Women’s health 2019: Osteoporosis, breast cancer, contraception, and hormone therapy

Cleveland Clinic Journal of Medicine. 2019 June;86(6):400-406 | 10.3949/ccjm.86a.18130
June 3, 2019|Cleveland Clinic Journal of Medicine
Anna Camille Moreno, DO, NCMP;Sabrina Kaur Sahni, MD, NCMP;Taryn L. Smith, MD;Pelin Batur, MD, FACP, NCMP, CCD
Author and Disclosure Information

Anna Camille Moreno, DO, NCMP
Ob/Gyn & Women’s Health Institute, Cleveland Clinic

Sabrina Kaur Sahni, MD, NCMP
Ob/Gyn & Women’s Health Institute, Cleveland Clinic

Taryn L. Smith, MD
Ob/Gyn & Women’s Health Institute, Cleveland Clinic

Pelin Batur, MD, FACP, NCMP, CCD
Ob/Gyn & Women’s Health Institute, Cleveland Clinic; Associate Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Steering Committee, Women’s Preventive Services Initiative, American College of Obstetricians and Gynecologists and US Department of Health and Human Services, Health Resources & Services Administration

Address: Pelin Batur, MD, FACP, NCMP, CCD, Women’s Health Institute, A8-406, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; baturp@ccf.org

Release date: June 1, 2019
Expiration date: May 31, 2020
Estimated time of completion: 1 hour

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ABSTRACT

This review summarizes evidence that may enhance and influence clinical practice of women’s health. Supporting articles were identified by reviewing high-impact medical and women’s health journals published in 2017 and 2018. The chosen articles are pertinent to osteoporosis screening, hormonal contraceptive interactions with antibiotics, hormone replacement therapy in BRCA1 mutation carriers, breast cancer diagnosis using digital tomosynthesis, and risks of hormonal contraception.

KEY POINTS

  • The US Preventive Services Task Force recommends screening bone density when the 10-year risk of major osteoporotic fracture is more than 8.4%.
  • Women can be reassured that nonrifamycin antibiotics are unlikely to reduce efficacy of hormonal contraception.
  • Hormone replacement therapy after prophylactic bilateral salpingo-oophorectomy does not increase breast cancer risk in women who carry the BRCA1 gene mutation.
  • Hormonal contraception may increase the risk of breast cancer by 1 extra case per 7,690 women, although most studies suggest there is no increased risk.
  • The use of digital breast tomosynthesis along with digital mammography can increase cancer detection in women with dense breast tissue, but it is not yet routinely recommended by most professional societies.

MAMMOGRAPHY PLUS TOMOSYNTHESIS VS MAMMOGRAPHY ALONE

The same 44-year-old patient now inquires about screening for breast cancer. She is curious about 3-dimensional mammography and whether it would be a better screening test for her.

Digital breast tomosynthesis (DBT) is a newer imaging modality that provides a 3-dimensional reconstruction of the breast using low-dose x-ray imaging. Some studies have shown that combining DBT with digital mammography may be superior to digital mammography alone in detecting cancers.18 However, digital mammography is currently the gold standard for breast cancer screening and is the only test proven to reduce mortality.18,19

In a retrospective US study of 13 medical centers,20 breast cancer detection rates increased by 41% the year after DBT was introduced, from 2.9 to 4.1 per 1,000 cases. DBT was associated with 16 fewer patients recalled for repeat imaging out of 1,000 women screened (as opposed to mammography alone). Two European studies similarly suggested an increase in cancer detection with lower recall rates.21,22

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Is 3-D mammography a better option?

In a 2-arm study by Pattacini et al,18 nearly 20,000 women ages 45 to 70 were randomized to undergo either digital mammography or digital mammography plus DBT for primary breast cancer screening. Women were enrolled over a 2-year period and were followed for 4.5 years, and the development of a primary invasive cancer was the primary end point. Recall rates, reading times, and radiation doses were also compared between the 2 groups.

Overall, the cancer detection rate was higher in the digital mammography plus DBT arm compared with digital mammography alone (8.6 vs 4.5 per 1,000). The detection rates were higher in the combined screening group among all age subgroups, with relative risks ranging from 1.83 to 2.04 (P = .93). The recall rate was 3.5% in the 2 arms, with relative risks ranging from 0.93 to 1.11 (P = .52). There was a reduction in the number of false positives seen in women undergoing digital mammography plus DBT when compared with digital mammography alone, from 30 per 1,000 to 27 per 1,000.

Detection of ductal carcinoma in situ increased in the experimental arm (relative detection 2.80, 95% CI 1.01–7.65) compared with invasive cancers. Comparing radiation, the dose was 2.3 times higher in those who underwent digital mammography plus DBT. The average reading times for digital mammography alone were 20 to 85 seconds; adding DBT added 35 to 81 seconds.19

Should you advise 3-D mammography?

The patient should be educated on the benefits of both digital mammography alone and digital mammography plus DBT. The use of digital mammography plus DBT has been supported in various studies and has been shown to increase cancer detection rates, although data are still conflicting regarding recall rates.19,20 More studies are needed to determine its effect on breast cancer morality.

Routine use of DBT in women with or without dense breast tissue has not been recommended by organizations such as the USPSTF and the American College of Obstetricians and Gynecologists.23,24 While there is an increased dose of radiation, it still falls below the US Food and Drug Administration limits and should not be the sole barrier to use.