The menopause
The word ‘menopause’ quite literally means ‘end of monthly cycle’ – the hormonal cycle that the body goes through to prepare for pregnancy. If a pregnancy doesn’t happen, it results in a period. If someone has gone through the menopause, it means that they haven’t had a menstrual period for 12 months or more and they are ‘post-menopausal’. The period (pardon the pun) of time leading up to this point is known as the ‘perimenopause’, and it means that your body is moving towards the menopause.
The average age to reach the menopause in the UK is 51, with the perimenopause typically starting several years before this, from our mid 40s onwards. This is when you might notice your periods becoming irregular, and you might experience menopausal symptoms including hot flushes, night sweats, brain fog, a lower mood, vaginal dryness, and problems with sleep.
Why does this happen? Why do our periods become irregular? Why do we experience these mental and physical changes? Our ovaries are at the centre of it all. The job of an ovary is to produce hormones (oestrogen, progesterone and testosterone) and release eggs. This is all part of our monthly cycle, and as we grow older, our ovaries produce less and less of these hormones, and release eggs less frequently, causing the menopausal symptoms and irregular periods, until eventually, the menopause is reached.
Menopause which happens as part of the natural aging process is often called a ‘natural menopause’. If someone goes through the menopause between the ages of 40-45, this is called an ‘early menopause’ and if under 40, a ‘premature menopause’ (also sometimes referred to as premature ovarian insufficiency/failure). If you have surgery to remove your ovaries, then you will have what is known as ‘surgical menopause’. These changes will be sudden rather than gradual, and due to the sudden drop in hormone levels, the symptoms can feel more extreme. Chemotherapy and radiotherapy can also affect the ovaries and stop them from functioning either temporarily or permanently.
Hormone Replacement Therapy (HRT)
Regardless of how someone experiences the menopause, the drop in hormone levels can be difficult to cope with, that’s where HRT comes in. HRT is exactly what it says it is – treatment to replace hormones that are no longer being produced and to help relieve menopausal symptoms.
It’s important to note right away, that HRT is a very individual thing. Someone’s HRT prescription is specific to them; there isn’t a magic ‘one size fits all’ HRT super-pill and not everyone who goes through the menopause will need, want or be able to have HRT.
There has been a lot of confusion around the link between HRT and cancer, people would like to take it but are worried about getting cancer, and many research articles have been published with mixed messages about whether HRT is ‘safe’ or not.
So, does HRT give you cancer? The short answer is no, it doesn’t give you cancer, but it can increase your risk of breast, ovarian and womb cancer. The increased risk varies for each of these cancers depending on the type of HRT.
Types of HRT
For most people taking HRT, it will be either combined HRT (oestrogen and progesterone), or oestrogen-only HRT. Testosterone is prescribed by some doctors (one of the benefits is that it can help increase libido) but isn’t currently approved for use in women. Some GPs are happy to prescribe it ‘off licence’ and others refer their patients to a specialist to make this decision.
If you have had a hysterectomy to remove your womb then you can have oestrogen-only HRT, but if you still have your womb then it will need to be combined HRT.
HRT comes in several different forms. Oestrogen is available in a patch, tablet, gel, and spray. Progesterone is available in a tablet or through an intrauterine device (IUD) commonly known as the coil. Many people who take combined HRT will use two separate types, e.g. the coil and oestrogen patches, as adjustments to find the right balance of hormones can be made more easily but there are tablets and patches available that contain both oestrogen and progesterone.
Tablets can be called oral HRT, and patches, gels and sprays are transdermal HRT which means they are absorbed through the skin. Both the oral and transdermal methods of HRT are systemic, which means that the hormones go into our bloodstream and affect our whole body.
Some people going through menopause may experience vaginal atrophy, the thinning, drying and inflammation of the tissue lining the vaginal walls due to the lack of oestrogen. It can cause discomfort, pain during sex and sometimes light vaginal bleeding. This can be treated with vaginal oestrogen, which is a ‘local HRT’, meaning that it stays within the vagina and very little oestrogen is absorbed into the rest of the body. Vaginal oestrogen comes in a cream, gel, pessary or silicone ring, it is often an option for women with vaginal dryness who can’t or don’t want to go down the full HRT route.
Cancer risks with different types of HRT
Now let’s look at the risk of each cancer when using each type of HRT for 5 years:
Breast Cancer:
- Combined HRT: around 8 extra cases per 1,000 people
- Oestrogen-only HRT: around 3 extra cases per 1,000 people
HRT can increase the risk of breast cancer returning, if you have previously been diagnosed, which we discuss in more detail below. When both types of HRT are stopped, the increased risk of breast cancer starts to go back down. To put these numbers into perspective, being overweight, before and after the menopause and drinking 2 or more units of alcohol a day will increase someone’s risk of developing breast cancer more than being on HRT for 5 years.
Ovarian Cancer:
- Combined HRT: around 1 extra case per 1,000 people
- Oestrogen-only HRT: around 1 extra case per 1,000 people
Like with breast cancer, the increased risk of ovarian cancer begins to reduce when HRT is stopped.
Womb Cancer:
- Combined HRT: no increased risk
- Oestrogen-only HRT: around 4 extra cases per 1,000 people
Unlike breast and ovarian cancer, the increased risk of womb cancer may remain for several years after oestrogen-only HRT is stopped. This is why oestrogen-only HRT isn’t normally prescribed to those who have a womb. If you have had a hysterectomy (surgery to remove the womb) then you may be able to take oestrogen-only HRT.
Like with breast cancer, being overweight is a greater risk factor for womb cancer than HRT; being overweight almost doubles someone’s lifetime risk of developing a womb cancer. This is because fat tissue make oestrogen If there is too much oestrogen, it can cause the cells in the lining of the womb to grow and divide. Cancer can happen when the cells grow uncontrollably, until they mutate and turn into a cancer.
What about people who have previously had a breast, ovarian or womb cancer, or those who are at a higher risk of developing one of these diseases? The below information is general guidance but can vary depending on each person’s situation.
HRT for people who have cancer or an increased cancer risk:
Lynch Syndrome
an inherited genetic alteration that means someone is at a higher risk of developing bowel (colorectal) and womb cancer, and a small but higher risk of several other cancers including ovarian cancer. Many women and people with gynae organs with Lynch Syndrome choose to have a hysterectomy (removal of the womb) or hysterectomy and bilateral salpingo-oophorectomy (removal of the womb, and both ovaries plus fallopian tubes) after they have completed their families. This is known as risk-reducing surgery. HRT is generally considered safe for those with Lynch Syndrome, especially considering the protective effect that oestrogen can have on the colon.
BRCA
the gene alteration that means someone is at a higher risk of breast and ovarian (and prostate and pancreatic) cancer. Like with Lynch Syndrome, many women and people with gynae organs with a BRCA gene alteration choose to have a risk-reducing bilateral salpingo-oophorectomy. HRT is generally considered safe for BRCA alteration carriers.
Breast cancer
HRT isn’t always offered to someone who has had breast cancer, but again, it’s about weighing up the risks and benefits. Whilst not routinely prescribed, some people who have had breast cancer will speak to their oncologist about the safest option for them and decide to take HRT. Vaginal oestrogen can generally be used for those with a history of breast cancer, as it is a localised treatment that will help with vaginal dryness and irritation, but very little oestrogen will be absorbed into the rest of the body. If you have had breast cancer and are considering vaginal oestrogen, this would still need to be discussed with your oncologist.
Womb cancer and a hysterectomy (womb removed)
HRT is generally considered safe, and oestrogen-only HRT can be discussed with your oncology team.
Ovarian cancer and salpingo-oophorectomy (ovaries and fallopian tubes removed) –
Most people who have had ovarian cancer will be able to take HRT, but it will always need to be discussed with your oncology team.
Cervical cancer
Most cervical cancers aren’t thought to be oestrogen dependent, so the majority will be able to take HRT, but it will need to be discussed with your clinical team as to whether it is right for you.
Taking HRT
For most women (who go through a natural menopause at around 51) to benefit as much as possible from HRT, it’s suggested that treatment starts within the first year (and preferably the first 3-6 months) of experiencing menopausal symptoms.
Once someone starts taking HRT, they will be reviewed by their doctor after 3 months, to see whether or not the current dosage is working for them, or if it needs adjusting. Because we are all so different, it can sometimes take a while to find the right balance. If your prescription is adjusted after your first review, then you will need to have another appointment in another 3 months. Any change to HRT means a 3-month review. When you and your doctor are happy with your HRT treatment, you will be reviewed every year. It’s very common to experience some vaginal bleeding during the first few months of HRT, but if you feel that something isn’t right, or notice any bleeding that hasn’t happened with a new dosage/change in HRT, please speak to your doctor as soon as possible, regardless of when your next HRT review is booked in for.
If the benefits continue to outweigh the risks, then there is no reason why you should stop taking HRT. Some people stop their treatment after a few years to see how they feel without it, and decide they no longer need HRT, others stop and then choose to go back to HRT because they still have symptoms. IT really is all about personal circumstance.
For women who go through menopause at a younger age (e.g. a surgical menopause) it’s usually suggested that they take HRT up until the typical age of menopause (around 51) and then reconsider their options. When someone decides to stop HRT, they can do so either immediately or gradually. Like with starting HRT, stopping HRT also needs to be discussed with your doctor so you can agree the best way to do this. If someone does stop HRT suddenly, they may find that menopausal symptoms return more quickly than if they gradually eased off their treatment.
So, why would we decide to take HRT and replace the hormones we’re no longer producing? Quite simply, because it makes us feel better. If we look at the positive aspects of HRT for a moment, then oestrogen really is the star of the show. It’s the ‘feel-good’ hormone; it helps with our skin elasticity and dryness, it improves brain function, is beneficial for heart, bone, gut and colon health, and helps to regulate body temperature.
Does HRT slightly increase the risk of breast, ovarian and womb cancer? Do some people choose not to take HRT because of the associated risks? Do many people decide that the benefits of having stronger bones, better cognitive function, a more stable mood, fewer hot flushes and night sweats, less vaginal dryness and better sleep outweigh these slight risks? The answer to all three of these questions is yes. No two people’s experience of HRT is the same and depending on your situation, your GP or hospital team can help make the decision that is right for you.
If you have any questions about menopause, HRT and cancer risk, or gynaecological health in general, please do get in touch with our free, expert information service, Ask Eve via nurse@eveappeal.org.uk or 0808 802 0019.