Menopause vs breast cancer: must I choose?
Nothing much usually stirs me before 7.30am, but when the report by the Institute of Cancer Research and Breast Cancer Now was announced on Radio 4 last Tuesday morning, I sat bolt upright in bed.
Running roughshod over those wonderfully comforting guidelines issued by Nice (National Institute for Health and Care Excellence) last year, it suggested that the risk of breast cancer highlighted by previous worrying (if wildly disputed) studies had actually been underestimated – and that Hormone Replacement Therapy (HRT) can in fact triple the risk.
In panic, I immediately left three messages for my gynaecologist, Professor John Studd. What should I do?
I can understand how some people become inured to stories about HRT and breast cancer, when there’s so much flip-flopping around the subject. But not me. As one who was diagnosed with oestrogen-positive cancer ten years ago, I need to know everything, as soon as it comes out, however alarmist or contradictory.
Beside, three times the risk? And this, apparently, for women who hadn’t even had it. That’s not nothing.
Cancer, of course, had come as a shock. In one way, I still can’t quite believe that someone didn’t make a terrible mistake when they told me the little grape seed I felt in my right bosom while having a shower in the summer of 2006 was not just a cyst.
In another way, I’m surprised I got off so lightly. (Grade I requiring a lumpectomy and radiation. No chemo, no mastectomy.)
Certainly, I’d always assumed that HRT would never be an option for me, given Nice regulations recommend it not be “routinely offered” to women with a history of breast cancer.
But it’s not so black and white, according to quite a few doctors I talked to when menopause hit a couple of years ago, at the age of 54.
Were my symptoms that bad? They never are, in retrospect. But they were bad enough – the hot flashes, the sleeplessness, the anxiety and, worst of all, the weight gain – to have me seek a second (and third) opinion after being told by the first (a charming Frenchman from the menopause centre at Clinique La Prairie in Montreux, Switzerland) that I wasn’t eligible.
One was from Professor Studd, founder of the first menopause clinic in Europe in 1970, and a somewhat controversial — he would say pioneering — figure because of his belief in HRT.
He told me that I was not, in fact, at risk and that I’d be mad not take it with my history of lacy bones and depression. Another specialist in New York, Erika Schwartz, agreed.
So, in the autumn of 2014, I started taking a bio-identical (more on this later) combination of oestrogen in gel form and progesterone in pill form and almost immediately the hot flashes went. So did the sleeplessness and the anxiety and the bloatedness.
Having always guiltily thought I should be strong enough to suck up my symptoms on my own (as my mother and sister had done) I suddenly realised just how much hormones (or the lack of them) had been ruling my life.
My lovely Harley Street oncologist Carmel Coulter wasn’t exactly over the moon but, hey, my bloods were fine, my last MRI scan, which I have every year along with a mammogram and ultrasound, was negative, and my cancer had “only” been low grade.
Besides which, the hormones Studd prescribed were “bio-identical” — unlike Premarin, the most common form of hormone replacement therapy, made of reconstituted horse wee — and designed in a laboratory to mimic the exact kind manufactured by the human body (although whether this makes them safer is yet to be clinically proven).
Even more reassuring were those revised Nice guidelines last year, which went quite far in outlining the benefits of HRT after the bad name it got via two major studies at the beginning of this century.
Both the University of Oxford’s Million Women Study and the US Women’s Health Initiative Study had reported that the taking of combination (oestrogen and progesterone) HRT raised the risk of breast cancer – not to mention stroke, blood clots and gallstones.
In their wake, the number of prescriptions for HRT halved. But over the years their findings were disputed, and lost in the worry were the benefits of taking HRT for preventing osteoporosis, colon cancer and heart failure (a far bigger killer of women than breast cancer).
Finally, after a decade urging caution, in 2015 Nice concluded that up to a million women could be “suffering in silence”, and that doctors often “overestimate the risks and contraindications [of HRT], and underestimate the impact of menopausal symptoms on a woman’s quality of life”.’
All in all, I was covered, right? Or so I thought, until Tuesday.
Though on holiday in France, Professor Studd messaged me back. Yes, I can just stop, but why would I?
This study, he said, was based on women who took a combined, one-size-fits-all synthetic prescription, continuously. (I take transdermal oestrogen daily, but I only take progesterone – the supposed “culprit” when it comes to breast cancer risk, but necessary if you still have a womb, to decrease the risk of womb cancer – the first seven days of every other month.) My preparation, he insisted, is both beneficial and safe.
“It has been known for ages that progesterone is the risk factor and that oestrogen-only does not carry a risk, as the available studies show no risk or [even] a decreased risk of breast cancer on this treatment,” he wrote. “The epidemiologists have looked at the least safe HRT preparation. They know this. Although producing high-profile bad news does help next year’s funding!”
Phew. Sort of.
One thing in my favour is that I don’t drink any more. The reasons I stopped were manifold, but one was the evidence, almost everywhere I looked, of a link between oestrogen-positive breast cancer (the most common) and alcohol. Who knows what caused mine, but instinct tells me a love of wine may have had something to do with it.
When a gynaecologist I met while doing the menopause doctor rounds told me I was probably better off taking the “worst”, cheap horse wee type of HRT and not drinking alcohol than taking the HRT made of, as it were, mermaid’s tears, and drinking, something clicked. Eight months ago, I stopped. Was it hard? Yup. Do I feel better for it? Immeasurably.
Aside from my medical history then, I’m actually low risk. I have a BMI under 21, I don’t smoke, I eat well and exercise regularly. Having already had cancer I get checked regularly and I’ve only been on HRT for two years (the study identified the highest risk among women who had been taking it for 15 years of more).
Indeed, there is some inferred data that suggests Utrogestan, the bio-identical progesterone I am using, may in fact be protective against breast cancer (but as yet there are no specific studies on outcomes). According to this latest report, if I did decide to stop now, my risk factor would go right back to what it was before I started taking it.
To be honest, I’m more worried about my short term memory than I am about my cancer recurring, and in the optimistic fug of my first coffee I feel, on balance, that for me the benefits of the one just about cancel out the risk of the other.
And yet, as the day wears on, I find myself wavering.
Maybe, after two years, I don’t even need HRT any more. Maybe, just maybe, the effect was partially psychosomatic? Maybe – and this is a little out there – I should have had a hysterectomy so as not to bother with the progesterone?
It seems so innocuous, that single pump of Oestrogel I rub into my wrists every night, and though the Utrogestan pills make me a little bloated (and have given me back my period) I must only endure them for seven days every other month.
And yet, however much Professor Studd’s no-nonsense manner always manages to reassure – I’m booked in to see him upon his return – I can’t help but wonder if I’m a bit of a guinea pig.
Due to begin my next round of progesterone pills on Thursday, I’m still in two minds as to whether to continue with them or not. Hopefully I’ll make the right decision.
The Sunday Telegraph
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