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Int J Cancer. 2019 Feb 15;144(4):730-740. doi: 10.1002/ijc.31851. Epub 2018 Nov 1.

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

Author information

National Cancer Institute, Bethesda, MD.
Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Jacobs School of Medicine and Biomedical Sciences University at Buffalo, Buffalo, NY.
Fred Hutchinson Cancer Research Center, Seattle, WA.
Albert Einstein College of Medicine, Bronx, NY.
University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA.
University of Washington School of Nursing, Seattle, WA.
University of Wisconsin School of Medicine and Public Health, Madison, WI.
City of Hope National Medical Center Duarte, CA.
Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, MD.


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.


conjugated equine estrogens; conjugated equine estrogens plus medroxyprogesterone acetate; estrogen alone; estrogen metabolism; estrogen plus progestin; women's health initiative observational study

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