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.

@Coronateachingagain

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?

Hello @Coronateachingagain - we can confirm that this post is not sponsored. We reached out to Dr Newson to work with her, as part of our wider efforts around making the menopause better for women, to publicise the lack of good information on HRT

@JuliaMumsnet

Given there is no shortage of epidemiological evidence of the link between lifetime exposure to Oestrogen and the risk of Breast Cancer though understanding of it is evolving slowly perhaps for balance you could ask a specialist on Breast Cancer risk to do a piece to explain the latest research. Just a quick google gives you numerous studies on it but it would really help to have someone brief women on the latest research.

These are just two

ascopubs.org/doi/10.1200/jco.2001.19.12.3111

www.ncbi.nlm.nih.gov/pmc/articles/PMC314432/

I would also like to see a Q and A on the pros and cons of taking HRT. Dr Newson has one view. I'd very much like to know if breast, ovarian, womb and endometrial cancer specialists and researchers agree the balance of risks means most women would be better off taking HRT.

I have found the comments, following on from the original post by Dr Newson, very helpful. There’s been a balance and I too would be interested in hearing from a cancer specialist.

I too would like to hear from a breast cancer specialist. Also though if all breast cancer specialists do training in hrt. I get the impression from threads on mumsnet the medical world isn’t very joined up on this topic.

@Emilyontmoor

Your links are to papers published in 2001 and 2003 so I would say they are out of date.

This is a more up to date paper from 2020
www.bmj.com/content/371/bmj.m3873

Secretdoor I realise they are older studies but with a quick Google they highlight the epidemiological evidence that lifetime exposure to Oestrogen and high levels of oestrogen in women are risk factors for hormonal Cancers. Every Breast Cancer specialist I have spoken is quite convinced of that, it hasn’t gone away and there is research going on to better understand that lifetime risk.

Your paper is only addressing the issue of Cancer risk for the whole population of women taking HRT. However over a woman’s lifetime she may be exposed to Oestrogen from many sources as a result of pharma, environment, lifestyle and genetics. HRT may be of no risk to one woman, or even most women, but the studies show that it is a bigger risk to women who have been exposed to higher levels of oestrogen over their lifetime. That is why we want to hear from someone who is up to date on that research and on how women can understand their personal risk. I obviously did not even make it to be a candidate for HRT my risk was so high as a result of having such high levels of oestrogen in my body for so long, yet I had done everything the OP says is protective (and a lot else besides, late menarche, three years of Brest feeding). What I didn’t know was all that had in reality a minimal impact on my risk, and exposure to Oestrogen made it a certainty in my case.

So some women have too much oestrogen and some not enough? How are we meant to know what to do and when?!

@Newgirls

So some women have too much oestrogen and some not enough? How are we meant to know what to do and when?!

Well exactly. Most women are 'lucky' to get just one (usually inappropriate) FSH test from their GP or gynae.

@JuliaMumsnet I think you need to get the OP back to answer some questions. Otherwise it just leaves everyone in a morass of confusion and lack of clarity.

I posted earlier in the thread and wanted to clarify that I didn't mean to imply that nobody should use HRT, I just wouldn't (and have been told I can't). This thread has thrown up so many questions for me and I thank those who have included useful links which I will take the time to read.

I have been dismissed out of hand by almost everybody in the medical team who treated me (with the exception of one specialist clinical nurse) when I have asked about the contribution the treatment my GP gave me to control peri bleeding might have made to my BC diagnosis. Everybody has said "no nothing to do with that, but never take them again". It's like the ranks close. I am struggling to believe that it isn't responsible. I had a two healthy boobs right before I started that treatment (I know this because I was on a clinical trial). I hadn't had any hormonal contraception since my early 20's and I was 50. First it was the Mirena that made the bleeding ten times worse and had to be taken out because I was losing so much blood I could barely leave the house. Then it was two doses a day of Desogestrel, topped up with Norethestrone. I was told it was all "perfectly safe". My own instincts told me otherwise but I was so desperate I went with it. I'm a single mum to a 10 year old ASD child and I simply couldn't function with the relentless blood loss and caring for him. Within 9 months of starting that treatment, I had a very large tumour in my milk ducts.

My point is, a poster (who doesn't want to be tagged so I won't), gave information about synthetic progestins and indeed there has also been a mention of a link with ductal carcinomas. So you can understand my bubbling fury about this and the fact that nobody but nobody will discuss it with me. I was not a risk factor for BC, like others here, fit, healthy, tons of exercise, good diet, zero family history. I'm baffled if it's nothing to do with the overload of progesterone!

I have a couple of BC friends who are taking HRT under strict, carefully monitored conditions. I get why they are and in some ways I'm envious as managing a sudden Tamoxifen induced menopause is not easy! However, they have been told that there is risk so their decision is informed.

@MNHQ, this thread has raised more questions than answers for so many. It would be brilliant to have a proper Q&A about this subject with a specialist or indeed the good Doctor herself. I imagine it would be extremely helpful for many.

Hello everyone - thanks for your comments. We can confirm that someone from Dr Louise Newson's team at Newson Health will be coming back onto the thread either this week or the next to address some of your questions. We'll be taking into consideration suggestions to do more on this, whether that's a guest post or a Q&A

That's great, thanks for that, @JuliaMumsnet. Much appreciated.

Great so appreciated!!

Brilliant @MNHQ, thank you very much!

Thanks, @JuliaMumsnet - this is the kind of thing that makes MN so brilliant and such an important website for women.

Testing...

@Blooter

Does this mean that it is safe for women with a history of ER+ breast cancer to take body identical HRT?

Are there any implications of these studies for the effectiveness/ineffectiveness of tamoxifen?

Thanks @Blooter, for women with history of ER+ breast cancer it's more of a mixed picture, there's a lack of good research in this area. Some women decide they would rather take HRT with a small/unknown risk than live miserably with lots of symptoms and a poor quality of life. I have a booklet on this subject on menopause doctor website under Resources-Booklets and factsheets.

@Sonarl

So once I am 50/51 what do I need to make sure my GP prescribed me - is there one patch that contains the body identical oesstrigen and micro progesterone?

This confused me as older friends seem to get given 2 types of pills, a patch and pills etc?

Thanks @Sonarl, you don't have to wait until you're 50/51, if your periods start to change and you have one or more symptoms you can ask for HRT. The safest type of estrogen is through the skin in patch, gel or spray. You can get a patch that has estrogen and progestogen in it, which is still effective and low risk, but it is not micronised progesterone (which is the safest type) and comes in capsule form.

Is there any link to ER- breast cancer?Is there any benefit to taking HRT after the menopause if you have never taken it before?

@SimonedeBeauvoirscat

Thanks for this, very reassuring. I have 2 questions, if we’re allowed to ask?

1. how long should one take HRT for? Is it for life? Or is there a point at which the balance of medical benefits / risks change?

2. if one’s doctor is reluctant to prescribe, is there a way of challenging this / getting a prescription elsewhere? Are there any official guidelines for doctors which are helpful for patients encountering resistance?

Hi @SimondeBeauvoirscat great questions! 1) It is up to the individual, for most women that remain healthy the benefits continue to outweigh the risks for ever and 2) you can ask for a 2nd opinion, if you're able you can see a private menopause specialist, you can write a letter to your doctor and refer to NICE guidelines NG23 that state for most women HRT benefits outweigh the risks. I also have a page on my menopause doctor website called 'My doctor won't budge' which is very helpful and full of advice.

@Reallyreallyborednow

Why should someone ask for HRT? Is it routinely recommended for older women, or only if symptomatic?

I saw a thread here recently which seemed to suggest everyone should take it, to combat things such as weight gain, decreased libido and bone density loss.

I’m 50, showing no signs of menopause at all so far, have gained some weight and lost libido but I put that down to being so sedentary over the last year, plus stress generally. I’ve started weight training to combat that now gyms are open.

So should someone like me without any actual menopausal issues still be asking for HRT? Are there still benefits? I hesitate because I absolutely do not get on with hormonal birth control.

Hi @Reallyreallyborednow, taking HRT is obviously up to individual choice. It is worth remembering that even if you're not getting any symptoms, HRT helps to lower your risk of heart disease, osteoporosis, dementia, bowel cancer and depression as you age.

@booface

Thanks very much for coming on to answer our questions. I am in my mid 50s and post menopausal (confirmed by hormone blood tests). My mum and grandmother were crippled by osteoporosis. Do you recommend I take HRT to prevent suffering osteoporosis myself? I don't have any other menopausal symptoms and seem to be coping quite well fortunately. Should I ask for a baseline Dexa scan perhaps and take it from there?

Thanks @booface, yes I agree with you, if you have a family history of osteoporosis, getting a DEXA bone scan and starting HRT would be a very wise decision even if you don't have any menopausal symptoms yet. HRT is the best treatment to prevent osteoporosis during the menopausal years.

@Emilyontmoor

I had strongly ER positive Breast Cancer at the age of 43 after a lifetime of very heavy periods that took the highest dose of the Oestrogen pill to control (Eugynon 30) which I had to stop after 5 years because of concerns I was showing early signs of a stroke. I also had another hormonal cancer , cervical cancer in situ, and fertility tests showed that high levels of Oestrogen were one of the factors in failing to conceive. My Oncologist said this type of medical history was one she saw too often in women. There is no family history of BC and I was extremely active, a runner and gym bunny and eat extremely healthily. As I understand it the risks of Breast Cancer are not well understood with only a small percentage of risk accounted for by the factors you list and most of that is family history. So it is entirely possible that there is a genetic predisposition to be vulnerable to exposure to environmental factors such as exposure to Oestrogen as opposed to a directly linked gene like BRCA. There are so many of us in my support group with similar stories.

So as you can imagine I am extremely sceptical of this shift to saying that a hormone that I believe tried to kill me is not so bad after all. How would you address that scepticism? Incidentally my chemo imposed menopause was actually a relief after the hormonal roller coaster of my periods.

Hi @Emilyontmoor you raise some good points, there is a lack of good research on this topic. It is really down to personal choice and up to you to weigh up how you feel now, compared to any possible risks. I have a booklet on my menopause doctor website - Resources - Booklets and factsheets for women after breast cancer that is useful and you might want to listen to my podcast with Mel Martins, one of our doctors who had ER+ breast cancer herself.