Panel discussion on Breast Cancer, Menopause and HRT

As we close Breast Cancer Awareness Month (October 22) a group of leading clinicians took part in a panel to discuss Breast Cancer, Menopause and HRT, (Hormone Replacement Therapy) tackling some of the myths associated with the subject whilst championing the emergence of a pioneering screening process and existing innovative diagnostic procedures available to patients offering greater precision in the treatment of breast cancer. (Click here to watch) or see below under media.

Between 1 in 7 women in the western world will get breast cancer in their lifetime. Many women now understand that if they are asymptomatic, but carry a BRCA mutation they are at a high lifetime risk of developing cancer.

Professor Zoe Winters, Senior London Consultant Breast Cancer Surgeon at New Victoria Hospital contributed to the discussion by sharing news that HRT produces huge overall health benefits that particularly derive from Oestrogen replacement at the time of perimenopausal symptoms. Safest forms of Oestrogen comprise transdermal administrations that don’t significantly raise risks of breast cancer in the long-term. It is Progesterone long-term that does this, where it is required in women with an intact uterus to reduce unopposed oestrogen effects on the uterine lining.

All women should be aware that we are not all at the same risks for breast cancer within the general population. We are currently guided by predicted averages in the general population. Based on a recent UK randomised trial, including European guidelines, we recommend commencing mammograms at 40 years of age annually. Fifty-year olds may safely undergo 2 yearly mammograms indefinitely.

A mammogram is performed to assess both breasts in total and by comparing it to previous mammograms. One key finding to communicate with each woman is “What is your breast tissue density?” This is quantified by the radiologist assessing the ratio of breast duct tissues that appear “white” compared to fatty tissues that appear “darker” on the mammogram. Breast tissue density is a strong predictor of one’s breast cancer risks, where very dense breast tissues raise your risks by 4-6-fold compared to very fatty breasts. Very dense breast tissues may also reduce the sensitivity of mammograms, and we may miss detecting 20% of breast cancers. However, this guides how frequently we recommend mammograms, and whether we include bilateral breast ultrasounds or breast magnetic resonance imaging or MRIs.

Dr Kate Panter, Obstetrician and Gynaecologist at New Victoria Hospital, Consultant Gynaecologist and a specialist at the British Menopause Society went on to discuss the taboos around both menopause and taking HRT. While she feels the peri-menopause itself can still be considered taboo since many women struggle to even admit they are experiencing symptoms, she explains: “The taboo around taking HRT has in large part, come from the way the media talks about breast cancer risks associated with HRT. They portray HRT as the only risk for breast cancer, and a huge risk at that, when in fact there are other more significant lifestyle factors, such as obesity for example that can put you at risk of breast cancer. “

Professor Barbara McGowan, an Endocrinologist agreed by saying that many women have been too scared to take HRT because the link between HRT and breast cancer has been greatly distorted by the media over the past 20 years. She went on to explain: “There are recent publications that suggest a slight increased risk of breast cancer with taking HRT but that it will depend on the type of preparation. Never- the- less that risk remains reasonably low, and, after stopping HRT that risk tends to regress in time”.

There is often confusion from a woman’s perspective about the various types of HRT available and knowing what would suit them best.

Dr Panter talked about the different administrations of HRT. She explained: “When a woman is peri-menopausal, or going through the menopause, within a year of reaching menopause, or immediately post-menopausal, the time when you are no longer menstruating, you need to take cyclical HRT.

This means taking Oestrogen throughout the month and progesterone for the second half of the month. If your periods have stopped, for approximately a year – then we can give you what we call continuous combined or no-bleed HRT, where we give you a little bit of oestrogen and a little progesterone every day.”

There are various ways to take HRT, options include taking HRT orally or transdermally (through the skin, like gel or patches) or a combination, oestrogen gel applied to the skin and progesterone tablets.

Dr Panter discussed the benefits of taking transdermal HRT: “HRT used to be given orally, but that’s no longer the case, now we prefer to give oestrogen through the skin, as it doesn’t have to withstand digestion and so we can give an exact copy of your hormone, a bio-identical form of HRT, one that more closely represents our body’s own hormones, so there are benefits to transdermal administration. A natural copy of progesterone, Utrogestan, can be taken orally. There are also synthetic progestogens to be taken orally and they are much stronger than the hormones our bodies produce.”

There are alternatives if women decide they don’t want to use HRT or can’t take HRT for example if they have had hormonal cancers, these include vaginal lubricants and non-hormonal vaginal moisturisers as the vaginal area can be dry during menopause and Selective Serotonin Reuptake Inhibitors (SSRIs) anti- depression drugs which are effective for night sweats and CBT or Cognitive Behavioural Therapy for anxiety.

Dr Panter explained: “By the time most women come to someone like me they have already tried to manage their symptoms, they’ve visited the health shop, tried Magnesium, Red Clover, spent a lot of time and effort on diet and exercise and are very often at the end of their tether. One of the things I do recommend, is a self-help guide to Managing Hot Flushes and Night Sweats: A cognitive behavioural self-help guide to the menopause written by Melanie Smith and Myra Hunter a professor from King’s College London, which I think is helpful for women to work through as it helps to think about our symptoms differently and CBT is incredibly effective at managing depression and anxiety. “

Professor Winters spoke about symptoms that women should be aware of before visiting a one-stop-clinic such as New Victoria Hospital for a triple assessment to determine if they have breast cancer:

A discrete or a perceived lump in the breast, that can be differentiated from the surrounding firm but normal dense breast tissues, and the intervening soft fatty tissues. The one-stop breast clinic assessment requires careful clinical examinations and explanations alongside complimentary breast imaging interpreted by expert consultant radiologists. She explained that over 95.5% of breast pain is benign and rarely related to breast cancer.

Other key symptoms to be aware of are any bloody nipple discharge or ongoing nipple discharge that could also be exacerbated by HRT, however, any sustained inflammatory changes to the breast skin or nipple skin should be investigated.

Professor Winters explained: “In a one-stop setting, we are teaching women how to examine their breasts and trying to be very clear about what a lump constitutes, compared to what normal breast tissues feel like.”

On the topic of how long to take HRT and when or of to stop taking it, Dr Panter said if you are going to take HRT the maximum benefit and the fewest risks are to start it early, so around the time of your menopause to derive the most benefit and least risk, particularly if you start it early, where there is no benefit on holding out.”

Dr McGowan reiterated during the session that the benefits far outweigh the risks and urged women not to be scared to use HRT if it’s appropriate in their case. Dr Panter explained that HRT will help our lifestyles and more holistically will help us to sleep, to be calmer and to cope at work and at home. Professor Winters said she looked forward to a more personalised and finessed breast screening processes as breast cancer care evolves in the future.

Biographies: Contributing Guests –

Professor Zoe Winters – Breast  Cancer Consultant Surgeon & Breast Specialist

Professor Barbara McGowan – Endocrinologist

Dr Kate Panter – Consultant Gynaecologist at the New Victoria Hospital

With thanks to New Victoria Hospital and JFPR Consulting for putting this together.