Often women are told they can’t have HRT. Dr Sarah Ball, a GP with a special interest in menopause, explains why it should ultimately be a woman’s choice.
Woman are often told by their doctor that when they reached 60 they can no longer have HRT, or that they’re too young to start taking it in their 40’s.
Women who’ve had breast cancer are told they can’t ever have it – but is this always the best information?
Dr Sarah Ball argues that women should be given all the facts so they can make their own decisions about whether they take HRT or not – because often their quality of life is so miserable that they actually wish they hadn’t survived.
You can see the original interview here.
Breast Cancer – in perspective
Dr Ball says “breast cancer is probably the top concern that turns women off HRT and unfortunately the risks of breast cancer have been hugely exaggerated in the media, but also in the minds of women and even health care professionals, sadly.
“None of us want to have breast cancer obviously, but it’s not the only thing to affect women’s health. The biggest killer of women is dementia, then heart disease and strokes, and breast cancer actually comes in at number 7 on the list. So yes, it’s crucially important but we have to think about the other diseases that could affect us as we go through our lives.”
She says the concerns about breast cancer arose from the WHI trial in the early 2000’s which was poorly designed, looked at older forms of synthetic HRT and exaggerated the risks.
“So we have this fixation that HRT causes breast cancer but we really don’t think it does. There is an association statistically of taking HRT and being diagnosed with breast cancer but that doesn’t mean that one has caused the other.
“And although this is a fairly simplistic answer, the way I look at it is this: as women we should all worry about breast cancer because we all have breasts. For those of us born after 1960 there is about a 1 in 7 to 8 chance of us getting breast cancer at some stage of our lives irrespective of whether we are taking HRT. That’s quite a high number, and the older we get – the higher the risk.”
There are genetic and lifestyle factors at play, she says, and often the tumours may develop around mid-life – about the time when we start to take HRT.
“So what we think is that if you’ve got a tumour that HRT may make it grow faster – but it hasn’t caused it in the first place.
“We tend to find the women who use HRT tend to look after themselves well and are more aware of breast cancer and tend to go for the mammograms when they’re called, so we may have a higher number of cases diagnosed because they’ve gone for the test in the first place. Those ladies are usually picked up early, are usually easy to treat and they are usually cured.
“Now, there’s never been a study that shows that women who take HRT are more likely to die from breast cancer. There are studies that show that there is a small increased risk of being diagnosed – about 1 in 1000 per year, and it’s an important difference to note.”
While there maybe “a very slightly increase their risk of getting breast cancer, women who take HRT are decreasing their risk for other diseases like heart disease and dementia – so statistically they improving their survival,” she says.
“If you use the newer kinds [of body identical HRT] you can be pretty certain it’s not going to give you breast cancer- it’s just that if it’s going to happen, it’s going happen.”
The most important factors in reducing our risk of breast cancer are maintaining a healthy weight, not drinking too much alcohol and exercising regularly.
What if you’ve had breast cancer? Can you have HRT?
“What is crucial about ladies who have had breast cancer is that they should not be written off. There is a choice,” Dr Ball says.
“There are different types of breast cancer – some are oestrogen receptor positive, some are oestrogen receptor negative and there are other types that are lumped in the same group as breast cancer but don’t react the same way, like one called DCIS or ductal carcinoma in situ – which doesn’t spread and should not be affected by hormones.
“But these women are told they can’t have the HRT.”
Know what type of cancer you have
“If it’s an oestrogen receptor positive cancer women are often put on drugs that block oestrogen, or the treatments they’ve had have put them into an early menopause. We also know that women who have had breast cancer often have worse menopause symptoms than women who haven’t had breast cancer.
“And we also know, none of us want to have breast cancer but if you get it now there is a 90% chance you’ll survive – and if you are cured you have the rest of your life to lead with possibly very debilitating symptoms.
“Now, none of us are purely the product of our breasts. We all have brains and hearts and vaginas so when we see ladies in our clinic who have had breast cancer we look at them as GPs, not as breast surgeons or oncologist, and we consider the whole person. We try to find out as much about her cancer and her history, treatments she’s had, her symptoms, what’s worrying her most, and many say it’s the vaginal issues that are worrying them most. Now, these ladies can use localised oestrogen in their vagina without any safety issues. It’s stays locally and there are no safety issues, despite what the product leaflet says.”
In the end it’s about balancing the risks with the benefits and one example she sites is this:
“One woman I saw was having a hot flush on the hour, every hour, and had done so for 11 years. So she hadn’t slept through for a single night in 11 years. The stress this puts on her body means her risk of developing other illnesses or another type of cancer is not insignificant. She can’t exercise, she’s gained weight,” all of which put her at a higher risk.
“And when you talk to these women and ask about how they are, they say things that really stick in your head like ‘I survived breast cancer but I really wish that I hadn’t – I’m not living now, I haven’t had a sex life for years, I can’t play with my children, I’ve had to give up work’ – these sorts of things.”
Dr Ball says there is no data to show that HRT increases the risk of a recurrence of breast cancer and “a woman needs to know that if you’ve had breast cancer you’re more likely to die of heart disease because the treatments for cancer can affect the blood vessels. But HRT could reduce that risk because of the positive effects it has on the blood vessels.
“So, you just have to weigh up the choices. There are positives and negatives. If you’re going to worry about a recurrence every day then it’s not for you, and there are other alternatives for the symptoms – but I wouldn’t say ‘no, you can’t have it’ to a woman. In the end it’s the woman’s choice.”
Why are the older, synthetic versions still available?
“Life is about choices really, isn’t it? For example I quite often take a holiday in France and all the ways of getting there have pro’s and con’s – some are safer than others – but it doesn’t always mean the safest way suits everyone. In the 1970’s-80’s HRT was in its hey day and many women did very well on it – they had far fewer broken bones or heart attacks. but there’s always a risk associated with it in terms of blood clots etc. But it doesn’t mean it’s bad, and for someone it is a better option as they don’t absorb the [transdermal] oestrogen well, or they may have a poor memory and wont remember to put a gel on everyday – so the tablets may be a better option. And of course, they are cheaper, so that may be a factor too.”
Is a healthy lifestyle enough to get you through menopause?
“There isn’t much point in taking HRT and having a rubbish lifestyle. HRT enables women to have a healthier lifestyle. We see many women at the clinic who exercise, eat well, do yoga but they still get symptoms. We can only do so much without the fuel – and in this case the fuel is the HRT. I could push my car down the road but why would I when I can put the fuel in it and it would be an easier ride.”
How long can I take HRT for?
You can take it for as long as you like, Dr Ball says. “There is no duration limit – despite all the apparent rules that have crept in over the years, none of them are still valid.
She explains there is an ideal “window of opportunity” – starting within 10 years of your last period – but you can start it after that too. But, there will be slightly higher risks if you are beyond the ideal ‘window’.
“It’s about understanding whether the benefits outweigh the risks for the individual” and then – it’s their choice.