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.

@JinglingHellsBells

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. :(

Disagree. Whatever it was, 20 years of it was not wise, I am not sure what point you are making unless you have other reasons

Disagree. Whatever it was, 20 years of it was not wise, I am not sure what point you are making unless you have other reasons

@Coronateachingagain The point is quite clear.

The types of HRT used 20 years ago, which is when that woman presumably started, or even further back, are not the same as HRT nowadays. There is research into the risks of older types and more recent research into the types used now.

Everything that Dr LN posted here is in line with the International Menopause Society and the British Menopause Society. They have studied all the research and come to a consensus, which (one example) includes no time limit on using HRT if (for the individual) the benefits outweigh risks.

A lot of this is on their websites if you want to read it.

@LadyWithLapdog

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

British Menopause Society

Prevention and treatment of osteoporosis/

First two bullet points

Summary practice points

• HRT reduces the risk of both spine and hip as well as other osteoporotic fractures.

• Oestrogen remains the treatment of choice for osteoporosis prevention in menopausal women, and especially in those with premature ovarian insufficiency.

@JinglingHellsBells

Disagree. Whatever it was, 20 years of it was not wise, I am not sure what point you are making unless you have other reasons

@Coronateachingagain The point is quite clear.

The types of HRT used 20 years ago, which is when that woman presumably started, or even further back, are not the same as HRT nowadays. There is research into the risks of older types and more recent research into the types used now.

Everything that Dr LN posted here is in line with the International Menopause Society and the British Menopause Society. They have studied all the research and come to a consensus, which (one example) includes no time limit on using HRT if (for the individual) the benefits outweigh risks.

A lot of this is on their websites if you want to read it.

20 years of non stop HRT, whatever latest technology you use, is probably not best practice for the great majority of women. Full stop.

20 years of non stop HRT, whatever latest technology you use, is probably not best practice for the great majority of women. Full stop.

That's your opinion. You are entitled to it, but it's not what the IMS and the BMS say. I think women should read the science and make up their own minds based on facts.

@JinglingHellsBells

20 years of non stop HRT, whatever latest technology you use, is probably not best practice for the great majority of women. Full stop.

That's your opinion. You are entitled to it, but it's not what the IMS and the BMS say. I think women should read the science and make up their own minds based on facts.

In my opinion, and many others, dangerous advice - I agree though, you should read ALL expert research and advice available - unbiased and not paid by pharma producing these products or organisations funded by pharma if at all possible.

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.

Buy as a PP said, surely it doesn’t matter what the hormone we put into our bodies is made of now, historically it wasn’t always “exactly the same structure as our won hormones”.
Some Cancer consultants seem to be saying that the amount of hormones, no matter how they are made up, can effect a woman’s chances of cancer and surely it needs to be considered when thinking of HRT.

I am 20 years on from menopause and a diagnosis of osteoporosis both bought on by chemo in my early 40s. Obviously HRT was not a treatment option and after 5 years of tamoxifen which is bone protective I declined to move to the other bone and hormone protective drugs because they weren’t very effective on the BC front. So with exercise and a Calcium supplement my back score has stayed the same and my hip score has actually improved slightly.

I was recently part of a study into what lifestyle and genetic factors might have contributed to me getting Covid asymptomatically which found that my risk of heart disease was half that of the average healthy woman my age (and incidentally that my Vitamin D and Omega 3 supplements did show a correlation with getting Covid mildly)

Of course all bodies are different and I may have lucked out but it seems to me that whilst there was little I could do to avoid the 1% of BC risk known to be down to lifestyle factors, exercise and a healthy diet with supplements appear to have helped me avoid the risk of deteriorating bones and heart disease.

Blooter I don’t know much about Testosterone but it seems as if overloading your body with many pollutants leads to it producing Oestrogen, it is suspected to be why alcohol adds to risk. Amongst the women I know who have had ER breast cancer it is very common for them to have complicated gynaecological histories that suggest hormone overload. In fact one thing that is very common is that when they had fertility problems they then were exposed to even more hormones during fertility treatment.

After I had finished treatment one thing that made it very clear to me that I was free of hormones was that my remaining breast (I had a single mastectomy ) pretty much instantly stopped being dense, lumpy and painful even compared with time between periods let alone during them. It was a very obvious sign of what Oestrogen had been doing to them.

I’m worried this thread is full of stuff without actual medical expertise.

Oestrogen falls naturally from mid 40s. Yet we have most breast cancers after that time. It’s such a complex issue and to imply that oestrogen supplementation is bad for all isn’t massively helpful.

It’s also important to note that hrt products have evolved and changed. Most breast cancer research has been done on women over 60. Who if they took hrt by logic took products that women in their 40-50s are no longer prescribed.

It is an ever changing situation and one that we clearly need more info on than this thread has provided. More pls mumsnet!

It’s such a complex issue and to imply that oestrogen supplementation is bad for all isn’t massively helpful

Equally implying that it’s good for all - which is the message I’m getting from here and other threads- is equally unhelpful?

*It’s such a complex issue and to imply that oestrogen supplementation is bad for all isn’t massively helpful

Equally implying that it’s good for all - which is the message I’m getting from here and other threads- is equally unhelpful?*

Exactly that. I don’t think anyone on here has said Oestrogen supplementation is bad for all, on the contrary what we are arguing is that everyone needs to make a decision based on their own bodies and their history of Oestrogen exposure. However this doctors post is not balanced, it is advocating HRT is safe for all (although elsewhere she acknowledges that it is not for you if actually diagnosed with Oestrogen receptor positive cancer but even then saying some will take it!)

I think most women who have had a history of unbalanced hormones and experienced all the side effects will know that full well. However they probably won’t know it puts them at increase risk of hormonal cancers - it certainly came out of the blue for me and yet my history came as no surprise to my Consultants as they see women all the time with histories like mine developing hormonal cancers. I swallowed the rhetoric that she is peddling here that because I was young, thin, fit and eat healthily and had no family history I was not at risk. Actually that only removed 1% of my risk……

And actually I am sceptical as to why the debate is so unbalanced. I get it that doctors generally are ill informed but they are ill informed on both the pros and cons. There is though no money in warning women away from taking additional Oestrogen in all it’s lifetime pharmaceutical forms…. money even in treating them if it does result in Cancer.

We know the playing field in the research into treatments for Cancer is seriously tilted towards expensive treatments even with long term side effects. I was given chemo for a ER positive cancer because nobody had done the research into the outcomes of women with Hormone receptor positive Cancer versus receptor negative Cancer, When they did chemo actually worsened the outcomes for women with hormone receptor cancers when it didn’t throw them into menopause (delightfully termed chemical castration) . It was ten years after my treatment that panicked Consultants started calling in friends in that situation post chemo and offering them drugs and surgery to bring on menopause, and stopped the use of chemo as a treatment for strongly ER positive tumours. Yet ten years earlier I had had that conversation with my Oncologist. They knew hormones played the major role in the treatment of those Cancers but nobody had shifted the supertanker the 5 degrees to confirm it.

I have a feeling the same is happening here. For so long the HRT /Breast Cancer connection has dominated the narrative so now doctors like this one want to change the narrative, with good reason, but they are throwing the baby out with the bath water and the Brest Cancer Consultants could educate them on that.

www.nhs.uk/conditions/hormone-replacement-therapy-hrt/risks/

The NHS webpage is quite positive about HRT

@SecretDoor

https://www.nhs.uk/conditions/hormone-replacement-therapy-hrt/risks/

The NHS webpage is quite positive about HRT

This is a useful link to NHS guidance ^^

Perhaps a few more GPS should read it too

Interesting thread. As someone who never took the pill or HRT yet still had breast cancer and now has osteoporosis I am still baffled!

Are you a doctor / specilaist @JinglingHellsBells? I only ask because you have obviously got an interest in the topic.

I think MN ought to come back and arrange a Q&A with a medical professional on this topic, preferably not someone with a financial interest?

Yes I agree. Some answers to these questions would be helpful as it seems that the original post has raised more questions than it answered.

I had assumed the OP would be replying to people - isn’t that why this is a forum post rather than an article on the main website?

HRT saved my sanity.

Where can we find the answers to all of these questions @AnnaCMumsnet ?

Really hard to make an informed decision about this when your GP won't discuss it. And seemingly has not had much up to date training on the issue.

I've requested someone talk to me about this, but my surgery doesn't even have a women's health lead!

Yes there's lots of positive news on HRT at the moment. Especially online. Buy what is fuelling this?
So confused.
And peri menopausal.

Some clearer answers would be helpful.

[quote JinglingHellsBells]@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.[/quote]
Sounds like you have done lots if research jingle.

@AmIPeriOrAreYouJustAnnoying

Where can we find the answers to all of these questions *@AnnaCMumsnet* ?

@AmIPeriOrAreYouJustAnnoying You can find out almost all you need on the following sites. You will probably find that everything in the guest post is confirmed by these other sources.

www.womens-health-concern.org/help-and-advice/

thebms.org.uk/publications/consensus-statements/

www.menopausematters.co.uk/oestrogens.php

(Follow the links across the top of this page including risks/ benefits/decision tree etc.)

lizearlewellbeing.com/podcasts-videos/podcast/making-sense-of-hrt-nick-panay/

Nick Panay is a top UK NHS gynae running the menopause clinic at the Chelsea and Westminster Hospital, and has spent his life researching HRT/menopause etc.

Includes
What are the first signs of early menopause?
Can we prevent menopause?
How has HRT prescribing changed over the years?
Does the type of HRT matter?
What is micronised progesterone?
Is HRT plant-based?
What role do GPs play in menopause care?
What are the benefits of taking HRT?
Can mindfulness and CBT help menopause symptoms?
Can alternative therapies help?
Does progesterone boost mood?
Can you buy HRT online?
What is the difference between bio-identical and body-identical HRT?
Is compounded HRT safer?
What is DHEA?
Can women with breast cancer take HRT?
Do women need testosterone?
Is there a case for taking HRT early?
Can we continue to take HRT forever?
Should women without symptoms take HRT?

Ok, that' s all from me. (I'm not going to reply so please no more tags.)