HRT and cancer risk

Lots of women come to our discussion forums and post that although they are in surgical menopause, they cannot take hrt because they have relatives with cancer. Or they come to us because either the media or their doctors have assured them that if they take hrt, it will give them cancer.

It's not actually that simple. And a lot of the discussions we have on that topic are to explore that situation in a lot more detail. Although it's easy to paint a picture where the risks are all on one side of the issue, that is absolutely not the case. So let's take a more in-depth look at this whole issue.

What kind of cancer risk?

The first part of the exploration any woman owes herself when making a decision of this magnitude is just what kind of cancer risk she actually has. One uncle with prostate cancer, to use a fairly easy example, is not the same thing as having one's mother, two aunts and three sisters all die of estrogen-receptor breast cancer. Even within the realm of breast cancer, there are cancers sensitive to estrogen, cancers sensitive to progesterone, and cancers indifferent to both hormones.

Given that, then, an informed decision about personal risk must begin with working with an oncologist, a cancer specialist, to explore our own personal risk level. This will include taking a detailed history, not only about our own health, but about those relatives who had cancer. It may include genetic testing. It may involve a medical records search for exact pathology of previous family cancers. It should be very thorough.

And when it's done, the question to ask is not "should I take hrt?" Any responsible oncologist will answer that question with a resounding "no!" Their specialty focus is preventing and combatting cancer, so they generally view no cost at all (and we'll get into those costs a bit more further along in this discussion) as outweighing any degree of cancer risk.

Instead, it may be more helpful to ask the question: "what are my relative risks?" Another way of asking this question is "if I had kept my ovaries, would I have had to have them removed in menopause in order to prevent a high probability of developing cancer?"

Because our goal with hrt supplementation in surgical menopause is really just bringing us up to a level of support that women in natural menopause receive from their ovaries, that's really the equivalent situation. In other words, if our menopausal ovaries would not have presented an unacceptably high level of risk, there's some question as to whether supplementing our hormones with hrt to that same level would present any greater risk. (That's qualified, however, because women who take certain progestins as part of their hrt may in fact experience a higher level of risk from that particular type of hrt.)

Yeah, but if there's any risk at all, shouldn't I abstain from hormones?

The problem is that risks aren't one-sided. There are many beneficial things that estrogen enables.
For example, women who take hrt have a well-documented lower incidence of colon cancer, which is a major killer in the US. If you have no family history or special genetic risk of breast cancer but do have a colon cancer family history, then you might want to weigh this decision differently from a woman whose risks stack up on the breast cancer side. There are no guarantees and there are many lifestyle factors that also play into risks or can be used to help mitigate them, but it's important to keep in mind that we can't let the word "cancer" make our brains short out entirely with panic.

While the exact role of estrogen's preventative actions is still being thrashed out by researchers, the overall maintenance of functional hormone levels does have some pretty compelling evidence for its importance. Doctors used to feel that ovarian production of hormones was essentially insignificant for health if a woman were no longer fertile, and that guided many to recommend removal of healthy ovaries as part of any hysterectomy on the grounds that this would reduce any chance of subsequently developing ovarian cancer. And since those hormones weren't needed and hrt was linked with breast cancer, many women found themselves up to their ears in symptoms of surgical menopause with no support beyond what non-ovarian estrogen their own bodies could make and whatever xenoestrogens they picked up from food and their environment. Still, that was healthier, according to their doctors.

That position was reconsidered a few years ago when studies on young women who had oophorectomies without subsequent hrt support revealed that by the time they reached the "normal" age of menopause, they had experienced a 70% increased incidence of mortality compared to women of the same age who had kept ovaries (supporting articles). In fact, in no group studied for risk (all causes, fatal and nonfatal coronary heart disease, or lung cancer) was oophorectomy associated with increased survival (source). Other studies have suggested that the same issue of increased risk exists with Parkinson's disease and dementia (source).

While these study results typically follow younger women, there's no reason to suggest that this risk is tied to a specific age. More broadly speaking, then, we have to question whether life in hormone deficiency at any age also carries significant risk of death by these other disorders, or at least an enhanced risk of developing them. There is no research to date that suggest that there is any sort of shelf date on our hormone needs.

And that really complicates our decision process. If, for example, a woman has a high incidence of cardiovascular disease in her family, such that most family members die by age 50 of heart attack or stroke but no one ever lived long enough to develop cancer, she might well want to think long and hard about her personal relative risks. It's not just a quality of life issue—although that's plenty significant for many of us. It's instead a health issue of just as much potentially fatal magnitude as that cancer risk on the other side.

If we make this anti-hormone decision based on cancer risk, we're making a cancer treatment decision

Many women who choose not to supplement their hormones due to a documented or perceived cancer risk find themselves miserable and desperate to improve their quality of life. "How can I feel good?" they demand on our discussion forums.

To some extent, we can alleviate some of the symptoms of hormone deficiency with non-hormonal measures. Some of those options are discussed elsewhere on this site.

But these women may be disappointed to find that not all of their areas of concern or symptoms have a non-hormonal "fix." Even where help is available, those approaches themselves often have pretty significant risks or side effects, or they may only reduce but not alleviate the problem. The bottom line is that not only are they embracing specific health risks with this strategy, but they are also going to have to put up with compromises in terms of quality of life.

Now this is where the medical sites all cheerily assert that life can be just fine with the proper attitude. All we need is a positive outlook or our religious faith and these minor bumps in our otherwise delightful life can be overcome. If that works for you, great. You probably don't need to read any further and can go on with your life. We're really happy for you.

Now, we're not saying that attitude isn't important. But if you're still grappling with the idea, here's a concept that may help you keep a balanced perspective: the things you are choosing to undergo in terms of hormone-deficiency-related effects are the specific choices you are making as part of treating your cancer. It doesn't matter whether you actually had cancer in the past or you just feel that you have such a high certainty of developing cancer in the future that this is your health priority, what you are engaged in is a medical treatment. And in common with all medical treatments, there are costs. These hormone-related symptoms are your costs.

So when you are hot flashing or lying awake at night or even wondering where your sex life went, while you're working on finding a set of good non-hormonal maintenance practices, you can remind yourself that you are not a helpless victim here: you have cancer and you are treating it. You are choosing these things specifically to battle your cancer. You're fighting back with every hot flash. Sure, they're miserable and you are wishing for the happily ever after you thought we were all promised, but you have cancer and you're fighting back in this way. The glass may only be half full, but cancer treatment is what it contains. That may not make it all better, but it does give it purpose.

Another critical question to ask

If my risk is so high that I need to treat it with hormone deprivation, should I also be taking drugs to suppress my own hormone production and use? Should I be observing special dietary precautions to limit exposure to xenoestrogens (estrogens from outside sources)?

Again, this isn't a question you can entirely answer on your own. But when you consult an oncologist, it's a good one to kick around. It's easy to for doctors to tell us not to do something and once they put our file folder away in the office records room, our hot flashes won't be keeping them awake at night. But if our risk is so severe that we have to endure hormone deficiency and we have to embrace an up to 70% risk that we'll die early anyway, shouldn't we do even more to reduce that risk?

Yeah, that casts things in a different light. When we ask a doctor to do something, like prescribe hormone-blocking drugs for us, then they have to much more explicitly consider the risks of that treatment. Then they may admit that the symptoms caused by these drugs make a lot of women give them up, or that these drugs have some significant risks. But hrts are only a small incremental exposure to hormones (even in surgical menopause, we make most of our post-ovarian estrogen in our adrenal glands), so if we have only that slight a risk and don't need to take that further step, do we really need to limit our hormones below normal menopausal levels at all?

This isn't a pep talk to make you see your way towards taking hrts. There truly may be a compelling reason why just this much deprivation and no more is exactly and totally what you need to be safe from cancer. All we're trying to do is suggest some ways to explore the options from different angles, to make sure that the treatment you select really is one that makes sense for you and will really do what it is you are wanting. "Don't take hrt and you won't get cancer" is a very simplistic thing to recommend, and because of that, we need to hold it up to close examination to make sure it's totally valid for our own personal situations. Because if we can do this, if we can embrace the sense of whatever measures we decide to take to treat our cancer, then we can live with the consequences of that decision with greater grace.

Are there other things I should do to reduce my risk?

This is a great question for all of us to ask, not just those who are actively treating a cancer or cancer risk. To some extent, we're all at risk and so we all should do what we can to minimize that risk. Even if we don't want to skip hrt, even if we don't want to practice hormone deprivation therapy, we can all work on risk reduction.

The first way we can reduce our risk is to supplement our hormones with only the minimum amount of hrt that otherwise meets our goals. We can do that by approaching our needs by working up from a low dose, by stopping increasing as soon as we feel okay. We can do that by challenging ourselves every few years with a trial of a small dose decrease, to see if our needs have changed. These are easy things, but because our overall risk of estrogen-related breast cancer is related to our cumulative lifetime estrogen exposure, these are a real risk reduction measure.

There are all sorts of dietary risk reduction strategies that we can find out there, some of which have good foundations in actual medical research and some of which are dramatic, profit-making wishful thinking. Just how far each woman wants to go with this is up to her, of course. But here is some of what we know.

Dietary fiber seems to hold a real relationship with reduced breast cancer incidence. Fruits and veggies do as well, although the actual components that have this effect have not been isolated so recommendations are for whole foods rather than refined elements taken as nutraceuticals. We know that there are xenoestrogens found in fruits and vegetables grown using pesticides and that much commercial meat raising involves dosing the animals with estrogens and other hormones that persist after slaughter. Alcohol and grapefruit raise our circulating estrogen levels and our risks, but coffee and tea don't test out as doing so. Red meat and a high fatty intake also raise risks.

There are also more subtle things we can look at to manipulate risk. The glycemic load of our diet and our fasting blood sugar level have been found to be tied to breast cancer risk. Anything that increases our proportion of body fat increases risk and losing weight lowers risk. All by itself, increasing exercise lowers risk. All of these things have actual research backing them up, and you can read articles on diet and breast cancer for yourself in our bookmarks account.

So that's a lot of lifestyle stuff we can work with to pitch in to the effort. And yes, they're maybe hard to want to change and to stick with. But remember: this is part of treating cancer risk. How much fat/red meat/inactivity/whatever is to (literally) die for? It's up to us but we owe it to ourselves to be honest about our efforts. No one's checking up on us or keeping a scorecard. If it's important enough to be worth not taking hrt for, isn't also important enough to modify our habits for?

The bottom line

Cancer isn't for wimps and neither is cancer treatment. That's why we need to be sure that we're not just responding in knee-jerk panic at the very thought of cancer but are realistically and with expert advice looking at our exact, personal level of risks and what we can do to reduce them. We have choices that range from blocking our body's ability to use any hormones to just reducing our hormone supply slightly to using other factors to help reduce our risk while we meet our minimal level of post-fertile hormone needs. Each choice has its own costs and level of benefits, and we have to remember that no choice is safe. Shall we say that again? There are no safe or easy choices. We only get to choose which of the risks we will experience.

What if I choose quality of life and the cancer risk that goes along with it?

That's a legitimate choice and many women, especially women who've successfully battled cancer, are asking just that. While their oncologists are advising them that the best way to reduce risk is to abstain from hrt forever, these women understand that there is more than one kind of risk and they're willing to undergo some risk to feel better now. Here's how one woman put her choice on our forums:
This past Saturday I discovered a mass in my left breast, above and to the left of the original tumor site. Recurrence is most likely in the first two years following diagnosis; it also has the poorest prognosis, especially given the aggressive treatment I had already gone through for the original cancer. I couldn't call for an appointment until Monday; once I called, they couldn't schedule me until Tuesday. My breast hurt, a dull achy pain with occasional sharper twinges - pretty much identical to what I had felt with the original tumor.
I had three days in which to worry and despair and think about what came next if it was a Terrible Bad Thing - yes, there's an 80% cure rate, but someone has to be in the 20%, and I'm well aware it could me. I kept very busy, trying not to think, and there were times when I sank to the floor weeping regardless.
The mass is fat necrosis, a result of radiation treatment - the fat cells in the breast die off when their blood supply is compromised, and they can then form a thickened layer of scar tissue and dying cells. The pain and discomfort will probably abate in time. I'm fine.
It was profoundly interesting to me though, that throughout that time - as I was contemplating a single or bilateral mastectomy, and whether I would opt for reconstructive surgery, and what course of adjuvant therapy I would be willing to consider, and how to tell everyone - there was truly no moment in which I regretted my decision to pursue ERT, even though I knew that had it been a recurrence, ERT would doubtless have been seen as a contributing factor.
Quality over quantity - and when it came down to the wire, I felt the same. That's good information to have, though the process of getting there was brutal.
If I do at some time face a recurrence, ERT *may* have contributed to that. I still will not regret it, and I will seek to continue therapy as palliative care.
We don't mean to suggest that every woman can or should feel this way, but we do feel that this choice belongs to you, not your doctors.  And if you'd like to see what other women have written on this topic or to discuss your own concerns in this area with them, please join us on our discussion forums.