As I look back on the year 2021, it would be easy to talk about all things COVID-19 or COVID-19 and vaccines. I’m going to do neither and, rather, recognize that issues in gynecology and primary care for women roll on and the need for natural therapies in women’s health continues to be dominated by those we are accustomed to—menopause symptoms, pelvic tumors, breast cancer, dysmenorrhea, bladder and vaginal infections, insomnia, primary dysmenorrhea, endometriosis, PMDD, pregnancy, fertility, depression, anxiety, cystitis, and on and on.

For this women’s health issue of the Townsend Letter, I usually look back at studies I’ve read and written about in the year previous and then select those that I have found to be influential in my clinical practice, or compelling or intriguing in the use of a natural medicine or lifestyle habit in women’s health. Here are a few.

The Effect of N-Acetylcysteine on Uterine Fibroids

Uterine fibroids (aka leiomyomas) are a common benign uterine tumor that originates from the smooth muscle of the uterus. They are not cancerous growths. The incidence, in general, in US women is about 9.6% of the female population, but it is more common in black women with an incidence of 18.5% (and possibly other nonwhite women). Approximately 25% to 50% of women with fibroids are symptomatic, experiencing heavy menses, reproductive issues, pain, increased urinary frequency, and anemia, and are more symptomatic in black women.

Uterine fibroids are the most common cause of gynecologic surgery worldwide; yet still, the underlying cause remains unclear. More than 100 gene abnormalities are identified in leiomyomas, involving the genes for hormone receptors, growth factors, extracellular matrix and collagen. The current factors that may be involved include genetic factors, estrogen/progesterone receptors in the uterine muscle cells, growth factors such as insulin-like growth factor, and extracellular matrix, which is the material that makes cells stick together.

When we do not understand the cause of a medical condition, it makes it very hard to identify prevention and treatments. The current state of affairs offers three basic conventional options: 1) surgery (hysterectomy or myomectomy or hysteroscopic removal of intrauterine fibroids; the surgical options depend on fibroid location, size/mass of the fibroids, symptoms and other medical issues that might influence the best surgical option) 2) hormonal drugs that can temporarily shrink the fibroids prior to surgery; or, hormonal drugs that can improve some of the symptoms such as heavy bleeding 3) uterine artery embolization. In general, conventional medicine is left with insufficient non-invasive treatments where no pharmaceutical agent is known to shrink the fibroids in a long-term way.

The premise for N-acetyl cysteine (NAC) is as an antioxidant that inhibits free oxidative radicals and hopefully results in neutralizing the proliferation of uterine fibroid tumor cells. The hope is that the known antioxidant mechanism of NAC that reduces oxidative stress by inhibiting free radicals and glutathione synthesis, thus preventing the peroxidation of membrane lipids and preventing their release, may also lead to a reduction in uterine fibroid volume.

The current study is a randomized, double-blind controlled pilot study in Iran, 2017-2019. Women included in the study were diagnosed with uterine leiomyoma based on transvaginal ultrasounds and had a fibroid at least 8 cm or more, less than four uterine fibroids, and just one type of fibroid (either submucosal, intramural or subserosal), with no pedunculated fibroids, were premenopausal, not pregnant, had not taken hormonal medications in the previous six months and no hormonal medication for their fibroids in the past three months and did not have certain diseases that were listed as exclusionary criteria. Women also had to have regular menstrual periods, onset of menses between ages 12 and 14, and had previously presented with heavy bleeding and painful periods.

A total of 50 women were accepted into the study with half being given NAC 600 mg/day for three months and the other half the placebo. Pelvic ultrasounds were performed before and after taking medication. No statistically significant difference was found between the two groups in terms of number and type of fibroids, and menopause status. The mean rates of volume reduction in group A (NAC group) were 25.25% and group B (placebo) was 1.08%. At the beginning of the study, heavy bleeding and painful menses were reported by women in both groups. The bleeding pattern changed during and after NAC treatment with a significant reduction in volume of bleeding and menstrual pain. There was also a significant reduction in fibroid and soft tissue tumor size in the treatment group. The average severity of pain in the NAC group was between 8 and 9 out of 10 before treatment and between 4 and 5 after treatment. Before NAC, women had heavy bleeding and after, a pattern of moderate bleeding was reported.

Commentary: I am not sure of the fundamental logic for considering NAC for uterine fibroids. However, given that we have a significant lack of non-invasive treatment options, I’m certainly open to ideas and pilot studies. I also consider 600 mg/day of NAC to be a low dose when compared to the studies on polycystic ovary syndrome and endometriosis; although for endometriosis it was 600 mg three times daily for three days/week and for PCOS we usually see the studies at 500 mg three times daily. The study results lacked specificity for me…especially in its reported reduction in heavy bleeding; we do not know how many women improved and what defined heavy vs moderate. I can believe a reduction in symptoms after three months of any herbal or natural agent, but to reduce volume size within three-months’ time is harder to believe. Believable or not, I will certainly try this non-invasive safe, natural therapy for my patients with non-pedunculated uterine fibroids with less than four fibroids. I will likely also not just limit my patients to those with a fibroid of at least 8 cm. There is only a small amount of other published research on natural agents, including green tea and black cohosh. While I will continue to make efforts with natural therapies to reduce bleeding and pain, to actually reduce size and number of fibroids has left me with very little optimism after 36 years of clinical practice. It is important for the woman with fibroids and her medical provider to recognize when it’s time for surgery or uterine artery embolization (UAE) and the benefits and risks of each kind of pelvic surgery or if UAE is a viable option.

Aghaamoo S, et al. The effect of N-acteyl cysteine on the volume of uterine leiomyoma: A ranrdomized clinical trial.  Int J Gynecol Obstet. 2021. 2021:00:1-5.

Uterine Fibroids May Be Reduced with Green Tea Plus Vitamin D

Uterine fibroids are the most common benign tumor in the uterus. Most do not cause any symptoms and don’t require any investigation or treatment. But, for some women, maybe about a third, uterine fibroids, also called uterine myomas, may need a therapy—either to control abnormal uterine bleeding, reduce the size due to pressure and effects on bladder and/or digestive function, interference with fertility, or just plain aesthetics and discomfort due to size and abdominal distention. Conventional treatment options included medications to control bleeding or shrink the fibroids temporarily or surgical options. All of this depends on the scope and severity of the symptoms, the size, number and desire for pregnancy. Minimally invasive surgical procedures are possible for some but not all fibroids. Others might require a hysterectomy—either abdominally or vaginally.

Women often seek alternative or integrative medicine options to see if non-surgical or non-pharmaceutical treatments may help. The research is sparse, and the success is hit and miss. The most likely help we can offer is to help control abnormal bleeding. The least likely help we can offer is actually reducing the size of fibroids, especially larger ones. However, a small amount of research has emerged, including in the area of green tea. In the current study, vitamin D and epigallocatechin gallate (EGCG) offers some hope with women who had symptomatic fibroids.

Women were included in the study if they were 18 or older, premenopausal and had at least one myoma >2 cm (either intramural or subserosal and/or submucosal fibroids), as detected on a vaginal and abdominal ultrasound, with moderately severe myoma-related symptoms…and required no other treatment.

This pilot study enrolled 30 women with myomas, who were divided into two groups. One group (n=15) received one tablet of 1,000 IU (25 mcg) vitamin D plus 150 mg EGCG plus 5 mg B6, twice daily for four months. The second group (n=15) received no treatment for four months. The primary outcome was the change in volume of myomas as detected by transvaginal and/or transabdominal ultrasound. The secondary outcomes were variation of the number of myomas, heavier menstrual bleeding, pelvic pressure, fatigue, quality of life, and the severity of any of these symptoms.

None of the women dropped out of the study in either group, and there were no discernable side effects of the treatment. The total number of myomas in the treated and control group was 23 and 21, respectively. In the treated group, the incidence of intramural myomas was 43.7%, subserosal 12.5%, and submucosal 43.75%. In the control group it was 47.4% intramural, 10.5% subserosal, and 42.1% submucosal.

A significant reduction in the volume of myomas in the treated group was 10.84 cm at baseline to 8.04 cm after four months. The reduction of the volume of myomas was unrelated to the type of myomas. In the control group, the volume was 10.17 at baseline to 10.94 after four months of treatment. This translates to a 34.7% reduction in the volume of myomas in the treatment group and an increase of 6.9% in the control or untreated group. The number of myomas did not change in either group.

While the specifics were vaguely reported, there was an improvement in quality of life and reduction in severity of symptoms in the treatment group.

Commentary: Uterine myomas, aka uterine leiomyomas, aka uterine fibroids are monoclonal tumors of the smooth muscle cells of the myometrium. Myomas consist of an accumulation of collagen, fibronectin, and/or proteoglycan that can form in or on the uterus. Where they form determines the classification of intramural, subserosal, or submucosal. A woman can have any combination of these or just one kind. They are most common between the ages of 35 and 50 and may vary by ethnic groups with African American women having three-to-four times higher risk of developing myomas as compared with Caucasian American women. Uterine fibroids are the leading cause of hysterectomies in the US accounting for about 39% of all hysterectomies. Clearly, we are not doing enough to understand the cause and offer successful treatments.

The exact cause of myomas is still unknown but their development and growth is at least in part affected by estrogen and progesterone. But also, we must consider the roles and influence of the hormone receptors and that the dysfunction is at the receptor rather than any particular rise or fall of the hormones. It is a mistake to think that fibroids are only under the influence of estrogen. For some women, it’s progesterone that can actually adversely affect growth of myomas. It’s a much longer discussion, and discussion and theories are the name of the game rather than true knowns. But, we might consider growth factors, cortisol dysregulation, dysfunctions in hormone metabolizing enzymes, environmental endocrine disruptors, body fat and obesogens…and more. And speaking of more, a robust research effort would be welcomed to explore these theories, questions, and attempts at solutions.

Back to vitamin D and EGCG. There is at least one study showing an association between hypovitaminosis D and a higher prevalence of uterine fibroids, along with more severity related to the fibroids. (Int J Womens Health. 2013; 5: 93-100.) Mild symptomatic fibroids may be able to improve once an outright vitamin D deficiency (<30 ng/mL) is corrected. (Medicine (Baltimore) 2016; 95: e5698.) In one previous green tea study, EGCG for four months reduced the myoma size in premenopausal women. (Int J Womens Health 2013; 5: 477-486.)

The current study, along with support of the small amount of previous data on vitamin D and EGCG, supports the possibility that a simple and safe approach could at least offer something more than wait and watch—and possibly for some, may spare them a surgery and improve their myoma symptoms and quality of life. In addition, we could consider an integrative plan, offering the herbal/nutraceutical treatment along with other pharmacological therapies that are being used to control heavy bleeding. A uterus is worth saving, if possible, and avoiding any surgery, if possible, is wise and worth an effort. If surgery is necessary, a good surgeon with a broad understanding of pelvic floor support and implications for menopause is an important part of an integrative treatment team.

Porcaro G, et al. Vitamin D plus epigallocatechin gallate: a novel promising approach for uterine myomas. European Review for Medical and Pharmacological Sciences. 2020; 24: 3344-3351.

Valerian Root for Sleep Disorders – A Further Understanding

Insomnia comes in all sizes and shapes; but in essence, it is a common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep. Insomnia is considered chronic if it occurs at least three nights per week and has been going on for at least three months. Insufficient sleep and/or disrupted sleep can lead to fatigue, poor ability to handle stressed, mood disorders, cognitive impairment, poor performance during the day, and even increase the risk for chronic conditions such as hypertension, hyperlipidemia, type 2 diabetes, heart disease, and dementia. While conventional medicine has a plethora of treatment options, including over the counter and prescription medications, most if not all of these have been associated with cognitive decline when used regularly for years. Some of the prescription medications can be addictive as well.

Valerian root is one herb that has a long tradition of use for sleep disorders. The results of studies have been mixed. The current paper is a systematic review and meta-analysis with the hope of bringing some clarity as to efficacy and to offer possible explanations for the inconsistent research.

Three searches were conducted for both controlled and observational studies. Search A included clinical trials found on PubMed between January 1980 and November 2019. Search B was conducted on ScienceDirect between January 2000 and November 2019. Search C identified all clinical trials in the Cochrane Library through December 2019.

A total of 696 articles were identified. Of those, 629 did not meet inclusion criteria which leaves 67, although 7 of those were excluded for unknown reasons. Of the 60, 40 studies evaluated valerian as a single herb and 36 of those were randomized controlled trials, two were observational studies, and two studies evaluated potential induction of CYP. Others used valerian/herbal combinations.

Of those 40, 23 tested the efficacy of valerian for sleep problems and 13 studies found valerian to be effective as a sleep aid, although only four of the studies included patients with diagnosed insomnia. Of the remaining 10 studies, three showed no significant effect of valerian as a sleep aid when compared to a placebo.

The information for analysis also classified herbal preparations into four groups: hydroalcoholic extracts, aqueous extracts, unspecified solvents, and whole root/rhizome. Here is where it gets interesting. A single dose of valerian hydroalcoholic extract did not improve sleep quality; however, it did improve REM sleep in patients diagnosed with insomnia. Repeated doses demonstrated inconsistent outcomes with four studies reporting efficacy, three reporting no improvement, and one reporting improvement in sleep latency after repeated doses for two weeks but no improvement after a single dose.

Out of three studies evaluating the use of an aqueous extract, two studies found improved subjective sleep quality and latency in healthy participants after a single dose. One study found improved deep sleep for elderly participants after one week of a repeated dose. Of the three studies using unspecified solvents, two RCT reported negative outcomes and one observational study reported a positive outcome.

All five studies evaluating the use of dried root/rhizome showed improved sleep in at least one subgroup (four RCT and one observational study).

The anxiety-reducing potential of valerian was also analyzed. It did exhibit antianxiety benefits with high variability in results using the extracts and more positive outcomes using the whole dried root. Other effects of valerian included reduced symptoms of obsessive-compulsive disorder (OCD), improved cognition in patients receiving hemodialysis, and preventative benefits against a decline in cognition after coronary bypass surgery.

A different species of valerian was also evaluated, Taproot valerian (V. edulis). It showed some effectiveness for sleep latencies and sleep quality in kids with intellectual challenges along with primary sleep problems. Another taproot valerian study showed a reduction in the number of awakenings in patients diagnosed with insomnia and showed an increase in REM sleep.

Better sleep quality and reduced wake time after sleep onset was seen in patients diagnosed with insomnia after they received a combination of valepotriates from Indian valerian (V. jatamansi syn. V. wallichii) over 15 days.

Nineteen studies used herbal combinations. The most common combination was valerian and European hops. Valerian and lemon balm had positive outcomes on sleep disorders, anxiety and reduction in hyperactivity and improvement in concentration in children who struggle with these symptoms. Two observational studies used valerian and St. John’s wort in patients diagnosed with depression and children with affective disorders. A reduction in anxiety and depression, and improved sleep was seen.

Commentary: There is a robust list of underlying causes of sleep disorders and this paper did not consider that. However, the results do suggest that valerian is most useful in treating those with insomnia associated with anxiety. In reading this, I came away thinking the best results in the most ways are seen with the dried root (sleep quality, sleep latency, decreased wakefulness) although the water extract can shorten the time it takes to fall asleep, ease return to sleep if early wakening, and improve REM sleep and overall sleep quality. Combining valerian root with lemon balm appears optimal for sleep disorders with anxiety, as well as improving concentration and hyperactivity in children with sleep issues.

Shinjyo N, Waddell G, Green J. Valerian root in treating sleep problems and associated disorders – A systematic review and meta-analysis. J Evid Based Integr Med. January-December 2020;25:25

Vitamin D Supplementation May Help Primary Dysmenorrhea (your average case of menstrual cramps, not caused by endometriosis)

Primary dysmenorrhea is defined as menstrual pain without any pelvic pathology. This is the most common menstrual symptom in adolescent girls and young women. The onset of menstrual pain usually occurs just before or at the first onset of the menstrual flow and typically lasts a half day to three days. Some women have additional symptoms such as headache, fatigue, and even nausea/vomiting and diarrhea.

In the current double-blind, randomized, placebo-controlled clinical trial in Iran in women aged 18 to 32 years, with regular menstrual cycles and with a pain score of 4 or more out of an 11-point rating scale. These women also had a laboratory value of 25-hydroxyvitamin D <30 ±ng/mL which means some were insufficient (20-30 ng/mL) and some were deficient (<20 ng/mL). There were 58 participants in the vitamin D supplement group and 58 in the placebo group. Women received vitamin D3 capsules 50,000 once weekly for eight consecutive weeks or placebo.

Results: The serum level of 25 (OH)D significantly increased from 20 to 37 ng/mL in the vitamin D group and no significant changes in the placebo group. Even with this robust dosing of vitamin D for eight weeks, 24% of the women receiving vitamin D supplements still showed low levels of 25(OH)D <30 ng/mL at week 8. A significant change in pain intensity was found in the vitamin D group and no significant change in the placebo group. The significant reduction in pain intensity was measurable at week 4 (the first menstrual period), as well as week 8. The average pain intensity at baseline was 7.0 ± 1/7; 6/3 ± 1.7 at week 4; and 5.6 ± 1.7 at week 8. There was also a significant change in the number of days with pain in the vitamin D group and none and no significant change in the placebo group. By week 8, the reduction in number of days went from 2 at baseline and 1 at week 8. Even the number of pain relief medications used per day was reduced in the vitamin D group by half vs no significant change in the placebo group. Lastly, there were even improvements in the systemic symptoms associated with their dysmenorrhea in the vitamin D group, including headache severity and diarrhea, with no significant change in the placebo group.

Commentary: One of the things I was curious about was whether or not there was an association between the increase in serum vitamin D level and the improvement in pain intensity. The researchers found no such correlation and surprisingly, there wasn’t even a difference in pain intensity in the vitamin D group with those who did achieve normal serum levels (> 30 ng/mL) and those who did not achieve that.

A suggested mechanism causing primary dysmenorrhea is the increased production of prostaglandins in the endometrium (line of the uterus). This rise in prostaglandins in women with primary dysmenorrhea increases uterine tone and high-amplitude contractions. Both upregulation of cyclooxygenase activity and prostaglandin synthesis are generally observed in women with primary dysmenorrhea. Consequently, whether herbal or pharmaceutical, non-steroidal anti-inflammatories that inhibit the expression of cyclooxygenase enzyme that is involved in the synthesis of prostaglandin should be considered first-line options for treating acute primary dysmenorrhea. The herb ginger root has some nice, published research for this purpose.

Given the frequency of vitamin D insufficiency or vitamin D deficiency, the possible role of these insufficient levels should be considered as a possible role of causing or exacerbating primary dysmenorrhea.

Rahnemaei F, et al. Vitamin D supplementation for primary dysmenorrhea: a double-blind, randomized, placebo-controlled trial. Obstetrics Gyn Sci. 2021, May 18 (epub ahead of print).

Milk Thistle for Hot Flashes of Menopause: Yet Another Option

Hot flashes and/or night sweats, collectively called vasomotor symptoms (VMS), are the most common symptom of perimenopause/menopause. The average duration of VMS is about seven years, so more options to address this frequently significant symptom, is always welcomed. While VMS can come in all sizes and shapes, varying from mild to severe and infrequent to frequent, they are bothersome for a large number of women, interrupting sleep, altering mood, and affecting quality of life.

This trial of milk thistle was conducted in Iran between September 2018 and December 2019. Women were postmenopausal between the ages of 40 and 60 years, and who had experienced VMS ≥14 times weekly for the past two months, and who had a total Greene Climacteric Scale (GCS) score between 15 and 42 and a Hot Flash Related Daily Interference Score (HFRDIS) ≥ 40.

Women were excluded if they used tobacco, had an underlying chronic disease, history of allergy to herbal medicines, use of other treatments to treat hot flashes, history of asthma and allergies, history of abnormal pap smears and pelvic ultrasounds, and history of a breast, ovarian, or uterine cancer.

A dry extract of milk thistle in the form of a powder was encapsulated with 400 mg per capsule of milk thistle standardized to 80% silymarin. Eighty women were randomized into two even groups, and each group took a 400 mg capsule twice a day for eight weeks: one group milk thistle and one group placebo. Women recorded the frequency and severity of hot flashes for twelve weeks including the four weeks after stopping the capsules. Data was collected every four weeks with a visual analog scale to evaluate the severity of hot flashes; women reported the average of their frequency and severity for each day.

The GCS was used to measure menopausal symptom severity and HFRDIS assessed the vasomotor interference level during their daily activities. The mean age of women in the study was 52.5 years. Seven dropped out of the study: two from the milk thistle group and five from the placebo group due to gastric pain, bloating, and increased symptoms.

The women in the milk thistle group reported a decrease in the frequency and severity of hot flashes, while the placebo group saw no significant changes. The GCS questionnaire mean score and HFRDIS mean scores decreased in the milk thistle group while the placebo group had no significant changes. The conclusion was that the milk thistle reduced postmenopausal VMS within the first month and lasted a month after discontinuation as well.

Commentary: We still do not know the exact mechanism for VMS but the most recent thinking is that there are abnormalities in the hypothalamic thermoregulatory center due to fluctuating estrogen levels and ultimately lower estrogen levels.

The primary conventional treatment for VMS includes estrogen therapy, but other therapies such as SSRIs, gabapentin, a selective estrogen receptor modulator (SERM) in combination with an estrogen and clonidine. There are a host of botanical and nutrient therapies that have published research. The conventional pharmaceuticals all have benefits and risks, with hormone therapies having the most benefits, with very small risks in most women. The botanical/nutraceuticals have benefits and small to no risks, although the benefits for VMS do not statistically meet the same level of results as with systemic estrogen. That said, what we care most about is what are the individual benefits and risks for each woman and the individual results she achieves with her treatment, whatever the treatment is.

I am most familiar with the use of milk thistle (Silybum marianum, Asteraceae) for liver and gallbladder conditions, but there are other historical uses for fever, kidney, and spleen diseases.

The primary active constituent in mild thistle, silibinin, could have an agonistic effect on estrogen receptor β, or one might also theorize it is affecting serotonin receptors via the gut/grain axis

Saberi Z, et al. Evaluation of the effect of Silybum marianum extract on menopausal symptoms: A randomized, double-blind placebo-controlled trial. Phytother Res. December 2020;34(12):3359-3366.

Good News for Breast Cancer Patients – Drink Coffee and Tea, Especially Coffee

In July 2018, I reported on a meta-analysis of coffee intake and breast cancer risk. The design of that meta-analysis was to assess associations between amounts of decaffeinated and caffeinated coffee (from 0 to 7 cups of coffee per day) and breast cancer risks, including categories of body mass index, hormone receptor status, and menopause status.

The analysis included 13 prospective studies totaling over 1 million participants and concluded in showing no significant association between coffee consumption and breast cancer risk.  However, when the analysis was specific to postmenopausal women, there was an inverse relationship to the tune of consumption of four cups of coffee per day was associated with a 10% reduction in postmenopausal cancer risk, no matter body mass index or hormone receptor status, or caffeinated or decaffeinated coffee. Conclusion: coffee consumption is associated with a decreased risk of postmenopausal breast cancer. (Lafranconi A, et al. Coffee intake decreases risk of postmenopausal breast cancer: a dose-response meta-analysis on prospective cohort studies. Nutrients. 2018;10(2). pii:E112.)

The more recent study I want to report on is the role of post-diagnostic coffee and black tea consumption among women with breast cancer in prospective cohort studies.  The women who were included in this analysis were 8,900 women diagnosed with stage I through stage III invasive breast cancer from 1980 through 2010 who were part of the Nurses’ Health Study (NHS) and then also from 1991 through 2011 who were part of the NHS II.

A food frequency questionnaire (FFQ) of coffee and black tea consumption every four years after the diagnosis of their breast cancer was assessed.  Total coffee consumption included regular and decaffeinated coffee, and total tea consumption included regular and decaffeinated tea.

Approximately 70% of the women in the study had data, including estrogen and progesterone receptor status, human epidermal growth factor receptor 2, cytokeratin 5/6, Ki-67 and epidermal growth factor receptor. These are common markers analyzed from breast tumor biopsies. Researchers gathered data every two years post diagnosis.

The investigators reported on 1,054 deaths due to breast cancer and 2,500 total deaths over 30 years of follow-up.  A higher post-diagnostic coffee consumption was associated with a lower mortality specific to breast cancer.  Women who drank >3 cups of coffee per day had a 25% lower risk when compared with non-coffee drinkers.   There was also a lower mortality rate due to any cause observed in the coffee drinkers.  Compared with women who did not drink coffee, >2 to 3 cups per day was associated with a 24% lower risk and >3 cups/day was associated with a 26% lower risk.  Post-diagnostic tea consumption was also associated with lower all-cause mortality.  Greater than 3 cups/day was associated with a 26% lower risk compared to nondrinkers but not a reduction in breast cancer specific mortality.

In addition, the more you drank the better the effect.  For each one cup/day greater intake, the breast cancer mortality hazard ratio dropped 7% for regular coffee and 2% for decaffeinated coffee.  There was also a benefit for reduction of all-cause mortality for greater intake for both regular and decaffeinated coffee.  For each one cup of caffeinated coffee per day, the hazard ratio dropped 7% and 5% for decaffeinated.

When the intakes of coffee and tea were added together, an inverse association with breast cancer specific mortality was seen for consumption of >3 cups/day vs nondrinkers, but not for tea of >3 cups/day vs nondrinkers.  For all-cause mortality, significant inverse associations were seen for both coffee and tea at >3 cups/day vs nondrinkers.

In breast cancer survivors, higher amounts of coffee consumption after breast cancer diagnosis were associated with better survival rates from breast cancer and from any cause.

Commentary:  I can’t tell you how many patients tell me they are going off of coffee, or they already went off coffee.  I then ask…why?  More often than not, I recommend they continue their coffee (and black tea) habit.  If they don’t have heart palpitations or a rapid heart rate or chronic insomnia, or perhaps breast tenderness, I do not see a reason to discontinue, and in fact proceed to tell them the benefits.

You might be surprised to learn that coffee is a robust source of antioxidants and in 2005, it was listed as the #1 source of antioxidants in the American diet, providing almost 1,300 mg of antioxidants daily in the form of polyphenols.  Black tea provides 294 mg and bananas 76 mg.  I list these two because they are the second and third dietary sources of polyphenols in the American diet.  That’s actually not particularly fabulous in my view… as I would prefer a diet richer in other polyphenol-rich foods (berries, citrus, red fruits, apples) and then preferably lower glycemic fruits than bananas (berries again).  And, we haven’t even gotten to the other robust nutrients and fibers in the long list of polyphenol-rich foods.

Past studies examining the relationship between coffee consumption and breast cancer mortality are inconsistent, but the current study is the most comprehensive.  It’s curious why coffee drinking spurs negative health concern; now, it could be the sugar added, or the croissant or scone with the coffee.  Worse, smoking a cigarette with your coffee.   I would agree with those negatives.  But when it comes to having breast cancer, coffee should be encouraged, not discouraged.   And while not all like the taste of coffee, she can at least be encouraged to drink her black tea as it will reduce her risk of all-cause mortality, even if not breast cancer mortality.

Cheers!

Farvid M, et al.  Post-diagnostic coffee and tea consumption and breast cancer survival.  Br J Cancer. 2021; 124(11):1873-1881.