More confused after HRT clinic

[RolfNotRudolf]

I saw my GP in August and said I wanted to consider HRT, and she referred me to clinic because my mother had breast cancer and died in her 50's. Also, my dad at same age had series of strokes and died.
Went to clinic today. The consultant was great and discussed options, and told me that there is an increased risk of BC with the "non-bleeding" HRT but not with "bleeding HRT". He also told me that the risk of CV disease is reduced on "bleeding" HRT. He therefore prescribed oestrogen patches and progesterone pills.
Now I've come home and read the NICE guidance again. That says that both oestrogen and progesterone should be given to women with a uterus (that's me) but that oestrogen only should be prescribed where there is a risk of BC. I had forgotten which way round the NICE guidance had it when I went into clinic so didn't question it unfortunately.
I'm confused! I have follow-up appointment in 3 months.

It's fantastic news that the dr you saw is on the ball and singing from the same hymn sheet as the top gynaes who research HRT and who contributed to NICE. What you have been told is spot-on with what my own top consultant says.

However, I think you need to check the NICE guidelines and post the part you found about estrogen-only here if you'd like to. There is nothing to my knowledge that says what you have posted. Estrogen only HRT is for women who have no uterus. This is because the uterus either needs a bleed to keep the lining under control (or it may become cancerous) or daily progestogen (which keep is thin but also increases the risk of BC it seems, especially the synthetic types of progestogen.)

Your dr is right- you can't have estrogen only HRT, but you can minimise risk with a sequi type and using Utrogestan rather than synthetic types.

Hi Polly and thank you for your helpful post and reassurance

I was C&P'ing from the NICE guidance last night. This was one section:-
"Breast cancer
1.5.11 Using table 3, explain to women around the age of natural menopause that:
• the baseline risk of breast cancer for women around menopausal age varies from one woman to another according to the presence of underlying risk factors
• HRT with oestrogen alone is associated with little or no change in the risk of breast cancer
• HRT with oestrogen and progestogen can be associated with an increase in the risk of breast cancer
• any increase in the risk of breast cancer is related to treatment duration and reduces after stopping HRT."

And in the NICE guidance for patients:-
"Breast cancer
Studies show that for women around menopausal age:
• Oestrogen only HRT causes little or no change in the risk of breast cancer.
• HRT that contains oestrogen and progestogen may increase breast cancer risk. This risk may be higher if you take HRT for longer but falls again when you stop taking HRT."

My emphases in italics.
You're right - the guidance doesn't say women at risk of BC should be given oestrogen only, but it does imply a greater risk of BC where O and P are prescribed - but the consultant today did seem to say the risk was lowered with a combined regime.

Having said that, while my mother had BC none of my other long-lived relatives (and they all are) have had it, so I don't think there's a genetic BC thing in my family, and these days I am less concerned about the possibility of "inheriting" it and willing to accept a slight HRT risk if there is one.

As you can see - I am very confused!

It is utrogestan he prescribed. He told me to take it for 12 days from the first of every month. I thought the 1st of the month was a convenience/easy to remember the date thing - but reading up on it am I right that it is to be taken from middle of cycle which would be around the first if I'm applying first patch today?
Or can I simply start taking it today along with the patches?

What I have been told personally, and also read through research, is that the BC risk is more higher with synthetic progestogen. If you want to google 'breast cancer risk with different progestogens' you will find papers on them. They may even be linked to in the references in the NICE report.

Off the top of my head, the stats show MPA the highest risk, followed by Norethisterone, followed by (lowest risk) dydrogesterone (only available in a pill - Femoston.) Research into micronised progesterone (Utrogestan) shows little or no increase in BC but larger studies need to be done. There is a French study EN3 (I think) with some results.

I think what your consultant meant is that the risk is lower with a sequential regime- that is using the progesterone for 12 days a month, or less, rather than every day in a continuous regime. This is what I have been advised.

When you take Utrogestan depends on your own cycle and how far you are in peri or post meno. If you are having periods, it makes sense to follow the cycle and start mid cycle around day 15. If you are not having periods you can start any time. Some women start on 1st day of each month, but you could start today and always start on the 15th of each month.

Hope this helps.

Thanks Polly. The doc did say he was starting me on the natural something and would see how it worked before moving to synthetic if necessary, so I guess that was the progesterone he was talking about.
I am definitely post-meno so have to confess to being a bit disappointed about the prospect of resuming periods

Yes the bleeds are a real nuisance but it's a compromise always.

If you are post meno you can leave the progesterone till 1 Dec- 2 weeks of estrogen only now won't harm you and some of us have 6-8 weeks cycles anyway (under a consultant) rather than 4-weekly.