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HRT and Cancer: Where Are We Now?

We need to treat individual women, not statistics.

This is the sentence that concludes the BMJ journal editorial on cancer risk and HRT after Lancet paper study, that came out in August. The BMJ editorial was written in the attempt of explaining the limitation of the study, reassuring women about HRT usage, and helping people reading the study. We need to start from the beginning explaining that.  

Why women are taking HRT during menopause in the first place?  

In the UK, most women go through the menopause between the ages of 45 and 55, with the average age being 51 years. Around half of the women will experience some physical or emotional symptoms from the decrease in ovarian function and consequent oestrogen diminished oestrogen production. Symptoms include hot flushes, night sweats, low mood, anxiety, joint and muscle pain, vaginal dryness, decreased sex drive, and hip fractures later in life due to osteoporosis. These are just some of the 34 symptoms associated with menopause.

Taking HRT can ease some of symptoms and give a more acceptable transition into menopause. What is really important to point out, is that every woman experiences the menopause differently. As said before, women are individuals therefore we all have different experiences and different ways to deal with those experiences. Although for many women this natural transition may be relatively straightforward and smooth, in around 25% of the cases, the symptoms associated with the menopause have a substantial or debilitating effect on their personal and professional lives, either in the physical compartment either in the emotional one.

Every woman experiences the menopause differently  

Unfortunately, only a minority of women will actively seek help to manage symptoms, often because they do not know who best to approach, and very often because no real help is offered. Even more often GP’s are not really prepared to face menopause and menopausal symptoms. (this is not the GPs fault of course, it’s how the system works and trains them even though recent efforts are being done to tackle this).   In any case, HRT remains the best option to treat menopausal symptoms and prevent some of problems (like osteoporosis and cardiovascular disease) correlated with menopause onset, in women that can take HRT. There are some women (with history of breast cancer or some other type of cancer) that cannot take them and they have to go for more natural alternatives.  

The findings published in the Lancet study in September 2019 provide data useful for both women and clinicians to help in discussions around the use of HRT. However, this new meta-analysis should be considered alongside the National Institute for Health and Care Excellence’s (NICE) 2015 guidance Menopause (available on the resources tab), which considered also all the available evidence on benefits and risks of the different treatment options available. The Lancet meta- analysis is complex and includes data from a large number of studies, published and unpublished, for a total number of 108,647 women. So, this study seemed to have a pretty good potential of providing accurate statistics, due to the high number of women involved, but like every study it has some limitations.  

The outcome of the study is that women taking ‘oestrogen only’ HRT have lower risk of having breast cancer later in life (but still have some risk according to the study), even though HRT shouldn’t be taken for more than five years, as it stated in the Lancet study. This span (indicated as the time in which is safe to take HRT according to the Lancet study) is even less for the combined (oestrogen-progesterone) HRT which in fact has a higher risk associated to breast cancer compared to oestrogen only HRT.  

One of the issues in the study is that it took into consideration the old oestrogen and progesterone formulation, without considering newer formulations or administration forms such as gel and patches or micronized progesterone. These more recent formulations available through NHS in fact are much safer as they are administered locally and there is no known risk associated with them. Oestrogen, for example, can be taken in the form of patches or gels. The optimal dose for each woman should be assessed and given in order to improve symptoms and also to optimise and maintain bone and cardiac health. Women can continue taking HRT for as long as the benefits outweigh any risks. And this is true for those specific formulations. They should have, however, an annual review with their specialist or GP. Progesterone instead can be taken as micronized progesterone which again, is a newer and safer formulation of progesterone.  

Going back to the Lancet study, , it also didn’t take into consideration that there are other risk factors associated with breast cancer, like alcohol or being overweight, which increases the risk of breast cancer 6 times just by itself. Interestingly some of the diseases that can arise with ageing itself that can be prevented by HRT such as cardiovascular disease, have a higher mortality rate than breast cancer and this is left out from the Lancet study as well.  

Additionally, this study did not address mortality, only the incidence of breast cancer, so findings must be compared against a recent systematic review that showed that starting HRT close to the menopause onset may also reduce all-cause mortality and cardiac death. Also, one of the most recent papers from the Women ’s Health Initiative randomised trials (we talked about it a previous article) showed that women who started treatment with oestrogen only between the ages of 50 and 59 still had an overall a lower mortality than placebo controls. Medicines and Healthcare Products Regulatory Agency (MHRA) issued a drug safety alert to all doctors and gynaecologist to communicate the breast cancer risk to women considering or already taking HRT. It included only the data from this publication and did not mention benefit in terms of bone loss and providing protection from cardiovascular disease, mood swing, hot flushes, depression caused by hormonal changes nor did it mention that there was no increased risk of death from breast cancer or all causes. It didn’t even mention patches or gels as formulations and the relative cost that it would have to the NHS compared to the cost of treating diseases arising during post menopause.

The best message we can retrieve from this paper is that HRT is a drug, and it comes with some risks (everything comes with a risk thinking well, when we are talking about any drug really such as paracetamol) and we need to treat each single case and personal history, because every woman is different. We know the benefits of HRT overtake the risks for most of the women. It is important to pay attention to risk and evaluate everything when starting a hormonal therapy, but also the quality of life needs to be taken into consideration.

The important thing is to be informed, get checked frequently and do what it is better for yourself, as everyone is different.