Radio 4 presenter Kirsty Lang, pictured, has decided to resume HRT following successful treatment for breast cancer despite the threat of the disease returning
I had been on hormone replacement therapy for four years when I was diagnosed with breast cancer aged 53.
After the surgeon delivered this shattering news, my first question to him was: ‘Was the HRT to blame?’ I felt guilty, thinking that I had put the happiness of my entire family at risk. My maternal grandmother had died of breast cancer at a similar age, so I was already at an increased risk. I’d also read around the subject, so was aware that extra hormones in the bloodstream was linked to the growth of breast tumours. On the other hand, my mother had been on HRT for decades and is a living, breathing advert for the benefits. The surgeon paused. ‘Unlikely. There will be multiple other factors, but the HRT would have acted like a fertiliser on the tumour.’
With that, I went home and threw my oestrogen patches and progesterone pills into the bin.
But now, after chemotherapy, radiotherapy and a lumpectomy to remove the tumour, I am preparing to go back on HRT. Am I crazy? Not necessarily.
I’ve spent the past few months weighing up the risks to my health versus quality of life, based on the latest evidence and scientific facts.
Despite many doctors’ warnings against taking hormone therapies if you’ve a history of cancer, some leading oncologists say HRT should be an option for all cancer sufferers.
In fact, I’ve learned that the daily dose of progesterone and oestrogen that makes me feel ‘me’ again may even help me to live a longer, healthier life.
I shiver, I’m tired, I’m achy and stiff … gremlins have invaded my body
As my tumour was fast-growing, I was immediately put on a drug called Letrozole as I waited for surgery to remove the tumour. The drug is given to post-menopausal women with this type of early-stage breast cancer as it blocks the production of oestrogen in your body.
Ms Lang, pictured with GP Louise Newsome, right, who specialises in menopausal woman, saw her libido disappear after being thrown back into ‘an unbearable menopause nightmare’ during her breast cancer treatment
Very soon, I was waking up several times a night drenched in sweat. My emotions were all over the place. I was anxious, tearful, fuzzy-brained, constantly tired and my joints were achy and stiff.
My libido had all but disappeared. It was like being turbo-charged back into an unbearable menopause nightmare. But I put up with it because I figured it was better than dying. Now, three years on, having been told there’s a 95 per cent chance my cancer won’t return, I’m still struggling.
Sometimes I feel like my internal thermostat has been taken over by vicious gremlins.
I alternate on an hourly basis between being so hot that my entire body is covered in sweat, to shivering with feverish cold.
I can only tolerate wearing natural fibres as artificial ones make me sweat and I’m constantly contending with the damp sticky feeling you get after a run.
I burst into tears at inappropriate moments which can be very embarrassing if it happens in a professional setting.
I’ve tried everything; acupuncture, evening primrose oil, electric fans, giving up coffee and alcohol.
My GP prescribed anti-depressants which helped a little, but they don’t make the symptoms go away.
Nothing is as powerful as HRT.
The studies to predict risk are flawed
Many British GPs won’t prescribe HRT because they are ill-informed about the risks and wary that patients may sue them if they get cancer. But according to much of the research and leading experts, including eminent American oncologist, Dr Avrum Bluming, HRT should indeed be an option for cancer sufferers. So where does this fear come from?
Being overweight is much more of a risk of developing breast cancer than taking HRT
In Dr Bluming’s book Oestrogen Matters, he argues that the design of the studies looking at the cancer risks of HRT are fundamentally flawed. One of the studies he investigates is the widely cited 2002 Women’s Health Initiative study in the US. The average age of the women taking part in this research was 63, meaning results didn’t reflect the risks for women in their 50s, when most experience menopause. Nearly 70 per cent were overweight and half were current or past smokers, two major risk factors for breast cancer.
Other studies do show that some hormone therapies can increase the risk of developing certain types of breast cancer in a cohort of post-menopausal women. However, the risk is very low, the same seen in drinkers and the overweight.
Consultant gynaecologist Charlotte Fleming is one of the leading experts on menopause in the UK. She says the way in which risks are explained to patients is ‘critical’. Fleming’s method of explanation is a visual aid; a picture with dots on.
She tells me: ‘Out of 1,000 women, 22 will get breast cancer over the course of five years. They appear as black dots on my chart. If the same 1,000 women take HRT, another five to six will develop it, so I put five green dots on the chart. It’s an increased risk but it’s quite small. If they have a glass of red wine a day, that’s another two dots. If their BMI exceeds 30, then you add another 22 dots to the chart.
‘Being overweight is much more of a risk than taking HRT’.
But what if you’ve had breast cancer?
As a breast cancer survivor, I’m in a different category altogether. No doctor can tell me exactly what my risk factors are. There may be endless reasons why I developed breast cancer, including family history, alcohol consumption, diet and exercise factors and my genetics.
Any of these factors may interact uniquely with HRT to cause a change in my cells. Or, they may have no effect whatsoever.
The problem is there are no randomised trials of breast cancer patients on HRT, the gold standard of scientific studies.
According to Ms Lang, without HRT it feels like her body’s thermostat has been taken over by vicious gremlins
A 2015 review of the available scientific literature by researchers at the MD Anderson Centre in Texas concluded: ‘Limited and conflicting evidence exists regarding the risks associated with the use of HRT in breast cancer populations.’
In fact, many specialists now agree that it is safe for women who have had early-stage breast cancer to take HRT providing they are on Tamoxifen. It is thought that this drug, which blocks oestrogen from reaching the cancer cells, interacts with the HRT in such a way that it counter-acts any potential cancer-causing affects.
There is no point taking HRT if you are on breast cancer drug Letrozole because the treatment blocks oestrogen completely.
Similarly, other studies show that topical oestrogen gels or patches – rather than tablets – can effectively alleviate the symptoms without increasing the risk of recurrence.
Last autumn, I attended a conference on breast cancer at the Royal Society in London at which Dr Bluming was speaking. I approached him after the lecture and asked if I should consider going back on HRT. He said: ‘Well, both my wife and my daughter have had breast cancer and they’re on HRT, I would suggest talking this through with your doctor.’
My doctor, consultant breast surgeon Professor Jayant Vaidya of University College London, remains equivocal. ‘It’s not black and white that taking HRT will worsen your chances [of getting cancer],’ he says, ‘but it’s not black and white that it won’t. We need more research.’ He does, however, have a ‘small cohort’ of patients on HRT. It is necessary, he says, given that their lives were hell without it.
Another role for HRT…Protection from disease
According to the current life expectancy for British breast cancer survivors, I could live one third of my life without the protection of oestrogen. This means that as I grow older, I will be at serious risk of osteoporosis (oestrogen protects the bones), cardiovascular disease and cognitive decline. Oestrogen is also important in stabilising mood, potentially warding off depression.
Studies show that women under 60 who take HRT for five years have less thickening of artery walls than those who don’t take the pills, slashing their risk of heart attack.
And a 2018 randomised, controlled trial published in the journal Neurology found that women taking combined HRT for seven years had lower accumulations of amyloid plaques – associated with the onset of dementia.
GP Dr Louise Newson, who specialises in menopausal health including HRT, has been astounded by the profound affect of HRT on her patients’ health.
Which type of HRT has the lowest risk of cancer?
Hormone replacement therapy (HRT) replaces oestrogen, levels of which plummet at the menopause, triggering night sweats, vaginal dryness, headaches, low mood, reduced sex drive and hot flushes.
Most women take combined HRT, which contains synthetic versions of oestrogen and the hormone progesterone, because taking oestrogen alone has been seen to increase the risk of womb cancer. Combined HRT can be taken every day without a break or in cycles.
Oestrogen is taken continuously and supplemented with progesterone every few weeks. Those who have had a hysterectomy can take oestrogen-only HRT.
Tablets, skin patches, gels, implants and vaginal creams, pessaries and rings are all available. Topical treatments, such as gels, patches and creams, are associated with a lower risk of cancer.
Non-hormonal options include tibolone (livial), which is similar to combined HRT and is particularly useful for women with endometriosis.
The blood-pressure drug clonidine and some anti-depressants can also ease hot flushes and night sweats.
I made an appointment at her practice, The Newson Health Clinic, in Stratford-Upon-Avon. It offers a holistic approach to menopause including yoga classes, nutritional advice and, of course, HRT. ‘What you don’t read about in the media is the increased risk of osteoporosis, dementia, strokes and heart disease that comes from NOT having enough oestrogen,’ she warns. ‘Those women you see thriving on the golf course in their 70s and 80s are probably on HRT. My oldest patient is 93 and she takes a low dose of oestrogen gel twice a week.’
So widely accepted are the benefits that 89 per cent of women’s health experts would themselves take HRT, according to a recent survey from the Royal College of Gynaecologists and Obstetricians.
Sitting in Dr Newson’s waiting room, I was struck by the distance some women had travelled to get there. One had flown in from Inverness. There’s a large box of tissues on her desk because patients often break down in tears describing their symptoms. Many have lost jobs and partners. ‘Most women I talk to haven’t had sex for at least two years,’ she tells me. ‘Their vaginal dryness is so bad, they can’t wear trousers or even sit down.’
And Dr Fleming’s patients are so crippled by depressive symptoms that they become agoraphobic – unable to leave the house.
It’s worth noting that the suicide rate for 51- to 54-year-old menopausal women is higher than in any other age group. For some women, HRT really can be life-saving.
So, given my medical history, would Dr Newson write me a prescription? ‘In your case, I would start with a very small amount of oestrogen and see how you feel. We have to start treating women holistically, and that means not just looking at the cancer risk but their quality of life.’
I leave with a pack of oestrogen gel and progesterone tablets. I’ve decided to give it a go for three months. If my symptoms disappear, I’ll continue. If they don’t I will conclude that it’s not worth the increased risk. Statistically, my symptoms could last for up to 20 years. I don’t think I can face that.
Health comment by DR ELLIE CANNON
Over the past 20 years, studies have found an increased risk of breast and ovarian cancer in some women taking HRT.
Britain’s health watchdog, the National Institute for Health and Care Excellence, recognise breast and ovarian cancer as a known risk of taking combined HRT – oestrogen and progesterone.
For this reason, the NHS states that HRT may not be suitable for those with these cancers.
It is thought that, in some cases, the sex hormones oestrogen and progesterone may influence the growth of tumours. However, the risks remain very small and must be weighed up against the potential benefits of hormone treatment.
And these risks don’t necessarily apply to everyone.
For instance, the breast cancer risk doesn’t apply to women who take oestrogen-only HRT or those who are aged under 45.
Nor does it apply to women who have had a hysterectomy. It are also much lower if you take HRT for less than five years.
As soon as you stop taking HRT, the increased risk diminishes. All health guidelines state that the decision to prescribe hormones must be based on an in-depth risk assessment for every individual.
For most patients, the untold benefits of HRT for both mental and physical health easily outweigh the very small risk of cancer.