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 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 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. 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.
Hormone Replacement Therapy (HRT)
HRT is a treatment to replace hormones that are no longer being produced and to help relieve menopausal symptoms. HRT is a very individual thing, there is no ‘one size fits all’ approach to HRT. Someone’s HRT prescription is specific to them and not everyone who goes through the menopause will need, want or be able to have HRT.
Types of HRT
For most people taking HRT, it will be either combined HRT (oestrogen and progesterone), or oestrogen-only HRT. 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. This is because oestrogen promotes the growth of the womb lining (endometrium) and progesterone helps balance this. If oestrogen is increased without progesterone to balance it, it can lead to a thicker womb lining, which can develop into a cancer.
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. A combined approach means that 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 those experiencing 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 developing certain types of cancer when using 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.
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 for each individual. 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.
Menopause can be a difficult time even if you haven’t just gone through a significant life event, so it can be even more challenging after a cancer diagnosis when cancer treatments might also make you feel unwell. But there are always options available that can help.
Lifestyle Interventions
Several non-hormone medications can help with a variety of menopause symptoms. These decisions should include a discussion with your doctor, as different treatments are helpful depending on your specific symptoms. For example, the treatment that can help you may differ if you have hot flushes or sleep problems, compared with weight gain, anxiety, low mood or aches and pains.
Addressing your lifestyle is helpful for everyone, as lifestyle strategies can help with your menopause symptoms, well-being and long-term health. For example, smoking and drinking too much alcohol can worsen menopause symptoms. You can ask your doctor for support with quitting smoking and help with reducing your alcohol consumption.
Daily movement and exercise improves your well-being and long-term health. If you feel exhausted and achy, remember that any movement is better than nothing. Walking around your house or the block for a few minutes is better than staying on the sofa all day. Focusing on small tweaks to your daily routine makes such changes more sustainable over time.
Eating the rainbow of fruit, vegetables and other natural foods, and reducing your ultra-processed food intake can help keep your weight healthy and help your gut health, among other benefits. You can get the benefits from fruit and vegetables when they’re frozen and tinned as well as when they are fresh, so there are lots of ways you can add a few more into your diet each day.
It takes time to notice the benefits of lifestyle interventions; they don’t work overnight, and it is best to start gradually to make any changes sustainable for the long haul.
Taking HRT
Once someone starts taking HRT, they will be reviewed by their doctor after 3 months, to see whether 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 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.
If you would like any further information or advice, our Ask Eve nurse service is here to help. You can get in touch for free and confidential advice on nurse@eveappeal.org.uk or 0808 802 0019.