Tuesday 22 May 2018

'I wouldn't take HRT, I'd leave well enough alone'

With new research showing definite links between HRT and breast cancer, our reporter finds out how Irish doctors and patients are approaching the issue

Carol Mallon, 69, who says her breast cancer diagnosis overshadowed her menopause symptoms. Photo: Tony Gavin
Carol Mallon, 69, who says her breast cancer diagnosis overshadowed her menopause symptoms. Photo: Tony Gavin
HRT can be taken in pill form

Gabrielle Monaghan

The enduring memory Carol Mallon has of being wheeled into an operating theatre 12 years ago to remove a cancerous lump in the breast, was worrying she would never wake up from the operation or see her husband or six children again.

The Co Meath woman had been so busy looking after her family and helping on their farm that she rarely had time to worry about her own health. Yet a lump under one of her breasts had been niggling at her for years. Despite a mammogram and needle biopsy showing that the lump was benign, later tests revealed that she did indeed have breast cancer.

"My brother had died of cancer 10 months earlier, and I thought I was going down the same route as my brother," she says. "I was terrified."

Mallon recovered after the lumpectomy and a course of radiotherapy. She is now a vibrant 69-year-old who is involved in fundraising activities for Breast Cancer Ireland and other charities.

Her brush with mortality made every other health concern she ever had pale in significance, including the menopause. In her 50s, during what some grimly call 'The Change', Mallon never even stopped to think about her hot flushes, let alone seek a prescription for hormone replacement therapy (HRT) to relieve what she describes as mild symptoms.

"I wouldn't even take medication for a headache," she says. "I wouldn't have taken HRT because I never saw a need. I'd prefer to leave well enough alone."

HRT can be taken in pill form
HRT can be taken in pill form

Read more: HRT triples the risk of breast cancer, biggest ever study shows

Until the early noughties, HRT had been hailed as a miracle cure-all for the physical and psychological symptoms of the menopause, which happens when a woman's ovaries start producing fewer hormones and periods becoming irregular until they stop altogether.

The average age for a natural menopause in women in Ireland is 52 years, with Department of Health statistics showing that about 260,000 women in Ireland are going through menopause at any one time.

These symptoms can range from dizziness, night sweats and joint and muscle pain to vaginal dryness, anxiety and severe insomnia. The severity of these symptoms can be crippling for some women, and HRT can provide relief by topping up decreased hormone levels, enabling the body to function normally again.

Here, finally, was a treatment that could make women struggling with a natural stage of mid-life supposedly feel and look like their younger selves.

But prescriptions for this perceived fountain of youth slumped worldwide when a series of studies published at the turn of this century suggested there was a link between HRT and breast cancer. The 2002 Million Women Study, conducted by Oxford University, found that long-term use of combined HRT, which uses both oestrogen and progesterone, raised the risk of the disease by 1.9pc.

The same year, the Women's Health Initiative in the US found that the combined version of HRT put women at greater risk of breast cancer, heart disease, and stroke. Within a few months, usage halved. The research findings were widely disputed, leaving many women and clinicians confused about the therapy. In some quarters, even speaking about using HRT became taboo, and not just because it was a sign of ageing.

Read more: How to work out the menopause

But concerns about the association between the therapy and breast cancer were renewed late last month after new research, published in the British Journal of Cancer, revealed that long-term use of HRT can triple the risk of breast cancer and that previous studies had underestimated the risk.

The new study, led by the Institute of Cancer Research in Britain, showed that women who had undergone HRT for five years were 2.7 times more likely to develop breast cancer than those who did not take the drug or were on oestrogen-based HRT, which is only suitable for women who have had a hysterectomy.

The risk of getting breast cancer was 3.3 times greater among women taking combined HRT for 15 years or more.

The latest findings are likely to unnecessarily ramp up anxiety among women seeking relief from menopausal symptoms, according to Dr Janice Walshe, a consultant medical oncologist at St Vincent's University Hospital.

"Anything that is associated with breast cancer always causes alarm, so there will be a fear factor associated with HRT," she says.

"But it is important for women not to panic and any decision they make about using HRT must involve their GP, who can help them base that decision by weighing up the risk and the benefits. The new study showed a stronger link between HRT and breast cancer, but the link is really only relevant for a small number of women."

The Irish College of General Practitioners (ICGP) agrees, saying individual women would have considered their own breast cancer risks, including whether there was a history of the disease in their family, and compared them with the benefit of HRT before starting the treatment. In addition, it said the risk "is still very small".

According to estimates based on the latest study, the risk of women in their 50s developing cancer is ordinarily 14 out of 1,000, but this rises to 34 in 1,000 women who are taking combined HRT.

The research was part of the Breast Cancer Now Generations Study, which has been following more than 100,000 women for 40 years to investigate the causes of breast cancer.

Some 39,000 women on the menopause were identified and monitored for six years, with follow-up questionnaires gathering data whether they used HRT, what type of the drugs they used, and the length of time they were on them.

During this time, 775 of these women developed breast cancer, but those who were on combined HRT for an average of 5.4 years were 2.7 times more likely to develop breast cancer during that period than women who had never used HRT. Crucially, this increased risk level returned to normal a year or two after stopping the therapy.

The researchers said this increased link to breast cancer could likely be explained by an increased exposure to hormones that can stimulate the development and growth of some breast cancers.

Read more: To HRT or not to HRT?

This is a prospect that Cathy O'Reilly, 54, had feared all along. After going into early menopause at the age of 44, she finally persuaded her GP three years later to prescribe HRT.

The medication quickly quashed the lethargy, half-hourly hot flushes, headaches, and the pains in her arms and legs that made her suspect she was developing fibromyalgia.

Three months later, however, O'Reilly's GP advised her to cease taking HRT because she had developed what eventually turned out to be benign lumps in her breasts.

"I would have carried on taking it, despite the long-term risks, but with a history of worrying breast symptoms, it wasn't possible," she says. "I had total relief - HRT had made me feel like myself again. Luckily, most of these symptoms eventually faded by themselves."

While some women would find any risk of breast cancer from HRT completely unacceptable, others are willing to accept a small risk because they experience such enormous benefits.

"A lot of women say to me 'my quality of life on the menopause was so horrendous, but I had 10 to 15 good years on HRT even though I went on to get breast cancer'," Dr Walshe says.

"If your symptoms are so bad that you have an inability to cope, the benefit of HRT is much greater than the risk, especially for a person who doesn't have a personal or family history of breast cancer.

"You need to use the lowest dose that is effective for the shortest time possible, because it's clear from the study that the risk of breast cancer is greater the longer you are on it. It's important people think about the length of time they need it, rather than being on it for a decade without thinking about it."

Dr Mary McCaffrey, medical director of the Scotia Clinic in Tralee, where she runs a menopause clinic, said she began contacting patients - almost all of whom are on combined HRT - after the report came out. She stressed it is "imperative" that her patients do not suddenly stop taking HRT until they speak to her or their GP.

Dr McCaffrey, who is also a consultant obstetrician gynaecologist at University Hospital Kerry, says: "My current practice is to risk assess each woman, and provide extensive information so that women can make an informed choices.

"We always present all alternative options and address lifestyle changes which can help. We will continue to provide the same information prior to prescribing treatments.

"In making a final decision, women who are post-menopause need to know that in not taking HRT, they may be at risk of complications of heart disease and osteoporosis, which are very likely to be greater than the risk of breast cancer after taking combined HRT for the shortest period of time at the lowest dose."

Dr Walshe, meanwhile, points out that women considering HRT or those who are on the medication can reduce their risk of breast cancer by changing their lifestyle. Being sedentary, overweight and consuming alcohol are greater risk factors for breast cancer among women between the ages of 50 and 55 than most forms of HRT between the ages of 50 and 55.

"If people got in shape, we would have a 10 times greater effect on reducing breast cancer than giving up HRT, which increases the risk by three times," she says.

What is HRT?

HRT can be taken in pill form

• Combined hormone replacement therapy (HRT) replaces the oestrogen and progesterone, the two female hormones that a woman's body is no longer producing because of the menopause. Continuous combined HRT is prescribed to women who have not had a period for at least a year and involves taking oestrogen and progestogen every day, without a break.

• Oestrogen-only HRT is usually only recommended for women who have had their womb and ovaries removed by hysterectomy. As they no longer have a womb, they do not need to take progestogen as there is no risk of endometrial cancer (cancer of the womb lining).

• HRT can be taken as a cream or gel, tablet form, a patch, or an implant inserted under the skin of the abdomen, buttock or thigh.

• The oestrogen used in HRT is different from the oestrogen used in the contraceptive pill, and it is not as powerful. This means it is still possible for a woman to get pregnant on HRT for up to two years after her last period if she is under 50, or for a year if she is over 50.

• Women may not be a suitable candidate for the therapy if they have a history of breast, ovarian or endometrial cancer, a history of blood clots, heart disease or stroke, or have untreated high blood pressure, liver disease, or are pregnant. HRT tablets (but not patches or gels) are linked with a higher risk of developing a blood clot.

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