My heart sank when I saw the news headlines last week trumpeting dire warnings about an increased breast cancer risk from hormonal replacement therapy (HRT). The reports were based on a new paper released by The Lancet medical journal. They echo the media frenzy around HRT in the early 2000’s which struck right to the heart of women’s darkest fears, causing millions to abandon treatments that were safe and life-enhancing. Is history repeating itself? Are we losing ground again after two decades of excavating the truth about HRT?
Thankfully last weekend’s congress of the Australasian Menopause Society provided an opportunity for Australia’s most respected menopause doctors to reflect on and discuss the recently released paper. Their responses were well-considered and balanced, reassuring me that current prescribing practices are still safe and appropriate.
The Lancet headlines focused mainly on the fact that HRT use increases breast cancer risk, which we have actually known for a very long time. For years I’ve counselled my patients about the very small increase in breast cancer risk associated with certain types of HRT after 5 years of use. Unlike the recent headlines however, I also explain that there are other types of HRT which do not seem as likely to increase risk. If they’ve had a hysterectomy for example, the type of HRT used is much lower risk. We also discuss other potential unwanted side-effects, most of which can be mitigated by the hormone type, dose and delivery method.
A woman’s individual risk assessment must consider all her risk factors. One very important point highlighted by last week’s paper is that obesity is a much greater risk factor for breast cancer than HRT use (about 6 times the risk, as shown in this great graphic representation from the British Menopause Society). Two standard alcoholic drinks per day is equivalent in risk to HRT use for 5 years, whereas exercise significantly reduces risk. iPrevent is a free online tool developed by the Peter MacCallum Cancer Centre in Melbourne to help assess your current individual level of breast cancer risk. If you have a strong family history of breast cancer then your GP should refer you to a genetic counsellor for advice about how that may affect you.
A complete risk assessment must also take into account a woman’s “background” risk level. Every Australian woman has at least a 1 in 8 lifetime risk of developing breast cancer, even higher if she has a strong family history or other risk factors. Regardless of what lifestyle or medication choices she makes this background risk persists. I always warn women that one-eighth of HRT users will get breast cancer, because one-eighth of non-HRT users will too. It’s important to understand that if you develop breast cancer whilst using HRT, it doesn’t mean the HRT caused the breast cancer.
But let’s take a step back here. We wouldn’t be having this discussion unless there was a good reason to use HRT: it’s incredibly effective at treating hot flushes and night sweats. For women whose quality of life is eroded by debilitating symptoms, perhaps causing lack of sleep and mood disturbance, HRT can make life worth living again. As a bonus, women who use HRT for these symptoms will have less bone loss and heart disease risk. They may also experience improvements in mood, vaginal dryness, musculoskeletal pain, brain function and sleep.
Overall, last week’s Lancet publication has not really changed things very much. Each woman must still work with her doctor to determine the best treatment options based on symptom severity, a personalised risk assessment and personal choice. If a woman believes that improved quality of life outweighs the potential risks, then her decision should be supported by a health professional who will help to mitigate the risk with regular treatment reviews. The key (as always) is in finding a compassionate doctor with expertise in managing menopausal symptoms to guide you.
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