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Is estrogen plus progestin menopausal hormone therapy safe with respect to endometrial cancer risk?†‡
Article first published online: 30 AUG 2012
DOI: 10.1002/ijc.27623
Copyright © 2012 UICC
International Journal of Cancer
Volume 132, Issue 2, pages 417–426, 15 January 2013
Additional Information
How to Cite
Trabert, B., Wentzensen, N., Yang, H. P., Sherman, M. E., Hollenbeck, A. R., Park, Y. and Brinton, L. A. (2013), Is estrogen plus progestin menopausal hormone therapy safe with respect to endometrial cancer risk? . Int. J. Cancer, 132: 417–426. doi: 10.1002/ijc.27623
- †
This article is dedicated in the memory of Dr. Arthur Schatzkin, visionary investigator who founded the NIH-AARP Diet and Health Study.
- ‡
Published 2012. This article is a US Government work and, as such, is in the public domain of the United States of America.
Publication History
- Issue published online: 20 NOV 2012
- Article first published online: 30 AUG 2012
- Accepted manuscript online: 3 MAY 2012 06:07AM EST
- Manuscript Accepted: 23 APR 2012
- Manuscript Received: 28 FEB 2012
Funded by
- Intramural Research Program of the National Cancer Institute
- National Institutes of Health
- Department of Health and Human Services
- Abstract
- Article
- References
- Cited By
- cohort;
- endometrial cancer;
- estrogen plus progestin;
- body mass index;
- menopausal hormone therapy
Given the strong link between use of unopposed estrogens and development of endometrial cancers, estrogens are usually prescribed with a progestin, particularly for women with intact uteri. Some studies suggest that sequential use of progestins may increase risk; however, the moderating effects of usage patterns or patient characteristics, including body mass index (BMI), are unknown. We evaluated menopausal hormone use and incident endometrial cancer (n = 885) in 68,419 postmenopausal women with intact uteri enrolled in the National Institutes of Health-American Association of Retired Persons Diet and Health study. Participants completed a risk factor questionnaire in 1996–1997 and were followed up through 2006. Hazard rate ratios (RRs) and 95% confidence intervals (CIs) were estimated using Cox regression. Among 19,131 women reporting exclusive estrogen plus progestin use, 176 developed endometrial cancer (RR = 0.88; 95% CI = 0.74–1.06). Long-duration (≥10 years) sequential (<15 days progestin per month) estrogen plus progestin use was positively associated with risk (RR = 1.88; 95% CI = 1.36–2.60], whereas continuous (>25 days progestin per month) estrogen plus progestin use was associated with a decreased risk (RR = 0.64; 95% CI = 0.49–0.83). Increased risk for sequential estrogen plus progestin was seen only among thin-to-normal weight women (BMI < 25 kg/m2; RR = 2.53). Our findings support that specific categories of estrogen plus progestin use increases endometrial cancer risk, specifically long durations of sequential progestins, whereas decreased endometrial cancer risk was observed for users of short-duration continuous progestins. Risks were highest among thin-to-normal weight women, presumably reflecting their lower endogenous estrogen levels, suggesting that menopausal hormones and obesity increase endometrial cancer through common etiologic pathways.
Endometrial cancer, a known hormone-associated cancer, ranks fourth in most common cancers in women in the United States, with approximately 40,000 cases diagnosed annually.1 Unopposed estrogens, from either endogenous or exogenous sources, stimulate endometrial cell proliferation thereby increasing the likelihood of genetic errors and malignant transformation.2 Given the strong link between use of unopposed estrogens and development of endometrial cancers,3–6 it has been a standard practice to prescribe estrogens in conjunction with progestins, particularly for women with intact uteri. Although it is widely assumed that this type of hormone therapy is safe with respect to endometrial cancer risk, some studies suggest that sequential estrogen plus progestin use may actually increase risk7–15; however, precise relationships according to detailed usage patterns and interactions with other risk factors remain unclear.
Obese women have three to five times the risk of endometrial cancer compared to women of normal weight,6, 16 reportedly reflecting increased conversion of androgens to estrogens and higher circulating estradiol concentrations.17 The effects of unopposed estrogens on endometrial cancer risk have been shown to be modified by body mass index (BMI), with enhanced risks among thin women. It is less well established whether similar modifications are seen for estrogen plus progestin use.
To address these issues further, we conducted an analysis within the large prospective National Institutes of Health-American Association of Retired Persons (NIH-AARP) Diet and Health Study. An increased risk of endometrial cancer with unopposed estrogen use, and modification of this association by BMI, has been previously reported using data from this cohort with follow-up through 2000.18, 19 Given six additional years of follow-up and twice as many endometrial cancer cases, we were able to evaluate risks associated with estrogen plus progestin regimen (sequential vs. continuous use of progestins) and duration of use with increased power. Specifically, this large dataset allowed us to analyze the association between estrogen plus progestin use and risk of endometrial cancer within subgroups of BMI.
Material and Methods
Study population
The NIH-AARP Diet and Health Study design and methodology have been described previously.20 Briefly, the cohort was established during 1995–1996 when 3.5 million AARP members aged 50–71 years and residing in one of six states (California, Florida, Louisiana, New Jersey, North Carolina and Pennsylvania) or two metropolitan areas (Atlanta, Georgia and Detroit, Michigan) were invited to complete a questionnaire ascertaining information on demographics, dietary intake and health-related behaviors. In total, 617,119 individuals (17.6%) returned the self-administered questionnaire, and 566,401 were nonduplicate and satisfactorily completed. Between 1996 and 1997, a second questionnaire collecting detailed information on family history of cancer, physical activity and menopausal hormone therapy (MHT) use was mailed to baseline questionnaire respondents who did not have self-reported colon, breast or prostate cancer. This questionnaire was returned by 337,075 individuals (62%). We excluded participants who died (n = 1,619) or moved out of the study area (n = 547) before their completed second questionnaires were scanned. We also excluded male participants (n = 188,117), participants who used a proxy respondent for the baseline (n = 6,959) or second questionnaire (n = 3,424) and participants who had no follow-up at the time of the second questionnaire (n = 2). The study population included 136,407 potentially eligible women. The Special Studies Institutional Review Board of the US National Cancer Institute approved the study, and all participants gave informed consent.
Cohort follow-up
Study participants were followed by periodic matching with the US Postal Service National Change of Address database and through processing of undeliverable mail, other address update services and direct participant responses. Vital status was ascertained by linkage to the US Social Security Administration Death Master File with verification in the National Death Index Plus. Follow-up time began at the scan date of the second questionnaire and continued until diagnosis of endometrial cancer, date of death and date moved out of registry ascertainment area, or December 31, 2006, whichever came first.
Analytic population
After exclusions for a previous diagnosis of cancer other than nonmelanoma skin cancer (n = 9,394), being premenopausal at baseline (n = 4,425), having a prior hysterectomy (n = 51,356), or unknown hysterectomy status (n = 1,492), or menstrual periods that stopped due to surgery (n = 1,059) or radiation/chemotherapy (n = 57), having developed nonepithelial endometrial cancer (n = 69) or nonprimary endometrial cancer (n = 76) during follow-up or having missing values for menopausal hormone use (n = 60), the analytic cohort consisted of 68,419 women.
Exposure ascertainment
As detailed elsewhere,18, 20 menopausal hormone exposure for our analysis was defined via information from the second questionnaire. The questionnaire asked about estrogen and progestin use separately and did not ask about the combined estrogen plus progestin pill, which was first marketed in 1995. For each pill type, participants reported the dates of first and last use, total duration of use, usual dose and name of the pill that they took for the longest time. Therefore, the categorization of sequential and continuous regimen use was based on the type of hormone used for the longest time. Current use was based on use at time of second questionnaire (1996–1997).
Incident endometrial cancer ascertainment
Incident endometrial cancers were identified through probabilistic linkage with cancer registries in the original recruitment areas and two common relocation states (Arizona and Texas). The North American Association of Central Cancer Registries certifies the ten cancer registries serving the NIH-AARP Cohort. Of the 68,419 postmenopausal women available for analysis, 885 were diagnosed with incident epithelial endometrial cancer after completing the second questionnaire and on or before December 31, 2006. The majority of cancers (85.6%; n = 758) were endometrioid. We further classified the incident epithelial endometrial cancers as Type I and Type II tumors based on the International Classification of Diseases for Oncology morphology codes.
Statistical analysis
Cox proportional hazards regression was used to estimate rate ratios (RRs) and 95% confidence intervals (CIs) with age as the time metric and ties handled by complete enumeration. Estrogen plus progestin only was defined if the reported date of progestin therapy use was within 90 days of unopposed estrogen use. In our estrogen plus progestin-only analyses, we excluded women who used unopposed estrogen followed by estrogen plus progestin to avoid any residual influence on risk of former unopposed estrogen use. The sequential regimen included estrogen plus progestin use for less than 15 days per month, and the continuous regimen refers to estrogen with "daily" use of progestin (>25 days progestin per month). A variable for progestin use of 15–25 days per month was included as a separate category in statistical models; however, the number of women was small, and the results were intermediate between sequential and continuous regimens and are reported only as a category for "days on progestin" and are not reported for analyses evaluating regimen of use.
We created combination exposure variables (e.g., recency and duration) based on cross-tabulations. We also evaluated the joint effect of duration (estrogen plus progestin) and days on progestin per month by including both covariates in a single multivariable model restricted to women who used estrogen plus progestin MHT. All models were adjusted for age at entry, race and duration of oral contraceptive use at baseline. Adjustment variables were coded as defined in Table 1, and the main effects were categorized as presented in Tables 2 and 3. Tests for linear trends across hormone use categories were calculated using an ordinal categorical variable. Likelihood ratio tests for interaction across levels of a priori effect modifiers (BMI, parity, smoking history and oral contraception use) were computed based on cross-product terms with hormone use measures categorized as presented in the tables. We tested the assumption of proportional hazards for each adjustment variable and main effect using a likelihood ratio test of interaction with the time scale (continuous) based on cross-product terms.
We computed age-standardized incidence rates across categories of menopausal hormone use and BMI category. We used the age distribution of women in the analytic cohort as the standard population. To account for potential changes in MHT use or prescribing patterns following the results of the Women's Health Initiative (WHI) trial that menopausal hormones should not be prescribed for chronic disease prevention in postmenopausal women,21, 22 we conducted one analysis truncating follow-up at June 30, 2002. This shortened follow-up period allowed us to evaluate the menopausal hormone–endometrial cancer association when the potential for exposure misclassification was the smallest. p-values for all comparisons were two sided, and an α-value less than 0.05 indicated statistical significance. SAS statistical software, version 9.2 (SAS Institute, Cary, NC), was used for all analyses.
Characteristics of the cohort
A total of 68,419 women contributed 606,903 person-years, with mean follow-up of 4.8 years for endometrial cancer cases and 8.9 years for noncases. The mean ages at entry were 63.1 years (SD = 4.8) and 62.4 years (SD = 5.2) for cases and noncases, respectively, whereas comparable mean ages at study exit were 68.4 years (SD = 5.4) and 71.8 years (SD = 5.6). The cohort included primarily non-Hispanic white women in their early 60s. Endometrial cancer was associated with increasing BMI,19 early age at menarche and later age at natural menopause and inversely associated with duration of oral contraceptive use, increasing parity and current smoking (results not shown).
Hormone usage patterns
Fifty-two percent (n = 35,580) of the postmenopausal women with intact uteri reported never using menopausal hormones, whereas 7.0% (n = 4,810) reported using estrogen-only, 37.6% (n = 25,739) any estrogen plus progestin and 3.3% (n = 2,290) other or unknown type of hormone therapy. Of the women who used any estrogen plus progestin, 74.3% (n = 19,131) reported using estrogen plus progestin only, 12.3% (n = 3,178) reported using estrogen alone followed by some combination of estrogen plus progestin and the remaining 13.3% (n = 3,430) used other combinations of hormones.
Baseline characteristics of the women included in our analyses are presented in Table 1 according to menopausal hormone use (never/ever) and type/regimen (estrogen-only/sequential estrogen plus progestin only/continuous estrogen plus progestin only). Compared to nonhormone users, women who used unopposed estrogen tended to be older, current or former smokers and more frequent users of oral contraceptives, whereas women who used sequential or continuous estrogen plus progestins tended to be younger and white, have lower BMIs and older ages at natural menopause, were more often current or formers smokers and more frequent users of oral contraceptives.
Risk of endometrial cancer among women using unopposed estrogen only
Sixty-eight endometrial cancers developed among the 4,810 women (7.0% of the analytic population) who reported having ever used unopposed estrogen hormone therapy only (RR = 1.13; 95% CI = 0.88–1.46; Table 2). Compared to women who never used menopausal hormones, current use of unopposed estrogen only was associated with increased endometrial cancer risk (RR = 1.74; 95% CI = 1.20–2.54). The risk was also substantially elevated among women who reported long-duration use (≥10 years; RR = 3.93; 95% CI = 2.62–5.89) with the largest increase in endometrial cancer risk associated with current, long-duration use of unopposed estrogen (RR = 5.04; 95% CI = 3.18–7.99).
Risk of endometrial cancer among women using estrogen plus progestin
Among 19,131 women (28.0% of analytic population) who reported having used only estrogen plus progestin regimens, 176 developed endometrial cancer (RR = 0.88; 95% CI = 0.74–1.06; Table 3). Women who reported using unopposed estrogens followed by estrogen plus progestin were at increased endometrial cancer risk (RR = 2.64; 95% CI = 2.10–3.32]. Compared to women who never used hormones, long-duration (≥10 years) estrogen plus progestin use was associated with elevated risk (RR = 1.43; 95% CI = 1.11–1.83). This was driven by the risk related to long-duration sequential (<15 days/month) progestin use (RR = 1.88; 95% CI = 1.36–2.60). To enable comparison with other studies that defined sequential use as <10 days of progestin per month or 10–14 days of progestin per month, we further evaluated long-duration sequential use in these categories and found that the increased risk of endometrial cancer was apparent within both categories of long-duration sequential use (<10 days progestin per month and ≥10 years duration: RR = 2.49; 95% CI = 1.51–4.11; 10–14 days progestin per month and ≥10 years duration: RR = 1.62; 95% CI = 1.07–2.44).
Shorter duration continuous estrogen plus progestin use was inversely associated with endometrial cancer risk (RR = 0.53; 95% CI = 0.39–0.73). Increasing days on progestin per month was inversely associated with risk (p-trend < 0.01). The inverse relationship with days of progestin used per month was independent of the direct association with long-duration estrogen plus progestin. For a fixed number of days on progestin per month, long-duration estrogen plus progestin use was associated with a substantially elevated endometrial cancer risk compared to short-duration estrogen plus progestin users (<5 years; RR = 1.70; 95% CI = 1.19–2.43).
BMI and MHT
Among thin and normal weight women (BMI < 25 kg/m2), unopposed estrogen as well as sequential estrogen plus progestin use was associated with substantially increased risk of endometrial cancer (unopposed estrogen: RR = 2.39, 95% CI = 1.52–3.78; sequential estrogen plus progestin: RR = 2.53, 95% CI = 1.71–3.74; Table 4). The latter association was apparent among estrogen plus progestin users who reported long-duration sequential usage (RR = 3.80; 95% CI = 2.37–6.12).
Unopposed estrogen use was associated with increased, albeit not statistically significant, endometrial cancer risk among overweight women (BMI = 25–29.9 kg/m2; RR = 1.37; 95% CI = 0.88–2.14), with higher risks observed for current and long-duration usage patterns (Table 4). Estrogen plus progestin use was not associated with any alteration in risk among overweight women (RR = 0.98; 95% CI = 0.71–1.36]. Furthermore, women in the overweight BMI category showed no increase or decrease in endometrial cancer risk with regimen of estrogen plus progestin.
Among obese women (BMI ≥ 30 kg/m2), unopposed estrogen (RR = 0.64; 95% CI = 0.40–1.02) and sequential estrogen plus progestin (RR = 0.76; 95% CI = 0.46–1.27) use were inversely, albeit not significantly, associated with endometrial cancer risk. Continuous estrogen plus progestin use was inversely associated with risk among obese women (RR = 0.34; 95% CI = 0.20–0.58; Table 4).
The associations between menopausal hormone use and endometrial cancer were not significantly modified by other factors associated with endometrial cancer risk, including parity, smoking history and oral contraceptive use (data not shown).
We performed several sensitivity analyses of the menopausal hormone–endometrial cancer association (data not shown). The overall associations between unopposed estrogen and estrogen plus progestin and the associations stratified by BMI were similar when restricted to Type I endometrial cancer cases. The results were essentially unchanged after further adjustment for calendar time and several additional endometrial cancer risk factors, including education, age at menarche, age at natural menopause, parity, smoking history, diabetes and physical activity. Results were also not substantially different when we truncated the follow-up at June 30, 2002, to account for potential changes in MHT use or prescribing patterns after the WHI trial reported that menopausal hormones should not be recommended for chronic disease prevention in postmenopausal women.21, 22
Age-standardized incidence rates
The incidence of epithelial endometrial cancer in the cohort was 14.6 per 10,000 woman years compared to 15.2 per 10,000 among women who reported no hormone use. Current and long duration, unopposed estrogen use was associated with the highest incidence (61.1 per 10,000). Among estrogen plus progestin-only users, incidence rates were lowest for short duration use of continuous progestins (6.0 per 10,000) and highest for long-duration use of sequential progestins (22.9 per 10,000; data not shown).
When stratified by BMI, the incidence of endometrial cancer among never users was seven times higher in obese women (35.9 per 10,000) than normal weight women (5.5 per 10,000) (Fig. 1). The incidence of endometrial cancer generally rose with increasing BMI category; for example, the endometrial cancer incidence for continuous regimen estrogen plus progestin users increased from 6.0 per 10,000 for normal weight women to 8.8 per 10,000 for overweight women to 11.9 per 10,000 for obese women.
Our study clearly demonstrates an increased risk of endometrial cancer related to current or long-duration use of sequential estrogen plus progestin therapy. Our results expand on previous studies that have reported some increases in endometrial cancer risk with current7 or long-duration use7, 8, 11, 12, 14, 15 of sequential progestins and refute the contention that this therapeutic approach is completely safe for endometrial cancer risk.23
In line with the notion that progestins ameliorate the adverse effects of estrogens on endometrial tissue,24 we found that risk diminished with increasing days per month that progestins were prescribed. Consistent with our results, continuous regimen estrogen plus progestin use was similarly associated with decreased endometrial cancer risk in a number of recent studies.10, 25, 26 Endometrial cancer rates, however, were not associated with 5 years of continuous regimen estrogen plus progestin use in the WHI study (RR = 0.83; 95% CI = 0.47–1.47).21 In other studies, continuous regimen estrogen plus progestin was associated with null9 and increased risk7, 13 of endometrial cancer. Furthermore, in our study, the decreased risk of endometrial cancer associated with the continuous regimen estrogen plus progestins diminished with long-duration use, whereas a recent case–control study in Washington State reported that the decreased risk of endometrial cancer persisted with long-duration continuous regimen use.26 Other studies have not reported risk estimates for long-duration estrogen plus progestin use by regimen; therefore, further studies are needed to determine risk associated with these preparations.
Obese postmenopausal women have higher levels of circulating estrogens, and many studies have found varying effects of hormone therapy according to body mass indices.19, 26–30 In line with previous findings from our cohort that unopposed estrogens exerted the strongest risks among thin women,18, 19 we found a similar relationship for sequential estrogen plus progestin regimen use. Increased risk of endometrial cancer among thin-to-normal weight estrogen plus progestin users has also been observed in the Nurses' Health Study9 and the European Prospective Investigation into Cancer and Nutrition (EPIC)10 studies; however, these studies did not report results by regimen. Endometrial cancer risk among thin-to-normal weight women in our study was highest for users of sequential preparations, where the risk was 2.5 times higher than among nonusers. Additional support for a potentially adverse effect of sequential use of progestins among thin-to-normal weight women derives from the UK Million Women study,30 which assessed current usage, and from a case–control study in Washington state,14 which found the association most enhanced among long-term sequential users. Conversely, obese women who used continuous estrogen plus progestin were at reduced risk of endometrial cancer; this finding is consistent with other studies that have reported results stratified by BMI19, 26–30 and provides a growing body of evidence that exogenous sources of progestin may also oppose the proliferative effects of endogenous estrogens.
Stronger associations between exogenous hormones and risk of endometrial cancer among thin-to-normal weight women could indicate that there is an endogenous estrogen threshold beyond which exogenous estrogen exposures fail to increase risk. Alternatively, the effective dose of exogenous estrogens may be affected by hemodilution and be markedly reduced in obese women compared to normal weight women.31 Given the extremely high rate of endometrial cancer among obese nonhormone therapy users, it is plausible that these women have higher endogenous estrogen levels and therefore have no need for MHT to relieve symptoms. However, in our data, the median BMI among obese women did not vary markedly by type of therapy used, ranging from 33.7 kg/m2 for never users, 33.0 kg/m2 for unopposed estrogen use and 33.1 kg/m2 for estrogen plus progestin use.
The major strengths of our study include the use of a large, prospective cohort with extensive data on MHT use. The detailed questionnaire also provided information on potential confounders and effect modifiers, which allowed for a thorough assessment of the independence of menopausal hormone use from other related factors and the joint effects between menopausal hormones and BMI. The MHT information in our study is likely accurate, given that previous validation research demonstrated greater than 95% agreement between self-reported data and prescriptions for MHT.32
Study limitations include exposure ascertainment at only one time point, evaluation of "current use" based on exposure assessment in 1996–1997, lack of information regarding hysterectomy status during follow-up and use of self-reported BMI. We could not evaluate whether cessation of or changes in menopausal hormone usage patterns after baseline differed by exposure or endometrial cancer status. Hormone usage patterns among our cohort participants likely changed during follow-up given increases in hormone use in the United States leading up to the WHI announcement in 2002 and changes in prescribing patterns after 2002. Furthermore, the reported duration of use at baseline would have systematically underestimated the true total duration of MHT use in the population during the study period. "Current use" in the context of this study was based on usage patterns at the time of the administration of the risk factor questionnaire in 1996–1997. Since the early 1960s, the use of MHT has changed dramatically. Thus, these dynamic exposures pose major challenges to accurate assessment of risk, especially for outcomes with long latency periods, such as endometrial cancer. The increased risk of endometrial cancer observed in this population among current estrogen only users, long-duration/current estrogen only and current sequential regimen users is likely more a function of the long duration of use or use of sequential regimen than the effect of recency of use and should therefore be interpreted given this limitation.
Lack of follow-up information regarding hysterectomy status was also a study limitation. The inability to censor women who have had a hysterectomy and were more likely to use menopausal hormones would result in bias of the effect estimates toward the null. Hysterectomy rates decline markedly after menopause,33 and therefore, the expected number of NIH-AARP study participants with a hysterectomy after baseline and included in the current analysis is likely small. Our measure of BMI was based on self-reported weight and height at baseline, and results could have been affected by inaccurate reporting. In general, self-reported height and weight are quite accurate, with correlations between measured and self-reported BMIs typically being greater than 0.9.34 Because participants of the NIH-AARP study represent mainly white, postmenopausal women who consented to participate, the results of our study may not apply to all women. Some of the MHT endometrial cancer analyses by BMI were based on small numbers, requiring a cautious interpretation.
Although some previous studies support a null association between estrogen plus progestin hormone therapy and endometrial cancer risk, there appears to be growing evidence that certain regimens of use confer increased risk. Long durations of sequential progestins are associated with increases in risk—particularly for thin-to-normal weight women. Such women have lower endogenous estrogen levels, supporting the notion that menopausal hormones and obesity increase endometrial cancer through common etiologic pathways. Although obese women have the highest risk of endometrial cancer, and among obese women risks are higher for nonhormone than hormone users, the reverse is true for sequential therapy use among thin-to-normal weight women. In the context of this accumulating evidence, it may be time to reconsider optimal hormone prescribing patterns in thinner women, especially given that their menopausal symptoms often support the greatest need for therapy.
The authors thank the participants of the NIH-AARP Diet and Health Study for their outstanding cooperation. Cancer incidence data from the Atlanta metropolitan area were collected by the Georgia Center for Cancer Statistics, Department of Epidemiology, Rollins School of Public Health, Emory University. Cancer incidence data from California were collected by the California Department of Health Services, Cancer Surveillance Section. Cancer incidence data from the Detroit metropolitan area were collected by the Michigan Cancer Surveillance Program, Community Health Administration, State of Michigan. The Florida cancer incidence data used in this report were collected by the Florida Cancer Data System under contract to the Department of Health (DOH). The views expressed herein are solely those of the authors and do not necessarily reflect those of the contractor or DOH. Cancer incidence data from Louisiana were collected by the Louisiana Tumor Registry, Louisiana State University Medical Center in New Orleans. Cancer incidence data from New Jersey were collected by the New Jersey State Cancer Registry, Cancer Epidemiology Services, New Jersey State Department of Health and Senior Services. Cancer incidence data from North Carolina were collected by the North Carolina Central Cancer Registry. Cancer incidence data from Pennsylvania were supplied by the Division of Health Statistics and Research, Pennsylvania Department of Health, Harrisburg, Pennsylvania. The Pennsylvania Department of Health specifically disclaims responsibility for any analyses, interpretations or conclusions. Cancer incidence data from Arizona were collected by the Arizona Cancer Registry, Division of Public Health Services, Arizona Department of Health Services. Cancer incidence data from Texas were collected by the Texas Cancer Registry, Cancer Epidemiology and Surveillance Branch, Texas Department of State Health Services.
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- Product Code: STA-79090
- UPC Code: 10077652790907
- Package Quantity: 100 Foil Teabags, 6.3 oz (180 g)
- Dimensions: 6.6 x 5.7 x 6.6 in, 1 lbs (0.45 kg)
Product Overview
- Premium
- Black Tea
- 100% Natural Ingredients
- Kosher Parve
For many years, Stash Earl Grey Tea has been a favorite of tea lovers. Many people seem to love the careful balance of citrusy oil of bergamot and the blend of fine black teas which our Earl Grey blend is famous for. Certain Earl Grey fanatics have grown especially fond of the top grade Calabrian oil of bergamot that we use and have asked for more,..More,... More! Thus Stash Double Bergamot Earl Grey was born.
This is a great late afternoon or early evening tea. It goes very well with shortbread and cream scones. And for a uniquely appealing cold beverage, try Double Bergamot Earl Grey tea on ice.
Suggested Use
Brew 3-5 minutes.
Other Ingredients
Premium black teas with oil of bergamot.
iHerb Customer Reviews
very good
Posted by Reviewer1461571 on Jul 04, 2013
very good tea!!!
Was this review helpful to you?
1 person found the following review helpful
Very nice
Posted by 5472016981365162322 on Feb 19, 2014
You can feel the quality of the tea
Posted by Reviewer2095704 on Mar 03, 2014
My favorite tea in the morning. It has the same taste as the more expensive Zhena Earl Grey Raspberry, in fact I cannot tell the difference! I've been drinking it for many years, & this is an economical way to purchase it!
stash tea purchase
Posted by 4681026569081182713 on Apr 06, 2015
Very pleased with the prompt delivery and online special/pricing which enticed me to purchase two of this product. Unfortunately I came back to the site to buy more but the product is no longer available. I asked for notification for when it is available again but have received nothing. Despite that I was very happy with my initial experience.

subset: commoncrawl


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Hey ladies,
My OB put my on Modified duty due to my siatic nerve issues and headaches. I can only work 6 hours a day. I am scared to tell my employeer because they are going to freak out!! Anyone do this before?!?! I need to know what to do first!


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American cars and trucks use over 3 billion quarts of motor oil annually – and at least 800 million quarts are not disposed of properly. Using NextGen helps ensure used oil doesn't find its way into our water supply, where it can have a myriad of harmful effects; just one gallon of improperly disposed motor oil can contaminate up to one million gallons of drinking water. Compared to production of non-recycled motor oil, NextGen's recycled oil content is produced using 48 percent less fossil fuels, 40 percent less harmful and acidic emissions, and has 20 percent less global warming impact.NextGen's debut in the Sprint Cup Series is a journey that started last summer when NextGen's racing formulation was put through extensive validation testing by Roush Yates Engines, earning approval from some of motorsports' top teams. Roush Fenway Racing, home of Carl Edwards, Greg Biffle and Matt Kenseth, started using NextGen recycled motor oil technology in competition to protect the engines of their stock cars.
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Looking back at 2015 I did okay on meeting the goals I had set. Never mind that they were the same goals as the year before…and probably the year before that so I after three years I ought to have finally accomplished something.
To recap from 2015.
I had set a goal of 1,500 miles again. In 2014 I did 1,800 and last year I was well over 2,100. Most of that was walking the dogs, of course, but I did swap out swimming for running most of the year and that helped the mileage total climb. I really didn't swim very much last year at all for a variety of reasons. I chalk it up primarily to burn out from swimming in general. Thanks to LJ leaving the way she did and the ensuing chaos and the (mostly self-imposed) stress of trying to hold the program together without a head coach or any support from the Y, I lost my motivation to make the time to get to the pool. It was just easier to put on my sneaks and go for a run.
The biggest change this year is, of course, giving up swimming. When the only thing I felt about the coming fall season was dread and anxiety, I knew I was burned out and it was time to back off. Hell, I couldn't even make myself get IN the pool. Thanks to LJ leaving the way she did and the ensuing chaos and the (mostly self-imposed) stress of trying to hold the program together without a head coach or any support from the Y, I lost my motivation to make the time to get IN the pool. It was just easier to put on my sneaks and go for a run. For coaching, originally I planned to do just one or two days a week. But after a couple of days of sitting with that decision, THAT didn't feel right either. So I stepped father away and agreed to just sub as needed. When I wasn't contacted at all during the fall to sub at all, the decision to just make a clean break when my "work a shift or get terminated as an employee" notice came was an easy one.
K decided to make a clean break from swimming too and that has been a good decision for her and for the family too. Not having to spend 15 hours a week at the Y, plus driving there 5 or 6 days a week, has given her plenty of time to try other things – guitar, fused glass, year book, movie club. We took a self-defense class together at BZ which was fun too. Not having swim on my plate - Every. Single. Day. – has let me do things like sleep later than 3am. I tell people that I didn't realize just how exhausted I was until I wasn't as exhausted anymore. It's helped with my health overall – I don't fell as awful all the time as I did while I was coaching every day.
I miss the kids and I miss some of the parents who I liked talking to. Every once in a while I check out how the kids are doing on meet mobile and I see some of them at high school meets when I am working them. I miss the illusion that I was making a difference in kids' lives. I'm still a bit out of sorts trying to find something that has meaning to take its place. I'm hoping inspiration will hit in 2016.
The other big change for me in 2015 was switching neurologists and heading to Jefferson Headache Center. My initial appointment included an hour with a pshrink to talk about all the ways the headaches impact my life and to make sure that I'm not crazy or drug seeking or so depressed that I need to be hospitalized or something. I loved the pshrink. He was the very first person who actually understood how awful it has been to have headaches 3, 4, 5 + days a week for all these years. I honestly teared up when he told me that even on the days that I didn't consider the headache to be an actual migraine that ANY symptoms were part of the migraine process and that living like this is completely unacceptable when there are things we can try. After I saw him and completed my psych testing, I saw the neuro. He ran through a ton of options and recommended either Botox or a clinical trial. He thought the Botox could be helpful for me. So I signed up for that and scheduled my first appointment at the end of June.
I've had three doses (?) of Botox so far. They've tweaked the placement of shots each time to try and give me a better result. The first time I got 35 shots. The 2nd time I got 46 (!) and this time (right before Christmas) I got 38 shots. It's the same amount of stuff, just distributed a little differently on my scalp plus the standard forehead, temples, occipital region, and traps. I'm used to not being able to move my forehead – there's just enough muscle control that I can raise one eyebrow and look slightly insane. I also wake up each morning looking like my face was folded in half between my eyes. I'm not sure what's going on with that. In terms of headache relief, I'm still undecided if it is working as intended. I had two really bad weeks from Sept – Dec but the rest of the time I had long stretches (two weeks at one point) without headaches and the headaches I did have seemed less painful and way less frequent. But with the less pain has come more nausea and more vision disturbances. So now I have three different anti-nausea drugs to take (no sedation, some sedation, and total sedation) plus my twice a week allowance of imitrex when I need it. I figure if I go a couple of weeks without taking it, I can spare myself an extra dose or two during those bad weeks (like this one has been).
So…to make a long story short, the jury is still out on whether it is working or not. It seems to be but it could be coincidence. I'll see how I do going into the spring and summer and then decide whether to continue.
So that's 2015, but what about 2016? I need some new goals for this year. I have tons of vague thoughts floating around, but very little in the way of concrete plans, which is why I am actually sitting down and writing for the first time in 6 months.
1. Become an NCAA official. This one is actually done already. A couple of weeks ago, a long time PIAA official (the last active official from when I was a kid and my parents were officials) who I like a lot encouraged me to do it. I looked into it, paid my $29 membership dues to the Collegiate Swim Officials Association, and studied for the test. Since I am a current PIAA official, I only have to take the shorter renewal test rather than the 100 question "become and official" test. Since pretty much all the rules are the same (a few little differences), easy peasey. I am not a CSOA certified official. Of course the season is almost over now so all I will do this year is buy my shirt and shadow a meet, but I'll be ready for go for the 2016-2017 season.
2. Target 1,800 miles for the year. I'm not going to set limits on how I will get there b/c I don't want to feel like I HAVE to run or a I HAVE to swim on a given day when I don't have time or motivation.
3. Be able to do 5 real pull ups. I had a pull up goal for when I turned 40 but I have gotten out of the habit of training for them and I'm not sure I could even manage 1 anymore.
4. Read my bible (app) every day. I was AWFUL at reading scripture last year and I can really feel the hit my faith took. This year I want to commit to reading something every day. I subscribe to 3 different daily devotions, plus I have a daily bread in my purse and my sister gave me a cool new devotional book for Christmas. All of them have scripture references associated with them. I also have two daily reading plans on my phone. From all those sources, I think I can manage to read a chapter or two every day.
5. Pray regularly. As my faith has gotten stale, my prayer life has suffered (chicken/egg?). Prayer doesn't have to be long and involved to be effective.
6. Take a class at the gym each month. Once a month? I think I can manage that. And maybe I'll even like it.
7. Continue to write in my gratitude journal. Instead of carrying it in my purse, I think I'll put it by my bed so I can do it before I go to sleep.
8. Get out of my rut at work. I'm not actually sure how to approach this one. I am ashamed to admit that my confidence has not recovered from the crap last spring. The combo of simultaneous bullsh*t at work and bullsh*t at the Y really did a number of me. The things that were said and done continue to bother me WAY more than they should and I find myself second guessing myself, questioning everything I do, and interpreting things that wouldn't have bothered me in the past through a very discouraged and, I acknowledge, distorted lens. I feel totally uncomfortable at work and I am too often certain that everyone holds the same opinion as the bat, sh*t crazy person(s) who started all this nonsense. I have taken some steps lately to try and get out of my rut, but I'm not entirely certain that they are good decisions and that I'm just not doing things out of desperation. Right now I have something in the works to join a team at HQ. It would be an official but collateral duty that would be limited to 20% of my time for about 3-4 months. I worry that 1) I won't be good at it; 2) won't be allowed to cut back my real job to accommodate the additional 20% and that I'll actually be doing 120%; or 3) I'll hate it. The good thing is that I like the people on the team very much and have worked with them in the past on other things. And if I hate it, it's only for a couple of months. At least it will give me something to focus on during the dark, cold winter months. I'm hopeful that doing some of the other things in regularly in my life will make me feel better about work and life in general.
9. Get outside every day. Speaking of dark, cold winter months – I am committed to getting out into the sunshine for 15-30 minutes every day. It will be easy when I am at home – the dogs will enjoy a lunch time walk. When I am in the office though, it will be challenge since I don't usually (ever) take a lunch break.
10. Take my vitamins. I am getting better at this one. It's a habit I need to get into just like flossing or putting anti-aging serum on my face before bed. Right now I am taking a calcium/magnesium combo and a b-vitamin combo, both of which are supposed to help with migraines (and PMS). I just started taking fish oil too (huge pills. So gross). I also intermittently take two supplements which are supposed to help with anxiety and sleep, especially when it is so dark and cold out. Those are the ones I have to get into the habit of taking every day.
11. Write. Dare I commit to actually blogging more than once a year? Right now I don't have anything that is actually worth writing and certainly not worth reading. Maybe finding some purpose elsewhere and getting some confidence back will give me more motivation to write. I have an acquaintance who is a freelance writer and sometimes I think I'd like to try that. First I have to get back to blogging and then maybe I'll try writing ABOUT something.
How about you, dear readers*? Any goals for the year?
* and of course by this I mean, mom, my sister and my friend A who are the only ones who ever read the blog to begin with!


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Dino-Mite Cupcake Holder. Give your treats a truly Dino-Mite look at your prehistory party with this three-tiered Dino-Mite Cupcake Holder! Don't let its name fool you. The durable foam construction makes this holder perfect for displaying more than just cupcakes. Easy assembly makes this colorful display a must-have for adding an eye-catching touch to birthday parties and stone age celebrations! 16" x 14" diam Simple assembly required. © OTC


text: 25 Hilarious Passive Aggressive Elevator Notes By Andrew LaSane Andrew LaSane is a freelance writer from South Carolina who currently resides in Brooklyn. He spends most of his life connected to the grid, obsessing over and customizing sneakers, and trying to relive the '90s. Follow him on Google+, Twitter, and Instagram Share Tweet 0 0 Work in Progress Work in Progress Now shut up and fix it yourself or take the stairs. via Watch Now Tags: Lists, Hilarious, Notes, City Guide, Art & Design Like Us on Facebook Follow Us on Twitter Show Comments


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No-Bot, the Robot with No Bottom (Paperback)Sue Hendra
Paperback Published: 03/01/2013
- 10+ in stock
Click & Collect From your local shop
Bernard the Robot loses his bottom on the park swing, and sets off to find it. Every time he gets close, it disappears again! Bird was using it as a nest, but it was too heavy; Bear used it in his drum kit, but it was too tinny; the Squirrels built sandcastles with it...and now it looks as if they're sailing away in it. Will Bernard EVER get his bottom back?
Publisher: Simon & Schuster Ltd
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I work in a primary school and I read this book to a class of year 1 children and they found it hilarious! Bernard loses his bottom at the park and asks his friends to help. Good pictures for the children to look at... More
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At Least for the Moment, a Cooling Off in the Culture Wars
Published: November 13, 2001
(Page 2 of 2)
''For a time back there before Sept. 11 it was as if it was the most important issue in Western civilization, the content of movies and TV,'' said Sean Daniel, a film producer and former studio executive. ''Hopefully this will put it in its proper place.''
Why this is happening and whether it amounts to a permanent shift in thinking about popular entertainment or merely a temporary truce are the subjects of widespread conjecture in Hollywood.
''Like so much cultural noise and chatter and froth pre-Sept. 11, most of what passed for the culture wars was a luxury of peaceful and prosperous, fat and happy times: a kind of ritualized, dopey, endless, W.W.F.-style battle between Hollywood and Washington,'' said Kurt Andersen, a novelist, social commentator and founder of Inside.com and Spy magazine. ''Since the America that we now find ourselves fighting a war to defend is the ultratolerant America of free expression and eccentric ideas and -- figuratively and literally -- rock 'n' roll, it would be awkward for the Joe Liebermans of the world to push their censorious agenda.''
In other words, Mr. Andersen and others contend, when many in the fundamentalist Islamic world are criticizing American popular culture, attacks on that culture have the uncomfortable side effect of placing a person, however tangentially, in agreement with the country's enemies.
''Up until Sept. 11, it was as though Hollywood was the whipping boy for almost any domestic problem that we had, from teenage pregnancy to school shootings,'' Mr. Thompson said. ''But now you can't make the kind of arguments that you used to be able to make without allying yourself with the terrorists.''
Conservatives might detect a little liberal opportunism masquerading as patriotism in that position. Which is one of the things that lead many to wonder whether the current truce in Hollywood-Washington bickering might be a brief respite rather than a fundamental shift in thinking. More likely, they argue, this is simply one more issue that has been overshadowed by more important concerns.
''I just think we've all got bigger fish to fry,'' said Jerry Weintraub, a veteran film producer. ''Look, I'm 64 years old, and I truly believe that in what's left of my lifetime I will never again see a period without war. The world will never go back to the way it was before Sept. 11. So in that kind of atmosphere the culture wars stuff is just a drop in the bucket over there. Even the bucket is not that important anymore.''
Others suggest that the current truce is the result of a deeply felt sense of dislocation in the wake of the attacks, a confusion among the producers of culture about how they should respond.
''I think what's happened is that culture itself has been temporarily put aside,'' said the Australian film director Baz Luhrmann, who has crossed the world in recent weeks promoting his latest film, ''Moulin Rouge,'' and sampling the anxious moods in half a dozen countries. ''The problem, for filmmakers and other artists, is that there is no context. Oh, there are the show-must-go-on people, but even they are just going through the motions without knowing what the eventual cultural context will be.''
In the meantime each side is keeping a wary eye on the other. Mr. Wildmon said he suspected that some liberal groups were taking advantage of a distracted nation to ''go under the radar'' and push through legislation meeting their agendas. He mentioned several recent moves at the state and local level around the country to pass legislation granting health benefits and other legal rights to the partners of gay workers. And Mr. Neas said that his group was likewise keeping tabs on conservative thinkers who might try to capitalize on the moment.
But the overarching dynamic has been one of cooperation. Who knows, some say, the current situation might even provide the climate necessary to change or resolve some issues central to the cultural debate.
''To the extent that the jihad is motivated by America's global pop cultural hegemony, the old culture-war discussion now has the opportunity to be a far more subtle and interesting and profound one,'' Mr. Andersen said.
If the truce gives artists and executives time for reflection and that reflection builds understanding of the national and global consequences of American cultural products, some permanent change may result.
''Perhaps, with luck, it will end the kind of thrill-ride movies that exploit what I think of as the comedy of violence,'' Mr. Luhrmann said. ''All of that seemed to come out of a pre-Sept. 11 world where people were not really feeling anything, and so the cinema was all about physical sensation. Well, there is no shortage of feeling now. I've seen it all over the world in the last few weeks. Even when people are happy, they are hysterically happy. They laugh like they're going to die tomorrow, because they think they might.''


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Sylvia Sue Hall, 57, of Indianapolis, formerly of Greencastle, passed away Tuesday, July 20, 2010 at St. Francis Hospital in Indianapolis.
Born Jan. 4, 1953 in Greencastle, she was the daughter of Bennie Lee and Sylvia Jane (Martin) Hall. She was a 1972 graduate of Greencastle High School.
Sue had worked at the Humane Society of Putnam County, Jackson's Double Decker Restaurant and the Angwell Curtain Factory.
Survivors include her mother; a sister, Brenda Todd and husband, Larry; a niece, Tabatha Johnson and husband James; and nephews, Steven Fisher and fiancée Michelle and Bennie Fisher.
She was preceded in death by her father, Bennie Lee "Popeye" Hall.
Funeral services will be held at 1 p.m. Monday at the Hopkins-Rector Funeral Home. Burial will follow at the Clinton Falls Cemetery.
Friends may call at the funeral home from 4 to 8 p.m. Sunday.
Condolences may be shared with the family at www.hopkins-rector.com


text:
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13804 Views 9 Replies Latest reply: Aug 20, 2008 12:07 PM by Nathan C
Ansuz82 Aug 20, 2008 12:01 PM
in response to TK90There really is no way to tell if its a refurb or not.
If it is refurbished, you don't have the ability to ask for a new replacement. Apple's iPhone warranty allows them to repair/replace defective products with either new or refurbished products at their sole decression.
It doesn't really matter. Refurbs are tested to ensure that they have 100% of the functionality as a new phone, as well as no cosmetic flaws.
Message was edited by: Ansuz82 - spelling
ukfe11a Aug 20, 2008 12:00 PM
in response to TK90I think I would actually prefer a Refurbished one? They apparently go through more stringent testing!
hexonxonx Aug 20, 2008 12:01 PM
in response to TK90An iPhone is refurbished if the serial number begins with 5K. It is the same method Apple used for refurbished iPhones last year.
You agreed upon purchasing the phone in the warranty that replacement iPhones may either be new or refurbished and that the choice is for Apple to make.
joeuu Aug 20, 2008 12:01 PM
in response to TK90The packaging would most likely be the best indicator.
Refurb would be in a brown box, new would be, well, new.
hexonxonx Aug 20, 2008 12:03 PM
in response to joeuuA friend of mine got a refurb white iPhone and it came in the white box just as the new phones do.
neuroanatomist Aug 20, 2008 12:10 PM
in response to TK90Check the serial number. Refurbs are given new serial numbers, apparently beginning with a "5" (although the source for this seems to be a post on eBay - so, take that for what it's worth). As Ansuz82 states, the terms of the warranty allow Apple to replace your unit with a refurbished one, at their discretion, not yours.
Hope this helps...
ukfe11a Aug 20, 2008 12:05 PM
in response to joeuuI don't think this is true, I got a New iPhone in an Apple store that was in a Brown box I asked the Genius if it was a refurb, he checked the serial number and told me No, it was a New one. He told me that the stores get issued with replacements that could be new or refurb, it just depends. Oh mine was a 1st gen iPhone and this was within the last 2 weeks.
Nathan C Aug 20, 2008 12:07 PM
in response to hexonxonxhexonxonx,
Actually, no it doesn't, even new ones can start with 5K.
Hope this helps,
Nathan C.
hexonxonx Aug 20, 2008 12:11 PM
in response to Nathan CIgnore, I was looking at the wrong reply.
Thanks Nathan.
Message was edited by: hexonxonx


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My neighborhood, after a heavy Shower. But Rain is so beautiful.
Excellent shot,like 106,greetings
Thank you Leo, best wishes, Biplab.
Very nice composition with fantastic reflections on the big puddle
Best wishes, Daniel
Many thanks to you Daniel for the visit, best wishes, Biplab.
Beautiful picture with very nice reflections, LIKE+YS, regards Lucien
Thank you Lucien, best wishes, Biplab.
**very beautiful view wonderful picture! greetings KALWAP
Thank you KALWAP for the visit, best regards, Biplab.
Nice reflection.
Friendly greetings. Valentine
Thank you Valentine, best regards. Happy New year to you all from India, Biplab.
Charming shot - like and YS! Thanks for your YSL to one of my photos.
Thank you Søren Terp, best regards, Biplab.
L 116 + F 59. Saludos amistosos.
Thanks María Fernando, best regards, Biplab.
ysl 60/112!!!!!
Thank you very much Pepino. Best regards, Biplab.
nice mirror shot, like it, brg jani
Thanks a lot jani, my best regards, Biplab.
Photo taken in EE Block, Sector II, Salt Lake City, Kolkata, West Bengal, India


text: London 2012 Rain doesn't damper Olympic spirit in spectators Add to ... AP Video Published Sunday, Jul. 29, 2012 5:18PM EDT Last updated Tuesday, Jul. 31, 2012 9:26AM EDT Rain showers failed to dampen the spirits of Olympic fans in London on Sunday. Spectators put on plastic raincoats and got out their umbrellas to shield themselves from the downpours which are so common to the city. Watch More Video: Raptors coach predicts team will 'come out fighting' in Game 6 Watch the Canadian Olympic Committee's 'Ice in Our Veins' video Raptors guard DeRozan says 'patience' was key for Game 5 win 'Zika-proof' clothes? South Korea designs some for the upcoming Olympics Toronto Raptors prepare for game five at ACC UFC fighter Rory MacDonald on using the right music to get pumped Raptors' Kyle Lowry remains 'confident' despite Pacers win in Game 4 Raptors hope to keep momentum after Game 2 win over Indiana How a one-time tennis pro found a new love in rowing DeMar DeRozan says last year's playoff failure helped the Raptors Kobe Bryant on his last game: This is kind of crazy to me Hockey player shares secrets behind a great slapshot Tour inside the Chicago Cubs' new clubhouse Take a look at Canada's official Rio Olympic Games outfits Toronto Maple Leafs hopeful for next season Ex-New Orleans Saints player killed in road rage shooting The Jays are confident, hungry to win for Toronto: Marcus Stroman Ex-trainer reflects on Rexall Place as Oilers prepare to move on The MLB rule behind Jose Bautista's interference play Villanova University cancels classes to celebrate NCAA win Comments AA More Related to this Story In Photos A wee bit soggy: fans brave the rain at the Olympic games


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The decision process starts with the obvious questions…


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Step 1: Apply for Admissions
You must choose a program of study. Credits WILL NOT be evaluated without a program of study selected. If you are unsure of which degree to apply for, the Professional Studies general program, AS.PS.GEN, is suggested. If you subsequently decide to change your curriculum, a change of curriculum form can be obtained from the Center for Student Success, room A-118.
Step 2: Activate Your Account
Activate your Student Portal Account. Your acceptance letter will provide your Bergen User Name, ID number and Bergen Email. All admissions, testing, financial aid, billing, and registration information will be sent to your portal address.
Phone: (201) 447-7109
Step 3: Complete the FAFSA
Complete the FAFSA
Free Application for Federal Student Aid ~ School Code: 004736
Phone: (201) 447-7148
If you were receiving financial aid at your previous institution, log into your FAFSA account and identify Bergen Community College as your new college. It generally takes 2-3 weeks before BCC receives your FAFSA information. After this time period, meet with a financial aid counselor at BCC to determine if you need to provide further information to the department.
Step 4: Submit Official Transcripts
Please see "Transfer Policy" below.
If you would like to receive credit for studies at previous institutions, submit an Official Transcript from each institution. Unofficial transcripts will not be evaluated. Transcripts also may be delivered in person as long as they are in a sealed envelope stamped by the registrar's office of the sending institution. Transcripts from other institutions will not be released to the student or to a third party.
If you studied in a foreign country, please refer to the "International Evaluations" information below.
If the transcript reflects a former or maiden name, please notify the Office of Admissions at [email protected].
Have transcripts sent directly from previous institutions to:
Bergen Community College
Office of Admissions and Recruitment
c/o Transcript Evaluation
400 Paramus Road, Room A-115
Paramus, NJ 07652
Step 5: Take the Placement Examination - Office of Testing Services
Placement testing is required for all degree or certificate seeking students prior to registration. The Office of Testing Services can provide more information about the examination and eligibility exemptions.
Phone: (201) 447-7202
If you completed a college-level English and/or math course, or a placement exam at your other institution, you may be waived from taking the placement exam. A copy of your transcript must be on file, or you must provide a copy of your transcript or placement exam results to the Office of Testing Services.
Step 6: Meet with an Academic Advisor
· Discuss your placement test results and requirements for your major.
· Select your courses/Build your schedule.
· Transfer students should bring a copy of their Program Evaluation in order to facilitate the process of advisement and registration. This evaluation can be found in the WebAdvisor for Students – Academic Planning section of the Portal system.
Center for Student Success, Room A-118, Phone: (201) 612-5480
Step 7: Register for Classes
· Online
· In Person - Registration Office. Phone: (201) 447-7218
Step 8: Make a Payment
· Online, in person, or by telephone
· Cash, Checks, Money Orders, Credit Cards, 3rd Party Sponsorship and Financial Aid are accepted
· Payment Plan options available
Bursar (Bill Payment Center), Room L-127, Phone: (201) 447-7105.
Bergen Community College will accept credits for courses taken at regionally accredited colleges and universities (and from properly accredited programs) provided that the course is compatible with the curriculum of Bergen Community College, as approved by the faculty, and the course is applicable to the requested program of study.
Bergen Community College also accepts transfer credits based on statewide agreements and will consider awarding credits based on established articulation agreements.
Only courses that have received a grade of "C" (or the equivalent) or better are accepted for transfer. Transfer credits are not included in computing the grade point average and are recorded as "TR" grades.
It is the student's responsibility to provide, in a timely manner, all the transcripts and documents needed to evaluate any previous educational experience. Transcripts should arrive after the student has applied to the college and received a student ID number.
No more than 45 transferred credits will be applied toward earning an associate degree, and no more than 18 transferred credits will be applied toward earning an academic certificate. These credits may be earned from a prior Bergen Community College degree/certificate, transfer credits from other institutions, and proficiency and/or CLEP examinations. The list of approved subject examinations for CLEP credits may be viewed in the College Catalog, www.bergen.edu/catalogs. The balance of credits required for any degree or certificate must be earned through actual course enrollment at Bergen Community College.
When Bergen Community College receives your Transcript(s), a receipt communication will be sent to your Portal account, under My Documents.
Your transcript(s) will be scanned into the college system, evaluated, and the results posted to your WebAdvisor Program Evaluation within 2-4 weeks. A transfer equivalency report will not be mailed to you.
Transferred courses will show in your Program Evaluation with a grade of TR (transfer) and a code TE (for transfer equivalency). Grades do not transfer. 199 and 299 codes reflect elective credit.
For questions or appeals, students can contact the Transcript Evaluator, (201) 493-3774, [email protected], room A-126A.
Steps for Transfer Students to follow:
Reference materials/Handout:
To request this information in an alternative format, please contact the Office of Admissions & Recruitment at [email protected] or 201-447-7200.
Students can transfer a maximum of 45 credits into an Associate Degree program, or 18 credits into a Certificate program. Two General Education courses can be transferred in for students in Certificate of Achievement programs, but if course work has recently been completed, student can speak with the department chair for further credit or course substitutions.
Student can get an exception to a course required in their program if student completed a related course at another school for which no transfer equivalency exists. The student would fill out an "Adjustment of Degree Requirements" form and ask Department Chair to sign it, then bring the form to the Office of Registration. A Registrar would have to enter the course into the student's account. For example, a Holocaust course which BCC does not offer could fulfill the Diversity or History requirement.
High school students who completed college course work should have an official transcript from the college that sponsored the course work delivered to the Office of Admissions in a sealed envelope from the college.
High school students who have completed one or more Advanced Placement (AP) examinations may receive college credit with a score of three or above. Please refer to the College Catalog for details. Scores must be sent to the Office of Registration directly from the College Entrance Examination Board (CEEB) before credit is awarded. High school students who completed International Baccalaureate (IB) courses cannot receive credit for this program.
Current or former college/university students wishing to receive college credit at Bergen Community College (BCC) must deliver an official transcript from each college attended to the Office of Admissions in a sealed envelope from the college. An English 101 course completed at School 1 and listed on the transcript for School 2 does not qualify.
Bergen only accepts courses from Regionally Accredited Colleges and Universities. Look on the college's website or back of transcript for one of the following accreditations (note: these can change yearly):
ACE ( American Council on Education)
Anthem Institute (formerly Chubb Institute)
Berkeley College
Computer Learning Center (defunct)
Devry University
Dover Business School
Eastwick College/ Ho-Ho-Kus School
Katherine Gibbs School
Lincoln Tech/ Cittone Institute
Students who attended institutions of higher learning in other countries must have their transcript translated into English and evaluated course by course by an agency associated with the National Association of Credential Evaluation Services (www.naces.org). Evaluations from the NACES member must be delivered to the Office of Admissions in a sealed envelope from the NACES member.
Since Bergen Community College is a SOC institution, credit is awarded for basic or recruit training by submitting your official separation paper (Form DD214). An honorable discharge entitles you to 2 credits for health education, WEX 101, and 1 credit for physical activity, WEX 112. Military personnel can also submit a Joint Services Transcript which may lead to the awarding of WEX 101, WEX 112, 6 credits of free electives, plus other credit based on the determination of academic department chairs.
Bergen Community College (BCC) established an agreement with the Bergen County Law & Public Safety Institute to grant graduates of the Institute with college credit. Students need to present their graduate certificate or an ACE evaluation to the Office of Admissions in order to receive credit [ACE= American Council on Education. Students send their course work to ACE (www.acenet.edu) and ask for an evaluation to be sent to BCC.].
Bergen County Police Officers
Bergen County Correction Officers
Bergen County Emergency Medical Technicians
Bergen County Firefighters
Students possessing IBEW Certification (3 year Communications or 5-year Inside Wireman Apprenticeship) will receive college credit at Bergen Community College (BCC). Students need to submit paperwork to the American Council on Education (www.acenet.edu) and ask for an evaluation to be sent to the Office at Admissions at BCC. Students are given credit only if enrolled in the Electronics Technology program, and will receive credit for: ELC 100, 101, 201, 203, 204, 214, 215, 452; TEC 180.
Advanced Placement Examinations (AP)
Students who have taken one or more advanced placement exams in high school may receive course credit with a score of three or above. Please refer to the College Catalog for details. Scores must be submitted to the Office of Registration directly from the College Entrance Examination Board before credit is awarded.
College Level Examination Program (CLEP)
CLEP offers students an opportunity to receive college credit for what a student already knows, by earning qualifying scores on any of the 30+ CLEP Exams. Please contact the Office of Testing at Bergen Community College for further information. Scores must be received by the Office of Admissions directly from the College Entrance Examination Board before credit is awarded.
NYU Foreign Language Proficiency Testing
Through New York University's School of Continuing and Professional Studies, students may take a foreign language proficiency exam to earn credit at Bergen Community College. Students must take the 16-point exam (not the 12-point exam) and score 13 out of 16 points. Students will receive credit for the first language course (3 credits). Students who wish to test in Spanish, German or French should consider taking the College Level Examination Program (CLEP) exam, from which a student can earn 12 credits in Language.
Life Experience Credits
Bergen Community College
400 Paramus Road
Paramus, NJ 07652
(201) 447-7100


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