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[Tracey E]

With all the news stories over the past week and continual progesterone where does this leave the Mirena Coil? I'm due to have one fitted shortly and now I really don't know what to do.  Will my risk of breast cancer increase using this method or because it's a localised progesterone will my ongoing risk be not so bad. Confused.com. 

[Natatters]

Agree totally Tracey E! I have to decide whether to have fibroids removed and mirena coil inserted or partial hysterectomy, tried many progesterone and none can stop the bleeding and cramps. I was thinking before this report that would be better off with the hysterectomy, as extreme as it sounds, it would mean I could get rid of the progesterone element of the hrt. I too would like to know where the mirena is on the scale. Will be seeing my menopause dr in mid sept to help me decide. Will be interesting to hear what she says.

[Tracey E]

Hi Natatters, I can totally relate to that, I've been thinking about a hysterectomy myself. Intolerant of all the progesterone I've tried so far, ths was my last hope and now it's all gone 'tits up'.

Countrygirl neither have I, but then I haven't seen that it's a safer option either. What's a girl suppised to do. Help!

[Hurdity]

I don't have time to scrutinise the report in detail (and actually don't have to desire to as it's lots of stats!) so I don't know whether any studies quoted have included the Mirena coil or its constituent progestogen - levonorgestrel. Possibly not the Mirena? ie no studies? A lot of the studies used in this analysys are older. However the amount absorbed systemically from the Mirena is very approx comparable to the amount absorbed transdermally from Femseven patch (so I estimated some time ago - from data available on systemic concetrations) - which is much less than oral progestogens.

In the absence of randomised controlled trials looking at each specific type of HRT we have to assume, and as recognised by BMS and the medical profession, that there may be a small increased risk of breast cancer from some HRT types which is greater from (synthetic) progestogens. This much was known anyway. The responses to the study counsel women to weigh up the risks and benefits in collaboration with their GP in making their decision. As said many times on the other thread and on this forum generally - there are other greater risk factors for breast cancer than HRT, notably being overweight (with fat not muscle), lacking exercise,  too much alcohol, poor diet, so we can minimise our overall risk by attending to these lifestyle measures. Also that the many benefits from HRT (effect on bones, cardio-vascular health etc) especially up to approx age 70 outweigh the risks - which will vary with individuals.

Personally I would not be unduly concerned but can understand why you feel this way - however there are risks and disadvantages from a hysterectomy anyway.

Quality of Life is paramount!

Hurdity x

[Dancinggirl]

Hurdity - thank you for your wise words.  I was very concerned when they featured the latest risks of HRT on the news - not concerned about the breast cancer risk but concerned that yet again GPs have been given another weapon to prevent women from using HRT which can have so many benefits.
The side effects I felt when I tried an anti depressant were awful and continued for many weeks after I stopped it, yet these drugs are dished out so readily but side effects and consequences are rarely mentioned.

This latest study is already out of date because it is based on women who were probably on the older types of HRT.  There was also little mention of the greater risks of being overweight, smoking or drinking alcohol.
It's so easy to frighten women off HRT - I would like to see a far more balanced viewpoint from the medical profession so women can truly understand their options. DG x

[Countrygirl]

Thank you Hurdity you explain it so it's much more easier to understand  x

[bear]

Hi Tracey E,

This is from the recently published study 'Collaborative Group on Hormonal Factors in Breast Cancer. Type and
timing of menopausal hormone therapy and breast cancer risk: individual participant
meta-analysis of the worldwide epidemiological evidence.'

'Users of systemic oestrogen-only preparations were further subdivided by the oestrogenic constituent (equine
oestrogen, oestradiol, oestriol, estropipate, or other), by dose, and by whether the oestrogen was given orally or
transdermally. Users of oestrogen-progestagen preparations were further subdivided by the progestagenic
constituent (medroxyprogesterone acetate, nor-ethisterone, [levo]-norgestrel, dydrogesterone, promegestone,
nomegestrol, micronised [natural] progesterone, or other) and by whether the progestagen component was
administered daily or intermittently (eg, for 10-14 days per month). No information about use of hormonal
intrauterine devices was routinely collected, but in the CPRD dataset <1% of those last prescribed an oestrogen-
only MHT had also been prescribed a progestagen-releasing intrauterine device in the 5 years prior to the index
date. If this is typical, then few oestrogen-only MHT users would also have been using a progestagen-releasing
intrauterine device.'

Intrauterine devices like Mirena coil were not included because information on their use was not routinely collected.

The results for vaginal oestrogen creams and pessaries didn't show increased risks for breast cancer.

Mirena coil's effects are likely confined to the womb.

I think it can be inferred from the results they have found for vaginal oestrogen creams and pessaries, that Mirena coil probably does NOT increase the risk for breast cancer.

BeaR.

[Tracey E]

Hi Tracey E,

This is from the recently published study 'Collaborative Group on Hormonal Factors in Breast Cancer. Type and
timing of menopausal hormone therapy and breast cancer risk: individual participant
meta-analysis of the worldwide epidemiological evidence.'

'Users of systemic oestrogen-only preparations were further subdivided by the oestrogenic constituent (equine
oestrogen, oestradiol, oestriol, estropipate, or other), by dose, and by whether the oestrogen was given orally or
transdermally. Users of oestrogen-progestagen preparations were further subdivided by the progestagenic
constituent (medroxyprogesterone acetate, nor-ethisterone, [levo]-norgestrel, dydrogesterone, promegestone,
nomegestrol, micronised [natural] progesterone, or other) and by whether the progestagen component was
administered daily or intermittently (eg, for 10-14 days per month). No information about use of hormonal
intrauterine devices was routinely collected, but in the CPRD dataset <1% of those last prescribed an oestrogen-
only MHT had also been prescribed a progestagen-releasing intrauterine device in the 5 years prior to the index
date. If this is typical, then few oestrogen-only MHT users would also have been using a progestagen-releasing
intrauterine device.'

Intrauterine devices like Mirena coil were not included because information on their use was not routinely collected.

The results for vaginal oestrogen creams and pessaries didn't show increased risks for breast cancer.

Mirena coil's effects are likely confined to the womb.

I think it can be inferred from the results they have found for vaginal oestrogen creams and pessaries, that Mirena coil probably does NOT increase the risk for breast cancer.

BeaR.

Bear thank you so much for this info.

[bear]

You're welcome, Tracey E 

Hurdity - thank you for your wise words.  I was very concerned when they featured the latest risks of HRT on the news - not concerned about the breast cancer risk but concerned that yet again GPs have been given another weapon to prevent women from using HRT which can have so many benefits.
The side effects I felt when I tried an anti depressant were awful and continued for many weeks after I stopped it, yet these drugs are dished out so readily but side effects and consequences are rarely mentioned.

This latest study is already out of date because it is based on women who were probably on the older types of HRT.  There was also little mention of the greater risks of being overweight, smoking or drinking alcohol.
It's so easy to frighten women off HRT - I would like to see a far more balanced viewpoint from the medical profession so women can truly understand their options. DG x

Hi Dancinggrirl,

Only smoking has not been taken into account in this study because most published data on HRT and breast cancer so far have not included it as a risk factor, maybe because there is more consistent data on the link to HRT, obesity and alcohol consumption.

'To ensure women in one study were compared directly only with similar women in the same study, analyses were routinely stratified by study, centre or region within study, age (<40, single years of age from 40 to 69, 70-74, 75-79 and 80-89), body mass index (BMI <25, 25-29, 30+ kg/m2; ‘lean‘ = <25 and ‘obese' = 30+ kg/m2); adjusted for family history (first degree relative with breast cancer, yes or no), alcohol consumption (0, <10, 10+ g/week), and reproductive history (nulliparous, and, among parous women, by parity [1-2, 3+] and age at first birth [<20, 20-29, 30+ years]). They also allowed for age at menopause, but in a different way (see below), as this important information was not always available. For all stratification or adjustment factors the data provided by the principal investigators were used, with definitions as similar as possible across studies.'

BeaR.

[Hurdity]

Hurdity - thank you for your wise words.  I was very concerned when they featured the latest risks of HRT on the news - not concerned about the breast cancer risk but concerned that yet again GPs have been given another weapon to prevent women from using HRT which can have so many benefits.
The side effects I felt when I tried an anti depressant were awful and continued for many weeks after I stopped it, yet these drugs are dished out so readily but side effects and consequences are rarely mentioned.

This latest study is already out of date because it is based on women who were probably on the older types of HRT.  There was also little mention of the greater risks of being overweight, smoking or drinking alcohol.
It's so easy to frighten women off HRT - I would like to see a far more balanced viewpoint from the medical profession so women can truly understand their options. DG x

Hi Dancinggirl - thank-you and long time no "see"! How are you?!  You might like to have a look at this  thread where that paper was discussed and there have been numerous links to the official responses to the study https://www.menopausematters.co.uk/forum/index.php/topic,45086.0.html. Warning - it's very long!!!!

Hurdity x

[Hurdity]

Hi Tracey E,

This is from the recently published study 'Collaborative Group on Hormonal Factors in Breast Cancer. Type and
timing of menopausal hormone therapy and breast cancer risk: individual participant
meta-analysis of the worldwide epidemiological evidence.'

'Users of systemic oestrogen-only preparations were further subdivided by the oestrogenic constituent (equine
oestrogen, oestradiol, oestriol, estropipate, or other), by dose, and by whether the oestrogen was given orally or
transdermally. Users of oestrogen-progestagen preparations were further subdivided by the progestagenic
constituent (medroxyprogesterone acetate, nor-ethisterone, [levo]-norgestrel, dydrogesterone, promegestone,
nomegestrol, micronised [natural] progesterone, or other) and by whether the progestagen component was
administered daily or intermittently (eg, for 10-14 days per month). No information about use of hormonal
intrauterine devices was routinely collected, but in the CPRD dataset <1% of those last prescribed an oestrogen-
only MHT had also been prescribed a progestagen-releasing intrauterine device in the 5 years prior to the index
date. If this is typical, then few oestrogen-only MHT users would also have been using a progestagen-releasing
intrauterine device.'

Intrauterine devices like Mirena coil were not included because information on their use was not routinely collected.

The results for vaginal oestrogen creams and pessaries didn't show increased risks for breast cancer.

Mirena coil's effects are likely confined to the womb.

I think it can be inferred from the results they have found for vaginal oestrogen creams and pessaries, that Mirena coil probably does NOT increase the risk for breast cancer.

BeaR.

"Mirena coil's effects are likely confined to the womb.

I think it can be inferred from the results they have found for vaginal oestrogen creams and pessaries, that Mirena coil probably does NOT increase the risk for breast cancer."

Is this a quote from the study or a response or your own view?

Just to clarify, as I have already said below in my earlier post - the progestogen from the Mirena (levonorgestrel) is absorbed systemically to some extent so is not only confined to the womb. In addition the studies did include some data on levonorgestrel and risk, even if not the mirena coil. I don't have time to delve into the data to see exactly what the preparation was that contained levonorgestrel.

However I would suggest, whilst I understand you are trying to give reassurance to Tracey E, there is insufficient information for you to give such an optimistic reassurance - especially from a lay person. All we can say regarding the Mirena coil is just that - there is insufficient information but because the absorbed amounts are quite low and comparable with other transdermal HRT progestogens, if there is a risk (and we are still talking about observational rather than experimental data), it is likely to be much smaller.

Vaginal oestrogens and creams are a completely different case altogether because they are extremely low dose oestrogens and systemic absorption absolutely minimal. In any case it is the progestogen component which confers the increased risk (according to the data) with oestrogen only systemic preparations themselves carrying a very small additional risk.

Tracey E - this is not to try to worry you - but I think we (on the forum) have to be careful with what we say and how we interpret all of this very complex information - and take our cue from those experts who have analysed the report in detail and have made their responses which are extensively linked to on the other thread. Nothing that they have said indicates that most women need to change whatever they are doing/taking as a result of this new analysis of existing information (the published paper), rather to continue to weigh up our own individual benefits and risks in maing our decisions.

Hurdity x

[Tracey E]

Thanks Hurdity, just trying to way up the pro's and con's of continuing taking Utrogestan compared to having a Mirena coil fitted. Utrogestan used vaginally surely would be absorbed similarily to the progesterone that's released from a Mirena coil. I would prefer to have the least possible collateral damage. Still really confused and my doctor is no help at all.

[Hurdity]

Yes Utrogestan is absorbed systemically when used vaginally. Really I think what you use is the one that gives you better quality of life overall and makes you feel better as there is insufficient information about either of these. So far it is thought that natural progesterone ( ie bio-identical = Utrogestan)  is not associated with increased breast cancer risk but more work needs to be done. Thereis a big difference between the two in how well some women tolerate them so I would say you are doing the best you can for yourself by choosing the one that enables you to cope with menopausal symptoms with the least side effects.

Please try not to worry so much...

Hurdity x

[bear]

Hi Hurdity,

In response to your enquiries:

"Mirena coil's effects are likely confined to the womb.

I think it can be inferred from the results they have found for vaginal oestrogen creams and pessaries, that Mirena coil probably does NOT increase the risk for breast cancer."

Is this a quote from the study or a response or your own view?

That Mirena coil's effects are likely confined to the womb wasn't in quotation marks, so no, it's not a quote from the study.
The intention was to say that most of its effects are confined to the womb (I will correct that), but of course the overall HRT risk for breast cancer also applies to Mirena.

Just to clarify, as I have already said below in my earlier post - the progestogen from the Mirena (levonorgestrel) is absorbed systemically to some extent so is not only confined to the womb. In addition the studies did include some data on levonorgestrel and risk, even if not the mirena coil. I don't have time to delve into the data to see exactly what the preparation was that contained levonorgestrel.

I didn't say Mirena's levonorgestrel is confined to the womb, I said Mirena's effects, but I agree there are few studies. Although I will link to some recent ones below.

However I would suggest, whilst I understand you are trying to give reassurance to Tracey E, there is insufficient information for you to give such an optimistic reassurance - especially from a lay person. All we can say regarding the Mirena coil is just that - there is insufficient information but because the absorbed amounts are quite low and comparable with other transdermal HRT progestogens, if there is a risk (and we are still talking about observational rather than experimental data), it is likely to be much smaller.

Suggestion taken. However, I used the word 'probably' exactly because this is not optimism, it's just my personal view on the data available. Re being a lay person, aren't we all on here? Regarding your statement about Mirena coil 'insufficient information' this was exactly the reason why the meta-analysis didn't use it. If 'absorbed amounts are quite low' and 'if there is a risk it's likely to be smaller', so what you're saying is that there's no way to weigh risks and benefits of using Mirena?

Vaginal oestrogens and creams are a completely different case altogether because they are extremely low dose oestrogens and systemic absorption absolutely minimal. In any case it is the progestogen component which confers the increased risk (according to the data) with oestrogen only systemic preparations themselves carrying a very small additional risk.

I agree that concentrations and hormones are different, but I felt personally reassured that local hormone therapy is much better than systemic (oral or transdermal) after this study. I think that it's better to have a Mirena coil or take Utrogestan vaginally than taking oral Utro or transdermal synthetic progestagens.

Tracey E - this is not to try to worry you - but I think we (on the forum) have to be careful with what we say and how we interpret all of this very complex information - and take our cue from those experts who have analysed the report in detail and have made their responses which are extensively linked to on the other thread. Nothing that they have said indicates that most women need to change whatever they are doing/taking as a result of this new analysis of existing information (the published paper), rather to continue to weigh up our own individual benefits and risks in maing our decisions.

Hurdity x

I agree. However, as you say, this study has 'very complex information', so I don't think 'those experts who have analysed the report in detail' had time to analyse it in detail and 'their responses' , at least some of them, are quite emotional instead of rational.
That 'nothing that has been said indicates that most women need to change whatever they are doing/taking as a result of this new analysis of existing information', is a valid but perhaps premature assumption. Risk/benefit ratios are the way to go, I agree.

I don't have time to scrutinise the report in detail (and actually don't have to desire to as it's lots of stats!) so I don't know whether any studies quoted have included the Mirena coil or its constituent progestogen - levonorgestrel. Possibly not the Mirena? ie no studies? A lot of the studies used in this analysys are older. However the amount absorbed systemically from the Mirena is very approx comparable to the amount absorbed transdermally from Femseven patch (so I estimated some time ago - from data available on systemic concetrations) - which is much less than oral progestogens.

Unfortunately I also don't have time now to post many relevant studies on the matter, but I can provide them, if necessary, later on.
I haven't quoted any studies, only the recent published one. As I quoted above, they have not considered IUS-LNG in this study, so there's no way of knowing what brand the available studies (again, not used in this particular study) were. I also have no idea if systemic absorption of IUS can be compared to patches (can you post a link, when you have the time?). Systemic concentrations may differ a lot from localised concentrations, particularly in breast tissue extremely rich in hormone receptors.

Some recent articles on the matter https://www.sciencedirect.com/science/article/abs/pii/S001078241930229X https://www.sciencedirect.com/science/article/pii/S0090825818301252 https://link.springer.com/article/10.1007/s10549-017-4491-2 https://www.maturitas.org/article/S0378-5122(16)30040-8/abstract  Unfortunately most recent article are pay-per-view, but I do have access to Maturitas, so if you need some more info I can post small bits.

Re the studies used in this meta-analysis: 'Studies were identified by searching any formal and informal sources regularly from Jan 1992 to Jan 2018'.

Hope this helps,

BeaR.

P.S. How can I multiquote? I couldn't find a way.

[Tracey E]

Hi BeaR, once again thank you, I'm trying to digest these findings and make some sort of sense if the info provided.