Breast Cancer and HRT: What I learned about The Menopause that convinced me HRT is the right option for me. Part 2
Last week I started the first of a series of posts in which I explain some of the rationale behind my decision to start HRT during peri-menopause. And I wanted to do this because over the past couple of decades, I feel like women have been sold down the river on the risks of HRT and many are not only having to put up with really unpleasant symptoms associated with The Menopause, but are also making decisions that could affect their long term health without knowing some of the more recent facts around it.
So lets talk about HRT and breast cancer, because this is the big one around HRT isn’t it? That there is this massive increase in breast cancer in those taking HRT? Hmmm. A bit of background to this for you.
Background to the links between breast cancer and HRT
Back in the early 90s a huge study was undertaken in the US looking at a number of aspects of women’s health, and the effects of HRT on post-menopausal women was one of them. This was the Women’s Health Initiative (WHI) and it is this study that informed (and continues to inform for some reason) medical recommendations for HRT.
The long and short of this study is that in 2002, results were published that claimed HRT caused a 26% increase in breast cancer, a 29% increase in heart attacks and a 41% increase in stroke in those women taking combined HRT (estrogen and a progestogen). Well, you can imagine the massive drop in the number of women who stopped taking HRT after this bombshell and subsequent repercussions.
Now, you can read a lot about this in quite some detail in many books, reports that have re-analysed the data over time and the original study itself. But to cut to the chase, there were so many things wrong with this study, it’s laughable it was ever taken seriously. In addition, several studies have been conducted since then showcasing new findings.
Problems with the WHI study
Now a caveat before I carry on. These are some of the things that I based my own decision on and I’m not here advocating HRT for everyone. I appreciate that people will have underlying conditions that make HRT riskier for them, while others will have different views that make not taking HRT right for them. That’s cool. Like many things in life, we all have to weigh up risks and make decisions accordingly. But here are the big problems with the WHI and its findings:
1. The data looked at post-menopausal women and so the age range of those taking part was 50 – 79. The average age of women in this study who started taking HRT was 63. Twelve years after they went through menopause (the average age of going through menopause being 51)! But if you’ve been following anything about The Menopause, anywhere, The Menopause (including peri-menopause which is a key stage) can start much earlier. Generally early to mid 40s.
This is important for a couple of reasons.
a) These days we know that there is no risk of breast cancer as a result of HRT if you take it under the age of 51.
b) There is now also a view that there is a golden window for HRT in women who start taking it up to 10 years before they go through menopause (the anniversary of 12 months without a period). But this study was looking at women who started taking HRT once they were already Menopausal, on average 12 years after they’d last had a period. Don’t get me wrong, you can start HRT once you’re already Menopausal but the benefits and risks may be a bit different.
2. 69% of the women in the WHI were either obese or considerably overweight. This isn’t a judgement. But the risks of developing breast cancer are four times greater for those people in this category than for those taking HRT. And that is important in the context of this study. Not only is this a pre-cursor for breast cancer but also cardiovascular disease which relates to the findings around heart attacks and stroke.
These factors (age and obesity) already put women at risk of heart disease and cancer. The reality is that a large proportion of these women should not have made the sample group in the first place.
3. Like many things, medicine moves on and the types of estrogen and progestogens that were being used then were very different to those used now. There are many different combinations of HRT and ways that you can take them which offers many options for many people. Unless you’ve had a hysterectomy, you are likely to need combined HRT where you take a combination of estrogen and a progestogen. In this study, women were given oral estrogen (tablet form) and a synthetic progestogen. Back in the day there were a number of unpleasant ways in which progestogens were produced. Nowadays, micronized progesterone is made from wild yams and observational studies suggest that it may be associated with a lower risk of breast cancer than non-micronized progesterone.
Interestingly, the WHI data has been re-analysed in different ways over the years, and although there are still concerns over the make up of the sample, this re-analysis has shown that the benefits outweigh the risks for most women who start taking HRT under the age of 60.
The risks of developing the diseases mentioned here centre around a number of things, some which we can’t control: genetics, age we experience our first and last periods, family history. And others which we can control: diet, exercise, alcohol consumption, smoking, being overweight, stress, exposure to radiation (this is not an exhaustive list)
Breast cancer and estrogen-only HRT
I think it’s important to say that studies suggest there is no increased risk of breast cancer if you’re taking estrogen-only HRT, which you would if you’ve had a hysterectomy for example.
Other factors not related to WHI
So that’s the thing around the WHI study. And it’s a big thing.
But what is also interesting to me are other things that I never knew about which can help to manage risks, because nobody is saying that taking HRT is risk-free, but it’s A LOT less risky than many of the day-to-day things we do and anything that we are still led to believe through the media and even our own GPs.
So, you can take HRT in a number of different ways – orally in tablet form where it’s processed in the liver, or transdermally – through the skin via a patch, gel or spray. You can take estrogen one way and progestogen another way. Or you can take them both the same way, any combination of which will have its pros and cons. Again, you can read about these different ways in many different sources: British Menopause Society has a wealth of information on its website, Louise Newson’s very easy to read book ‘Menopause’ is great as is Maisie Hill’s ‘Perimenopause Matters’ (other books and publications are available). However, I decided to take estrogen transdermally and progestogen in tablet form for a few reasons.
1. There is a slightly greater risk of blood clotting if you take estrogen in tablet form because it has to be processed by the liver, whereas with a transdermal option it goes straight into the bloodstream. So a patch was a bit of a no-brainer for me and I’m also really rubbish at remembering to take tablets daily!
2. I did go for the pill version of the progestogen however, even though there is a combined estrogen and progestogen patch available. That would have made things much easier logistically, but the progestogen in the patches is not body identical in its make-up (i.e. it does not exactly match the make-up of progesterone created in the body). Someone once described hormones and receptors a little bit like a lock and key, and so if a hormone created synthetically doesn’t quite match what is produced in the body, then it’s not going to work as well. Body-identical progestogen does match. The risk of breast cancer through taking HRT is also reduced if you’re taking a micronized, body-identical progestogen.
So there you go, the information I gained from reading a little bit more into the issues surrounding the WHI, which I think has a tremendous amount to answer for, and the pros and cons of administering HRT in different ways got me to the point I’m at now. Estrogen patch, progestogen tablet.
There are a few other beneficial things about transdermal versus oral HRT but I’ll save that for another day!