Caution needed: Dr Carol Benn says if a woman takes hormone replacement therapy for more than five years she risks 'fertilising' cancerous tissue in the breast. (Lisa Skinner)

The flush of hormonal success

Amy Green
Replacement therapy for menopause symptoms is considered safe – if the breast cancer risk is addressed.

Melinda Scott* (56) pressed her hands against the green-striped wallpaper she was hanging. Once she knew it wouldn’t fall she grabbed the roller on her left and violently rolled the paper flat against the wall. She was breathing hard, moving quickly. When she had completed the section she took her craft knife and begun to cut the edges near the bottom of the wall.

“Dammit,” she exclaimed as she tore a 10cm piece off by mistake. This was the last straw – she collapsed in a heap on the ground, head in hands, breathing hard.

“I had just got a call from the radiologist telling me I had breast cancer,” said Scott, from Springs on the East Rand. “And I wanted to finish that wallpaper then and there in case I popped the next week.”

One year later, after a double mastectomy and reconstructive surgery, Scott is happy, healthy and cancer-free but what her breast surgeon told her still puzzles her.

“I was told my cancer had something to do with the hormone replacement therapy [HRT] I was taking for menopause.”

Menopause
According to Tobie de Villiers, a gynaecologist from Stellenbosch University and immediate past president of the International Menopause Society, when “a woman goes into menopause, usually between her late 40s and 50s, her ovaries stop producing the hormones oestrogen and progesterone that they had done since she started menstruating”.

“In about 20% of women this can lead to problems or symptoms like hot flushes, night sweats, insomnia and mood swings,” he said.

“Women can also experience vulvar vaginal atrophy, which is when the vaginal wall thins and intercourse can become uncomfortable and painful.”

Another symptom is loss of bone density, which leads to osteoporosis.

HRT, oestrogen or progesterone, or a combination of the two, is the only medication that effectively treats these symptoms, said De Villiers.

Fertilising bad tissue
Scott took the hormone tablets for symptomatic relief of hot flushes. According to her breast surgeon Carol Benn, who works at Netcare Milpark and Helen Joseph hospitals in Johannesburg, the HRT can sometimes “fertilise” cancer cells already present in the breast.

“If you take HRT for a prolonged period of time – over five years – you run a small risk of fertilising the bad tissue in the breast,” she said.

In Scott’s case, Benn suspected the tumour had been there for many years but, owing to its small size, it was undetected: the HRT could have accelerated the growth of the cancer cells.

According to De Villiers, the association between HRT and breast cancer is complex.

“It relates to the duration of treatment: if you take it for a longer period – about seven years or more – it can have a small effect in promoting the growth of cancer cells already present in the breast,” he said. “When we talk about a further effect after 10 years we are not sure whether there may be a slight causative effect on top of the promotional effect.”

HRT: alternative options
On the other hand, women who have had a hysterectomy can take oestrogen only and “studies have actually shown this single therapy has a slight benefit for breast health”, De Villiers said.

Women who still have their uterus have to take a combination of oestrogen and progesterone, or risk endometrial cancer, “and we think it is the additional progesterone that contributes to breast cancer risk”, he said.

According to the South African Medical Journal (SAMJ), the risk of breast cancer attributable to HRT is “low and falls into the same risk category as several preventable risk factors”, including obesity, never having breast-fed, having a first pregnancy after 37 years of age and excessive alcohol intake.

As a strategy to avoid the risk of cancer, De Villiers suggests that women who still have a uterus insert an intrauterine contraceptive device which only secretes progesterone and take oestrogen orally.

“If you do this, the progesterone does not reach the breast, and you still get all the benefits of using HRT,” he said.

For women who only experience the menopausal symptom of vaginal dryness, localised oestrogen in the form of a pill or cream can be inserted into the vagina, said De Villiers. “If taken in this way the symptoms will be cleared without the hormone affecting other parts of the body.”

Difficult to predict risk
With research showing one out of nine South African women will get breast cancer in their lifetime, Benn said it was important for women to be aware of their risk profile.

But women should not forgo HRT if they are only worried about their breasts, she said.

“Six out of 10 ladies who get breast cancer have no risks, meaning you need to check your breast health even if you are healthy and think you are safe,” she said. “Responsible medicine means you should not be taking medicine unless you’ve checked things out. People would not be going on to hypertension medicine unless their blood pressure is being monitored regularly.”

Similarly, when taking HRT, breast health should be monitored regularly with self-examinations and yearly mammographic screening.

The Cancer Association of South Africa advises that symptom-free women over 40, and who are not on HRT, should go for a mammogram at least once every three years.

Duration of treatment
When considering how long women should stay on HRT, De Villiers said they should remain on treatment “until the indication is no longer valid”.

“This means if you are taking it for hot flushes you should stop it every few years to see if they return and if they do not you should discontinue treatment.”

A seemingly contradictory point is that the risk of breast cancer is lower for overweight or obese women on HRT whereas “risk is increased in lean women”, according to an SAMJ article.

Scott, an active mother of three, is not obese, does not drink more than two units of alcohol a day or have a family history of breast cancer. Her HRT use and low weight of 55kg for a height of 1.6m seems to have been her only risk factors.

“When I got that phone call from my radiologist I was shocked. That ‘C’ word is very frightening,” said Scott. “When Dr Benn suggested a double mastectomy I wasn’t worried about losing my breasts: you have to get the cancer out.

“After reconstructive surgery, my breasts are also bigger than they ever were,” she laughs. “On a recent family holiday to Durban my teenage son said to me on the beach: ‘Mom, you know you’ve got an hour-glass figure’.

“You know, at 56, I am more comfortable with my body than I have ever been,” Scott blushed.

* Name has been changed to protect the source’s identity


Menopause’s remedy: Benefits outweigh risks

Hormone replacement therapy (HRT) is the only medicine available to treat the symptoms of menopause, according to Tobie De Villiers, a gynaecologist from Stellenbosch University and immediate past president of the International Menopause Society.

During menopause, which usually starts when a woman is in her 40s or 50s, ovaries stop producing oestrogen and progesterone. In about 20% of women this can lead to hot flushes, night sweats, insomnia, mood swings, vaginal dryness which can make sex painful, loss of libido, and bone thinning which can result in osteoporosis. 

However, De Villiers said, since the early 2000s, when a study showed few protective benefits for the medicine, many women went off HRT and others became scared to seek this treatment. 

“Since then the findings of this study have been reinterpreted, with a global consensus on the benefits of HRT in that they outweigh the risks in most scenarios,” said De Villiers. 

There are ways to take the medication to ensure one is protected, he said. 

There is a window of opportunity during which a woman should start taking HRT: between the ages of 50 and 60 or within 10 years of the onset of menopause, noted the South African Menopause Society’s guidelines published in the South African Medical Journal earlier this year. 

If a woman begins HRT within this window any risks associated with HRT are significantly minimised and the “benefits far outweigh the risks”, according to the authors. 

These benefits include protection from heart disease, osteoporosis, and the alleviation of symptoms associated with menopause, said De Villiers. “If a woman begins HRT after this window, there is no heart disease benefit, but the bones will still be protected.” 

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breast cancerbreastfeedingobesityalcoholHRT