DEAR DR. ROACH: I was diagnosed with breast cancer in 2020, and along with surgery, chemotherapy and radiation, I have been taking 1 mg of anastrozole daily. The bone mineral density of my left hip has not changed significantly. The bone density of my lumbar spine has decreased 6.3% compared to 2020. Several of the doctors I’ve worked with are open to using natural hormone blockers, such as diindolylmethane, instead of the anastrazole. What would you recommend? — B.C.N.
ANSWER: Anastrozole is in the class of medicines called aromatase inhibitors (AIs), which block the body from making estrogen. AIs reduce estrogen levels by about 85%. In women with tumors — especially breast cancer — that are sensitive to estrogen, these medicines significantly improve response rates compared with other medications, such as the tamoxifen that was often given before AIs were introduced. AIs are typically given after getting treatment for breast cancer, such as surgery (often followed by chemotherapy or radiation), and decrease the rate of recurrence by about 15%.
Diindolylmethane (DIM) does have some ability to block aromatase and affect circulating estrogen levels, which was found in a trial of women taking tamoxifen. It may have other potential benefits as well. However, since AIs have been proven superior to tamoxifen, and because the level of estrogen inhibition is very high with AIs, I recommend strongly against using over-the-counter estrogen blockers like DIM instead of AIs. A role for these medications in combination may ultimately be proven, but that awaits further study.
Side effects from AIs often limit the ability for people with breast cancer to take these effective medications. One of these is accelerated osteoporosis. Because loss of estrogen routinely causes bone loss, osteoporosis should be aggressively screened for and, if possible, prevented through a combination of diet, exercise, calcium and probably vitamin D. Women with breast cancer on AIs should have bone density levels checked before treatment and at intervals afterward, such as every two years. Women with high risk for fracture despite lifestyle modifications benefit from medication treatment.
DEAR DR. ROACH: Is there any physiological reason that a sneeze needs to involve the vocal cords? I can sneeze and suppress any noise, but a friend yells (using vocal cords) with every sneeze. I say this yelling can be avoided, but my friend says he has no control over the noise. Are either of us right? I know it’s a silly question, but I’m interested in your answer. — G.H.
ANSWER: A sneeze is a complex reflex that has many possible triggers and a few associated reflexive behaviors. Sneezing can be triggered by bright light or a full stomach, but is most commonly triggered by chemicals or physical stimulation of nerves inside the nose.
When we sneeze, air is reflexively brought into the lungs through a deep inhalation, then forcefully expelled from the mouth and nose (at upwards of 100 miles per hour, spreading upwards of 100,000 liquid particles, which potentially carry bacteria and viruses). There is typically a sound made, as the air is expelled through the (initially closed) glottis; however, most people can override this reflex and sneeze without making any noise from the vocal cords. Not everyone can suppress these reflexes. Some people become so accustomed to making noise during a sneeze that they may find it very hard to break the habit.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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