard this question as unsettled? Scholars offer several explanations. Paula Derry (board member of the Society for Menstrual Cycle Research) proposed in a 2008 article that faulty decision-making criteria are in play, such as
not valuing rigorous scientific thinking (e.g., ignoring normal rules for judging what counts as scientific evidence, sometimes while claiming to be scientific); not placing a primary value on avoiding harm (e.g., considering heart disease outcomes while not simultaneously considering other risks such as stroke); and basing judgments on a preconception about menopause (i.e., that menopause is an estrogen deficiency disease that causes health problems). [Derry, 2008]
Adriane Fugh-Berman and Anthony Scialli also say the perception of menopause as an estrogen deficiency disease still influences doctors. They speculate that certain features of the unique culture of obstetrician-gynecologists are involved in the continuing promotion of HT. For example, gynecologists are one of few medical specialties that see mostly healthy patients.
Managing medications in healthy women gives a doctor something to do and ensures a continuing relationship with women no longer in need of obstetric expertise.The promise of eternal youth ensures the patients’ consent and gratitude. Healthy women require little or no monitoring and are resilient enough to survive most prescriptions.
Personality factors may play a role, as they cite sources that claim certain types of persons are drawn to gynecological practice. And “reliance on expert opinion and personal experience rather than on evidence from randomized controlled trials may be common among physicians in general.”
Fugh-Berman and Scialli assert that many of those experts are actually sales representatives from pharmaceutical companies. That takes us back to marketing of menopause.
Derry, Paula S.(2008). Update on Hormones, Menopause, and Heart Disease: Evaluating Professional Responses to
the Women’s Health Initiative. Health Care for Women International, 29:7, 720-737