Guest Post from Dr Louise Newson, GP and Menopause expert: "Should I be worried about breast cancer and HRT?"

[AnnaCMumsnet]

Today Mumsnet launches our survey, which reveals that four in ten menopausal women are worried that taking HRT could increase their risk of breast cancer.

HRT Dr Louise Newson featured in the ‘Sex, Myths and Menopause’ documentary with Davina McCall that aired on Channel 4 in May. Here, Louise fact-checks some myths around the menopause and treatments and address concerns raised, particularly about the risk of breast cancer with HRT. A guest post by Dr Louise Newson:

"With all the increased conversation around menopause and perimenopause in the media recently, your thoughts may have turned to your own hormones, checking whether you tick a lot of boxes on the symptoms list, and even deciding if you should take the plunge and start HRT.

The results from the recent survey within the Mumsnet community echo what I see in my clinic and hear on social media every day. You know you’re perimenopausal (if you’re still having periods) or menopausal (if periods stopped more than a year ago) and you’re getting fed up of the toll it’s taking on your body and impact on your life. But the one thing that is stopping you getting help – and relief from symptoms – is that nagging doubt in your mind that HRT is too risky and causes breast cancer.

First of all, don’t worry, and secondly, let me have a few minutes of your time to explain where those rumours came from in the first place and show you what the good-quality evidence shows us.

A brief history of HRT
As part of the feminist movement in the 1960s the idea of ‘feminine forever’ was introduced in a bestselling book by an American doctor, Robert Wilson, who recognised menopause as a hormone deficiency that was curable and preventable by oestrogen replacement.

In European countries and the US, HRT grew in popularity over the decades, rising significantly in the 1990s. The majority of menopausal women took HRT and healthcare professionals were very happy and willing to prescribe it to most women. Women’s health on a larger scale saw fewer instances of heart disease (including heart attacks and strokes) and much less of the bone-weakening disease osteoporosis, as a result of the widespread use of HRT.

Everything changed virtually overnight with the publication of one study, the Women’s Health Initiative (WHI) study in 2002, that is referred to in Davina's documentary.

The WHI study
This notorious study was halted prematurely due to concerning results they were finding linking HRT with breast cancer. The conclusions were then leaked to the media before proper analysis could be carried out. Later, analysis of this data revealed the link was not statistically significant - in fact it had completely vanished - but of course, this news didn’t make the headlines. It was too late. The notion was now firmly planted, in the minds of women and healthcare professionals alike, that HRT causes breast cancer. And the number of women taking HRT in Europe and the US – much like their hormones – fell right off a cliff.

Taking a deep dive into the WHI study will show you that:

• The average age of women in the study was 63, yet researchers generalised their conclusions to include women entering menopause in their early 50s.
• Nearly half the participants were current or past smokers, many had heart disease in the past, more than a third had been treated for high blood pressure, and 70% were seriously overweight or obese.
• The study claimed HRT increased the risk of heart problems, but the fine print revealed that the risk occurred only among women who were starting in their 70s and older.
• The investigators then revised their findings five years after they were initially published and concluded that women who started HRT in the first 10 years following menopause actually reduced their risk of heart disease, but this didn’t make headlines either.
• The types of HRT used in this study were tablet oestrogen (derived from pregnant horses’ urine) with synthetic progestogen, which are very different from the body identical HRT (derived from yam plants) that we now usually prescribe, which has lower risks and is very safe.

The fallout from fake news
This study was 20 years ago and the good news about oestrogen is still struggling to break through the damage caused.

More than 70 years of findings from animal studies, human studies, observational studies and randomised control studies demonstrate the benefits of oestrogen and show HRT to be a very safe and effective treatment for perimenopause and menopausal symptoms, and for reducing your risk of future diseases. Today in the UK, only around 10% of women take HRT, and many who would like to struggle to find a doctor or healthcare professional who will prescribe it for them.

Factcheck: HRT and breast cancer
So what does the good-quality evidence show us about the risks of HRT?

• Most types of HRT do not increase the risk of breast cancer at all. Oestrogen-only HRT has actually been shown to lower the future risk of breast cancer compared to women who don’t take HRT.
• Some studies have shown that women taking combined HRT (containing oestrogen and a progestogen – a synthetic progesterone) may have a very small increased risk of breast cancer. The risk is related to the type of progestogen in the HRT, not the oestrogen. However, this risk is very small and is less than the risk of breast cancer for women who are overweight or who drink a large glass of wine every evening. (Remember Davina in the ball pit and how many more pink balls there were for weight or alcohol intake than for HRT?)
• Taking micronised progesterone (‘Utrogestan’ in the UK) has not been shown to be associated with a statistically significantly increased risk of breast cancer.

‘Body identical’ HRT has the same molecular structure as the hormones we naturally produce and contains oestrogen that is transmitted through the skin via a patch, gel or spray, and micronised progesterone (needed to protect your womb, if you have one). This type of HRT is also safe for women who have migraines, have a history of a blood clots or stroke, and also for most women who have had cancer or have a family history of cancer.

It is important to remember that the risk of breast cancer is most influenced by factors that you can’t do much about, like your age and family history, and three key things you can influence – your weight, exercise and alcohol intake. These risk factors are associated with a greater risk of breast cancer than any type of HRT.

I believe (and the NICE menopause guidelines tell us) that most women would benefit from taking HRT to help their symptoms of perimenopause and menopause and also to help protect against heart disease, osteoporosis, dementia, depression, bowel cancer and type 2 diabetes.

It’s time to change the narrative around HRT, shake off false beliefs about the risks, and take back control of your wellbeing in the present and improve your health for the future."

Dr Louise Newson is a menopause specialist, and founder of The Menopause Charity and the free Balance menopause support app.

Having just recovered from a hormone led breast cancer, I've been told quite clearly that HRT is not an option for me going forward. I am fine with this and am currently managing my symptoms. As a pp said, I had high levels of oestrogen but was very fit and healthy with no family history at all. Yet here I am. My cancer was almost certainly triggered by an overload of hormones that my (female) GP prescribed to deal with peri bleeding that was impacting on my daily life. I wasn't happy about this and it triggered me to ask about BC risk. She waved her hand at me and said "negligible". Shortly after I had a clear mammo. 9 months after that I discovered I had a pretty large (but fortunately contained) tumour which I found by accident due to its position. There is not a hope in hell I would take the risk after that. I lost count of the amount of women I met on the unit during treatment who had suddenly developed BC after starting HRT. Coincidence? Maybe. I wouldn't take the chance.

@TheFormidableMrsC

Having just recovered from a hormone led breast cancer, I've been told quite clearly that HRT is not an option for me going forward. I am fine with this and am currently managing my symptoms. As a pp said, I had high levels of oestrogen but was very fit and healthy with no family history at all. Yet here I am. My cancer was almost certainly triggered by an overload of hormones that my (female) GP prescribed to deal with peri bleeding that was impacting on my daily life. I wasn't happy about this and it triggered me to ask about BC risk. She waved her hand at me and said "negligible". Shortly after I had a clear mammo. 9 months after that I discovered I had a pretty large (but fortunately contained) tumour which I found by accident due to its position. There is not a hope in hell I would take the risk after that. I lost count of the amount of women I met on the unit during treatment who had suddenly developed BC after starting HRT. Coincidence? Maybe. I wouldn't take the chance.

Surely though that the age of women who are mostly likely to be diagnosed with breast cancer - 50s onwards - is the same as those who might take hrt? It doesn’t necessarily mean they are linked - although they may be in the cases you say. We don’t know their history and other lifestyle risk factors.

Thank you so much for this. Started HRT last week due to horrendous brain fog, headaches, mood swings and complete inability to keep my weight under control. I figured the risk of breast cancer was more if I just ballooned with belly fat than if I managed my hormones effectively. Too early to feel the benefits yet. But waiting and hoping.

I stated HRT 3 months ago and it’s dramatically changed my life. I’ve had no hot flushes for 8 weeks and am subsequently able to actually sleep uninterrupted for the first time in two years.

I’m not overweight, have normal blood pressure, have never smoked, started my periods at 15 and also have never been on the contraceptive pill, so whilst nothing is 100% safe, I’ll take my chances with HRT. I think each women should be allowed to make an informed decision, weighing up the risks and benefits of HRT BUT GPs need to get up to date with information and facts.

Wouldn’t it be great to have products to help us without this fear? Is that too much to ask in 2021?

@TheFormidableMrsC

Having just recovered from a hormone led breast cancer, I've been told quite clearly that HRT is not an option for me going forward. I am fine with this and am currently managing my symptoms. As a pp said, I had high levels of oestrogen but was very fit and healthy with no family history at all. Yet here I am. My cancer was almost certainly triggered by an overload of hormones that my (female) GP prescribed to deal with peri bleeding that was impacting on my daily life. I wasn't happy about this and it triggered me to ask about BC risk. She waved her hand at me and said "negligible". Shortly after I had a clear mammo. 9 months after that I discovered I had a pretty large (but fortunately contained) tumour which I found by accident due to its position. There is not a hope in hell I would take the risk after that. I lost count of the amount of women I met on the unit during treatment who had suddenly developed BC after starting HRT. Coincidence? Maybe. I wouldn't take the chance.

I completely understand how someone who has had BC must feel over HRT and I'd not for a minute try to persuade them of anything. I hope you are okay?

However, for other people reading, what Dr N was doing here, was showing that a lot of the old 'facts' were scientifically flawed.

What is known now is:

It's unlikely that estrogen causes cancer. It's thought it stimulates a cancer already there in some women.

The research shows that women who use estrogen -only have 4 fewer cases of breast cancer per 1000, compared to women not using HRT. So that disproves the estrogen causes cancer.

The research appears to show that the risk of added hormones is from synthetic progesterone. That's why in her post Dr N says that some types of HRT have no added risk, or too small to be scientifically valid, by using micronised progesterone which is a natural type.

IF there is a risk, it's between 3 and 4 extra cases per 1000 women over 10 years. That's a 0.4% additional risk over a 10 year period.

For women who are overweight, the risk is an extra 28 cases per 1000, over 10 years. That's a 2.8% added risk.

Drinking and being inactive all have a higher risk factor than HRT.

We all need to make our own judgements on what is best for us and it's not an easy choice.

The research appears to show that the risk of added hormones is from synthetic progesterone

This worries me as I’m on HRT patches. Does this mean I should be asking to change to a gel progesterone? I wonder how my “anti Depressants are the best thing for hot flushes”Dr, will react to that?!

@LizzieSiddal

The research appears to show that the risk of added hormones is from synthetic progesterone

This worries me as I’m on HRT patches. Does this mean I should be asking to change to a gel progesterone? I wonder how my “anti Depressants are the best thing for hot flushes”Dr, will react to that?!

The different risks are in the research (you can find it by googling 'different progestins risks, hrt' - or words to that effect.) There are several papers on it.

The hierarchy is
Most risk highest first

1 MPA
2 Norethisterone
3 Dydrogesterone (in femoston)
4 Micronised progesterone

It's not a HUGE difference but between 1 and 4, it's around 2-3%

It's also not 'recent news' as 14 years ago my meno dr said they thought it was progestins that carried the risk.

I find the IP's post a bit one sided. Nothing about other variables like the amount of time you are on HRT and how that influences the risk, and the age at which you start or stop, whether you are taking it because you had early onset menopause, etc..

Separately, can Mumsnet confirm this article is not sponsored at all?

Jingling Cells misfire in our bodies all the time, in that sense we all have Cancer all the time. The issue is not what causes the Cancer, it is what causes the immune system to fail to mop up those mutant cells as it constantly does in a healthy body. In breast cancer the cells make use of the hormone receptors that exist on healthy cells to feed their growth so they can overwhelm the immune system. So Oestrogen may not cause the Cancer but it does fuel its growth.

And lifetime exposure to Oestrogen is a risk factor for Breast Cancer.

Both you and the doctor assume that the risks of Breast Cancer are understood but only 5% of risk is accounted for by known risk factors. Lifestyle factors account for just 1%, drinking and being overweight are just part of that 1%. And actually the jury is out on being overweight as there is contradictory evidence that being slightly to moderately overweight as opposed to morbidly obese is protective. So 95% of risk is not known, likely a combination of genetics and environment. I know quite a few women who have been diagnosed with ER positive Cancers in their 40s like me. My Oncologist always comments “You did everything right, just like most of the women who walk through my door”

My Oncologist is quite convinced that ultimately the link between lifetime exposure to Oestrogen and the rise in hormonal cancers will be uncovered as on a par with the link between smoking and Lung Cancer.

I am not saying that women should not make informed choices about HRT. It is just that I think the medical profession no more understands the cons of Oestrogen than it does the pros. It is misleading to say there are no cons, because nobody knows

Corona, I believe Dr Newson is in private practice as a HRT expert, so it isn't going to be independent as such.

I would add that my scepticism increase when anyone starts focusing on lifestyle factors as the cause of Cancer, especially Breast Cancer where it accounts for 1% of risk. It suggests victim blaming in the cause of other agendas. Whether it is the Daily Mail blaming us for not staying in the kitchen or some doctor crusading for Oestrogen….

@Emilyontmoor

Jingling Cells misfire in our bodies all the time, in that sense we all have Cancer all the time. The issue is not what causes the Cancer, it is what causes the immune system to fail to mop up those mutant cells as it constantly does in a healthy body. In breast cancer the cells make use of the hormone receptors that exist on healthy cells to feed their growth so they can overwhelm the immune system. So Oestrogen may not cause the Cancer but it does fuel its growth.

And lifetime exposure to Oestrogen is a risk factor for Breast Cancer.

Both you and the doctor assume that the risks of Breast Cancer are understood but only 5% of risk is accounted for by known risk factors. Lifestyle factors account for just 1%, drinking and being overweight are just part of that 1%. And actually the jury is out on being overweight as there is contradictory evidence that being slightly to moderately overweight as opposed to morbidly obese is protective. So 95% of risk is not known, likely a combination of genetics and environment. I know quite a few women who have been diagnosed with ER positive Cancers in their 40s like me. My Oncologist always comments “You did everything right, just like most of the women who walk through my door”

My Oncologist is quite convinced that ultimately the link between lifetime exposure to Oestrogen and the rise in hormonal cancers will be uncovered as on a par with the link between smoking and Lung Cancer.

I am not saying that women should not make informed choices about HRT. It is just that I think the medical profession no more understands the cons of Oestrogen than it does the pros. It is misleading to say there are no cons, because nobody knows

This. How long you take HRT and when in your hormone life cycle is quite important and not addressed appropriately by the post.

I think what is clear is that not all specialists agree with each other @Emilyontmoor and @Coronateachingagain.

The jury is most definitely not out on the relationship between being overweight and BC. The stats show that very clearly.

What you have posted Emily is actually what I said- that in some women, estrogen fuels an existing cancer. But according to the stats, it's not as big a risk as drinking 2 units a day or being overweight.

If you read the work / listen to interviews of Prof Michael Baum, a leading breast oncologist whose own mother died from BC, and whose daughter runs a support group for menopausal women, he is in favour of HRT. As is the US oncologist who wrote Estrogen Matters.

We all have to decide for ourselves. It's not an easy call, but some women may want 20 good years from 50-70 on HRT if their life is unbearable with symptoms, and take the chance of whatever may happen later on. Quality of life is as important as length of life for some people.

There are risks of NOT using HRT. I know someone who had early menopause, is now crippled with osteoporosis, many fractures and wheelchair bound, has heart disease, and now in her 80s, she's got BC which is inoperable because of the fraility and heart disease.

@Sheerheight

Corona, I believe Dr Newson is in private practice as a HRT expert, so it isn't going to be independent as such.

You will find NHS consultants saying the same things.

Jungling I am not saying that women should not consider the balance of risk and benefit of HRT. What I am saying is that this piece lacks the balance of highlighting the reality of what is understood of the risks of Oestrogen, which is very little, and that women need to take their lifetime exposure to Oestrogen into account in weighing up the risks.

Oestrogen is still very much chief suspect in the rise of hormonal Cancers like Receptor positive breast cancer, particularly in young woman. The youngest I know was 22.

Indeed the whole issue of Oestrogen overload / dominance is also little researched or understood though it accounts for a lot of life limiting symptoms as well. From the age of 17 when I started my periods I spent a week a month coping with the pain (which I later realised was the contractions you get in Labour - actual Labour was a breeze) and a flow which meant I could not be away from a loo for more than an hour, and it seriously impacted on my ability to function at work and that is manifesting itself in my DDs with the same lack of support from GPs. When I was found to have very high oestrogen levels that were causing multiple miscarriages / preventing me getting pregnant nobody thought to warn me it put me at risk of hormonal Cancer, and they had nothing to offer to treat it either.

I am very aware that Consultants disagree! One thing you soon learn when you have a life changing disease is how little the medical
Profession know though it doesn’t stop them as this doctor is doing, professing they know the answers based on the little they do know.

You do have to become an expert in your own body and do your own research.

I am told it was the menopause that enabled me to defy odds of 40% I would not survive to see my young children grow up so as you can imagine I have a very different perspective on this. It was actually a welcome end to a very toxic relationship with hormones and improved my quality of life, the long term side effects of chemo including osteoporosis aside.

As to the studies on weight, I am in a support group with an autistic person who surveys every paper on Breast cancer risk
and treatment so I do know that there are contradictory studies on weight. I have no skin in that game, I am not overweight and I had chemo before they used steroids to reduce the ill effects, but it is an added worry for women who put on weight during treatment as a result and struggle to lose it after so the studies she has found have been reassuring.

The only time I have seen my lovely calm caring oncologist angry was when she had just seen someone whose GP had prescribed the Oestrogen pill to for twenty years - “And then they are surprised when they have to send her to me? Entirely their fault”

@Emilyontmoor I'm not disagreeing with you that there is a lot that is unknown. It's very hard for women to make sense of all the conflicting info and all we want is to live a good life for as long as possible. Who'd be a woman! :)

However, since research began into HRT many years ago, one consistent finding is that women who can take estrogen only (they have had a hysterectomy) have less breast cancer than women in the general population who have never used HRT. How do you feel on that?

Also, Avrun Bluming is a US oncologist and his book Estrogen Matters turns the whole debate upside down and he does not think estrogen is the 'bad guy'.

I am sure you know that many more women die annually from osteoporosis complications in older age (100K) than all the women who die from BC.

1:2 women will get osteoporosis. The lifetime risk of BC is 1 in 7 for all women. HRT as far as we know (current stats) may raise that from approx 14% to 14.3% but those figures are on the old types using synthetic progestins, not micronised progesterone.

It's very hard knowing what to do for the best because a lot of women are faced with 'Do I not take HRT and then get osteoporosis,[ 1:2 will] and have to take other drugs which have very bad side effects' or risk HRT and protect my heart and bones.

It's very hard knowing what to do for the best because a lot of women are faced with 'Do I not take HRT and then get osteoporosis,[ 1:2 will] and have to take other drugs which have very bad side effects' or risk HRT and protect my heart and bones

Presumably though a good weights and cardio exercise program can counteract bone loss and cardiac heath to an extent?

Does anyone know anything about the impact of testosterone levels?

I have had highly ER+ BC (8/8) and also recently found out I have high levels of testosterone due to PCOS. Apparently excess testosterone is converted to oestrogen in the body (estradiol) and is linked to BC. So I am wondering if the excess testosterone caused by having PCOS could have contributed to my BC? I am early 40s, slim, fit, vegetarian, don't drink much and have no family history so it's a real puzzle to me why this happened to me relatively young.

Will a good diet/supplementation also protect against osteoporosis?

Weight bearing exercises, a calcium rich diet etc helps with osteo BUT it’s treatment when you have it is hormone therapy. Osteo is incredibly serious but perhaps less high profile than cancer so I’m not sure enough women understand what it is and their personal risk of it.

The only time I have seen my lovely calm caring oncologist angry was when she had just seen someone whose GP had prescribed the Oestrogen pill to for twenty years - “And then they are surprised when they have to send her to me? Entirely their fault”

My friend who was diagnosed with BC at 39, was told by her consultant a very similar thing. She was put in the pill form 15, due to very heavy and painful periods, she didn’t have a break from it until she was 36, her consultant was so angry about this.

But why aren’t these consultants getting this info out to women. I’ve never heard that women shouldn’t be on the pill for long periods of time and I’m in my 50s.

What's perturbing is that the medical profession is not 'joined up when it comes to this issue. And there are widely differing opinions amongst experts.

@LizzieSiddal The CCP is totally different to HRT. It's a completely synthetic form of estrogen and progesterone. It's not possible to compare them. Modern HRT is made from yams and is exactly the same molecular structure as our own hormones.

Also, when someone quotes a dr as saying 'what did they expect' after 20 years on HRT that seems very unfair indeed. We don't know what type, (it was 20 years ago, so presumably not the same dose and type used nowadays) what that woman's history was, etc.

I'm sure this guest post was supposed to help and be informative but it seems as if it's done the opposite. :(

I thought we’d moved away from HRT for bones?