27 AUGUST 2016
BREAST CANCER AND HRT
Nothing much usually stirs me before 7.30am, but when the report by the Institute of Cancer Research and Breast Cancer was announced on Radio 4 early last Tuesday morning, I sat bolt upright in bed.
Running roughshod over those wonderfully comforting guidelines issued by Nice last year, it suggested that the risk of breast cancer highlighted by previous worrying (if disputed) studies had actually been underestimated - and that HRT can in fact triple the risk.
In panic, I immediately left three different messages for my gynaecologist, Professor John Studd. What should I do?
I can understand how some people get inured to stories about HRT and breast cancer, when there’s so much flip-flopping around the subject.
But not me. As one who was diagnosed with oestrogen positive cancer ten years ago, almost to the day, I need to know everything that is out there, as soon as it comes out, however alarmist or contradictory.
Breast cancer had come as a shock and, I’d always assumed, meant that HRT would never be an option for me - but not so.
Besides… three times the risk? And this, apparently, for women who hadn’t even had it yet. Well, that’s not nothing.
Cancer, of course, had come as a shock. In one way, I still can’t quite believe that someone, somewhere in the lab didn’t make some terrible mistake, when they told me that the little grape seed I felt in my right bosom while having a shower in the summer of 2006 was not just a cyst.
In another way, given my capacity to cane it, I’m surprised I got off so lightly. (Grade I requiring a lumpectomy and radiation. No chemo, no mastectomy.)
Certainly, I’d always assumed that HRT would never be an option for me, given Nice regulations recommend it not be “routinely offered” to women with a history of breast cancer.
But it’s not so black and white, according to quite a few doctors I talked to when menopause hit a couple of years ago, at the age of 54.
Were my symptoms that bad? They never are, in retrospect. But they were bad enough - the hot flashes, the sleeplessness, the anxiety and worst of all, the weight gain - to have me seek a second (and third) opinion after being told by the first (a charming French man from the menopause centre at Clinique La Prairie in Montreux, Switzerland) that I wasn’t eligible.
One was from Professor Studd, founder of the first menopause clinic in Europe in 1970, and a somewhat controversial - he would say, pioneering - figure in the medical profession because of his stout belief in HRT.
He told me that I was not, in fact, at risk and that I’d be mad not take it with my history of lacy bones and depression. Another specialist in New York, Erika Schwartz, agreed.
Were my symptoms that bad? They never are, in retrospect. But they were bad enough
So, in the autumn of 2014 I started taking a bio-identical (more on this, later) combination of oestrogen in gel form and progesterone in pill form and almost immediately the hot flashes went. So did the sleeplessness and the anxiety and the bloatedness.
Having always guiltily thought that I should be strong enough to suck up my symptoms on my own (as both my mother and sister had done) I suddenly realized just how much hormones (or the lack of them) had been ruling my life. So this is what it was like to be in perfect hormonal synch! Something I hadn’t felt since — well, probably before adolescence.
My lovely Harley Street oncologist, Carmel Coulter, wasn’t exactly over the moon about my decision but, hey, my bloods were fine, my last MRI scan, which I have every year along with a mammogram and ultrasound, was negative, and my cancer had “only” been low-grade.
Besides which, the hormones Studd prescribed were “bio-identical” - distinct from Premarin, the most common form of HRT, which is made of reconstituted horse wee - and designed in a laboratory to mimic the exact kind manufactured by the human body (although whether this makes them safer than FDA-approved synthetics is yet to be clinically proven).
Even more reassuring were those revised Nice guidelines, last year, which went quite far in outlining the benefits of HRT after the bad name it got via two major studies at the beginning of this century.
Both the University of Oxford’s Million Women Study and the US Women’s Health Initiative Study had reported that the taking of combination (oestrogen and progesterone) HRT raised the risk of breast cancer - not to mention stroke, blood clots and gallstones.
In their wake, the number of prescriptions for HRT halved around the world. But over the years, their findings were widely disputed, and lost in the worry were the very profound benefits of taking HRT for preventing osteoporosis, colon cancer and, in particular, heart failure (a far bigger killer of women than breast cancer).
The benefits of HRT got a bad name via two major studies at the beginning of this century, which saw prescriptions halve around the world
Finally, after a decade urging caution, in 2015 Nice concluded that up to a million women could be “suffering in silence” after being frightened off treatment, and that doctors often “overestimate the risks and contraindications [of HRT], and underestimate the impact of menopausal symptoms on a woman’s quality of life.’’
All in all, I was covered, right? Or so I thought, until Tuesday.
Though on holiday in France, Professor Studd messaged me right back. Yes, I can just stop, if I so choose - no need to taper off as with, say, Prozac - but why would I want to do that?
This study, he said, was based on women who continuously took a combined, one-size-fits-all synthetic prescription, distinct from what I was taking. (I take transdermal oestrogen daily, but only take progesterone - the supposed “culprit” when it comes to breast cancer risk, but necessary if you still have a womb, to decrease the risk of womb cancer - the first seven days of every other month).
“It has been known for ages that progesterone is the risk factor and that oestrogen-only does not carry a risk, as the available studies show no risk or [even] a decreased risk of breast cancer on this treatment,” he wrote, en vacances. “The epidemiologists have looked at the least safe HRT preparation, which is oral continuous combined oestrogen plus progesterone. They know this.”
My preparation, he insisted, is both beneficial and safe. “We need the epidemiologists to wake up. Although producing high profile bad news does help next year’s funding!!”
Phew. Sort of. But the headlines can’t help niggling.
One thing very much in my favour is that I don’t drink anymore. The reasons I stopped were manifold but one was the evidence, almost everywhere I looked, of a link between oestrogen positive breast cancer (the most common kind) and alcohol. Who knows exactly what caused mine, but my instinct tells me a love of wine may just have had something to do with it.
When a gynae I met while doing the menopause doctor rounds told me I was probably better off taking the “worst” most bludgeoning type of HRT (that is, the cheap horse wee type) and not drinking alcohol than taking the HRT made of, as it were, mermaids tears, and continuing to drink, something clicked. Eight months ago, therefore, I stopped for good. Was it hard? Yup. Do I feel better for it? Immeasurably.
Aside from my medical history then, I’m actually what you call low risk. I’ve got a BMI under 21, I don’t smoke, I exercise regularly and eat well. Having already had cancer I get checked regularly and I’ve only been on HRT for two years (the study identified the highest risk among women who had been taking it for 15 years of more).
Indeed, there is some inferred data that suggests bio-identical progesterone of the kind I am using, Utrogestan, may in fact be protective against breast cancer (but as yet there are no specific studies on outcomes). According to this latest report, if I did decide to stop now, my risk factor would go right back to what it was before I started taking it.
To be quite honest, I’m far more worried about my abominable short term memory than I am about my cancer recurring, and in the warm optimistic fug of my first coffee I feel, on balance, it is worth it; that, for me, the benefits of the one just about cancels out the risk of the other.
And yet as the day wears on, I find myself wavering.
Maybe, after two years, I don’t even need HRT any more. Maybe, just maybe, the effect was partially psychosomatic? Maybe —and this is a little out there —I should have had a hysterectomy so as not to bother with the progesterone any more?
It seems so innocuous, that single pump of odourless Oestrogel I rub into my wrists every night, and though the Utrogestan pills make me a little bloated (and, look away chaps, have given me back my period) I must only endure them for seven days every other month.
And yet... however much Professor Studd’s no-nonsense James Robertson Justice-like manner always manages to reassure - I’m booked in to see him, upon his return – I can’t help but wonder if I’m being a bit of a guinea pig here.
Due to begin my next round of progesterone pills on Thursday, I’m still in two minds as to whether to continue with them or not. It's a deeply personal decision, for every woman. Hopefully, I'll make the right one.