Hormone replacement therapy isn't suitable for everyone. Photo / File
October is World Menopause Awareness Month – but hormone replacement therapy is not a ‘one size fits all’ treatment.
Ever since Davina McCall started her menopause revolution, I’ve been sitting on the sidelines, wondering if I’m allowed to join in. While women embrace hormone replacement therapy as a miracle cure for hot flushes, night sweats and brain fog, my family history of breast cancer means it’s not a simple decision for me.
While I don’t have the BRCA gene, my mother and aunt both died from the disease, and my uncle, now in his nineties, also had it. Add to that my aunt’s bout of ovarian cancer, and the genetic maths isn’t great. As a gene specialist at London’s Royal Free Hospital said, “You probably have a cancer gene, but we don’t know what it is yet.”
Studies show a very small increase for those on combined systemic HRT containing both oestrogen and progestogen, with body-identical hormones considered the safest and lowest risk. But with an already raised risk, I’m not sure I’m willing to add to it by also taking HRT.
Use of oestrogen-only HRT carries little or no risk, but is only for women who have had a hysterectomy, because it increases the risk of womb cancer. It’s not an option for me.
The longer you take HRT, the greater the risk. The Women’s Health Initiative showed four extra cases per 1,000 of breast cancer for women in their 50s over five years taking older synthetic HRT. The risk from taking new body identical hormones is likely to be lower.
NICE (National Institute for Health and Care Excellence) generally advises against HRT use for women who’ve had breast cancer, and although a small Danish study published in July this year suggested HRT use may not result in any increased risk of recurrence in breast cancer patients, many studies have previously shown a link.
What’s more, women with endometriosis, a history of blood clots or migraine could also find themselves feeling left out of the HRT party, as they may be advised that taking it may worsen their condition.
So what are the options for those for whom HRT is deemed too risky, such as breast cancer patients, or people like me for whom it adds to our risk? Or for those who simply don’t want to take it. Specialist Dr Clare Spencer from MyMenopauseCentre said, “Menopause management is not one size fits all. A discussion should be had about where the benefit and risk ratio lies for a woman as an individual, and how she feels about uncertainty.
“Some women experience significant menopause symptoms, affecting quality of life. Many want to take HRT, understanding the risk. Others feel anxious about the risk of recurrence [of breast cancer] and this outweighs the impact of symptoms.”
Dose and type should also be discussed, she says: for instance, women with a history of blood clots would be advised not to take HRT in tablet form, but transdermally [absorption through the skin].
Like so many, I didn’t even have that discussion: in my mid-40s, a GP dismissed HRT out of hand, even though taking any type under the age of 50 is generally safe (even if you have a genetic risk factor for breast cancer, there is no additional risk of taking HRT under 50). At 51, I’ve missed that window and now have to weigh up the pros and cons.
One thing Dr Spencer told me strikes home: drinking alcohol is a greater breast cancer risk for me than being on HRT would be. What’s the point of missing out on the greater protection against heart disease, bone health and dementia studies show HRT could offer when I’m drinking 14-21 units a week? That’s one big change I can make, and it has really made me think twice about my alcohol consumption. I can’t take on the risk of family history, plus alcohol, plus HRT - so if I really start to struggle with symptoms, I’ll have to cut back.
Indeed, for women who can’t take HRT, lifestyle changes such as ditching booze can not only reduce cancer risk but also alleviate crippling menopausal symptoms. Hypnotherapist and wellbeing coach Geraldine Joaquim was diagnosed with oestrogen-reactive breast cancer in 2020 at the age of 50.
She says, “Tamoxifen [cancer hormone therapy] made my menopausal symptoms, such as disturbed sleep, ramp up. But the oncologist told me HRT was off the table. It feels like everybody’s having a lovely time on the HRT bus but I haven’t got a ticket and it can be scary when you hear you’re also missing out on protective benefits.
“However, in the rush to get HRT people forget if you’re not managing your lifestyle either, if you’re drinking loads, eating sugary foods or are overweight, that’s not going to help. What I can do to protect myself is eat healthily, do yoga and strength training.”
Sam Palmer, a former nurse and menopause expert from Midlife Makeover, offers advice to women who can’t take HRT. She says, “HRT has been presented as the panacea for all perimenopausal symptoms, but we can’t ignore lifestyle, movement, exercise, rest, sleep, stress management.
“I advise moving for at least half an hour a day. There are three types of non-negotiable exercise - cardio, strength work and restorative, such as yoga. And include a range of plant-based foods to your diet, up to 30 a week. Research shows if you have a variety, gut bacteria helps keep what hormones you still have more balanced.”
Palmer adds that herbal supplementation may also help. In a 2010 study, Black Cohosh reduced hot flushes and sweating by 25 per cent and some smaller short-term studies have backed this up. However other studies have been inconclusive and long-term risk is unknown.
Research has also been carried out into phytoestrogen supplements, such as soy and red clover extract to see if they reduce symptoms. A 2020 meta-analysis concluded phytoestrogens, which are plant-based compounds which can mimic or block oestrogen, may reduce symptoms but reduction may be “small and slow in onset”. Crucially, as with Black Cohosh little is known about long-term safety: adding food containing phytoestrogens to your diet is a safer approach than supplementation. Calcium is recommended for bone strength - but always seek medical advice first.
Finally, explore alternative therapies. Palmer says, “Cognitive behaviour therapy can help with hot flushes. Acupuncture and aromatherapy can reduce stress and anxiety and improve sleep, which in turn can improve symptoms.”
The message is, if you can’t take HRT, don’t panic. As Geraldine Joaquim tells me, “Our health is in our hands.” I may yet decide to join the bandwagon - but first, I’ll change my diet, and maybe even ditch that booze habit.
Nutritionist Hannah Hope from www.hhopenutrition.com advises the following:
Going up the slide is okay, actually. (Sometimes.)