Estrogen metabolism in menopausal hormone users in the women's health initiative observational study: Does it differ between estrogen plus progestin and estrogen alone?

• Published in: International journal of cancer Vol. 144; no. 4; pp. 730 - 740
• Main Authors: Falk, Roni T., Manson, JoAnn E., Barnabei, Vanessa M., Anderson, Garnet L., Brinton, Louise A., Rohan, Thomas E., Cauley, Jane A., Chen, Chu, Coburn, Sally B., Pfeiffer, Ruth M., Reding, Kerryn W., Sarto, Gloria E., Wentzensen, Nicolas, Chlebowski, Rowan T., Xu, Xia, Trabert, Britton
• Format: Journal Article
• Language: English
• Published: United States Wiley Subscription Services, Inc 15.02.2019
• Subjects: 17β-Estradiol; Aged; Breast cancer; Breast Neoplasms - drug therapy; Breast Neoplasms - pathology; Cancer; Case-Control Studies; conjugated equine estrogens; conjugated equine estrogens plus medroxyprogesterone acetate; Drug Therapy, Combination; Endometrial cancer; Endometrium; estrogen alone; estrogen metabolism; estrogen plus progestin; Estrogen Replacement Therapy - methods; Estrogens; Estrogens - administration & dosage; Estrogens - metabolism; Estrogens, Conjugated (USP) - administration & dosage; Estrone; Female; Health risk assessment; Health risks; Hormone replacement therapy; Humans; Hydroxylation; Medical research; Medroxyprogesterone Acetate - administration & dosage; Metabolism; Metabolites; Middle Aged; Observational studies; Post-menopause; Postmenopause; Progestin; Progestins - administration & dosage; Risk Factors; Sex hormones; Treatment Outcome; women's health initiative observational study; Womens health; conjugated equine estrogens plus medroxyprogesterone acetate; estrogen metabolism; estrogen alone; conjugated equine estrogens; estrogen plus progestin; women's health initiative observational study
• ISSN: 0020-7136; 1097-0215
• DOI: 10.1002/ijc.31851

The WHI found an unexpected reduced breast cancer risk in women using CEE alone. We hypothesized CEE alone induces estrogen hydroxylation along the 2‐pathway rather than the competing 16‐pathway, a pattern linked to reduced postmenopausal breast cancer risk. One thousand eight hundred and sixty‐four women in a WHIOS case–control study of estrogen metabolism and ovarian and endometrial cancer were studied of whom 609 were current E + P users (351 used CEE + MPA), while 272 used E alone (162 used CEE). Fifteen EM were measured, and analyses were conducted for each metabolite, hydroxylation pathway (2‐, 4‐, or 16‐pathway) and ratios of pathway concentrations using inverse probability weighted linear regression. Compared to E + P users, all EM were higher in E alone users (significant for unconjugated estrone, total/conjugated estradiol, total/unconjugated 2‐methoxyestrone, 4‐methoxyestrone and unconjugated estriol). The relative concentrations of 2‐ and 4‐pathway EM did not differ between the MHT users (2‐pathway EM comprised 15% and 4‐pathway EM <2% of the total), but 16‐pathway EM were lower in E alone users (p = 0.036). Ratios of 2‐ and 4‐pathway EM compared to 16‐pathway EM were significantly higher in E alone compared to E + P users. Similar but not significant patterns were observed in CEE‐alone and CEE + MPA users. Our data suggest that compared to E + P users, women using E alone have more extensive metabolism via the 2‐ vs. the competing 16‐pathway. This is consistent with epidemiologic evidence of reduced postmenopausal breast cancer risk associated with this metabolic profile and may provide a clue to the breast cancer risk reduction in CEE alone users during the WHI. What's new? The Women's Health Initiative discovered that women taking conjugated equine estrogens (CEE) and medroxyprogesterone acetate (MPA) together increased their risk of breast cancer, but surprisingly, taking CEE alone reduced the risk of cancer. Here, the authors investigate the mechanism involved. To trace the pathway of CEE metabolism, they measured 15 different estrogen metabolites, using serum from women in the WHI Observational Study. In women taking estrogen alone, they found more activity in the “2‐pathway” over the “16‐pathway” of estrogen metabolism, which leads to reduced cancer risk. Those taking estrogen and progestin together showed more activity in the “16‐pathway,” associated with higher cancer risk.