• One in seven women will develop breast cancer during their lifetime
• Some treatments for breast cancer can lead to menopause
• Advice on menopause treatment options if you have a history of breast cancer

If you’ve had breast cancer and are wondering what your treatment options are for menopausal symptoms and future health, this guide is for you. It has been written by healthcare professionals and includes contributions from women affected by breast cancer.

Breast cancer and hormones

Breast cancer is the second most common type of cancer in the UK: about one in seven women will develop the disease over their lifetime [1].

Breast cancer is a complex disease, and there are many different types, and the role of oestrogen in the disease is still poorly understood.

When cancerous cells are examined after a biopsy or surgery, it’s established whether or not they have receptors for oestrogen. If they do, it’s known as oestrogen-receptor-positive (ER-positive) breast cancer; if they don’t, it’s ER-negative. This is important when it comes to deciding on treatments for menopause symptoms: knowing whether your cancer was ER positive or negative may influence your decision about taking HRT or not.

All cells in your body have oestrogen receptors on them, so having an ER-positive breast cancer does not mean that oestrogen has caused breast cancer.

RELATED: Dr Corinne Menn: I’m a doctor who’s had breast cancer: here’s what I want you to know

Menopause explained

The usual definition of menopause is a year after a woman’s last menstrual period.

Menopause is related to a decline of the hormones oestrogen, progesterone and testosterone, which are produced in the ovaries and also other organs and tissues, including your brain.

Hormones work as chemical messengers throughout your entire body – reaching and having an effect on every single cell. The hormones oestradiol (the beneficial type of oestrogen), progesterone and testosterone have been shown to improve thousands of cellular actions which then improves function of your body systems and organs. In particular, they have many beneficial actions on bone, brain, circulation, urinary, genital and nervous systems.

When might menopause happen for me?

The average age a woman in the UK experiences menopause is 51 [2]. However, it can occur earlier or later than this – health conditions, genetics, ethnicity and your social economic background can influence the age you experience it, as well as treatment for cancer.

Your menopause may occur at a younger age as some treatments for cancer, such as chemotherapy or radiotherapy, affect ovarian function resulting in hormones levels reducing. This might be a permanent or temporary menopause depending on the type of treatment you have.

RELATED: Surgical and chemical menopause

What kind of symptoms can menopause bring?

Common symptoms of menopause include:

• Night sweats
• Hot flushes
• Mood changes
• Memory problems
• Fatigue and poor sleep
• Brain fog
• Loss of interest in sex or relationships
• Joint pains and muscle aches
• Hair and skin changes
• Worsening migraines and headaches
• Vaginal and urinary symptoms.

It can be difficult to know which symptoms are due to side effects of treatment for cancer, and which are menopausal symptoms.

RELATED: Surprising menopause symptoms

Spotlight on aromatase inhibitors, tamoxifen and menopause symptoms

Tamoxifen is a type of hormone therapy used for the prevention and treatment of breast cancer. It is a selective oestrogen receptor modulator (SERM), which means it blocks oestrogen on some cells, including in the breast, but not on others.

Aromatase inhibitors are a type of hormone therapy used to treat breast cancer in post-menopausal women whose ovaries are no longer producing oestrogen. Sometimes they are used in those who are pre-menopausal, but usually only if their ovaries are ‘switched off’, which is usually done with a hormone injection. The purpose of taking aromatase inhibitors is to prevent the production of oestrogen anywhere in your body.

If you are taking an aromatase inhibitor and experiencing severe menopause symptoms or side effects, you could talk to your breast specialist about the possibility of either stopping your medication for a few weeks to see if this improves your symptoms or taking tamoxifen or another alternative treatment.

RELATED: Podcast: breast cancer treatment and HRT

How can I mange my menopause?

Every woman’s experience of menopause is different and your decisions regarding menopause treatment may change over time.

Your menopause may be temporary due to one of your treatments, for example if you are taking an aromatase inhibitor, or it may be permanent, for example if you have had your ovaries removed or you are at the age of menopause.

Optimal menopause care involves both improving symptoms and safeguarding your future health. Lifestyle changes such as optimising your nutrition, exercise and wellbeing are key, though this can of course be challenging if you are struggling with menopause symptoms or side effects of your cancer treatment.

Here are some lifestyle strategies that can be beneficial:

Keep active

Movement and exercise are important for your general health and also help to keep your bones and heart strong. Ideally you should aim for a combination of activity that raises your heart rate but also impacts through your joints. If fatigue is still a factor, start with a gentle, lower impact activity such as walking, and gradually build up the duration and frequency you are active for. This can improve your emotional wellbeing too.

Make time for you

Spending time doing things you enjoy is beneficial for your mental health. Whether that is going for a walk, catching up with a friend, or spending some much-needed time by yourself enjoying a hobby. Learn to value time just for you.

Eat well – and cut out unhealthy habits

Foods that are beneficial include are those rich in calcium for your bones, friendly to the gut containing prebiotics and probiotics, carbohydrates that have a low glycaemic index (GI) and are broken down more slowly, and foods rich in omega 3 oils. Prioritise fresh fruit and vegetables and adequate protein, as well as trying to limit the amount of processed food you eat.

Some women find that alcohol, particularly red wine, triggers hot flushes and night sweats, though the evidence is mixed in this regard [3,4].

Smoking can worsen hot flushes [5] and increases your risk of developing more than 50 serious health conditions including many types of cancer, heart and blood vessel diseases, and conditions affecting your breathing and lungs [6].

How might the menopause affect my future?

After menopause, your levels of the hormones oestradiol, progesterone and testosterone will remain low forever, unless you take hormone replacement therapy (HRT). Menopausal women have an increased risk of developing heart disease, osteoporosis, type 2 diabetes, clinical depression and dementia.

An earlier than expected menopause may also impact any plans you had to start or add to your family: if you’re struggling with an early menopause and prospect of infertility, The Daisy Network is a charity you may find useful. They have lots of helpful information on their website at www.daisynetwork.org about all these issues, including forums to chat with other young women facing similar issues.

Menopause treatments

Talking therapies

There is some evidence that cognitive behavioural therapy (CBT) can improve some symptoms and improve your quality of life. However, CBT will not improve future health and has not been shown to improve all menopausal symptoms.

Non-hormonal prescription medications

There are numerous preparations marketed for menopausal women either to buy or available on prescription. There is little evidence to support their use for many of them and many of these preparations have not been tested in studies on women who have had breast cancer.

Some types of medication, including gabapentin, pregabalin and antidepressants, such as venlaflaxine have been shown in some studies to improve hot flushes, night sweats and for some women, mood. However, they will not improve all symptoms nor improve future health and many women experience side effects with them. Fezolinetant is a new drug that has been approved to treat moderate to severe vasomotor symptoms in menopausal women. Fezolinetant does not treat other menopausal symptoms, and there is no long-term data regarding the impact of fezolinetant on cardiovascular and bone health, or breast cancer incidence. There are no studies involving women with breast cancer taking fezolinetant. The have been concerns about risks of liver disease and also cancer in some women taking this medication [7, 8].

RELATED: Fezolinetant explained

Hormone treatments

Hormone replacement therapy (HRT) is usually the first line treatment for the management of perimenopausal and menopausal symptoms [9]. There are systemic and local (vaginal) hormones – these have different effects, benefits and risks.

It is important to see a doctor who has clinical experience and knowledge both in managing women who have had breast cancer and menopause – often more than one clinician will be involved in your treatment decisions. It is essential that you are involved in all treatment decisions.

The type of hormones you need and the doses you’re given vary between each woman – it is not a ‘one type fits all’ prescription. HRT will usually contain oestradiol, progesterone and sometimes testosterone. These hormones are usually prescribed separately and it is important that you are given the right type and dose.

RELATED: Getting to the truth around HRT and breast cancer with Dr Avrum Bluming

Women are prescribed hormones to both improve their symptoms as well as their future health. HRT can include the following three hormones:

Oestradiol: this hormone is produced predominantly by your ovaries, but it is also made in your brain and other tissues. Levels fluctuate during perimenopause before declining in menopause and staying low for the rest of your life. Oestradiol helps to regulate your menstrual cycle, plays an important role in bone health, memory and cognition and cardiovascular health and is essential for many bodily functions.

Progesterone: if you still have your uterus (womb), taking oestrogen can cause the lining (endometrium) to thicken. To prevent this, you will usually need to take progesterone to keep the lining of your womb thin and regulate or stop bleeding. Progesterone can also relieve perimenopausal and menopausal symptoms such as sleeping problems, low mood and anxiety, and can be taken by women who have had a hysterectomy or use a Mirena coil as part of an individualised consultation for their symptom control.

Testosterone: this hormone is perhaps best known for improving libido, but you have testosterone receptors all over your body so the decline in levels can also lead to a loss of energy and brain fog, muscle and joint pains, low energy, poor sleep as well as other symptoms.

Can I take HRT if I have a history of breast cancer?

NICE guidance on early and locally advanced breast cancer states HRT should not be routinely offered women with menopausal symptoms and a history of breast cancer [10]. In exceptional circumstances, it adds, that HRT can be offered to women with severe menopausal symptoms and with whom the associated risks have been discussed.

Some women may choose to accept an increased risk of relapse in exchange for relief from menopausal symptoms and an improved quality of life, and that preferences may vary according to individual circumstances and the absolute risk of relapse, which is uncertain due to lack of solid evidence and research in this area.

The lack of evidence from prospective studies and randomised controlled trials highlights the importance of shared decision making in this highly complex area.

What does the research show about HRT in women who have had breast cancer?

The research that has been undertaken regarding taking HRT after breast cancer shows conflicting results: many studies are of poor quality and so the results are difficult to interpret properly. In addition, the studies have often involved older formulations of HRT to the types often prescribed now.

Since 1980, there have been 26 studies published on this area (25 studies have shown no increased risk and 5 showed benefit; 4 reported decreased mortality) [11,12]. Only one, the Hormone Replacement After Breast Cancer – Is It Safe? (HABITS) trial, reported an increased risk of local recurrence, but not metastatic disease or breast cancer death [13]. This study also used older and synthetic types of HRT.

There is a lack of robust evidence on giving HRT and testosterone to women who have had a past history of breast cancer and their risk of recurrence. There is some evidence that testosterone may be beneficial for women who have had breast cancer [14]. However, some women chose to take HRT and/or testosterone as their quality of life is suffering without it. They are also keen to obtain the future health benefits of taking natural, body identical HRT, as women who take HRT have a lower future risk of osteoporosis, diabetes, coronary heart disease, clinical depression, dementia and also some cancers [15].

What is key is that all treatment decisions are based on your individual circumstances, and if you decide you may want to take hormonal treatment, this should be a shared decision-making process with you and your healthcare team.

There are different types and doses of hormones. Testosterone has been shown in some studies to be beneficial to women who have had breast cancer, including those women who are also taking an aromatase inhibitor [16,17].  

Hormones used in HRT are much lower that the doses of hormones in contraceptives and they are also natural (they are synthetic in all contraceptives) – so the same chemical structure as the hormones you produce when you are younger. They are also short acting in your body, so do not build up with time.

Some women decide to take HRT for a few months and then assess how they are feeling and how many of their symptoms improve. They feel reassured knowing that they can stop taking HRT at any time and the hormones will all be out of their body within a day of stopping them.

What are the risks of systemic HRT if I’ve had breast cancer?

It is not possible to quantify risks as they vary between different people and are likely to be different for different types of breast cancer in the past too. If you have had breast cancer, your healthcare team should explain any potential individual risks when it comes to taking HRT, so you can weigh up the pros and cons of any decisions around possible treatment.

It’s important you are informed about benefits and any potential risks and how treatment might impact your quality of life and future health, so you have enough information make an informed decision.

Ductal Carcinoma in Situ (DCIS) and Lobular Carcinoma in Situ (LCIS)

It is unlikely that women taking HRT after DCIS and LCIS have increased risks, however studies have not been undertaken in this area.

ER-negative breast cancer

If you have had an ER-negative breast cancer in the past, then some women consider taking HRT as this cancer does not have receptors for oestrogen in it and so taking HRT is unlikely to be detrimental to future health or risk. 

ER-positive breast cancer

If you have ER-positive breast cancer, you should talk to healthcare professionals who are experts in treating people for the menopause after breast cancer – it’s usually advisable to talk to a menopause specialist, as well as a breast specialist oncologist to talk about your individual circumstances.

HRT and aromatase inhibitors and tamoxifen

Tamoxifen works differently in different women and does not block oestrogen throughout your body. Research has shown that some women who take tamoxifen actually have more oestradiol in their bodies than women who do not take tamoxifen [18]. Some women take HRT with tamoxifen with benefit to both their symptoms and their future health.

Taking HRT containing oestrogen will not usually have any benefit to your symptoms if you are taking an aromatase inhibitor. However, some women take testosterone with their aromatase inhibitor with beneficial effects to their symptoms and possibly their future health [19].

Spotlight on vaginal hormones

Vaginal hormones, also known as local hormones, are different to HRT as they are very low dose and do not get absorbed into your body. They can usually safely be prescribed for women who have had any type of breast cancer [20,21,22,23].

Vaginal hormones can improve symptoms of vaginal dryness, soreness, irritation, pain as well as improve urinary symptoms such as cystitis, recurrent urinary tract infections, increased frequency of passing urine, incontinence and urgency.

They can be given as an oestrogen pessary, vaginal tablet, gel, cream or ring, or as a daily pessary called prasterone. The prasterone pessary contains a hormone called dehydroepiandrosterone (DHEA), which converts to both oestrogen and testosterone in the vagina and surrounding tissues. Vaginal hormones can often be beneficial in women who take aromatase inhibitors or tamoxifen [24].

Managing vaginal and urinary symptoms

Whether you use vaginal hormones or not, if you are experiencing localised symptoms then you may find the following measures help:

• Avoid using soap, shower gels, deodorants, or ‘intimate’ products, and try a gentle emollient wash instead
• Panty liners, spermicides and many brands of lubricants can contain irritants which can make symptoms worse
• Tight-fitting clothing and long-term use of sanitary pads or synthetic materials can also worsen symptoms
• Vaginal moisturisers such as YES VM, Sylk Intimate, or Regelle can help hydrate your tissues and reduce soreness and discomfort throughout the day
• Specialist lubricants for when having sex, such as Sylk, YES OB or YES WB can ease discomfort and make the experience more enjoyable. If you’re using a barrier method of contraception, water-based lubricants are usually best.

Speaking to your healthcare team about managing your menopause

You should be able to make decisions about treatment with your doctor or other healthcare professional. Guidelines from the General Medical Council and recommendations from NICE show how decisions should be made between a patient and doctor and specify that a shared decision-making process should be used.

This involves:

• Encouraging you, the patient, to take an active role in making decisions about their treatment

• Taking into account what is most important to the patient, their expressed needs and priorities and treatment options are explained in light of these

• Open discussion of the risks, benefits, and consequences of each treatment option, including doing nothing, with the acceptance that the patient’s views can differ to the professional’s

• Allow time to answer questions and time to make decisions, making it clear that the patient can change their mind down the line

• Come to a joint decision that is satisfactory to you, the patient.

Here are some other strategies that can help menopause conversations with your healthcare team.

Be your own advocate: being informed means about symptoms and treatment options allows you to be more involved in treatment choices that are right for you – just ensure you uses reputable sources

Keep a record of your symptoms: recording the range, frequency and severity of menopause symptoms helps to build a picture for your healthcare team – the balance menopause support app has a free symptom diary.  You can also use these tools to measure any improvement in your symptoms once you start a treatment.

Plan ahead for your appointment: you might want to ask for a double appointment. Write comments or questions down beforehand and inform your healthcare professional what you want to discuss in advance: this ensures you get the most out of your consultation and gives them an opportunity to do their own research.

Also remember that if you do not get the desired outcome at the first appointment, you do have a right to ask for a second opinion. You can ask to see another clinician within your practice or for a referral to an NHS menopause specialist clinic in your area. Another option is having an appointment with a private menopause specialist.

RELATED: How to talk to your doctor about HRT – and get results

Real life stories from women who have had breast cancer

Caroline went through breast cancer, surgery and chemotherapy and became menopausal when she was 39. She says of her experience:

‘In hindsight, much of my anxiety around taking HRT was due to the symptomatic effects of the menopause. I couldn’t think straight and needed time, the right information and guidance. In the end, small steps worked. Since going on HRT, my anxiety has dramatically reduced, and I can make clearer decisions that are driven by logic rather than fear’

Mel decided to try vaginal oestrogen several years after her breast cancer treatment finished. She says:

‘I recently made the decision to start using vaginal oestrogen. Enough was enough. My symptoms were so severe and worsening, and it was really impacting on my quality of life. For me, it has been a great decision and it has made a huge difference.

However, I don’t regret not making the decision earlier, as I believe you have to make each decision in life based on the information available and how you feel at the time – you can’t look back with regret.

My point is, things can change, the balance can be tipped and that’s ok. The most important thing is being comfortable that it is the right decision for you. I can truly understand why women who have had breast cancer may choose to either have or not have hormones, either vaginally or systemically. But they should have the opportunity to make an informed choice, and most importantly, be at peace with that choice.’

Further resources and recommended reading

 National Institute for Health and Care Excellence (NICE) (2024)  ‘Menopause: Identification and management’

NICE (2024) ‘Early and locally advanced breast cancer: diagnosis and management’

Avrum Bluming ‘Oestrogen Matters’. Published by Piaktus, London.

British Society of Sexual Medicine, ‘Position Statement for Management of Genitourinary Syndrome of the Menopause (GSM)’

References

1. Cancer Research UK, ‘Breast cancer statistics’

2. National institute for Health and Care Excellence (NICE) (2024), ‘Menopause: what is it?’

3. Sievert, L. L., Obermeyer, C. M., Price, K. (2006). ‘Determinants of hot flashes and night sweats’, Annals of Human Biology, 33(1), pp.4–16. doi.org/10.1080/03014460500421338

4. Schilling C., Gallicchio L., Miller S.R., Langenberg P., Zacur H., Flaws J.A. (2007), ‘Current alcohol use, hormone levels, and hot flashes in midlife women’, Fertility and Sterility, 87 (6), pp.1483-6. doi: 10.1016/j.fertnstert.2006.11.033

5. Butts S.F, et al (2012), ‘Joint effects of smoking and gene variants involved in sex steroid metabolism on hot flashes in late reproductive-age women’, The Journal of Clinical Endocrinology and Metabolism, 97 (6), E1032–E42, doi.org/10.1210/jc.2011-2216

6. NHS.uk (2018), ‘What are the health risks of smoking?’, www.nhs.uk/common-health-questions/lifestyle/what-are-the-health-risks-of-smoking

7. Douxfils J., Beaudart C., Dogne J.M. (2023), ‘Risk of neoplasm with the neurokinin 3 receptor antagonist fezolinetant’, Lancet, 402(10413):1623-5. doi.org/10.1016/S0140-6736(23)01634-3

8. Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012–. Fezolinetant. 2024 Oct 10. PMID: 39441946

9. National Institute for Health and Care Excellence (NICE) (2024) ‘Menopause: identification and management’

10. NICE (2018), ‘Early and locally advanced breast cancer: diagnosis and management’

11. Cold, S, Cold, F, Jensen, M, Cronin-Fenton,D, Christiansen, P, Ejlertsen, (2022), ‘Systemic or Vaginal Hormone Therapy After Early Breast Cancer: A Danish Observational Cohort Study’, JNCI: Journal of the National Cancer Institute, doi.org/10.1093/jnci/djac112

12. Bluming, A, (2022) ‘Hormone replacement therapy after breast cancer: it is time’, The Cancer Journal, 28 (3), pp. 183-90, doi: 10.1097/PPO.0000000000000595

13. Holmberg L, Anderson H, (2004), ‘HABITS steering and data monitoring committees. HABITS (hormonal replacement therapy after breast cancer–is it safe?), a randomised comparison: trial stopped’, Lancet, 7;363(9407) pp.453-5. doi: 10.1016/S0140-6736(04)15493-7. PMID: 14962527.

14. Glaser R.L., York A.E., Dimitrakakis C. (2019), ‘Incidence of invasive breast cancer in women treated with testosterone implants: a prospective 10-year cohort study’, BMC Cancer, 19(1):1271. doi: 10.1186/s12885-019-6457-8

15. Gambacciani, M., Cagnacci, A., Lello, S. (2019), ‘Hormone replacement therapy and prevention of chronic conditions’, Climacteric, 22(3), 303–306. doi.org/10.1080/13697137.2018.1551347

16. Glaser R.L., Dimitrakakis C. (2013), ‘Reduced breast cancer incidence in women treated with subcutaneous testosterone, or testosterone with anastrozole: a prospective, observational study’, Maturitas, 76(4):342-9. doi: 10.1016/j.maturitas.2013.08.002

17. Glaser R., Dimitrakakis C. (2015), ‘Testosterone and breast cancer prevention’, Maturitas, 82(3):291-5. doi: 10.1016/j.maturitas.2015.06.002

18. Berliere M. et al. (2013), ‘Tamoxifen and ovarian function’, PLoS One. doi: 10.1371/journal.pone.0066616

19. Glaser R., Dimitrakakis C. (2015), ‘Testosterone and breast cancer prevention’, Maturitas, 82(3):291-5. doi: 10.1016/j.maturitas.2015.06.002. Epub 2015 Jun 24. PMID: 26160683.

20. Agrawal P. et al. (2023), ‘Safety of vaginal estrogen therapy for genitourinary syndrome of menopause in women with a history of breast cancer’, Obstet Gynecol,142(3):660-668. doi: 10.1097/AOG.0000000000005294

21. McVicker L. et al (2024), ‘Vaginal estrogen therapy use and survival in females with breast cancer’, JAMA Oncol, 10(1):103-108. doi: 10.1001/jamaoncol.2023.4508

22. The 2022 hormone therapy position statement of the North American Menopause Society advisory panel (2022), ‘the 2022 hormone therapy position statement of The North American Menopause Society’, Menopause, 29(7):767-794. doi: 10.1097/GME.0000000000002028

23. Hussain I., Talaulikar V.S. (2023), ‘A systematic review of randomised clinical trials – the safety of vaginal hormones and selective estrogen receptor modulators for the treatment of genitourinary menopausal symptoms in breast cancer survivors’, Post Reprod Health, 29(4):222-231. doi: 10.1177/20533691231208473

24. Mension E. et al (2022), ‘Safety of prasterone in breast cancer survivors treated with aromatase inhibitors: the VIBRA pilot study’, Climacteric, 25(5):476-482. doi: 10.1080/13697137.2022.2050208

The post A guide to menopause if you’ve had breast cancer appeared first on Balance Menopause & Hormones.

This week on the podcast, Dr Louise is joined by Dr Corinne Menn, a New York-based, board-certified OB-GYN and North American Menopause Society Certified Menopause Practitioner, with more than 20 years of experience caring for women.

When she was 28, Corinne was diagnosed with breast cancer. Following her BRCA2+ diagnosis, she underwent multiple surgeries and chemotherapy then navigated pregnancy and menopause plus longer term survivorship issues.

Corinne received support from the Young Survival Coalition, an organisation that advocates for women under 40 with breast cancer, and worked with her oncologists to manage her pregnancy, menopause and treatment options.

She feels passionately that women who have or have had breast cancer receive individualised care and treatment for their cancer and menopause symptoms, and shares three tips to help with quality of life:   

1. Do not minimise your menopausal symptoms, your hot flushes, your night sweats, sleep etc. So whether you use hormonal therapy or non-hormonal medications, make sure you get help and can sleep so you function better and breaking the vicious cycle of spiralling menopausal symptoms.
2. Please do not neglect vaginal sexual health. Again, if you can preserve a little bit of that, it can stop a negative cycle of suffering, of urinary tract infections and relationship and intimacy issues.
3. Scheduling time to have a separate appointment with your oncologist and your GYN. Come prepared. Listen to Louise’s podcast. Listen to Menopause in Cancer podcast and Instagram page. Be empowered because you and your quality of life are worth it.

You can follow Corinne on Instagram at @drmennobgyn

Click here to find out more about Newson Health.

The post Dr Corinne Menn: I’m a doctor who’s had breast cancer: here’s what I want you to know appeared first on Balance Menopause & Hormones.

This week on the podcast Dr Louise meets comedian Anne Gildea, who will be joining Louise on her 34-date theatre tour this autumn, Hormones and Menopause: The Great Debate.

Anne, a founding member of Irish musical-comedy trio The Nualas talks to Louise about her diagnosis of breast cancer, aged 45, and her ensuing menopausal symptoms, which she was unprepared for. She explains how her research inspired her to create her own show, How to Get the Menopause and Enjoy It.

Louise and Anne discuss why they’ve come together to create a new show that will take you on a journey through the history of women’s health and lead you to see menopause and hormones in a whole different light.

Finally, the pair share some of the reasons they think people should come to the show:

1. It’ll be a wonderful night out – a real sharing experience where you can also have a laugh.
2. There’ll be lots to learn with new content and a sharing of knowledge.
3. You’ll be able to ask questions and gets answers. Some shows will also have doctors available in the interval but Louise will answer questions on the stage as well.

You can follow Anne on Instagram @annegildea  

To buy tickets to the show click here

Click here to find out more about Newson Health

Transcript

Dr Louise: [00:00:07] Hello, I’m Dr Louise Newson, I’m a GP and menopause specialist, and I’m also the founder of the Newson Health Menopause and Wellbeing Centre here in Stratford-upon -Avon. I’m also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research, bust myths on menopause symptoms and treatments, and often share moving and always inspirational personal stories. This podcast is brought to you by the Newson Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. Today I’m doing something slightly different. I’m recording my podcast in the studio, so I’m going to be filmed in real life with proper equipment, not just on my screen. And I’ve got a special guest here today Anne Gildea, who’s come over from Dublin. Difficult journey, which will explain in a bit, but she’s here in real life. We’re going to be talking about the tour that we’re doing, soon, which is going to start in the autumn. So welcome Anne, thanks for coming today. You’ve seen the clinic, you’ve seen my second home, and we’ve got loads planned, haven’t we? [00:01:29][82.1]

Anne: [00:01:29] Yeah, I’m really excited about it, Louise. And it’s amazing. There’s nothing like meeting in person. And you just… There’s something magic about picking up the energy people, I think that’s beginning to be lost and there’s so much Zoom and everything now. It’s just… [00:01:43][14.0]

Dr Louise: [00:01:44] It’s exactly the same for when I see patients. It’s very convenient. It’s very easy to do things online. But actually you just the energy, the warmth, everything. You just learn different things about people. [00:01:56][12.3]

Anne: [00:01:57] You do and you just get a feel. And it’s an intuitive thing. It’s an animal thing. [00:02:02][4.8]

Dr Louise: [00:02:02] Yeah. Absolutely. Totally. So I’m very grateful because there’s a train strike today so you haven’t had the best journey! [00:02:09][6.9]

Anne: [00:02:11] My God Louise! Like I had my whole journey planned. I got my tickets and I had them already to go and I went to the train station and it’s like there’s no trains today. I had a real menopausal moment. It was like oh, it doesn’t compute. It was so funny that it took me. I thought oh well I’ll get the bus into Birmingham. There’s bound to be loads of coaches to Stratford. I took an hour and a half on the bus, so I’ve seen all the suburbs of Birmingham. And then it was funny because I, I just had to make transport decisions and think my brain was… [00:02:45][33.7]

Dr Louise: [00:02:45] So you’ve used your brain well. Despite being menopausal. But really it was great because when Chris Davis, who’s organising the show, said, I want you to meet Anne, I want you to look at her work. I had a little Goggle, had a read, had a watch, had a listen, had a laugh. And what you’ve done has been incredible. But I’m really keen to hear, like, how you got into even thinking about menopause and let alone doing a stand-up comedy show. [00:03:11][25.4]

Anne: [00:03:12] Well, I’d had this act and this reason I know Chris through other producers I’d worked with in the UK before, this act called The Nualas, and we were a comedy musical trio and we turned, we toured a lot in the UK and that was my Chris connection. And then we had come off the road, we’d finished doing that and so I needed to do something else, and so was in my 50s by then and I thought it would be really interesting to write something about being in mid-life, but it was going off in every direction. So it was my partner Paul, who said to me, he gave me, he just gave me the title. He wrote it on the whiteboard, how to get the menopause and enjoy it. And he went, that’s your title. And I was extremely resistant. [00:03:53][41.2]

Dr Louise: [00:03:54] Were you, why? [00:03:54][0.3]

Anne: [00:03:55] Yeah, I just felt such negativity around the word menopause. Now, this is several years ago, it was during lockdown, and there is a real moment where everybody’s talking about menopause now. But back then it was still a little, a lot of silence around it. And I just thought, well, at that point I was post-menopausal and I thought, I just I don’t want to go there, it’s medicalised. It’s just like, kind of sweaty, irritated women. That’s the image you get. And then I started reading about it and, the scales fell from my eyes. I kind of went into shock for a while. [00:04:28][33.0]

Dr Louise: [00:04:28] Did you? [00:04:28][0.2]

Anne: [00:04:29] Yeah, because I realised all I didn’t know, and I realised I knew nothing about my body. And I thought menopause was something that you just went through and then it’s over. I didn’t realise that the long-term effect of that hormone depletion and so one of the first things I did, was I went on HRT, I just thought… [00:04:53][24.2]

Dr Louise: [00:04:53] So you hadn’t thought about it before? [00:04:54][0.3]

Anne: [00:04:54] I absolutely hadn’t. I think I had this, I’d heard something about the Women’s… or the World… [00:04:59][5.7]

Dr Louise: [00:05:00] The Women’s Health Initiative. [00:05:00][0.0]

Anne: [00:05:02] Yeah. Women’s Health Initiative study. So the shadow of that was definitely still hanging over the whole HRT piece. So I thought, well, I can’t, I’d also had had breast cancer. So I just thought, not for me even though my cancer wasn’t oestrogen positive, it was triple negative. But I just thought no, it’s there’s too many negatives around it. But it was just a received opinion without looking into it. And then when I just got all the facts, I just I was yeah shocked that I had such ignorance. That there’s such general ignorance around what happens in our bodies. And I think particularly now, because, we all live longer and sustaining our health, post-menopausally is so important. It’s not just about treating those symptoms. It’s about keeping healthy into old age. [00:06:00][58.2]

Dr Louise: [00:06:01] Yeah. Menopause has been just portrayed as an annoyance, actually. You know, I knew when I started doing first presentation, like, ten years or so ago just to a group of healthcare professionals and just Googling menopause and thinking about it. It’s always hot flushes, it’s always night sweats, it’s always middle aged whereas we know 1 in 30 women under the age of 40 are menopausal so they’re not middle aged. It’s always like overweight woman with a fan with sort of beads of sweat. And then it’s sort of used a bit as a butt of jokes, oh she’s menopausal. Ignore her. Like, it’s just like very patronising really. And it’s something that actually women are very vulnerable when their menopausal. But they don’t understand necessarily exactly how it’s affecting our brains, how it’s really affecting us the bigger picture, because it’s never been talked about as a brain disorder. It’s a flushes, sweats disorder. And like you say it’s something that we’ll get through. And I think when people realise that you never get through the menopause and you want to make it a really positive experience, but if you haven’t got the knowledge, how can you make something positive when you don’t know what it means? [00:07:10][69.6]

Anne: [00:07:11] Louise, that is exactly the part that I just I had no realisation of that. And I think what I found shocking was I think it’s something that every woman should know and. [00:07:23][11.9]

Dr Louise: [00:07:24] And every man naturally. [00:07:24][0.6]

Anne: [00:07:25] And every man, because, you know, it is an inclusive condition. You don’t have to get it to suffer from it. [00:07:30][5.0]

Dr Louise: [00:07:30] No. [00:07:30][0.0]

Anne: [00:07:31] But it’s not to have negativity around it either. But it’s just, you know, it’s like thinking about the mental health issues around it, the low mood. And, a lot of women, I’m touring this show then, I wrote this show, How to Get the Menopause and Enjoy It, and I’ve actually been on the road three years with it in Ireland now. And, so I talk to a lot of women and it’s not just low mood. A lot of women talk about a lack of confidence then comes along. Like one woman told me she, she didn’t feel confident driving on motorways anymore. Like it begins to, life can begin to contract a little bit. [00:08:10][38.5]

Dr Louise: [00:08:10] It really does shrink, actually. And in fact, in the updated paperback of the book, someone called Joanne Harris, you might know she’s an author, she wrote a great book called Chocolat, talks about women being invisible and how convenient it is for society for women to be invisible. And I think there is a lot of invisibility in menopause and not wanted invisibility. But you’re absolutely right. I know when I was perimenopausal, I didn’t want to go out. I felt really flat, just very joyless. You just, everything’s a bit, you know, it’s not just thinking in treacle, you are wading in treacle. Everything’s an effort. And it’s like, oh, I just don’t want to. It’s just like, and this isn’t me. And then you compound it when people have got anxiety and thinking, like you say, not driving, I see lots of women who don’t go on a bus, they don’t go on the underground. So then they’re like, where they go out is very small. Then they stop going to work. They’ve stopped their identity, as who they are. It’s really awful. And it’s happened for many, many years hasn’t it? [00:09:16][65.8]

Anne: [00:09:16] Yeah, I’ve talked to women too who may be feeling that vulnerability too. And then in their job they’re having to do presentations and suddenly they’re having a hot flush. And you know, as these things build up, women do just go, I actually can’t do this any more. And they just step out of the workforce. They… [00:09:33][16.8]

Dr Louise: [00:09:34] Which you know, it’s 2024. I’m really shocked that we’ve got a treatable condition, that’s treatable with safe treatment. That the majority of women worldwide are not getting. [00:09:47][13.4]

Anne: [00:09:48] As you know, there’s still so many doctors who will say, is it safe? And you’ve all those warnings around cancer that relate to you know, that study? [00:09:57][8.6]

Dr Louise: [00:09:57] Yes. Well the study, the WHI study, which we know isn’t actually relevant because the type of HRT we prescribe is different. But even that study didn’t show the effects that were put in the media and the medical press, actually, because it was reported in the wrong way and reported wrongly, actually. But even this risk of breast cancer wasn’t statistically significant either. So it’s irrelevant. [00:10:21][23.4]

Anne: [00:10:21] Yeah, but you were saying a whole interesting piece too around the anti-inflammatory element of oestrogen and it’s almost anti-cancer rather than oh no it’s bad. When it’s gone it’s gone. [00:10:35][13.2]

Dr Louise: [00:10:36] Yeah, that’s exactly right. So the arm of the study that only gave oestrogen, so women who’ve had a hysterectomy, removal of the womb, often only have oestrogen. Those women when they were followed up, had a lower instance, 23% lower incidence, of breast cancer. So oestrogen seems to be protective of breast cancer, which really blows people’s mind when we’ve all grown up thinking that oestrogen is bad. But then also you think, you know, my 13-year-old daughter who hasn’t learned anything about oestrogen at school, but is like, Mummy, how can your own hormone be a bad thing? It doesn’t make sense biologically that we have something in our bodies that our body turns against us. It just doesn’t work like that. [00:11:18][42.3]

Anne: [00:11:19] Yeah but then that’s another piece around having hormone replacement that, you know, I have met women who go, it’s a natural process, menopause. And that’s unnatural. So why would you, just go with the flow but that, you know, the whole.. [00:11:36][16.9]

Dr Louise: [00:11:36] It’s really interesting isn’t it, the whole natural thing. And I think actually when you unpick what does natural mean because it’s associated with ageing, is a massive philosophical and medical debate. Is ageing natural or not? Which is very interesting. We actually, as we were saying before, our life expectancy is so much greater than it used to be. So actually, is it natural that we live to our 70s and 80s? Who knows? We don’t know but we never used to live that long for sure. But then also there’s a lot of conditions now, for example, raised blood pressure is related to ageing as well. It’s more common as we get older. But I wouldn’t not treat someone’s raised blood pressure because they’re in their 70s, because if I don’t treat it, that person has an increased incidence of a heart attack. So we treat the blood pressure, get it lower to normal range to reduce the risk of a heart attack. With menopause, as you found out when you did your reading, there is an increased risk of a heart attack when people are menopausal. Taking HRT halves that incidence of, or the risk of a heart attack. So actually, you could argue it’s in a similar way that we’re doing it. [00:12:47][71.5]

Anne: [00:12:48] Exactly. And it’s just keeping up. The big part for me was also the link with bone loss, as they call it. I didn’t realise a fall in oestrogen is correlated to that. And I just noticed in the women on my mum’s side of the family is very, you know, we just we’ve accepted this idea of the little old lady, that women would just shrink away. Like I say this in my show, that my mum used to be the same height as me and now she’s just the size of a coffee table. You know, the middle one in a nest. But I actually, I say it in the show and I laugh about it. And then I, I’m based in Dublin, but my mum actually lives in Manchester. And when I go to visit her, I do always do a double take and go, oh, you have, she’s got, she’s really lost so much height. And that is, that’s a real menopause correlation isn’t it. [00:13:43][55.2]

Dr Louise: [00:13:43] Yeah and presumably she’s not on hormones. [00:13:44][0.9]

Anne: [00:13:45] No. [00:13:45][0.0]

Dr Louise: [00:13:45] No. Because there is this shrinkage of the bones, we’ve got loss of bone density, but also the discs reduce in size, so all the discs between. So there’s just a shrinkage of everything, which then can reduce height. But obviously when you’ve got bone loss there’s increased risk of osteoporosis, the thinning of the bones, which is so common, yet we don’t know, well, many people don’t realise how common it is, what it means, but also that HRT can reduce and treat osteoporosis as well. [00:14:17][32.3]

Anne: [00:14:18] That was one of the big reasons I went on the HRT, and because I was, post-menopausal by the time I was reading around it but I just thought, long-term health, but then in particular because I’d really observed it in my mum’s side of the family. [00:14:33][15.1]

Dr Louise: [00:14:34] And so you were quite open about having had breast cancer before. And thankfully everything’s fine for you at the moment. But you were, did you have any chemotherapy or treatment? [00:14:47][12.7]

Dr Louise: [00:14:47] I did, I had… Talk about lack of knowledge, Louise. I had a swelling on my breast, but I had this received thing that cancer was a lump, that I imagined it as a discrete lump. So it was kind of a swelling that’s getting, a bit bigger. And I went, oh, that’s nothing. And then one day I showed it to my sister and I went, Do you think there’s anything? And she went, we’re calling the doctor now. And by the time I actually, went to the hospital, it was actually it was stage three. It kind of, it had gone to all my lymph nodes, I had all my lymph nodes removed. And as well as that I ended up having to have a mastectomy. And yeah, that was, that was quite a shock. [00:15:33][46.6]

Dr Louise: [00:15:34] And did you have any extra treatment? Did you have any chemotherapy? [00:15:36][2.0]

Anne: [00:15:37] Oh I did, sorry, yeah I did. I had chemo first. I had eight rounds of chemo and over four months, dense dose every two weeks. And then, I had a mastectomy and then I had seven weeks of radiation. And then, and then I got a fantastic reconstruction. And the wonderful thing about getting the reconstruction is I had a DIEP flap reconstruction. So it’s my own tissue. You just once it’s all done and dusted, you move on and you forget. I forget that I had cancer. [00:16:12][35.1]

Dr Louise: [00:16:12] Yeah. And were you still having periods when you were diagnosed? [00:16:15][2.8]

Anne: [00:16:16] Yes. And then the oncology. I was 45 years of age and the oncologist said to me, now, you know, the chemotherapy is going to shut everything down. And given your age, your periods are probably not going to come back. Now, they did come back a little bit and then they just petered out again. Here’s the thing, I would, and I talk about this on my show too. I would’ve said, you know, I would say maybe about three weeks after I started the chemo, I started having awful night sweats. As I say, every night I was wringing out the bed sheets, my nightie, my boyfriend’s neck. And I didn’t correlate that with menopause, but of course, because it shuts everything down, it had also shut down the hormone production, and I was plunged into menopause, as so many women are when they’re going through chemo. But that was never mentioned. And I suppose there’s so much else going on. I wish it had been mentioned because once I’d been through treatment, I was so relieved. And I actually, I went to this brilliant hospital in Dublin called Saint James’s, and all the doctors were amazing. And I was so inspired by the whole experience that when I came out the other end of it, I just had this new love of life and positivity about moving forward, but I had, terrible low moods and I thought, well, that low mood is definitely not circumstantial. So because I’m so low, this is a disposition, I have a disposition to low mood. This has just been that the cancer treatment had worked so well. So I was applying the science to my own mind. And God, this is dispositional and low mood and I should go on antidepressants. And I actually was on quite a strong dose of an antidepressant called Cymbalta for, for four and a half years because I thought I just had this disposition to low mood and I’ll just medicate it away. I look back and I go, that was totally a menopausal symptom. That’s why my mood was low. And I wish I’d had information around menopause and effects of hormone depletion at the time because I would never have gone on antidepressants. It was totally about that. And that’s why it felt strange. And then, it would have been a good time to talk about maybe some hormone replacement and to try a hormonal way of balancing out the mood. [00:18:52][156.9]

Dr Louise: [00:18:53] Yeah. Which has happened so often. I did a presentation yesterday to women and most of them have been offered or given antidepressants. And it seems so easy to get antidepressants, yet so hard to get hormones, which is wrong. And there’s so much that needs to change. But empowerment is good. Education is good. You learn more when you’re happy, don’t you? [00:19:18][24.4]

Anne: [00:19:18] Absolutely. Do you know with, it’s like medicine looks at women and goes, oh, they’re so complicated. Should we just tranquillise them? You know, it is like that. Just tranquillise them away as they drift post reproductively. They just drift away into the twilight years. [00:19:35][16.6]

Dr Louise: [00:19:35] And there is a bit of put up and shut up because other generations have done it. Why can’t you? And then that makes it harder to ask for help. So yeah, laughter is a great best medicine. You learn more as I said, when you’re happy. So your show, which I’ve seen bits of, people are really happy. They really love it. They love it, I think what I can see and tell me if I’m wrong, is that they they can relate to what you’re saying in a way that they’ve probably not been able to admit before that they’re experiencing similar symptoms. [00:20:07][32.1]

Anne: [00:20:08] That’s what women say to me and write to me. They go, you told my life. And, that relatability piece is so important. And I think it’s it’s coming through just the story of being a woman. And then when I add in the information, it makes it quite compelling. And then I pitch the whole piece around, menopause as reverse puberty. And I just say, think back to when you went through puberty and your body starts producing all these hormones, think of the profound effect and changes that had, that ensued. Well, now, you’re going through the other end of that, you know, you go through this depletion. So it’s a kind of an equal and opposite thing. So because I talk, frame it in that way, then I talk a lot about growing up in the 70s and 80s and I just remind women of things that are, like things like the sanitary products we used to have, like and the intimacy and remembrance of that, always gets a good laugh. [00:21:21][72.4]

Dr Louise: [00:21:22] But it’s important. I think women need to understand that they’re not alone. That’s really, really important because as we’ve already said, it’s really isolating. So your thoughts about the tour that we’re doing. I’m quite… I’ve never been on tour before. I’m feeling quite excited, bit nervous. [00:21:37][15.1]

Anne: [00:21:38] You know what I’m really excited about? Like, I’m really excited. I got really passionate about menopause when I started reading up about it. I’m really excited to be working with you because you’re an absolute expert in the field. And I love hearing the facts coming from the mouth of an expert. And like some of the detail you were explaining to me earlier and the information is still not out there in the full, you know, the full breadth of it. So that’s the thing I’m really passionate about. To be working with you Louise is totally immersed in all the cutting edge research around it and that you’re continually talking to women, with your patients and everything. You just know that… [00:22:27][49.5]

Dr Louise: [00:22:28] Yeah. I mean, I’m looking forward to sharing content that we’ve not spoken about before, that I have not spoken about through my book or other podcasts or other media, because there’s a lot I’ve been reading a lot of women’s history books as well actually, I think it’s so interesting, and medical books from the past as well, mainly written by men, I hasten to add, male doctors, but just people’s perceptions of what menopause is and how it affects women, and the treatments. [00:22:56][27.8]

Anne: [00:22:57] Oh the treatments, like for the what was it, the wandering womb in Ancient Greece or that they used to put leeches on women’s cervix? [00:23:07][9.3]

Dr Louise: [00:23:07] I know, I know, it’s incredible what women have gone through and endured, but what they still are enduring now. So a lot of that we can tease out, which will be great. I’m really looking forward to working with you. And how to again, life is something that can be very sad but also very frustrating. But I want some of that frustration to keep coming out because I think if you’re frustrated, you’re more likely to change things and you change the needle because this is actually something that’s affecting 1.2 billion women globally. It’s not just something that affects a certain demographic or a certain type of woman. We can’t escape from it. But actually to learn and to realise quite the injustice of what’s going on as well. And if you’re feeling alright, you’ll definitely know a friend or a relative or someone who isn’t or is struggling to get help. So I’m hoping it will group and join people together. [00:24:12][64.5]

Anne: [00:24:14] The thing I really like touring theatres is that women really love that environment. They love coming out together in groups. And it’s wonderful to make people laugh. It just opens everybody. And, it’s almost a spiritual experience. So I think it’s there’s that lift too. [00:24:33][19.0]

Dr Louise: [00:24:34] I get that. I’ve done a few book events, and I did one last week actually, down in Henley, and I was with Kate Muir, who’s absolutely brilliant, and we’re waiting to go on and just the buzz in theatre. Normally in theatres people talk or mumble, but there’s this energy where people were really happy and we did a question and answer as well. And this lady she was so lovely she said, I’m 82. I’ve been on HRT 30 years. I’m never going to stop it. And actually, the whole audience just clapped. They were all there with her in the room, you know, really supportive. And I thought, actually, there’s so not many live groups where people are there together. You know, you’re in your own little group, aren’t you but actually, the whole theatre were there by the end of it. [00:25:14][39.8]

Anne: [00:25:16] That is the thing that women say to me in my show that, in the intermission, that it’s like everybody, like the queue for the loo, everybody’s talking to each other, that there is suddenly you’ve opened up the topic, and that 80-year-old woman is lucky because I’ve met 80-year-old women who were, I’ve met 80-year-old women who had hysterectomies in their 50s, and they were and they were allowed HRT for a few years. And then the doctor absolutely insisted that they had to come off it. And you know, that was the received opinion that you couldn’t stay on it long term. That was another revelation I had researching the show that actually, you know, that you could carry on and that it actually does sustain your health. [00:26:00][44.5]

Dr Louise: [00:26:02] Yeah, it’s so important. People don’t realise that so there’s lots of myths that we want to dispel. Lots of facts that people can learn from quite a lot that people hopefully won’t know or won’t have put in context. And I think having the show, the context is really important. But we’re also going to do a Q&A as well. So I’m hoping there’ll be lots of questions from the audience. And that will vary every night, of course. [00:26:28][25.7]

Anne: [00:26:28] And that’s the exciting thing about you bringing your knowledge into that environment, because this specific detail you have… I’ve done a lot of research around it, but I haven’t heard it expressed so clearly and just the nuance around things like cancer, not cancer, the subtle effects of what the hormones are actually doing is really important information. [00:26:53][25.2]

Dr Louise: [00:26:54] Yeah, and I feel cheated as a doctor that I haven’t been allowed to have this information. You know, I wasn’t given it at medical school, I wasn’t given it as a postgraduate. I wasn’t given it as a GP trainee. I’ve searched and researched myself, but it’s all out there. But it’s hard to find something when you don’t know where to go. [00:27:13][18.6]

Anne: [00:27:13] But it’s also you bringing it all together. I think, I’m sure you know, I have never well like when I read your book, I hadn’t seen such a clear, concise, collation of all that detail. [00:27:25][11.9]

Dr Louise: [00:27:27] Yeah. So, well hopefully there’ll be lots and lots and this will, just empower people to think differently I think. And what you were saying even about your show making menopause positive, making it healthy as possible, making it something that is right for each individual as well. Because, you know, neither of us are judgemental about others. We just want women to be able to decide and do what’s right for them. So really great that you’re coming over to do the live podcast, in real life. Just really wanted to ask you three take-home tips. So I always ask for three tips. So three reasons why you think people should either buy a ticket for themselves or buy a ticket for somebody else to come to see us in the show. [00:28:13][46.6]

Anne: [00:28:14] I think that it’ll be a wonderful night out. I think I just know from touring around my own show, it is a real sharing experience. So, I’ve had three generations of families come along, daughter, mum, grandmum. So there’s a wonderful sharing and, have a good laugh, but learn. [00:28:37][23.7]

Dr Louise: [00:28:39] Yeah, yeah. Really good. So I’m going to give my three, which are like I give my three reasons why people could come. I think firstly it’s going to be a different event. It’s not going to be something that people have heard before. So for new content, really important. The other thing is the availability that they will have more of my knowledge that I can share to people, hopefully in a way that people can understand and take home from. And obviously, thirdly, the opportunity that people can ask questions and have answers. Some of the shows I’ve got some of my doctors who work with me are going to be there in the show as well so in the interval, so they will be able to answer questions, but obviously I’ll answer questions on the stage as well. So thanks ever so much Anne for coming today. It’s been wonderful having you here in person to do my podcast. [00:29:28][49.6]

Anne: [00:29:29] My pleasure Louise, and it’s just wonderful to meet you. [00:29:31][2.4]

Dr Louise: [00:29:32] Thank you. You can find out more about Newson Health Group by visiting www.newsonhealth.co.uk and you can download the free balance app on the App Store or Google Play. [00:29:32][0.0]

END

The post All about Dr Louise’s theatre tour Hormones and Menopause: The Great Debate appeared first on Balance Menopause & Hormones.

Content advisory: this podcast contains themes of mental health and suicide.

Dr Louise is joined by her patient Trudie Jennings in this episode to talk about the complexities around HRT during and after treatment for breast cancer.

Trudie describes how she started HRT to successfully manage crippling anxiety and other menopause symptoms and a few months later she was diagnosed with an aggressive breast cancer.

NICE guidance states women should stop taking systemic HRT if they are diagnosed with breast cancer. However, after careful discussion with her cancer doctor and nurse, Trudie decided to continue with HRT during her treatment as, for her, the menopause symptoms were more challenging than her cancer treatment.

Trudie and Dr Louise discuss shared decision making and informed consent, and how important it is for women with and after breast cancer to be fully informed about potential risks, benefits and uncertainties about HRT following a breast cancer diagnosis so they can make the best decision that is right for them.

Trudie’s three tips for women who have had breast cancer and are struggling with their menopause: 

1. Know that as a patient you do have choices about whether to start or continue HRT after breast cancer treatment.
2. Speak to your doctors and nurses and be informed so that you can make the right, personalised, decision for yourself. Trudie has found her healthcare professionals in cancer care open and helpful when discussing her need for HRT.
3. You know your own body best, so listen to your body to get the treatment that will be best support you.

Contact the Samaritans for 24-hour, confidential support by calling 116 123 or email jo@samaritans.org

Click here to find out more about Newson Health

Transcript

Dr Louise Newson: [00:00:11] Hello, I’m Dr Louise Newson. I’m a GP and menopause specialist and I’m also the founder of the Newson Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. I’m also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research, bust myths on menopause, symptoms and treatments, and often share moving and always inspirational personal stories. This podcast is brought to you by the Newson Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. Today on the podcast I’ve got someone with me called Trudie who’s very kindly agreed to share her story. So I first met Trudie about five years ago, and she came to the clinic as a patient and travelled many miles, actually, to come and see me. So welcome, Trudie. Thanks for joining me today. [00:01:20][69.5]

Trudie Jennings: [00:01:21] Thank you. [00:01:21][0.3]

Dr Louise Newson: [00:01:22] So when you first came, it was a few years ago now, about five years ago. And people weren’t really talking about the menopause as they do now. And I don’t know quite how, hopefully you’ll explain, how you found me. But then you came all the way many miles from the north to the clinic. So do you mind explaining what happened and when you discovered that you might be experiencing some symptoms? [00:01:42][20.0]

Trudie Jennings: [00:01:43] It was around 2017. I was 49, and that year I started to feel anxiety for no apparent reason. I was happy, I was healthy, I was enjoying life, married, no children, but a great life, really. And it was more irritating than anything else, this anxiety, because it didn’t seem to be thoughts associated with it, it just felt like a bodily sensation. Anyway. So I was kind of just trying to cope with that and ignore it. But then in December I came down with a tummy bug and I didn’t get better and I couldn’t get out of bed. And after about three weeks of consistent nausea, I was really starting to get worried and was going to the GP, certainly calling them two or three times a week and going at least twice a week. And my GP was saying that there was just nothing that they could find that was wrong with me. My bloods weren’t showing anything and then eventually they suggested I go for a brain scan and at that point I just knew that wasn’t the way forward personally. I knew there was something else going on. And then I had a friend, my friend Sarah, saying that my symptoms were so like morning sickness that she’d had with her youngest daughter that the parallels were just, she said that you’re describing exactly the same thing. And she said she remembered her doctor telling her to get out of bed and put herself together. But she said she was absolutely floored by it, which led us to start thinking about hormones, which sounds a bit daft now, but it just hadn’t been on our radar at all. I’d arranged privately to go for an endoscopy and colonoscopy just to make sure was that there was nothing going on. And after that I got the all clear. The consultant said that off the record he wondered whether it was menopause because he said his wife’s friends were coming down with so many strange symptoms with the menopause. And he said, it just seems like it’s a lot more than people realise. So that was really helpful. I went back to my GP who said that night sweats and hot flushes were the only symptoms that she felt were appropriate. And because I didn’t have them that she didn’t think it was the menopause, I started to worry about my coil that I just had fitted a few months previously thinking, oh gosh, is it to do with that and hormones? And I had that removed and immediately I plunged into anxiety that was beyond belief. I was internal shaking, agitated, just absolutely dreadful. We started scouting around and I found a doctor in a town not very close by, but close enough to go on a day trip to. And he took my bloods and found that I had no progesterone, oestrogen or testosterone. And he had sort of a, I don’t know, some sort of private pharmacist prepare hormones for people. And he sent me a sample through the post. And unfortunately, it did nothing at all. I had to put a little bit on the top of my arm, but it didn’t do anything at all. But at least I knew the hormones looked like it was a possibility. I actually came to you after that. I saw your name was starting to appear on things like the websites where women with symptoms similar to me were talking about how are we going to get some help for this? And I arranged an appointment with you and we drove down to, it was Birmingham then, and had an appointment and you said straight away, this is not anything other than what I would see as the menopause and I think I can help you. By that time I was taking antidepressants because of my anxiety. I say, anxiety, there’s almost a different book of symptoms for the menopause, if you ask me, because the anxiety was so physical. It was this internal agitation that wasn’t related to anything. It wasn’t related to thoughts. It was just this constant, almost biological, awful feeling. Anyway, you prescribed patches and testosterone and progesterone. And by June, saw you in the April of 2018, by June 2018, my husband and I went on holiday to Croatia and had a smashing time. In fact, we just you know, it was just unbelievable, the transition, the transformation. My appetite was back. I was happy. It was just great and we came back for review with you in the August of 2018. And yes, I don’t know if you want me to continue then what happened? The second chapter, part two, then was that I told you that I had an inverted nipple and you asked to have a look at it. And I think we both realised that it probably was quite serious. And you then wrote to my GP and asked for an immediate referral and I think it was the Thursday, the following week I was in hospital, diagnosed with breast cancer and I was on a fast track then. [00:06:27][283.8]

Dr Louise Newson: [00:06:27] Yeah, because I very distinctly remember that consultation, because I obviously asked if you wanted me to examine you because you said you had found a lump. And lots of people have lumps and most lumps are not cancer. And I examined you and I thought clinically, this is a cancer, but you don’t know until you have a proper histological diagnosis. And we both looked at each other, didn’t we? I remember very clearly saying, I can’t tell you for sure, but we need to get it checked out. And then the next question was you said to me was, do I need to stop taking my HRT? And you had only just started to feel so much better. And I remember we looked at each other and I said, well, we don’t know it’s cancer yet, shall we wait until you’ve got a diagnosis. And you said, yes, I think I’m happy to do that. And it’s an individual choice, some women will stop straight away and some women… but you decided, didn’t you, that you’re going to and I remember you contacted me because your appointment came through quickly and then you got the actual proper diagnosis, didn’t you? [00:07:31][64.4]

Trudie Jennings: [00:07:32] I did. It was an aggressive cancer. It was seven centimetres long actually, by then. And yeah, they were clearly expecting me. The oncology team was expecting me to come straight off the HRT, but were really understanding when I said that actually when I told them my story and said I don’t think I can get through this if I am not on HRT. And I gave them lots of articles and some of the articles that you’d advised me to have a look at, and they were absolutely fine with it. Totally supportive. Yeah. [00:08:02][29.6]

Dr Louise Newson: [00:08:03] Which is amazing because I actually remember, I’ve got quite a good memory and I often remember locations of when I’m doing something or speaking to someone. And I think it was at a weekend when I got through to you because my daughter was playing in a concert at Birmingham Conservatoire. She’s a trombonist and I really wanted to speak. I think you might have emailed me to say that I’ve been diagnosed and so I’m remember phoning you up. And I was trying to find a quiet place that was discreet in this concert hall before I did, because I dropped her off early so she could have a rehearsal beforehand. And I remember talking to you about your HRT and they’ve given you, didn’t you have chemotherapy first before surgery? [00:08:40][37.8]

Trudie Jennings: [00:08:42] I did, I did. I had quite a big bout of chemotherapy which shrunk the tumour, thank goodness. [00:08:45][3.4]

Dr Louise Newson: [00:08:47] What it’s usually called is neoadjuvant chemotherapy. So it just neo means ‘new’, before. So some people have the breast surgery and then they have chemotherapy. But because yours was, and please correct me if I’m wrong, but my recollection was because it was quite aggressive and a big cancer, what they want to do is shrink it before the surgery. Is that right? So you have heavy duty drugs, basically, chemotherapy. And your oncologist had decided that it was such strong chemotherapy that actually, whether you take HRT or not, is not really going to make a difference to your overall prognosis. And you know that the outcome from your cancer and I actually I mean, obviously it’s a few years ago now, more and more people who’ve having treatment for breast cancer or have had breast cancer are asking a question about hormonal treatment. But I thought actually how wonderful that you’ve had what felt like a very open conversation with some very wonderful doctors who could think in a reasonable way because it’s a very kneejerk, easy reaction to just say, stop your HRT. And obviously that happens a lot for a lot of women. And obviously without HRT there would be no risk for your breast cancer, but actually for your mental and physical health, which you needed to be really strong to cope with the treatment. That’s where you were coming from, wasn’t it? [00:10:12][85.2]

Trudie Jennings: [00:10:14] It was. There was just no, my husband said, you can’t, you can’t not have it. You know, it’s just a no brainer, really. So yeah, and I do think I got through it because of the HRT. I was still on the antidepressant. And I have to say, although it was pretty horrendous, the whole thing, and had a mastectomy, then I had radiotherapy. It was a walk in the park compared to the menopause stuff, genuinely, genuinely, genuinely. I remember saying that at the end I would, you know, no comparison. I was so poorly with the menopause and the cancer, I was, you know, I was but my head was okay. [00:10:48][34.1]

Dr Louise Newson: [00:10:48] That’s quite something, isn’t it? Because and I’m not here to belittle breast cancer at all and for everybody it’s different experiences and the treatment is different but it’s quite simplistic medicine to suggest that the menopause is something that doesn’t affect women as much as breast cancer treatment does and especially to have chemotherapy as well, which can cause, and it did cause side effects, didn’t it? [00:11:13][24.7]

Trudie Jennings: [00:11:16] Yes. I had sepsis at one point and, you know, I lost all my hair and all of that sort of thing, but really I felt okay. I knew it was something I had to get through. I had lots of support. I didn’t have internal tremors, I didn’t have blackness, and I didn’t have any of that. I was just back to kind of my normal self coping with something that was awful. [00:11:34][18.8]

Dr Louise Newson: [00:11:36] And then after your chemotherapy you had a mastectomy and then did you have other treatment after that? [00:11:43][6.5]

Trudie Jennings: [00:11:43] Yes, I had radiotherapy after that, yes. [00:11:45][1.7]

Dr Louise Newson: [00:11:45] And then after that. Did you have any other drug treatment or do they offer anything else or what was the plan after that? [00:11:51][6.0]

Trudie Jennings: [00:11:52] Yes. I’m on tamoxifen for ten years. [00:11:53][1.6]

Dr Louise Newson: [00:11:54] Right. Okay. And have you stayed on your HRT with tamoxifen? [00:11:57][3.4]

Trudie Jennings: [00:11:59] I have, I decided to stay on it. I had my bloods done pretty shortly after my radiotherapy and they were very low, two 200 milligrams of patches and I was only getting 84 on my reading and I’ve recently, probably shouldn’t have, but I went up to three just out of interest to see what whether I would feel dramatically different. I had my bloods done with my GP and they’ve only gone up to 97 with three patches. So I’m not a great absorber, that has to be said. [00:12:26][26.6]

Dr Louise Newson: [00:12:28] It’s very interesting, isn’t it? Because there’s a big debate, as you probably know over the last few months about the maximum dose, what we should be prescribing and it’s more about the amount that we absorb rather than the amount being prescribed. And we’ve been looking at all our data and we show like you, there are some people that have higher doses prescribed, but they have less in their blood compared to others and some have lower doses and they have higher absorption. And it’s so interesting because our skin is really different as well. So. So your blood level of oestrogen is actually still quite low, isn’t it? [00:13:00][32.4]

Trudie Jennings: [00:13:01] It is. It is. And when I use the testosterone, all it happens is that I grow hairs. That’s all that happens. So if I put it on my leg, I just get a big hairy leg. So it suggests it’s not absorbing terribly well there. [00:13:15][14.2]

Dr Louise Newson: [00:13:15] No, but you’re still using the testosterone. [00:13:17][1.5]

Trudie Jennings: [00:13:18] No, I don’t, because it was just creating hairs. And when I had that tested, it was just insignificant the amount that I had. [00:13:24][5.4]

Dr Louise Newson: [00:13:25] So obviously you weren’t absorbing this either, which is very interesting. Some people don’t. And this is where HRT is very individualised. You know, the guidelines are very clear that it should be individualised and we are all different. And also what works at one stage doesn’t always work at another stage as well. So, you know, constantly we look at choices of preparation. Sometimes we’ll change from a patch to a gel or a different type of patch or a different type of gel, or with the testosterone, we might try a different type of testosterone. And we are also different and there’s no right or wrong. And tamoxifen, for those listening, is interesting because it’s something called a SERM, which is a selective oestrogen receptor modulator. So it can be anti-oestrogen on the breast tissue, but it can actually be pro-oestrogen in other areas, including the lining of the womb, actually. And so we know also that some women who take Tamoxifen actually have a higher level of oestrogen in the bloodstream as well, even if they’re not on HRT. So we don’t really understand and it’s not as simplistic as oestrogen is the devil when it comes to breast cancer. And also I spoke to someone the other day actually who had been on HRT for six weeks, developed breast cancer, and she said the HRT must have caused it. I should never have taken it. And we still don’t know whether HRT is associated. It might be if there was a cancer there already when someone was taking HRT, it might grow a bit quicker. But we also know from evidence that women who were on HRT at the time of diagnosis of their breast cancer have a better outcome. And is it because those women it presents quicker and earlier because it’s growing quicker, so you’re more likely to feel it? Or is it that the oestrogen is anti-inflammatory and helps, you know, reduce some of the inflammation in the cancer and improves outcome? And we don’t know the answer. So it’s very interesting. But I think also it’s about you know, I know because I’ve spoken to you before, you don’t regret taking HRT even though you’ve had breast cancer, do you? [00:15:39][134.0]

Trudie Jennings: [00:15:39] Not at all. I don’t associate them. I mean, I used to drink socially an awful lot. And I would say if I want to try and pin it on anything, I would put it onto my overconsumption of alcohol. You know, when I read statistics, why would I think it was the HRT that I’d taken for a few weeks as opposed to the drinking I’ve done for the past 20 years, you know? So, yeah. [00:15:59][20.2]

Dr Louise Newson: [00:16:01] And for a lot of women, it’s bad luck actually, about one in seven women, as you know, develop breast cancer. And it’s the same as other types of cancer. Sometimes we just don’t know. And often it can be numerous things. It might be partly related to drinking, it might be partly related to your genetics, it might be partly related to something else that we don’t even know. And I think that’s really important because you can always blame yourself sometimes when you’ve had a diagnosis of something. And that’s just the worst thing to do because you are a really positive person, that’s for sure. And looking also at your future health, because you are a really healthy person, aren’t you? And you want to keep healthy. [00:16:41][40.0]

Trudie Jennings: [00:16:44] I am yes, and that’s that’s the idea now. [00:16:45][1.1]

Dr Louise Newson: [00:16:46] And we do speak to a lot of women who come to the clinic who’ve had breast cancer, and they actually say, I’m more worried about osteoporosis or heart disease or, or actually my day to day wellbeing than I am about having breast cancer. And I’ve heard and you’re not the first person who said I would prefer to go through all that treatment again if it meant I would feel better from taking HRT. And then this there’s a whole moral question for me as a doctor. How can I refuse a treatment where there is a woman who knows what it’s like first hand? To have had treatment for breast cancer says to me, I would prefer to do that again than continue as I am now. [00:17:30][43.8]

Trudie Jennings: [00:17:31] Absolutely. And I talked to my cancer nurse, the Macmillan nurse specialist who is absolutely amazing. And I said, what’s happening? So to continue the story then I felt so well after my recovery from cancer, I came off the antidepressants and my husband, honestly, he just went through the roof when I told him that, I decided to take my patches off and I just thought I feel great. And I literally fell through the floor. And I was fine after I came off the antidepressants. That was in the August, I think. And then in the December, I decided to take my patches off and within three weeks I was desperate. It was awful. Appetite lost, anxiety. And there’s something about it’s so hard to believe that it can be all about hormones. And I jumped straight back on to the antidepressant and again with my husband saying, please don’t, please don’t. This has been hormonal from the start, please. Me saying, I can’t. I can’t. I’m just so frightened. I can’t go back there. I can’t go back to feeling like that. And I had a terrible reaction to the antidepressants, the same one as I’ve been on previously. But I just had an absolutely terrible reaction. So then the GP prescribed me another one equally bad, I was going down and down and then another one. I’d gone back on the patches by this time, but I was suicidal by then. I felt so unwell and I wasn’t okay. It’s kind of a different feeling of suicide, I imagine to, I don’t know, but it felt like I feel so unwell. There’s just no point. I’ve had a great life. There’s just no point in feeling like this. And I could have just said, thank you very much, everyone. I’ve had a lovely time, but that’s it. You know, I can’t live like this. And another friend who is a psychologist said to me, Trudie, we can’t help you at all if you’re dead, but you know, we can help you if you stay alive. And I just thought that was just a really, really helpful way of putting it. And we ended up finding a private psychiatrist again, which took so much honestly. There was just no availability sort of locally within the health service. And she was amazing and she wasn’t interested in the menopause. She said, I’m just going to sort your brain out because you’ve overdosed yourself on so many different things here. And she did. And yeah, I’m still on the antidepressant. My husband is still adamant that all of this could have been avoided if I just stayed on my HRT. But I’m in a really good place and I would say the past two years are probably been the best two years of my life. [00:20:03][152.1]

Dr Louise Newson: [00:20:03] Amazing. So you’re going to stay on your HRT? [00:20:07][4.1]

Trudie Jennings: [00:20:09] I am, yes. Yeah, definitely I would. You know, there is part me that thinks could we just get it up a little bit, but I think nothing’s broken at the moment so and that would be one of the takeaways I would say to anybody, take, you know, get what you need, take what you need to get yourself back, because yeah, it’s just so dreadful not being yourself. [00:20:28][19.4]

Dr Louise Newson: [00:20:29] Yeah, and it’s a really important point as well, because HRT is not necessarily something that people have to take forever. They don’t have to make the decision when they start how long they’re going to take it for. We know the guidelines are clear. You can take it as long as the benefits outweigh the risk, review every year. And for most women, that is forever. But when women have, they’re taking it and they’re unsure of the risks/benefits as in for women who’ve had breast cancer, then it becomes a very individualised choice. But also, I always say to women, it is reversible. You don’t have to keep taking it. If you then have a wobble or decide you want to see what you’re like without it, of course you stop it. And as you found first hand, that it doesn’t build up in the system. It doesn’t last very long. So it really only lasts the day that you use it. And it means then that women are in total control, which I feel very strongly as a woman myself. I want to be in control of my destiny. I want to be in control of my health. I want to be in control of my future as well as much as I can. Of course, there are so many things that just you can’t be in control of. And with hormones, as long as women are taking hormones following breast cancer, knowing that there is uncertainty, knowing that there might be an increased risk, knowing that there are still benefits to your bones and heart and brain and everything else, then that’s why I feel very, very strongly and I’m very happy to be challenged, that women can make the decision themselves. If I was just sticking it on patches onto everybody that had breast cancer, that would be completely wrong. It’s a very individualised choice. And also, I don’t live your life, Trudie, I would love to live your life seeing that, you showed me before we started, where you live. A beautiful view of the sea. But I don’t live your life. And I don’t live with your husband. And for him as well, it has a massive impact for him when you’re not on hormones. And he’s incredibly supportive. But it has to be a choice that you’re comfortable with more than anyone else, but also the people that are with you as well. And I think your story just highlights that so clearly that there is no right or wrong in what we do. And we have guidelines as healthcare professionals and we in some of the NICE guidelines, it says in extreme cases we can prescribe HRT for women who’ve had breast cancer. I would argue that you were quite extreme because you were unwell. [00:23:19][170.0]

Trudie Jennings: [00:23:19] I was. [00:23:20][0.7]

Dr Louise Newson: [00:23:21] But also we’ve got the shared decision making guidance that we are allowed to share the decision. And even if we as healthcare professionals don’t feel comfortable, but the patient does and understands there might be risks of that treatment, then that’s fine as well. And informed consent, really important that you are allowed to accept or refuse treatment even if there are risks with that treatment or not having that treatment. And I think this is really important. You know, we’re in 2023. We’re not in the 1900s when women are locked away without any discussion because they’re hysterical. We have to move forward and allow women to have their life. Because you’ve relocated, you’re having a sort of new life almost but I’m not sure you would be doing that if you weren’t taking HRT would you? [00:24:10][49.0]

Trudie Jennings: [00:24:10] I don’t think I would. Absolutely not. And that’s why I’m taking it. Yes, it’s about very much about living in the moment. And I think that’s one thing all of this has taught us, my husband and me. Just take each day and just enjoy it because none of us know what’s around the corner. But if I can do anything to maintain my sanity and my physical wellbeing, I’ll take it now. I will. [00:24:35][25.0]

Dr Louise Newson: [00:24:36] Mmm. That’s so important. So I am so grateful Trudie because I know it’s not easy and I know it’s taken me a while to persuade you to come onto the podcast to talk about very personal things, but I know that your words will really help people and maybe make people think in a slightly different way rather than a very binary black and white yes and no way, because medicine is an art form as well as a science. And the art is getting it right for that individual patient. And I strongly feel that. So I’m very grateful. So just before we end, I always ask for three take home tips. So three tips for women who have had breast cancer, who are struggling with their symptoms and maybe are quite scared of HRT or have been told they can’t have it. What three things do you think would be good just to empower them to maybe think or get what is right for them? [00:25:32][55.9]

Trudie Jennings: [00:25:33] The cancer nurse specialist that I saw, so I asked her, how are the women that you’re dealing with that have come off HRT immediately they’ve been diagnosed with breast cancer, and she said pretty dreadful. And she said a lot of them come through it, but a lot of them are housebound and very unwell for a couple of years and that’s a couple of years of life. So she was actually, I can’t say delighted. She was very happy that I had taken the decision to stay on the HRT. And it’s just back to what you were saying, Louise. I think it’s about quality of life. You decide for yourself if you can maybe, you know, battle it out, just give up a few more years and get through the whole blinking thing. That’s a choice, of course. Mine was I just couldn’t. I just couldn’t face it. No chance. So that would be the first thing is, you know, that there is a choice there, as we’ve said. And to talk to you health professionals and, you know, I’ve generally found them really, really good. I went for my fifth and final mammogram just a couple of weeks ago down here. And because I had moved to a new area, they wanted to see me, the surgeon wanted to see me, actually. And he was just so brilliant. He didn’t bat an eye when I said about the HRT. And yeah, we had a really interesting conversation about it. And he said, if you have any symptoms because your cancer was so aggressive, you could come in here five times a week and say, you want to be seen and you will be seen. He said, so we don’t need to say we’re discharging you. And I just thought, that’s so reassuring as well. So yeah, yeah, really sensible. And of course I won’t because, you know, hopefully if, you know, I might have to go once or twice, but who knows. But I won’t be hammering on his door. But just to know that I could and I would be taken seriously was really, really good. It is very different, the menopause situation now. And I just devour every piece of literature, everything on the TV, all your stuff Louise on menopause. And I honestly just think, oh, it’s just it’s so good to hear because at least mostly women will think know that they’re not going mad. And that’s what I would say is you’re absolutely not going mad. You know your own body, you know what you’ve been through, even if you’ve had issues before, you know if it’s different, if it’s worse. And you get out there and get the treatment. And don’t let anyone tell you that, you know, you’ve been a bit of a hypochondriac or whatever. You get it, you know your own body. And can I just say then my relationship with my mum has got so much better actually. And what came out was and I asked her if I could say this, that when I was away at university she was 51 and she tried to take her own life and she was hospitalised. And my family kept this from me. And she said it was the menopause, wasn’t it? And I said, well, I don’t know, but it sounds awfully like it was. And we’ve talked about it and talked about how unwell she felt and how no-one would, exactly the same symptoms as me. When we were talking about it, she knew what I was talking about. And it makes, you know, and she said that’s why she always say you will get through it, though. You will get through it. You come out the other side and you feel great and all of this. That was really special, too. And I’m sorry that she had to go through that. And I think now hopefully she wouldn’t have to go through that. [00:28:53][200.0]

Dr Louise Newson: [00:28:56] Really important, so important and really empowering. And I think that’s the message that’s weaved through this whole podcast actually is about choice. It’s about being in control, being empowered, but also really being supported as well. And I think that’s really important. So it’s been wonderful. I’ve really enjoyed this podcast and I’m very grateful to you Trudie so thank you again. [00:29:18][21.9]

Trudie Jennings: [00:29:18] Thank you, Louise. It was great. Thank you. [00:29:20][1.7]

Dr Louise Newson: [00:29:25] You can find out more about Newson Health Group by visiting www.newsonhealth.co.uk. And you can download the free balance app on the App Store or Google Play. [00:29:25][0.0]

END

The post Breast cancer treatment and HRT appeared first on Balance Menopause & Hormones.

Leading US oncologist Dr Avrum Bluming joins Dr Louise Newson to talk about the crucial role of oestrogen in women’s health.

Despite HRT’s proven benefits in protecting against heart disease, bone fracture and cognitive decline, many women still avoid it over breast cancer fears.

It’s been more than 20 years since media headlines about a study called the Women’s Health Initiative linked HRT to an increased risk of breast cancer. In this podcast, Dr Bluming says that in fact we now know oestrogen alone decreases the risk of breast cancer development by 23% and risk of death from breast cancer by 40%. 

He also disputes the findings of the WHI study that combined progesterone and oestrogen HRT leads to a small increase in breast cancer cases.

‘It is very upsetting when such an influential study continues to misquote their own data,’ says Dr Bluming, who has spent 25 years studying the benefits and risks of HRT in breast cancer survivors.

Dr Bluming points out that oestrogen used to be a treatment for breast cancer before chemotherapy was developed, and that rates of breast cancer increase as we age, despite the fact our oestrogen levels fall as we get older.

You can read about Dr Bluming’s latest paper here, and listen to an earlier podcast Dr Newson and Dr Bluming recorded here.

Transcript

Dr Louise Newson: [00:00:11] Hello, I’m Dr. Louise Newson. I’m a GP and menopause specialist and I’m also the founder of the Newson Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. I’m also the founder of the free Balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research, bust myths on menopause symptoms and treatments, and often share moving, and always inspirational, personal stories. This podcast is brought to you by the Newson Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. So today on the podcast, I have someone who is in the US, so not near me, but I’ve had him on my podcast before and I’ll hopefully have him again. Someone called Avrum Bluming, who some of you might have known, who is a very inspirational and academic doctor who has got the most amazing knowledge and also clarity about things. And I first heard him talk at the Royal Society probably about seven years ago and thought, wow, this is so interesting because he’s saying some really common sense things and common sense often gets lost in medicine. We’re always trying to find the biggest, the best, the most impressive cure for something. And then we forget basic science and Avrum’s talk at the Royal Society just made me sit and reflect and think, Louise, what are you doing? Go back to basics in medicine, which is what we often do. So he’s helped me more than he knows over the last few years, really trying to unpick evidence in a very simple way. So I’m very delighted, Avrum to introduce you again to the studio. So thanks for joining me. [00:02:09][118.5]

Dr Avrum Bluming: [00:02:10] It’s a pleasure, Louise, as always. [00:02:11][1.5]

Dr Louise Newson: [00:02:12] So yours and my background are similar, but different in that you’ve been an oncologist for many years and I wanted to be an oncologist, and the only reason I changed was really for family reasons, just because, I just, with my husband being a surgeon, I thought, actually I want to work part time. And in the nineties, when I had to make career choices, after I’d done all my medicine exams, it was too difficult to go part time as a doctor then. So I’m always jealous of people that are oncologists. But actually I think I don’t regret what I do in the slightest. But you’ve written the most amazing book that many of my listeners would have heard of, and if they haven’t, they should look it up called Oestrogen Matters. And this is something that even the title actually, Avrum. Oestrogen is something everyone seems to be really scared of and actually oestrogen, can you just explain, it’s just a hormone in our bodies, isn’t it? [00:03:07][54.6]

Dr Avrum Bluming: [00:03:07] Yes, it is. Both male and female. Yes. And I gave a talk last week that you and I were just discussing in front of several hundred perimenopausal women. And I was aware that they were afraid of hormone replacement therapy and oestrogen specifically. And I asked them, what is it about hormones that you’re afraid of? And I put several options in front of them. I said, are you afraid of heart disease? And very few of those several hundred hands went up. Are you afraid of hip fracture? And very few went up. Are you afraid of cognitive decline? And a few more went up, but not many. And then I said, are you afraid of breast cancer? And almost all of the hands went up. Well, I am a medical oncologist. I have spent the last 50 plus years working with patients who have cancer, and 60% of my practice has been women with breast cancer. So I’m very familiar with that entity. In addition, my wife had breast cancer. My daughter had breast cancer. My wife’s sister was just diagnosed with breast cancer. I’m very grateful that all three of them thus far are in excellent health. But I’m very aware of the fear surrounding breast cancer, both as a patient and as a physician. And you mentioned the Women’s Health Initiative. The Women’s Health Initiative, as you well know, and many of your listeners know, is a 1 billion plus dollar study that was initially published in July of 2002. And that really put a target on hormones, a target that has been fired at many, many times. The prevalence of hormones in the United States fell from about 44% of the eligible population to less than 5% where it remains today. And the major fear was breast cancer. And so at your discretion, you let me know when you want us to get into that, and I will gladly get into that. [00:05:44][156.2]

Dr Louise Newson: [00:05:44] Well, let’s get into WHI in a minute. But before we do, let’s just talk about what a hormone is, because actually, some people think hormones are only oestrogen and the sex hormones, but we’ve got lots of different hormones in our body. And they’re just chemical messengers, aren’t they? Can you just elaborate what a hormone actually is? [00:06:02][18.4]

Dr Avrum Bluming: [00:06:03] Sure. I wouldn’t say just because I think they are miraculous chemicals. They are the chemicals that circulate in our bloodstream and go from the organs, secreting them to the organ receiving them, and tell the receiver organ what to do, when to grow, when to multiply, when to stop growing, whether you should secrete a certain product, whether your heart should increase its rate of beating per minute in response to exercise. Hormones are wonderful. The hormones that we talk about most specifically in women are oestrogen, which is a hormone that has now been shown to be responsible for many attributes of women that make us recognise them as women, but they also help decrease the risk of heart disease among women as they get older, decrease the risk of hip fracture among women as they get older, preserve the ability to think clearly and also prolong life if they’re started within ten years of a woman’s final menstrual period. We use one additional hormone, and I’m sure most of your listeners are aware of this, oestrogen alone can increase the risk of uterine cancer. And so women who still have a uterus when they are given oestrogen are also given progesterone, which is a hormone that prevents that increased risk of uterine cancer among women taking oestrogen. So when we talk about hormone replacement therapy, we’re talking largely about oestrogen and oestrogen plus progestin, progesterone, when a woman still has a uterus. [00:08:11][127.7]

Dr Louise Newson: [00:08:12] And progesterone has its own metabolic effects in the body as well. It’s an important hormone for many women, but we’re just sticking to oestrogen. We know that every cell responds to oestrogen and actually our ovaries produce oestrogen, but our brain produces oestrogen. And I’m sure other areas of our bodies produce oestrogen as well, don’t they? [00:08:32][19.9]

Dr Avrum Bluming: [00:08:32] Yes, they do. And oestrogen has a 640 million year history. It is present in octopuses, which go back that far. And for those of you who think I mispronounce the plural of octopus, I didn’t. It is octopuses. [00:08:53][21.0]

Dr Louise Newson: [00:08:55] They’re very interesting because as you know, and some listeners know, I’ve got a pathology degree as well, and we learned a lot about the role of our immune cells to fight infection, but also to fight disease. And as soon as I started to read more about oestrogen, knowing how we’ve got receptors for oestrogen on all our immune cells, and actually when we have low oestrogen in our body, it increases inflammation and also the way our cells work. As you say, our cells are so important, but we have mitochondria in the middle of our cells, which is actually like the powerhouse of the cells, isn’t it? It sort of works out the whole energy and determines how so many processes occur. And we know that oestrogen is very important for mitochondrial function as well as the immune cells, as well as lots of other processes in our body and as you say, in our brains. It works as a neurotransmitter, a really important chemical to allow our brains to work. So there are lots and lots of benefits. And we know actually for many years, haven’t we, in studies that women who have regular periods, women who are naturally producing oestrogen, are healthier than women who don’t have their periods. So, I mean, we’ve got some good studies from women who’ve had their ovaries removed. Their risk of disease actually increases quite quickly after and even my really non-existent menopause training as an undergraduate in the eighties, I was still taught that women are protected from various diseases, including heart disease, usually up until the age of 50, and then something happens. And that’s something obviously is the menopause. But they failed to tell us that. Then women catch up with men afterwards and their risk of heart disease and so forth increases. So this is why I’m talking at the start about this common sense medicine, really, isn’t it? Because oestrogen is really important when we have it naturally in our bodies, isn’t it? [00:10:52][116.8]

Dr Avrum Bluming: [00:10:52] And it’s not just theoretical, but women who have their ovaries taken out early or women who reach an unusually early menopause have increased risks of heart disease and bone fracture and cognitive decline. And giving them oestrogen eliminates that increased risk and helps prolong life. Yes. [00:11:15][22.6]

Dr Louise Newson: [00:11:16] Which makes sense, isn’t it? You know, in medicine, we try and replace what’s missing. And so if we know something is missing, we replace it and it improves. And also, lack of oestrogen can cause so many symptoms that we’ve talked about quite a lot before that are associated with the perimenopause when hormones start to decline and also the menopause. So I sometimes think which, just bear with me here, Avrum, if I was an alien from outer space and I knew nothing about the WHI, had read no adverse media about HRT, hormones or oestrogen. And I was listening to this conversation, I would then be probably asking you with my inquisitive mind. So. Right. So why aren’t we just replacing everyone with oestrogen? Because it’s a really important hormone. Women live a lot longer than they used to 100 plus years ago. We used to die earlier, so now we’re living into our seventies, eightes, nineties if we’re lucky. But a lot of time without hormones. We’ve just been talking how good it is as a biologically active hormone. So Avrum why are we not all taking oestrogen then? [00:12:23][66.6]

Dr Avrum Bluming: [00:12:23] Well, first at least half of us are males and we have problems taking oestrogen. So let’s focus just on the females among us. And if you were an alien, you might have seen the headline on The New York Times. If you were smart enough to get to Earth, you probably got The New York Times or the London Times, and you would have seen that there was this very expensive study that was looking to determine whether giving oestrogen to women as they pass the menopause line would help them. And the study first came out as a press conference, which is unusual. Usually a study is published in a medical journal. Healthcare providers have a chance to read the study and form an opinion. This time before it came out in the Journal of the American Medical Association, it was widely published in news media around the world. And what they said in the results of the study is that it increased the risk of heart disease, increased the risk of cognitive decline and increased the risk of death. They have walked back all of those and said, well, in fact, if it started around the time of perimenopause or within ten years of a woman’s final menstrual period, it actually improves all of those things. At the same conference in 2002, they said it also increases the risk of breast cancer. And that was the leading headline. Interestingly, at that time, it had no increased risk of breast cancer found to be statistically significant. But that didn’t prevent the press conference and the news media to widely publicise that. At that same time, the Food and Drug Administration in the United States issued what is called a black box warning that says if you take this, any product containing oestrogen, it will increase the risk of cancers and specifically breast cancer. We now know because the Women’s Health Initiative has published updates many, many times since then, and here we are 21 years later, and now we know that oestrogen they found and this goes along with other researchers as well. Oestrogen alone decreases the risk of breast cancer development by a statistically significant 23%. And even more importantly, it decreases the risk of death from breast cancer by 40%. That FDA black box warning is still in place. There is a movement among several scientists here in the states to change that, but it is still very much in place. The Women’s Health Initiative now says that, well, it’s the combination of oestrogen and progesterone that increase the risk of breast cancer. And in fact, what their data say is for women who start oestrogen and progesterone around the time of menopause or within ten years of the last menstrual period, the combination does not increase the risk of breast cancer. The population they studied was a population with a median age of 63. Many of them were considerably, half, were considerably older than that, and that hasn’t been widely circulated. Even if they were right that the combination of oestrogen and progesterone increases the risk of breast cancer, the increased risk would be one per 1,000 women taking it per year. And it doesn’t increase the risk of death from breast cancer, although they still claim that it increases the risk of breast cancer development. And in fact, even that claim is challengeable. What the paper I just published within the past few weeks says is there was no increased risk among the population that took the combination of oestrogen and progesterone, regardless of when they started taking it. That, in fact, I told you there was a decreased risk among women who took oestrogen alone. And if you graph the risk of oestrogen alone on the same graph as the combination, it is the identical curve. And yet oestrogen reportedly is associated with the decreased risk. And the combination increases the risk. There is no increased risk. It’s just that the placebo group against which the WHI investigators compared the women taking the combination had a lower than expected risk. Why should the placebo group have a lower than expected risk? Well, a significant number of them had been taking oestrogen before joining the study and being randomised to placebo. And if that population were removed from the data before graphing it, the increased risk completely disappeared. [00:18:16][352.7]

Dr Louise Newson: [00:18:18] Which is quite something, isn’t it? [00:18:20][1.5]

Dr Avrum Bluming: [00:18:20] I mean, more than something it’s actually very upsetting. It is not intellectually straightforward. And we rely on reports that help determine how we practice. And it is very upsetting when such an influential study continues to misquote their own data. [00:18:43][23.0]

Dr Louise Newson: [00:18:45] Now, there’s so many things that are wrong because it’s the same with us in the MHRA. Again, have this similar black box where it’s warning about oestrogen and in fact, cancer research over here, Cancer Research UK, say that significant number of breast cancers could be avoided if women did not take HRT. And when I’ve challenged them and I have on several emails, they’ve said yes, for oestrogen causes cancer. And again, I think about this alien thing. So if oestrogen caused cancer and I didn’t know any science and I didn’t know about the WHI, surely we would then be seeing a lot more cancer in younger women who produce naturally oestrogen, but also women who had more pregnancies. Because when we’re pregnant, we have very high levels of oestradiol in our bloodstream and there isn’t any evidence. In fact it’s to the opposite, isn’t it Avrum, for people who are pregnant? [00:19:40][54.8]

Dr Avrum Bluming: [00:19:40] That’s correct. The biggest risk factor for breast cancer, aside from gender, is age and the risk of breast cancer increases as age increases. And as you correctly state, we would think it should fall as oestrogen levels fall, and it doesn’t. In addition, we used to use oestrogen to treat breast cancer when we didn’t have chemotherapy or other agents. And there was a reported 44% response rates to giving oestrogen to women who have measurable breast cancer. And finally, a woman who is pregnant and gives birth before age 20 has a 70% reduced risk of lifetime development of breast cancer. There is a very interesting study that was just published by Ann Partridge this year from Harvard, saying that women who were taking a medication that is meant to interfere with oestrogen’s actions who were premenopausal and wanted to get pregnant, were allowed to take two years off from their treatment, get pregnant, which bathes the body in oestrogen and progesterone, and then come back to treatment. And they’ve been followed so far for seven years with no increased risk of recurrence. So clearly saying that oestrogen increases the risk of breast cancer is both wrong and not provable and harmful. One other thing. Progesterone deficiency is associated with a five times increased risk of breast cancer development. So blaming it on progesterone doesn’t make sense, especially since progesterone was also used to treat measurable breast cancer and was at least as successful as Tamoxifen. [00:21:47][127.0]

Dr Louise Newson: [00:21:48] Indeed. And so the other alien bit of me is thinking when the WHI came out, breast cancer incidence was probably about one in 11, one in 12 people, depending on what study you read. But people who, and we get a lot of letters of complaint in our clinic saying, how dare you put these women at risk of breast cancer by giving them HRT? And obviously we aren’t because we know the evidence. But if you were saying, as you did quite rightly, the prescribing rates for HRT in the U.S. were a lot higher, about 44% dropped to 5%. In the U.K., they were about 30% and they dropped to less than 10%. So you’ve got far less women taking HRT. So if you are saying, well, maybe it’s because it’s not the pure oestrogen, it’s HRT, because those three letters scare so many people. Surely with the reduction in prescribing of HRT, we will have had a reduction in incidence of breast cancer over the 20 years. So have we, Avrum? [00:22:55][66.4]

Dr Avrum Bluming: [00:22:56] Well, it depends on whom you ask. The Women’s Health Initiative investigators who still claim that oestrogen increases the risk of breast cancer do claim that there is a reduction in incidence as a result of the reduction in the frequency of hormone replacement therapy. There was a reduction in incidence of breast cancer in the US, which was noted starting in 1999, but which the investigators claim was really due to their 2002 publication. That doesn’t make sense. The reduction, they say, is still ongoing, but it’s not. The incidence of breast cancer around the world is increasing. And by the way, even that small reduction and it was small, was not seen in most countries around the world where hormone replacement therapy prescriptions dropped. And what’s most important to remember is the overwhelming majority of patients who take HRT do not develop breast cancer, and the overwhelming majority of breast cancer patients never took HRT. So to look at any population statistic and try to derive from that evidence of oestrogen’s carcinogenicity is misleading at best and dishonest at worst. [00:24:34][98.0]

Dr Louise Newson: [00:24:35] Absolutely. And certainly in the UK it’s around one in seven women who now develop breast cancer. And as you know, obesity has overtaken smoking as the commonest cause for all types of cancer, including breast cancer. So it’s not as easy as oestrogen causes breast cancer. And a lot of people are still told when they have an oestrogen receptor positive breast cancer, it’s an oestrogen driven or oestrogen caused. And actually, when I explain to women that not having a receptor is the abnormal bit, so when it’s oestrogen receptor negative, that means that the cancer’s mutated and is not actually as good prognosis often. We have oestrogen receptors, we’ve already said, everywhere. And so it’s not as easy and straightforward as just saying oestrogen causes breast cancer because there’s the alien bit of me that I keep talking about, which is a common sense bit, but there’s also the science bit and now we’ve got evidence as well. And what’s so sad for me is to know that an evidence-based approach has not been taken when it comes to oestrogen in HRT for women who’ve had breast cancer. And this study that has been really looked at by so many people and the majority people are in complete agreement with you, Avrum, it’s still the biggest barrier for women to be able to get HRT. And the other thing that I think is really sad is that choice is not being allowed. Now, you’ve already said women we know are scared about breast cancer, but actually when they know the facts, they are then more educated to think about how scary other conditions are. And so if I told you I had breast cancer or if I told you I’d just had an osteoporotic hip fracture, I think with all your knowledge and experience, you would be more concerned about my osteoporotic hip fracture because my outlook from that actually is more severe than most types of breast cancer. But it’s something about this word cancer. So we need to be thinking not also just about supposed risks of HRT that we’ve already said aren’t really there. We need to focus on the benefits because there are so many benefits from taking HRT for many, many women, aren’t there? [00:26:51][136.9]

Dr Avrum Bluming: [00:26:52] Yes, there are. And we have to be careful that we don’t dance around the question that most women ask, which is if oestrogen doesn’t cause breast cancer, why is breast cancer 100 times more frequent among women than it is among men? If oestrogen doesn’t cause breast cancer, why do treatments that we say impede oestrogen function seem to work on breast cancer? And the short answer is I can’t put it all together in a unified theory. I wish I could, but I can’t. I can avoid simplistic answers, however, and you had mentioned that an oestrogen receptor positive breast cancer often responds to some treatment that seems to interfere with oestrogen function. That’s true. Tamoxifen is the first drug that came on the scene for that. Tamoxifen has at least ten different functions besides oestrogen blockade. When Tamoxifen is given to a premenopausal woman, her level of circulating oestrogen goes up tenfold, and that doesn’t impair the therapeutic benefit of Tamoxifen. And by the way, the multiplying cells in a breast cancer that is responsible for the tumour growing is not an oestrogen receptor positive cell. Even among oestrogen receptor positive tumour patients, the oestrogen receptor is present on many cells in the body. You started the program off by saying that, and in oestrogen receptor positive breast cancer is a relatively slow growing breast cancer compared to an oestrogen receptor negative breast cancer. [00:28:55][123.1]

Dr Louise Newson: [00:28:57] It’s very interesting, isn’t it, yet women across the world, but actually also healthcare professionals across the world are still scared away from oestrogen. And it is really sad and I don’t quite know how that’s going to change. In fact, I’ve posted today, the day that I’m recording the podcast, not the day it’s going out, a little excerpt from your wonderful paper on my Instagram, and I only did it a few hours ago and already there’s lots and lots of interest. And actually the women are understanding and I think that’s what we work for, isn’t it? As doctors, we’re there, I remember you saying to me years ago, Louise, I’m an advocate for my patients. I’m here to listen and guide them. And I think that’s so important. But what we are realising with the work that we’re both doing in different ways in different countries is allowing women to have the knowledge and share, you know, what this sort of truth behind oestrogen as well, because it is quite easy when you know the facts. But there is so much good news about oestrogen. And so for you to write this article, I think is a real turning point. But it’s a shame it’s taking so long, isn’t it, for people to really understand? [00:30:19][81.8]

Dr Avrum Bluming: [00:30:20] It’s very important for women to understand. I was a practicing oncologist when the standard treatment for breast cancer was mastectomy, even a radical mastectomy, and it was thought for close to 100 years that breast cancer spread contiguously from one part of the body to tissue right next to it. And so you took off as much as you could, and that’s what doctors did. The reason it changed, even though we knew that a lumpectomy with radiotherapy was as good as a mastectomy as early as 1929, the reason it changed in the 1960s and early 1970s is because women got educated and said to their physicians, enough. They said, I’m not going to sign a consent form that allows you to remove my breast before I even know if I have breast cancer. You wake me up and we will talk about it. And women have to do the same thing here. A physician who dismisses you, if you ask about hormones, saying, I don’t want to kill you or I don’t want to give you poison, is not an informed physician, and your responsibility is either to help that physician find the appropriate information or you find a different physician. [00:31:52][92.7]

Dr Louise Newson: [00:31:53] Indeed, that’s such an amazing way to end. And I all for being the biggest supporter of my own future health, as well as a menopausal women myself who has been a patient to many different people before I received the treatment that I wanted. It’s really important that we have choice and that is so key. So I’m very grateful for your time, Avrum. And I hope people will listen to this podcast more than once because there’s a lot of information in there, there is a lot to unpick. So please take your time listening and hopefully share it with people, listen again in a calm way and you probably won’t be calm at the end because it’s very frustrating what’s been happening to women. But we can change it and we are changing things. So before I end Avrum, I always ask for three take home tips. So I’m very keen to ask you three things that you think will make the biggest difference over the next 20 years for women to get back onto hormones. What are the three things that you think are already helping or which will help more? [00:33:00][66.2]

Dr Avrum Bluming: [00:33:01] I think the single most important thing is for women to take an active role in their care. Now, we’re not pushing medicine, and this isn’t candy, like any medicine. Benefits versus risks. And we haven’t gone over the risks which are small, but they’re there, have to be calculated. But Eric Winer, who is the recent past president of the American Society of Clinical Oncology, in his presidential address, titled Partnering with Patients, saying that advancement of research and clinical care will be maximised if we partner with patients. Let them understand what we are suggesting and let them be active partners. I think that dwarfs anything else that would happen. I think the second step, and one that I would love to see but may not happen soon enough, is I’d love to understand what cancer is. Our current understanding of cancer as something that has to be cut out or burned out or poisoned out is a very simplistic understanding that doesn’t fit the experimental data that we already have. And once we understand it, we will be so much better off in being able to approach it intelligently. [00:34:36][95.6]

Dr Louise Newson: [00:34:38] Hmm. [00:34:38][0.0]

Dr Avrum Bluming: [00:34:39] That’s two. Offhand, I didn’t come prepared to discuss three, but of those two would be enough. [00:34:47][7.8]

Dr Louise Newson: [00:34:47] Oh I’m pleased you’re not greedy. Very good. I think. I think number three is keeping education for all healthcare professionals, actually, to allowing them a bit of time to really look at the evidence unpicked rather than just taking this top line that they’ve done for many years. And it is happening. Things are changing, definitely. So keeping professional curiosity not just for oestrogen, but for all aspects of medicine, I think is really important. [00:35:15][28.2]

Dr Avrum Bluming: [00:35:16] Being able to practice medicine, as you well know, is a wonderful privilege and very exciting. But in order to feel both privileged and excited, you must stay curious, recognise how little we know, and how much more we have to learn. [00:35:35][18.1]

Dr Louise Newson: [00:35:35] Absolutely. So thank you so much for your time today, Avrum. I really enjoyed it. [00:35:39][3.8]

Dr Louise Newson: [00:35:44] You can find out more about Newson Health Group by visiting www.newsonhealth.co.uk. And you can download the free Balance app on the App Store or Google Play. [00:35:44][0.0]

ENDS

The post Getting to the truth around HRT and breast cancer with Dr Avrum Bluming appeared first on Balance Menopause & Hormones.

Breast cancer specialist, Dr Tony Branson returns to the Dr Louise Newson podcast two years since his first appearance. Tony is a Consultant Clinical Oncologist at the Northern Centre for Cancer Care, based at the Freeman Hospital in Newcastle upon Tyne.

In this episode the experts discuss the current situations women can find themselves in when having treatments for breast cancer and experiencing the onset of menopausal symptoms. Tony supports the women he sees through some challenging decisions around managing the risk of cancer recurrence while for some, treating menopausal symptoms with HRT to improve the quality of their lives.

Episode Transcript:

Dr Louise Newson [00:00:09] Hello, I’m Dr Louise Newson and welcome to my podcast. I’m a GP and menopause specialist and I run the Newson Health Menopause and Wellbeing Centre here in Stratford upon Avon. I’m also the founder of the Menopause Charity and the menopause support app called Balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based information and advice about both the perimenopause and the menopause. So today with me, I have someone back by popular demand, actually. He’s already been on the podcast before, and some of you might have listened to him, but I have the pleasure of introducing, or reintroducing, to you Dr Tony Branson, who is a consultant clinical oncologist who works with women who’ve had breast cancer in the North East. So welcome, Tony, today.

Dr Tony Branson [00:01:08] Thank you.

Dr Louise Newson [00:01:09] So we first met several years ago now because I saw a lady in my clinic who had had breast cancer and I think she might have been on Tamoxifen – one of the treatments after having breast cancer. And she told me that her cancer doctor was quite happy that she took HRT and she’d come down to see me for some advice. So I got that cancer doctor’s name and got a hold of him and you’re here in front of me now doing this podcast. And it was really enlightening talking to you actually for lots of reasons. But I love the way that your patient is in the centre of everything you do, which for many of you that have heard me talk before, is certainly the way that I practice medicine. And indeed most clinicians do really, but you’re heavily experienced and really I just wanted to spend the next half an hour or so talking about people who’ve had breast cancer and how difficult it can be sometimes or often when they’re menopausal and have very limited options often.

Dr Tony Branson [00:02:15] Yes. I mean, the mutual patient we had, in fact, had a very, very low risk for invasive cancer and was actually referred to me merely to have some radiotherapy. And we started discussing that but it became very apparent during the discussion that she was very distressed and she was distressed because she’d been on HRT prior to the diagnosis and had done well on that and was told fairly firmly by the person who’d operated on her that she must stop the HRT and on stopping that had developed really quite a plethora of difficult menopausal symptoms and was very upset by this and I couldn’t really just sit there and just say, “well, don’t worry about that, you’re going to have some radiotherapy and everything will be fine.” So we started talking about it and basically the undercurrent or the basis of what I said was, “look, I cannot tell you that to continue with your HRT carries no risk. But I certainly can tell you from all the evidence that we have is that it carries a very small amount of risk. And in view of the way in which your life is being so diminished by not taking your HRT, that really, in my view, it would be more than reasonable for you to continue with it.” And obviously she was quite relieved to hear that and I felt this was not going out with the evidence. I didn’t tell her that I could promise her that it wouldn’t have any effect on her cancer coming back or that, in my opinion, whatever effect it had was likely to be diminishingly small. And probably I would have been hugely surprised if her cancer had returned and even more surprised if somebody could demonstrate to me it was due to her continuing HRT. So I think that was the beginning of that bit of the journey, although, I mean, prior to that I’d had discussions with patients with severe menopausal symptoms who had breast cancer, and we did talk about the risks and benefits. And I had an on occasion, actually prescribed, probably not all that adeptly, HRT to help them. And then obviously having through this met up with you, I became more interested in how we could make patients who’d had breast cancer – a not inconsiderable number of whom were suffering very considerably in and for whom we were not managing their problems that well – how we could be doing it better.

Dr Louise Newson [00:04:42] Yeah, and it’s very interesting actually Tony, some of you might know I actually wanted to do oncology, and it was only because I got married and had three children, I changed career track, but when I was working as a junior doctor in a big oncology unit in Southampton, I saw lots of women who’d had breast cancer. And when I was training in Manchester, I saw lots of women who had breast cancer and I knew that some of the treatments could affect the ovaries. But I didn’t really associate it with the menopause because I was just not very educated about the menopause then. And when I started seeing women in my clinic, like this lady we’ve described and others who have had breast cancer, who are really struggling often with symptoms of brain fog, memory problems, joint pains, fatigue, their quality of life has really deteriorated. I then reflected on my time, especially in Manchester, and I was really quite sad that I had missed out asking women and associating this cause and effect. And so I actually then got back in touch with Professor Tony Howell, who is still working in Manchester, who I did a project with, and I got on the train and went to see him and said “Tony, do you understand, did you realise how your patients are suffering? He said, “Well, it’s just a few flushes and sweats, isn’t it, the menopause?” And I said, “No, it’s far more.” And I don’t think he really realised. And he said, “Well I sometimes write to the doctor, the GP, and say, well, if they’re really struggling you could consider HRT.” And I said, “But Tony, they’re not getting it. People are just saying a blanket No.” And I’m really saddened actually, with stories of women who’ve had breast cancer who are then menopausal, who are just told, “well, just put up with it.” And he hadn’t really thought about it in the same way either, because I think – no disrespect to oncologists – they’re focusing on treating the cancer and making sure that women survive as long as they can and not have recurrence or any ill effects of their cancer. But that’s where it sort of ends, really, when it comes to the menopause. But it doesn’t always end for the women, does it, when they’re experiencing symptoms and don’t know where to go to get help.

Dr Tony Branson [00:06:51] I think it’s interesting because I think it goes back a long way in that I do not recall being taught very much about the menopause as a medical student.

Dr Louise Newson [00:07:03] No.

Dr Tony Branson [00:07:04] So when I qualified as a doctor, I was aware that women in their late forties, early fifties would stop menstruating and not be fertile, and that that was, as it were, the normal scheme of things. I mean, I must have known a bit about hot flushes and things, but I didn’t really have a great deal of consciousness about it. And then I guess, I mean, interestingly, one of the things which sort of got to me more when I was teaching medical students when I first came to Newcastle, was actually how little they knew about cancer as well. I mean, the only people who and in fact, I mean we were told that we really shouldn’t teach them about cancer. That was the job of the surgeons. Well, while I fully accept that actually the majority of people who are cured of cancer actually are cured by surgeons, and while it’s a bit of a sport to be occasionally a bit rude about them, they do, you know, an amazing job and they do make a big difference for people. But I think that there was at that stage and there is less now, but it’s still there, an inability to work together through things that are, say, perhaps a bit peripheral to actually managing to getting rid of the cancer. And I think you’re right in what you say is that a lot of what we do is particularly dominated by ensuring that people who have cancer if at all possible, are rid of it. And we sort of then believe that they will go on to live normal lives and not be worried by anything else, which of course is a complete illusion. You know, that’s what’s driving people. And it’s fair to say that since I’ve been in oncology, the outlook for women diagnosed with breast cancer has improved enormously, both worldwide. In this country, we’ve actually probably in terms of improvement done as well as just about anywhere else. Although we started from perhaps a rather low baseline. So we’re not doing too badly with breast cancer, but it’s very easy to be seduced by those good results to then sort of rather forget about, you know, what some of the women are left with. I think there’s been another bit. I mean, the last cancer, whatever it was strategy document – they keep having slightly different names – was very big on survivorship and living with and beyond cancer. And although most of the principles within that are very good, helping people to achieve greater wellbeing and live healthy lives, generally get over their treatment and their disease, it’s all rather non-specific. And I think a lot of it doesn’t take into account the various things that make people have difficulty getting back to a good life after cancer. I mean, there’s a lot to talk about ‘you don’t get back to normal. It’s a new normal’. And in some respects, that’s fully understandable in that having had a what is a life-threatening disease, even if you’re cured of it, is a life changing event and you are not the same person afterwards. But part of the difficulty is, for a lot of these women, they’re not the same person afterwards because they’re left with a large number of really very difficult and life changing symptoms.

Dr Louise Newson [00:10:30] And it’s really, I mean, it’s great that life expectancy has improved, of course, in breast cancer, but we know now that most women who’ve had breast cancer actually die from cardiovascular disease. So heart disease, rather than their breast cancer, which in some ways is wonderful. But in other ways, it means that we have to think of women as women who can develop other diseases, even though they’ve had breast cancer before. And a lot of patients I talk to when they’ve had breast cancer many years ago, they don’t want to be defined by their breast cancer. And it’s really important – I was reading an article recently and it was entitled Falling Off a Cliff: What Happens After Breast Cancer? And it was talking actually mainly about sexual health and about women who have really awful vaginal dryness and reduced libido. And nobody really thinks about their sexual health as a woman who’s had breast cancer. Whereas if a man has prostate cancer and has treatment for prostate cancer even before surgery, he has a lot of counselling about the possibility of not being able to have erections or having premature ejaculation. Whereas it doesn’t happen really with women. And often it’s not until they’re directly asked if they have symptoms that they admit that they have, it’s not something that they would just offer in a consultation.

Dr Tony Branson [00:11:49] It’s interesting because before I ended up doing only breast cancer, I was treating – in fact when I was appointed, my main specialist role was gynaecological cancer. That’s a huge area of problems, particularly for women who have radical pelvic radiotherapy, which obviously for young women will stop ovarian function. And I must admit that was one of the areas where I would regularly prescribe HRT, because it seemed to me that this was merely trying to correct some of the ill effects of what we’d achieved as side effects of our treatment. And it’s interesting, when I went back to doing this a bit to fill in the manpower shortage, this doesn’t seem to be being done as routinely as before, and I couldn’t quite work out why that was. And maybe that’s another area quite separate from this that needs to be looked into. But again, the other aspect, as you say, the whole business of sexual health and I think there are all sorts of problems that relate to it. I mean, undoubtedly having had cancer of any of the primary or sexual organs, does take a bit of getting over in terms – for some women, not all – but for some women in being able to return to how they saw themselves as a sexual being in a relationship. And I think to be honest, we are pretty poor at dealing with that. And the interesting bit going back to the survivorship is that one of the elements behind it, which a lot of us have leapt on because of our workload, is that we’ve stopped doing it with the breast cancer patients anyhow, what I used to describe as worrying the well in that we would see patients at set intervals and we would do what I rather slightly glibly described as the laying on of hands and tell them that they were okay and they would feel euphoric and we’d feel good about telling them something good. And then they would go away for another six months and then the few weeks before that would start being worried and often get symptoms and we’d then reassure them. And so the cycle went on. And in busily doing this and doing it also with this slightly delusional view that we were going to either prevent them getting a recurrence of their cancer or mitigate any recurrence that occurred by apparently spotting it earlier – and there’s no evidence of benefit for doing this – that because we were doing this, we probably were not concentrating on the other elements of having had the disease, in particular the menopausal symptoms, as a consequence of treatment, which either might be the premenopausal women who had ovarian failure as a consequence of chemotherapy, or ovarian suppression as a planned treatment, or treatment with Tamoxifen, which I mean, Tamoxifen is interesting because, you know, the variability of side effects with it is huge, ranging from really nothing as far as one can elicit from patients through to that it makes their lives intolerable. With the menopausal women, clearly more recently, where we started treating them with aromatase inhibitors which lower their circulating estrogen to less than they would have anyhow when they’re postmenopausal and giving them problems as a consequence of that, that we’ve not really in any way specifically dealt with that. And I think that has been a failing. And I think I mean, it’s interesting that the document about survivorship and what we would do after treatment in general terms for cancer, said that we should instigate stratified follow up. And it’s very interesting that even the team at Gateshead, who I think are very proactive and looking forward and are looking to do more things with the menopausal symptoms, have sort of surreptitiously put in front of the term ‘stratified’, the word ‘risk’. And they based a lot of what they do on how likely they think the woman’s cancer is to come back rather than need, which is how much of what’s happened to them has made their life, has diminished their lives and what could we do to help with that? Because deep down, although it’s fair to say that women who have breast cancer that recurs and has spread to other parts of them, if that is ignored for a long time, the possibility of helpful treatment to control the cancer – we can’t cure it – is significantly diminished. Actually, picking it up at a very early stage, as things stand, it may change, but as things stand, we have no evidence that doing that improves their survival outlook. In other words, treating something at a very early stage in these circumstances doesn’t mean they’re going to live any longer. So we’ve rather sort of been concentrating on the wrong thing and we’ve come on a little bit of sort of throwing out the baby out with the bathwater, in that we treat the patients and we then tend to sort of say, ‘well, we don’t need to do any more to you’, without always giving them the tools to manage their lives subsequently.

Dr Louise Newson [00:17:23] Which is a great shame. I mean, it’s really difficult for, I think, any condition, isn’t it, Tony, to generalise. So not everybody who has migraines will have a headache in a certain time, with the aura or with visual disturbances, or with slurred speech or whatever, or everybody that has a heart attack will have the same pain and the same symptoms and the same prognosis. So with breast cancer, which is very common, one in seven women, there are different ways that people experience, as you say, the medication, the treatment afterwards. And it’s also, I often find that the menopause can be very different in them, whether it’s a menopause that’s just naturally occurred or a menopause that’s occurred from their medication, it can be quite different. But also it can vary with time as well. And many women say to me, “do you know, I didn’t mind feeling ill for the first one or two years after my breast cancer diagnosis because all I wanted to do was to live each day and know that it was longer since my diagnosis. But now it’s five years after, I just can’t live like this. I can’t have another night where I am waking up with bone pain. And I feel that I, you know, I’m going to the toilet all the time and I’ve got such bad vaginal dryness, I can’t sit down, I can’t keep living like this.” And I think that’s when we have to individualise what we do and how we help people. And I think the whole area of hormonal treatment and breast cancer, either hormonal treatment as in things like aromatase inhibitor or Tamoxifen for the cancer, or giving HRT, is very individualised. And it’s impossible, isn’t it, to say that ‘you must have this’ or ‘you must never have this’, for example, because everybody is different and what they want one day might be very different the next day or the next year or the next decade mightn’t it?

Dr Tony Branson [00:19:21] I absolutely agree with that. And I think one of the difficulties, as you say, when people are given a diagnosis of a cancer, it’s pretty earth-shattering to most people. I mean, I slightly sort of say, “well, I guess when you were told you probably thought you wouldn’t live beyond the end of the week”, and then as time goes by, you know, your horizon moves away and you start thinking about other things. Most of the treatment decisions about breast cancer are made round about the time of the diagnosis. And it’s interesting talking to women, I mean, I talk with them about the benefits of having chemotherapy and endocrine treatment, particularly with chemotherapy, which is perceived to be pretty nasty at the time and is for some people. And a number of women who are told, you know, the benefit for this is relatively small, it will only make a difference to the, you know, single figure number of people, but a lot of them at that time, their view will be, but I’d be one of those people. I know I must do everything I possibly can to stay alive, prevent the cancer coming back, because that’s what’s most important at that time. And as you’ve just said, you know, as time goes by, those feelings sort of change. And I must admit, I mean, the only thing I’ve ever been able to put from personal experience is if you have a high-speed car crash and it rolls over lots of times and you climb out of it unscathed at the time, you think, that’s fantastic, nobody’s been hurt or killed. And then, you know, a bit later on, you think, I’ve written the bloody car off! And we do feel differently about things at different times. And I think for women with breast cancer, I mean, it varies as well. I mean, some of them go through significant periods of feeling everything’s great and then something that happens that sets them right back. Now, it may be that somebody they know, somebody who they’d been with when they were being treated, relapsing. It’s interesting the effect of Linda McCartney dying from breast cancer was really quite profound for a lot of women who’d been treated for breast cancer. I mean, there was a lot about it. I mean, she lived a very healthy life, apparently, had enormous resources to deal with her cancer, but she died from it. And for somebody who’s in much more modest circumstances, ‘well if she can’t survive, how can I?’ And that’s quite hard. And there isn’t a straight answer to it. It’s a feeling that they have. I mean, all I can say to people about breast cancer and their fear of recurrence and whatever, is a) that the fear will vary from time to time and b) that it’s normal. It’s not nice. Normal. It’s the people who get in this terrible, vicious circle of being worried about being worried.

Dr Louise Newson [00:22:22] Yes.

Dr Louise Newson [00:22:22] Which I mean, you can’t stop them doing it. I mean, I always felt that the biggest waste of breath in the whole world is to say, “don’t worry”.

Dr Louise Newson [00:22:31] Makes you worry more when you hear the word worry doesn’t it?

Dr Tony Branson [00:22:34] Think about your breathing. So, yes, you’re right. What matters to people changes. One of the difficulties, I mean, chemotherapy can have unpleasant long-term effects. Not in a majority, but in a significant number. You know, had a modest number of patients really in a terrible state after chemotherapy with neuropathies, hair that’s not grown back, gum and teeth disease and things like that. And this is nothing to do with hormones. That’s just there. The problem with endocrine treatment is firstly is that people sort of feel, well, now the side effects aren’t that bad and I think they have been minimised. And the other bit is of course it goes on for a long time now, up till recently we’ve sort of felt, we did feel, that the major benefit for Tamoxifen came over a period of five years and that was considered to be the time. Now, the reality is that we now have clinical evidence that going on for longer does reduce recurrence. The question is whether the relative amount that it reduces it, justifies continuing taking it. And for some women, taking a Tamoxifen tablet every day may be giving them minimal symptoms and they may feel that’s fine. For others, you know, it’s a living death having to say, “oh, you must take it for ten years.” It’s a very brutal sentence, put it like that. 

Dr Louise Newson [00:24:04] Yeah and I think people often do feel very, they feel that if they don’t take it, it’s really going to have a huge difference. And risk is a really hard thing to work out, especially when it’s individual as well. But I remember you saying on the previous podcast that we did together, for some women, they actually to have a holiday. It’s not really a holiday is it, but they stop taking the aromatase inhibitor or the Tamoxifen or whatever, just to see if the side effects are… it is side effects as opposed to something else. And I see quite a lot of patients who just for six weeks might stop their medication just to get a bit of a breath back really and to do that relaxing and seeing if it makes any difference to them. And then that’s the time where they can maybe talk to their oncologist about changing their hormone treatment. Or if they’ve been on it, sometimes I’ve seen ladies who have been on it for four years and ten months and they’ve been told it has to be five years and they really want to try and keep going but that last bit is just so unbearable. And you sort of think, well, that two months is probably not going to make a huge difference to you and it’s quite safe to stop for a few weeks and see, for most women. And that can be quite an empowering option, I think, sometimes for women, isn’t it, to know they can do that.

Dr Tony Branson [00:25:23] Absolutely, it’s certainly one that I would use regularly, that if women are having a lot of symptoms that may well be related to their Tamoxifen, I would definitely say stop it, and stop it for at least six weeks and see how you feel. Interesting, I did my first day back at work after one of my returns from retirement last week. One of the patients who I saw who was sent up by the Breast Care Nurse, who had a not very high risk breast cancer, moderate risk, but not high and was on Tamoxifen. She’d had chemotherapy and had really not been well at all. And had had odd… I mean, she said she didn’t feel her brain was working. She had a lot of fatigue. She’d had a couple of falls which were a bit hard to sort out because it didn’t sound like it was that she’d actually blacked out but she had fallen. And the worry that the nurse had had was actually that she might be developing brain secondaries and the symptoms were, didn’t fit very well. And it’s interesting in good discussion with her, and I said, “look, you know, you obviously got a lot of symptoms which we’ve got to try and sort out one way or another. They don’t really fit clearly into any clear pattern. I have to say, I wonder whether it’s the Tamoxifen.” And she said she’d wondered that, in fact, she’d been off it for about two weeks, which I said was probably not long enough. So we’ve agreed that she will stop it for six weeks. I mean, she she got odd sweating bits which she associated with this, but I wasn’t sure whether that wasn’t… And I said, you know, I mean, she’s 46, something like that. She’d had chemotherapy and I said, “well have your periods stopped”, which one would expect they would. Well she’d been on the mini pill beforehand so she didn’t have periods then anyhow, so she was uncertain about that. And so basically what I did was to suggest she stayed off the Tamoxifen and I’ve arranged actually for her to have a scan of her head because I don’t think it sounded very much like it was spread to her brain, but it would be much easier for her if she knew that that wasn’t the case. Easier for us as well. But it’s interesting, these sorts of odd, nebulous symptoms and I certainly think in these circumstances it’s well worth stopping either Tamoxifen or aromatase inhibitors. I mean, another thing is that there is some evidence to show that taking, particularly with aromatase inhibitors, taking them for, say, three months and then having a couple of months off and then taking them for three months, then the couple of months off, often would appear as far as one could tell – and it’s not the highest of high level evidence – probably to be as effective, or at least not significantly less effective, than taking them all the time. And for some people that works quite well because particularly the bone pain and joint pain also builds up. And by not taking it all the time, it never gets to be so bad. So I think there are all these little things that one can try. And I think it is important to have the discussion with people because I think – because you’ve a little bit alluded to this idea as well – “the doctor told me this is what I’ve got to take and I’ve got to take it for a long time.” I mean, essentially when they first started using adjuvant Tamoxifen, it was ‘you’ve got to take it for the rest of your life’ and then you had to give them a prescription for 28 days, which worries them.

Dr Louise Newson [00:28:52] But yeah, so I mean, things change and I think, well, it’s been really useful working with you and for some of you that have heard my podcast I did recently with Dr Sarah Glynne talking about the work that we’re doing together as a group to try and get this consensus document out, looking at the evidence is we’re very clear in the group that every woman should be treated individually and be allowed to have a choice. And that choice can change depending on how they feel. But I think some of the work that we’re doing and certainly some of the work I’m doing that I’m quite vocal about, has led to other oncologists, you know, I know some of your colleagues and others that you speak to, to start to think a bit more about the menopause, symptoms that could be related to the menopause, and health risks and also the individual risks versus benefits for women taking HRT, which is going to change depending on all sorts of factors. So I feel like the conversation we started many years ago when I first met you Tony, is sort of developing even more, which I think is very exciting. And I’m really hoping that it’s going to change the narrative actually for many women going forwards in future years as well.

Dr Tony Branson [00:30:06] I think one of the things which we’ve discussed a bit about the consensus bit about the whole business of the effects of chemotherapy on the ovaries. And there’s no doubt that it is quite clearly in the majority of cases, and it should be that for premenopausal women, the first line of approach in that respect is always tends to be based around fertility. Partly because for young women, for whom having a family is very important, there are now one can do egg harvesting and freezing, which may be an option. But because of concentrating on that, if one merely says the only consequence of ovarian failure, as a consequence of chemotherapies, not being able to reproduce, you’re missing the whole bit that comes out of it, because the ovaries do do other things. I mean, the other side again, which I know I’ve been guilty of this I’m sure, is to say to somebody, “well, you know, there’s a very good chance if you have this chemotherapy, that it will stop your ovaries functioning, which will put you into a menopause.” A patient then says, “you mean my periods will stop?” And I say, “yes”. And they say, “oh, that’s good”. And then that tends to be the end of the conversation. So yeah, I mean, let’s leave on a high, something that they perceive as a benefit, well, there may be other things which are very much not a benefit.

Dr Louise Newson [00:31:39] Hmm, now it is so important. And, you know, I think what we’ve teased out of this conversation is that women should be treated as a whole. They shouldn’t be just defined by their breast cancer, and they are allowed to have a voice in this conversation of their journey. And that’s really important. There’s no one size fits all for any sort of hormonal treatment or non-hormonal treatment or anything, really. I think the most important thing is women being able to have a voice and to be listened to and know that they can change their mind, they can decide their priorities might change as well with life. So I think it’s been really useful hearing your words of wisdom, which I always love listening to. But before we finish, Tony, I’d just like to ask you for three take-home tips, which I always do at the end of the podcast, but three things that you think that would be really useful for women who maybe have had breast cancer many years ago, who are now thinking about their future health. Really, what three things would you say or recommend that they could do?

Dr Tony Branson [00:32:46] I think what if you say many years ago by that do you mean ten years ago? 15 years ago?

Dr Louise Newson [00:32:52] Yes, I do, actually, because we’ve done podcasts about more recent. So I’m thinking about those women who have been ten plus years since their breast cancer who are maybe struggling with some menopausal symptoms and just wondering where to go now. And a lot of these women are maybe not under an oncologist anymore. So what would you recommend they do to try and get some help?

Dr Tony Branson [00:33:12] I’m actually not fully aware, but will be I hope fairly soon, working with some of the people around here is what the availability of menopause specialist treatment is. I mean, it tends to be gynaecologists who are sort of referred to, and it’s not necessarily for the majority of them, their major area of interest and expertise. So I think getting some form of menopausal expertise brought into it, I think that we’re going to have to look at being able to have conversations between oncologists and the menopausal specialist to give women a view of what their level of risk remains to be. For example, a woman who has an estrogen receptor negative breast cancer ten years out firstly is diminishingly unlikely to get a recurrence of that breast cancer. And frankly, anything that is done to, you know, in the way of hormone replacement therapy or whatever carries certainly no more risk to her than it would to any other woman who’s never had breast cancer. So the breast cancer bit is out of the window. And I think what you would say from the evidence that you have that using the appropriate hormone replacement treatment, actually the risk of breast cancer for a woman who hasn’t had breast cancer is diminishingly small, and that it would be the same for them. For a woman who’s had an estrogen receptor [positive] breast cancer, there is a risk that persists probably at least for 15, maybe 20 years of recurrence. By that time, it’s a very small risk, but I’m afraid it is a sort of regular event that we see. So now the question that is unanswered, but there are pointers which would suggest that having hormone replacement therapy for these women doesn’t actually change their risk to any significant degree. Now, it’s always this difficult thing is that if something untoward happens to you, you always want to pin it on something, whereas it might be something that was going to happen anyhow. And I think the temptation which is there to sort of say, “well, that’s because you did that.” And actually, we can’t do that about anything. You know, in the old days when I used to treat all cancers, you know, I could see somebody who’s smoking 50 cigarettes a day who gets lung cancer. I don’t know that it was the smoking that gave him lung cancer. I know that it made his risk very high. And the same goes for all of these things. And I mean, one of the things I used to say to women, I’ve seen a lot of women who have presented with new breast cancers who have been at the time of presentation on HRT. Now, if you take the worst data that there are, the number of them whose cancer was actually caused by the HRT, is a small proportion of those who got cancer. In other words, the majority of them would have got the breast cancer anyhow. But I’m afraid the nature of the need to pin it on something means that they will at least have been at some stage a subtle implication “well it was the HRT”. You know, even if it’s almost sort of, “well, you must stop the HRT because that’s what gave you the… So I think it’s important that people don’t think like that, or aren’t encouraged to think like that. So I guess the other thing that really is the, as I say, we’ve moved from seeing people at routine intervals. I mean, my predecessor used to see everybody from diagnosis to death at very long intervals. I mean, you would see them every two years because he never did very much other than touch some bit of them and mutter an interval of time. He could see 70 or 80 follow up patients in a clinic. When I took it over and went in and first told them who I was and then asked them how they were, the whole thing went horribly wrong! But what we’ve tended to do is to say, “Right, you know, you must go out, live your life and be fine, but if things happen that are not right, you know, you must be in touch and then we will try and sort it out.” Now, the problem is the implication of that is if you get lumps or bumps or pain or whatever, we will investigate it to see if the cancer has come back. But I think we ought to take that further and say if you are getting difficult symptoms that almost certainly relate to your treatment or for which the treatment may have implications related to your previous diagnosis, then you should come back into the system. But we need to have in place within the system the right people to deal with that, which I hope we’re going to be able to do. And I think the team in Gateshead are looking towards it, is to set up a specialised clinic, looking at women with breast cancer, with menopausal symptoms. With input from both oncologists and breast care nurses and menopause experts so that we can get these women together, which will at least have some form of support for them. And it will also enable us to look towards getting some better research into what are the best means and safest means of managing their symptoms and keeping them well.

Dr Louise Newson [00:39:02] Which is so important. And having more research in this area is really crucial. So I hope this is the start of lots of people thinking and conversations that are going to continue for many years to come. So thank you ever so much for your time today, Tony. I really appreciate it.

Dr Tony Branson [00:39:19] Nice to talk to you.

Dr Louise Newson [00:39:21] Thank you. For more information about the perimenopause and menopause, please visit my website, balance-menopause.com. Or you can download the free Balance app, which is available to download from the App Store or from Google Play.

END.

The post Supporting women after breast cancer with Dr Tony Branson appeared first on Balance Menopause & Hormones.

GP and menopause specialist, Dr Sarah Ball, makes a record fifth appearance on the podcast this week to discuss her work exploring experiences of menopause care in women who have had breast cancer.

The experts discuss findings from a recent survey carried out by Sarah and the Newson Health team to highlight how things have improved in recent years and identify some of the ongoing needs.

You can read more about Sarah’s survey and other recent menopause research carried out by Newson Health here.

View the breast cancer booklet here.

Episode transcript:

Dr Louise Newson [00:00:09] Hello. I’m Dr Louise Newson and welcome to my podcast. I’m a GP and menopause specialist and I run the Newson Health Menopause and Wellbeing Centre here in Stratford upon Avon. I’m also the founder of The Menopause Charity and the menopause support app called balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based information and advice about both the perimenopause and the menopause.

Dr Louise Newson [00:00:46] So today on the podcast, I have somebody who’s been with me on the podcast four times before, which is a record actually. So back again, I’ve managed to persuade Dr Sarah Ball to join me to talk about some of her work so thanks, Sarah.

Dr Sarah Ball [00:01:01] It’s a pleasure, Louise.

Dr Louise Newson [00:01:03] So Sarah is a GP and menopause specialist like myself and has been very like me, I think is it fair to say, overwhelmed with stories that we hear day in, day out from menopause and perimenopause of women which were not under our radar before we started doing so much menopause work? Is that fair to say?

Dr Sarah Ball [00:01:24] Yeah. I’ve been amazed at how many people have come to the surface and described their struggle and their suffering and their lack of knowing where to turn. So it’s trying to convey that to other people to understand how to try and help these people.

Dr Louise Newson [00:01:43] And I think what’s really hard – I mean, we’re talking today and a publication has come out in the BMJ being quite vocal actually and quite sort of anti women asking for HRT and also say there’s this undercurrent that some of the work, certainly that I’m doing, is undermining doctors and being quite negative. And I think that’s really sad actually, because I’m sure you agree every healthcare professional wants to do the best that they can, but it’s based on the knowledge that we’re given as well. And, you know, this is going off topic, but I remember when I went and did my minor surgery training to learn how to suture, to take out moles and things as a GP. And I thought I had done a really good job. And there is this little square with a sutures that you could take home, you know, like your homework to show at home. So I went home and showed my husband, who many of you listening know is a surgeon, and I said, “look Paul, look at this”, and he just said, “that is dreadful. I would never use that type of suture material and I would never do that sort of stitch. Please do not go near anybody.” So then I thought, okay, I’m never, ever going to do minor surgery. I did lots of joint injections and aspirations, but I never used a suture. And he was right. I was terrible, but I thought I was doing a really good job actually on my little course. I think that’s probably the same in menopause, isn’t it? There are some healthcare professionals who certainly haven’t had any education, and they think that it is wrong that women are asking for HRT. And they also don’t think that women’s joint pains or headaches or just their mood might improve with menopause because they’ve never been taught it.

Dr Sarah Ball [00:03:18] Yeah. And I, I used to think I was good at menopause care because I had the attitude that if a woman was struggling with symptoms, that I was happy to prescribe her HRT. I was reasonably confident to prescribe her HRT. But looking back now, I realise that I was waiting for them to tell me that they were menopausal and of course, I wasn’t looking for it because I presumed women would know, because I presumed they would know hot sweats and flushes means menopause. So I was quite happy in that sphere to do that. But actually, all those other patients I was seeing that had anxiety, depression, migraine, skin issues, genitourinary issues, I wasn’t joining the dots and so that’s most of the battle. There’s no point being confident in treating something if you don’t pick it up as a diagnosis in the first place. So, yes, it’s medical education is crucial, and doctors are – and all clinicians are – really time-pressed and pressured and good education and timely education and efficient and simple and relatable and practical education is absolutely crucial. So, you know, you don’t know what you don’t know, do you? And that’s what you’ve always tried to change.

Dr Louise Newson [00:04:36] Absolutely true. And I think very much, you know, your work as a clinician, my work as a clinician is putting the patient first and allowing them to be very much involved in decision making. And again, if they don’t know, they don’t know what to ask for. And I know very – I mean, you’ve worked with me, which has been wonderful at the clinic for so long now – but very soon after we started hearing stories that we’re not really heard before of such long suffering, we started then to see women who’d had breast cancer, who had sometimes actually undergone a double menopause. So a menopause maybe because of their hormonal treatment for their breast cancer, then maybe they become older, their period’s started and then they went through another menopause. Or some of them it was just once but very harrowing. And they came asking for some advice and clearly advice is fine. And then they started coming saying, “Well I’ve tried these alternatives, I’ve tried lifestyle, I’ve tried medication, I’ve tried some psychological treatments, and I’m on my knees and I would really like to try some hormones.” And I remember us all going, ‘oh gosh’, you know, what do we do? And we’ve talked about it. We’ve gone through a lot of evidence and some of you would have listened to the podcasts I’ve done with Sarah Glynne and Tony Branson, again, done two podcasts with him now talking about some of this work. But it’s really harrowing when you’ve got a patient in front of you and you’re thinking, well, no, I can’t do that. And they’ve been told by their oncologist or another menopause specialist often, that they cannot have a treatment, that you think, well, we know it might help some of your symptoms if they’re related, but we know for everybody then they’re going to increase their future health, so reduce their risk of heart disease and osteoporosis because there are benefits from HRT for everyone aren’t there? So you’ve been doing a lot of work, actually, not just listening to these women and helping them, but taking it a bit step further, haven’t you, with the survey that you’ve done. And I’d be really keen to hear more and you just to share about the survey that you did, if that’s okay.

Dr Sarah Ball [00:06:37] Sure yeah, I think I mean, I did a survey originally a couple of years ago when your clinic had only been open about 18 months because we were seeing women coming with breast cancer and I think we were all extremely moved by the stories we were hearing and wanted to make sure we were giving them all the right information about all their options and that we were listening to them. But also, there was a degree of surprise, I think, that we had so many women starting to come to see us, and I felt it was really important to try and find out what their experiences had been before they came to see us. Sort of say, you know, these women aren’t just having a knee jerk reaction of, ‘oh, I know, I’m going to go to that clinic that I’ve heard of and get some help’. You know, there was stories and stories and years of what had gone on before, and I wanted to find out more about that. So I did that survey and we talked about that in a previous podcast. And now sort of two years later, we’ve got even more patients with breast cancer. In fact, when I ran this survey, which was just before the summer this year, we had over 450 patients on our books that have had breast cancer, or DCIS, which is a kind of a pre-invasive condition. So I sent out a survey to all of those patients, it was all anonymous, and 175 people responded. So that’s actually quite a good number for an online survey of this type. And I wanted to know lots of things really, but I wanted to try and think back – and I know it’s difficult when you’ve been through cancer, your memory is often, you know, you can’t really think. It was all a bit of a blur at the time, but I wanted them to see could they remember when they had that initial diagnosis and they were having their treatment planned for them or with them, was there any mention about the menopause as anything that would be at all influenced? And only one quarter of the women that responded could remember any discussion about that. So in other words, three quarters of them didn’t realise that menopause was something that had any bearing on their story. And I kind of get that because as a, you know, member of the public, if you’re faced with a diagnosis of cancer, it does really matter what type of cancer your prime thing at the time is, ‘oh my gosh, will I survive? What treatment are we going to have? How’s that going to affect my immediate health?’ However, the menopause is very often induced, worsened, brought on by treatments for breast cancer, and therefore it should be factored in to longer term planning. And that might be something that you have a discussion about at the time of diagnosis. It might be something that you need to come back to later on either by discussion or having some written material, or just something that will remind the woman that in six months or six years or sixteen years, if she’s struggling, that she’s got some information and somewhere to know where to go for help. And that really is where the system in the current NHS for many people unfortunately, seems to fall down. And so carrying on with this survey, I asked them about, for example, what types of treatment they’d had and half of our respondents had had chemotherapy. And we know that chemotherapy is very toxic to the ovaries and so it can make you menopausal for either a couple of years and then sometimes your ovaries recover or that may be it, it may sort of finish your ovaries off. And so many women assume that all of the symptoms they possibly get, like brain fog, joint pains, mood changes, hot sweats, flushes, they put it all down to the chemotherapy or the stress of having a cancer diagnosis and don’t necessarily realise that this is actually the menopause and may or may not be a permanent feature. And so only – well less than half of – those that had chemotherapy had been told that menopause may feature. Quite bizarrely, 14 of our respondents had had their ovaries removed as part of their treatment, but nine of them weren’t told that that would also induce menopause. Now, maybe to you and I, that’s completely obvious. If you remove the ovaries, you’re going to be menopausal. But it’s not actually obvious to most of the public, and it’s a huge thing to have your ovaries removed. They might be tiny little grape sized features, but they do an enormous amount for how we feel now or for our future health, and so how you could not have a conversation about that is worrying. And then the most common treatment after breast cancer surgery is often the drugs that are used to block estrogen, and they can induce all sorts of symptoms and problems. And again, you know, it has its role in helping slightly to reduce risk of recurrence, but that can often be a very slight improvement. But actually, the symptoms that it brings about and the complications are very rarely spoken about. So most of the women remember being told how beneficial these drugs would be for their future risks from their breast cancer. But not many of them remember being told that there were any risks or possible side effects. And very few of them recall any mention that menopause would also be impacted by blocking estrogen. And so again, I think by this, we’re not in any way trying to criticise breast cancer surgeons or oncologists. Not at all. We’re just saying there’s something drastic is missing here because in order to treat the condition of breast cancer, you actually have a knock-on effect on the rest of somebody’s health. And those things are important. And you can’t adequately counsel a patient about cancer treatment if you don’t tell them about all the possible short and long term conditions. So the survey shows that that is a problem.

Dr Louise Newson [00:12:50] It is a real problem. I think what’s very interesting is that for lots of people, menopause just means stop of periods or loss of fertility. So when you’re faced with a diagnosis or a woman’s faced with a diagnosis of breast cancer and hearing words such as chemotherapy, radiotherapy, surgery, well, menopause is just oh, goodness me, that’s nothing, isn’t it? And in even, you know, some of the oncologists don’t have training in the menopause, so they think it was a few hot flushes. It’s not really – they trivialise it. And for some women, it might not cause many symptoms. But as we know, those hormone reductions can lead to health risks as well. But actually, for those women who think, well, their brain fog and their bone pain is a ‘chemo brain’ or the bone pain might be a bone metastases and they really worry about that. And a lot of women I see in my clinic, and you might be the same, have seen an oncologist before, but they know that they’re really busy so they have often seen other people, maybe a junior doctor or a nurse. And that focus has been all about their breast cancer. You know, have you noticed a lump? How have you been? You know, and that’s all they want, which is, don’t get me wrong, I’m not undermining it. And I know you’re not either. But, you know, they’ve had their mammogram, they’ve had their check, and that’s good. Their breast cancer has not recurred. Tick that box. And a lot of women don’t even have time to vocalise their symptoms or they often don’t realise their symptoms might be related to the menopause. And that’s something that you are finding as well isn’t it?

Dr Sarah Ball [00:14:23] Yeah. I mean, for example, with like aromatase inhibitors, we know that joint pain is a really common – and can be a very severe – effect of aromatase inhibitors. And yet most people, the public and healthcare professionals alike probably wouldn’t put the two together. So if you’re an oncologist and you’re, you know, you’ve got a busy clinic and a woman a few years post her breast cancer has come in and she’s saying, “oh, my joints are aching”, they probably aren’t likely to have maybe the knowledge or the time to, you know, process that information and to sort of direct her somewhere helpful and often, unfortunately, what ends up happening is women in secondary care or anyone in secondary care, where it doesn’t seem to come under the exact remit of why they’re there, are then sent back to the GP and the GP, quite understandably, is likely to be nervous of any cancer related possible effects or treatments or, you know, HRT,  because of everything that we’ve maybe been mislearnt about menopause and HRT. And so for these people, a common theme for a lot of these ladies in this survey was saying, ‘well, the oncologist did their job and the surgeon did their job. And now, you know, no one seems to now want to help me, but I actually feel worse than I did when I was having my breast cancer treatment.’ And so we can’t expect GPs to be able to manage that complexity and we do need a team approach. So in my ideal world, you would have in every breast cancer clinic, you would have a breast surgeon, an oncologist, probably a breast cancer specialist nurse and a menopause specialist, because actually, if all those were talking to each other and crucially to the patient, then you’re going to have a much more cohesive plan going forward. But at the moment, that’s all bitty and messy… in most cases it is.

Dr Louise Newson [00:16:23] And we do see, don’t we, lots of women who, as I said before, have been told you can never have HRT from their oncologist. And then maybe five, ten, fifteen, twenty years down the line, these women are really struggling and say, “I can’t keep living with these symptoms of the menopause.” And it’s not really appropriate always to refer them back because we know that the clinics are really busy and everything else and quite often I’ve spoken to oncologists, and when you talk through, then actually they’re very understanding and say, “oh gosh, I might have said that twenty years ago or ten years ago or whatever, or one of my colleagues might have said something.” But obviously things change with time. And, you know, we’re doing a lot of work, as many of, you know, sort of looking at the evidence, which is very limited. But then we need to look at the evidence of benefits of HRT, including benefits to quality of life as well as future health. And certainly, a lot of women I see, are more worried about osteoporosis than they are about recurrence of their breast cancer.

Dr Sarah Ball [00:17:22] Yeah. Absolutely.

Dr Louise Newson [00:17:22] And then I think as a clinician, it’s very hard to go against what a patient wants, isn’t it, when they’re fully consenting adults?

Dr Sarah Ball [00:17:31] Yeah, it’s… you know, we’ve got to start listening to patients and seeing them as not just a breast cancer survivor that they have usually these days, a very good prognosis and then likely actually to end up dying of something else one day. And that we can’t just completely ignore all their other parts of us which make us a healthy individual. So yeah, we’ve got to start listening. We’ve got to start involving women in the uncertainty and the decisions and not being, you know, paternalistic medicine is a thing of the past now. But we often don’t have the infrastructure to provide proper shared decision making.

Dr Louise Newson [00:18:16] Yeah. And I was looking at Macmillan, which I’m sure you’ve all heard of, and their, one of their sort of mission statements is to live life as well as possible, you know, beyond cancer. And it’s absolutely, really important, isn’t it? And a lot of women want to live rather than exist. And actually, a lot of women I talk to, well they don’t want to forget they’ve had breast cancer, but they don’t want to be defined as a woman who’s had breast cancer. They want to be defined as a woman who’s a managing director of a company, or a woman who’s got three children, or a woman who’s a wife or a partner to somebody or whatever. But it’s something that’s happened to them. And I don’t know whether it’s breast cancer more than any other cancers, but it does seem more than any other condition. You know, if I’d had a heart attack 20 years ago, people wouldn’t worry about what I did really, because it’s very likely that my heart is quite strong to keep me living 20 years. But with breast cancer, it is quite emotional and I think some of the work that we’re doing in this space, we get attacked a lot and actually what we’re doing is we’re not there saying, “I want to increase your risk of recurrence” and we’re not doing that. We’re saying “I want to improve the quality of your life and actually maybe the duration of your life as well”, because we know that most women who’ve had breast cancer die from heart disease, taking HRT can reduce that. But we’re not even saying every woman who’s had breast cancer should take HRT. We’re saying these women – and we don’t know the numbers, it might be a very, very small percentage – are really struggling with their menopause after breast cancer. And those women deserve to have the same level of care and attention as any other woman who’s struggling with their symptoms.

Dr Sarah Ball [00:19:55] Yeah, there’s you know, there are alternatives to HRT. And for some people, they’re very effective. And some patients that find their way to our clinic have tried some of them, but actually some of them haven’t even had any information about those. So, you know, if people think that, you know, we work in a clinic where we just talk about HRT and nothing else, they’re very wrong because actually having time to listen to these patients and talk about their lifestyle and things that they might just be able to do on a day-to-day basis with exercise or diet may be absolutely crucial. Or there might be other therapies, complementary therapies or non-hormonal containing therapies that might be useful. For example, in this survey, 86% of the patients had genitourinary syndrome of menopause, but actually less than 30% of them had been offered vaginal lubricants or moisturisers. Now, they don’t contain any hormones at all, but if that hasn’t even been mentioned, then there clearly is a big need, isn’t there? One positive I think we should take out of the survey is that about between 30% and 40% of those women had been offered some vaginal estrogen. Now, that’s still, you know, inadequate number in my mind, however, it’s a lot better than two years ago when we did the survey, when it was about 10%. So I am trying to take the positive out of that, that somewhere in the last two years, maybe the message has got out there that vaginal estrogen is an appropriate choice for women with breast cancer because it’s very safe and effective and can be life-changing for these women.

Dr Louise Newson [00:21:30] Yes. And that is really important. And I think, you know, there are alternatives, as in prescribed alternatives that can be useful for some women, but they’re often limited by side effects and they’ll often only really work for some symptoms like the vasomotor symptoms, the flushes and sweats, so they won’t help strengthen bones or whatever. But one of the drugs that’s been used and I just recently found out that £2.1 million of government money is being spent on a study looking at giving either venlafaxine, which is an antidepressant, as many of you know, or oxybutynin,  which is a drug that I used to prescribe quite a lot actually in the nineties and early 2000s for women who have urinary symptoms because it helps sometimes with urinary symptoms, but it’s really limited by its side effects because it works on something called the muscarinic receptors. And if you have these side effects, it can cause dry mouth, dry eyes, dry vagina, of course, because it effects those membranes. But also, there’s an increased risk of dementia in women, and men actually who use oxybutynin, it can affect memory. So I have a real issue actually that £2.1 million is being spent on giving women these drugs that might not actually make a big difference. And I’ve heard that there’s a bit of a recruitment problem with this study, and I’m not surprised because women don’t want them. And my daughter recently, some of you might know, has, my oldest daughter, has horrendous migraines, but she also has asthma. And she was given an inhaler recently and it contained something that was an anti-muscarinic. And she kept phoning me for six weeks and saying, “I feel bad, my migraines have worsened, but I’m still very low in my mood. I feel terrible. I can’t remember things. My skin’s really dry. I can’t focus on my phone, on my computer, I can’t read music” and she’s a trombonist. And I was hearing all these symptoms just on their own. And I kept thinking, oh maybe she’s a bit stressed, or maybe it’s related to her migraine because migraine can cause systemic effects. And then I feel really embarrassed, I sat down with Rebecca Lewis, as you know, who’s a Clinical Director at Newson Health, and said “I’m a bit worried about Jessica.” And she said, “what inhaler is she on?” and I told her the name and we both looked at each other and went, “oh, that’s an anti-muscarinic, no wonder!” So I told Jessica to stop. And it took about two weeks for her memory to come back. And last weekend, I was telling her about this study I had found giving this drug. I said “it’s very similar to your inhaler, but it’s a tablet form to women who’ve had breast cancer.” Do you know what she did? She burst into tears and said, “Mummy, you can’t give that drug to people. I cannot tell you how horrendous it’s been.” And I’m not saying everyone has those side effects, but they are quite common side effects, aren’t they? And oxybutynin we don’t use so much for urinary symptoms because there’s more refined drugs now aren’t there, that don’t have such side effects. So I feel like we’re going back in time a bit for women who’ve had breast cancer, which isn’t really pushing the needle forwards. And I’ve spoken to a lot of oncologists to say, can we not do a proper study with HRT? And then they’ve said, “well, there’s no funding because HRT is cheap and you know, all the cancer drugs are expensive”. So we’re doing more cancer drug studies, but if you’re looking at population improvement, isn’t it better to give something that’s cheap that we know is safe. And they say “well recruitment would be a problem, women are scared of hormones.” I said, “I don’t think there would be a recruitment problem, actually.” But it seems, I mean, I know you’re frustrated as well aren’t you? And it’s just very frustrating that we can’t move science further in this area.

Dr Sarah Ball [00:24:57] Yeah, we need more trials looking at actually what happens if you replace the hormones, but it’s so difficult to do studies like that these days. And in fact, I think it’s pretty difficult to do any sorts of studies in this day and age with a population who are generally more empowered and generally have a good idea of what they want, because women, well anybody, can access quite a lot of information now on the Internet and already has quite a good idea of what would suit their needs. And so they don’t usually want to be randomised into a trial where they don’t know whether they’re going to get the drug or the placebo option. So we talk all the time don’t we about evidence-based medicine and ‘well is there a trial that proves that?’ And actually, sometimes there is, sometimes there isn’t. But actually, the other two crucial parts of evidence-based medicine are what are actually the views and preferences of the patient? And that’s, you know, what we would always advocate spending time with. And thirdly, is the clinical expertise. And I couldn’t sleep at night if I saw patients with a history of breast cancer and didn’t talk to them about all the options, which includes HRT, because by my experience over the years, I have seen hundreds of women have their life transformed and thank me and be forever grateful that they can – I had a lady the other day who said, “Oh my God, I’ve just been on the underground. I haven’t been confident enough to do that for years. I was able to drive abroad”, you know, little things like that might sound like nothing to somebody else, but actually that can, you know, enhance their life no end. And actually, if it keeps them alive, which, you know, sadly, we have patients that filled in the survey who have talked quite openly about their plans for what they would do if they hadn’t had an appointment with us, in terms of feeling like they couldn’t go on. So I will offer HRT on an individual basis because of my clinical experience to date. And I don’t care if there isn’t a study that proves beyond all doubt that that’s fine, because my training as a doctor enables me to do that and I will defend myself mercilessly if I had to.

Dr Louise Newson [00:27:19] And I think that’s really important. I mean, just for those listening, just for reassurance, really. We collect the data from every single person who’s had breast cancer. And Dan Reisel, our Clinical Research Lead is looking at everything and every year we’re following people up and I’m hoping with time actually, will show that these women do have good outcomes and I’m sure we do and it’s very important, you know, we do a lot of training and education and we spent a few hours recently at an education event just for our healthcare practitioners and it was actually really well received, wasn’t it Sarah? You were presenting and we had others. We had an oncologist there and another specialist, and it’s really useful for anything in medicine that we can discuss uncertainty. And I think when you’re young, you expect doctors to know everything. And I think it takes a lot of clinical experience, like you say, to be able to share uncertainty with patients and to say, “look, I don’t know whether this is harmful or good. I know on balance, these are the benefits, these are the potential risks. And, you know, what do you think? And also, that you can change your mind at any time as well.” You know, every woman that you’ve seen, that you’ve started on HRT, you haven’t made them sign their life that they’re going to take it forever. They just often try and we review and they, it’s jointly done together. So I think it’s really important that nothing is a flippant decision. It’s done with a lot of consideration and support actually. We give a lot of support to our clinicians, but also women have a lot of support. Often they will go and talk to their family or their close friends before making a decision as well. And that’s really important, isn’t it?

Dr Sarah Ball [00:28:57] Yeah, it’s you know, I could see three people in a day and they might all have had the same type of breast cancer at the same stage with the same pathology results. And I might go through the options and we may have three entirely different outcomes. One may choose to use HRT, one might not. One might choose to do something else. One might want to change other medication, you know, and that’s fine. I’ve done my job if all the outcomes are different. 

Dr Louise Newson [00:29:26] Yes, absolutely. It’s so important. And, you know, this conversation is really just beginning. We’ve got a lot more that we’re doing. And Sarah’s on this clinical steering group that we’ve got together doing the DELPHI process. And it’s exciting because I think it’s trying to show that we’re not neglecting women because we don’t want to neglect anyone. And so I’m really grateful for your time doing the survey and being involved with all this, Sarah. And involved in so much of the education work that you do. And there’s just so much, I know many a time, many an evening, we both feel completely overwhelmed. But also, I feel like, you know, working together, working with others, we’re making a difference and that’s really important. So before we finish, I know you’ve probably done your homework because you’re so diligent, but three take home tips. I’m going to ask you to choose what the take home tips are because you’ve probably written them so you say what your three take home tips are.

Dr Sarah Ball [00:30:20] You know me so well, but I thought what I’d so, seeing as it’s the fifth time, is I would give you three quotes from the survey. Is that okay?

Dr Louise Newson [00:30:27] You know that’s perfect, thank you.

Dr Sarah Ball [00:30:28] So the first one, I’ll start with the most difficult one, I suppose. So one lady said, “At the point of making the appointment with yourselves, I was working on an end of life plan, including what I would need to do before the end of my life and where I would end it and who would have to find me.” So that’s obviously an illustration of the low points which some women, not all, I’m not saying all, but some women get to and why we need to deal with this group of women better. Secondly, “I want to be treated as an intelligent, informed woman and not to be lectured. I understand that no choice is without risk, but there should still be choice. I was very grateful to the NHS for my breast cancer treatment, but my choices were then limited to the preferences of my care team with limited opportunity for discussion.” And that’s where the whole thing about shared decision making and respecting our patients’ choices and listening and helping them make decisions is crucial. And thirdly, and I guess it was the summary of my survey really was, “there is a missing link in the NHS between finishing breast cancer treatment and starting to get your life back.” And that’s I think, where we really want to try and plug a big gap with more of the work that the Newson Health Menopause Society breast cancer group is doing.

Dr Louise Newson [00:31:44] Absolutely. Thank you ever so much yet again. And we’ll put some resources in the podcast notes and on the balance website. We’ve got a booklet that we’ve all written together for women who’ve had breast cancer. So very grateful again for your work and your time for the podcast. And I wonder how long it will be till you come back for number six. Thanks very much, Sarah.

Dr Sarah Ball [00:32:05] Thank you Louise.

Dr Louise Newson [00:32:09] For more information about the perimenopause and menopause, please visit my website balance-menopause.com. Or you can download the free balance app which is available to download from the App Store or from Google Play.

END.

The post Exploring experiences of menopausal women after breast cancer, with Dr Sarah Ball appeared first on Balance Menopause & Hormones.

GP and menopause specialist, Dr Sarah Glynne, joins Dr Louise Newson on the podcast this week to discuss menopause care after breast cancer.  The experts share more about the breast cancer steering group established as part of the Newson Health Menopause Society that is working towards producing a consensus statement to support clinicians and improve the quality of life for menopausal women who have had breast cancer.

Dr Sarah Glynne discusses the importance of individualising the risk-benefit ratio for every woman when making decisions around treating the cancer and weighing this up with treating menopausal symptoms. Sarah emphasises the importance of talking through the implications of each of these considerations using a shared decision making process.

Sarah’s three tips for women after breast cancer:

1. Understand the risks and benefits of the drugs used to treat your breast cancer and what this means for you personally. Ask your oncologist for more information about your own breast cancer, if you are not sure. You can then use the PREDICT tool online for understanding more about your own cancer risks and what additional benefits any treatments may offer.
2. Read about non-hormonal options to help your menopause symptoms and cancer recovery such as diet, yoga, or acupuncture. Try various approaches to find the ones that may bring some benefit to you. Vaginal moisturisers and lubricants may also help and these do not contain hormones, and there are other medications your GP may be able to prescribe for some of your symptoms such as hot flushes.
3. If your menopause symptoms are severe and your quality of life is suffering, ask your clinician to explain the risks for you regarding your cancer prognosis if you decide to take HRT, versus the risks to your quality of life and long-term health if you choose not to take HRT. If you have genitourinary symptoms of soreness and dryness, vaginal hormones are very safe for improving these symptoms. Read information on the balance website and the book ‘Oestrogen Matters’ by Avrum Bluming, and make a choice that is right for you through discussion with your clinician using a shared decision making process.

Episode Transcript:

Dr Louise Newson [00:00:09] Hello. I’m Dr Louise Newson and welcome to my podcast. I’m a GP and menopause specialist and I run the Newson Health Menopause and Wellbeing Centre here in Stratford upon Avon. I’m also the founder of The Menopause Charity and the menopause support app called balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence based information and advice about both the perimenopause and the menopause.

Dr Louise Newson [00:00:46] Today on the podcast. I am very delighted, excited to introduce to you someone who I’ve known for a while and we’ve now got a very close relationship academically and friendship as well. So someone called Dr Sarah Glynne, who has agreed to talk today about some of the work we’re doing, which we’re really excited about. So welcome, Sarah.

Dr Sarah Glynne [00:01:07] Hi.

Dr Louise Newson [00:01:08] So, Sarah, you were introduced to me by your lovely husband, Paul, and my husband’s called Paul, so there you go. Bit of a connection there. And you, like me, have got another degree as well as medicine, because obviously a medical degree isn’t enough. For some of you who are listening know that I’ve got a pathology and immunology degree and you’ve got a degree in allergies. So there’s a big overlap actually and in our – I hope you don’t mind me saying this – our geekiness, actually.

Dr Sarah Glynne [00:01:33] Absolutely.

Dr Louise Newson [00:01:35] Is that all right to say?

Dr Sarah Glynne [00:01:36] I’m very proud to be a fellow geek.

Dr Louise Newson [00:01:39] So we love seeing patients. And, you know, medicine is a great privilege and both of us get a lot of satisfaction making people feel better. We both went into medicine to make a difference, to help as many people as possible. But actually, with medicine, you have to understand what you’re doing. And sometimes it’s very hard, isn’t it, to know what the best thing is for that patient sitting in front of you. And I know sometimes when I’m not sure, I will go back to the basics and look at the basic physiology, the pathology, what’s going wrong in a disease, but think of it in a cellular level. And I think a lot of people don’t have the luxury of that. Maybe because we’ve got degrees, we’ve had time to reflect and think and go back to basics almost, haven’t we? So tell us a bit about why you’re doing what you’re doing, and then we’ll talk about the work we’re doing together, if that’s all right.

Dr Sarah Glynne [00:02:36] Yeah, sure. So, I mean, I started to develop an interest in the menopause probably around about 2017, 2018 ish. And the thing that led me to the menopause initially, which I’ve told you this before, was because I was having to start prescribing HRT for patients at the practice that I’d moved to and I didn’t know how to do it. And I found your Easy Prescribing Guide online, which just took all the fear out of prescribing HRT. And it’s one of the most practice-changing documents that I think I’d ever read. And I think partly because I started to think about HRT more at work, partly because I’m in my mid-to-late forties and a lot of my friends were coming up to me asking me about menopausal symptoms, I just started to get interested in it. And then the pandemic struck, COVID. Who knew that was around the corner? And in fact, it was a slide you put on Instagram quite early on in 2020 about the effects of estrogen on the different cells of the immune system. And I think it snagged my interest, obviously, because I’ve got this background in allergy and that was acute COVID, this was before long COVID was even a thing. Nobody knew about it. But I remember the slide was something to do with the effects of estrogen on the immune system and the fact that women were much less likely to die from COVID compared to men. Premenopausal women were much less likely to die compared to men. And it sort of went from there really, as the pandemic progressed, my husband started seeing COVID patients, I was getting interested in the menopause, becoming aware of this link between hormones, estrogen and COVID and long COVID. And as he started to see patients, I was telling him about what I was learning. And then he was asking me and I was asking him and you know, we were both working from home, which is the first time that’s ever happened. So we were able to bounce off each other a little bit and it just grew from there, really. I thought that at this stage I might be sort of learning how to paint and things like that. But instead, I’ve become a menopause specialist and now, alongside my interesting long COVID I’ve also become very interested in breast cancer, which is my other area of interest. And thanks to you, I got involved with this work that you’re doing at the Newson Health Menopause Society, which I’m just finding fascinating. And as you say, it’s very exciting and we hope that we’re going to publish something next year that will start to make a difference for the many, many women with breast cancer who are suffering, in some cases terribly with menopausal symptoms.

Dr Louise Newson [00:04:47] Yeah, because I’ve talked about breast cancer before on the podcast and I’m sure I will talk about it again. But, you know, breast cancer affects around one in seven women. And when I was at medical school, probably when you were at medical school as well, Sarah, breast cancer was actually less common. It was about one in 12 women when I was a medical student, then it was one in 11, and it’s become more common. And actually, there’s this big fear about HRT. We know it’s the biggest reason why people don’t take HRT. They’re worried about the perceived risk of breast cancer associated with HRT. And we know the risk really isn’t there. And certainly if it is there, it’s not statistically significant anyway. However, we know that HRT prescribing has plummeted over the last 20 years, but the incidence of breast cancer has increased. So not everybody who takes HRT will develop breast cancer, but also a lot of breast cancer cases are nothing related to hormones at all. And this causes a lot of confusion to people because when someone has breast cancer, they look at it, don’t they? And it’s, is it estrogen receptor negative or positive? And so if a woman has an estrogen receptor positive breast cancer, then it’s presumed – and a lot of people say – it’s estrogen driven and it’s caused by estrogen, which isn’t actually quite right, is it? So can you explain before we talk about the work we’re doing, what it means by having a estrogen receptor in breast cancer?

Dr Sarah Glynne [00:06:17] Yeah, it’s really interesting. And again, we’ve spoken about this before. The analogy would be prostate cancer. So men with prostate cancer, inevitably, if you take a biopsy from a prostate tumour, you will find testosterone receptors in it, which is not surprising. And one of the treatments for prostate cancer is anti-androgen or anti-testosterone therapy. But nobody thinks that testosterone causes prostate cancer, whereas with breast cancer, because breast tissue also contains estrogen receptors, they’re supposed to be there. That’s why we developed breasts at puberty. They’re important. And because if you take a biopsy from a breast cancer, about… I think it’s about two thirds, 75% of them will be estrogen receptor positive and one of the treatments for breast cancer is anti-estrogen therapy. And somewhere along the line that’s been interpreted as meaning that therefore estrogen causes breast cancer, which makes absolutely zero sense, as you say, in terms of HRT, the majority of women that develop breast cancer haven’t taken HRT. And the majority of women who take HRT don’t get breast cancer. It would make no sense for one of our own hormones to cause breast cancer. I think a lot of the data, the WHI study that was published 20 years ago that threw the major spanner in the works and reported that there was this association or rather causation between these estrogen and breast cancer. And I think it’s really important to remember that 20 years ago they were prescribing synthetic hormones, HRT, and they’re prescribing synthetic progesterone, a synthetic estrogen. In fact, in the WHI study, it was conjugated equine estrogen, which, or Premarin, which is a cocktail of about ten different estrogens, I think, that are not supposed to normally be in the human body. And those types of hormones are very different to the body identical hormones that we prescribe nowadays. And just because you’ve got estrogen receptors in your breast does not mean that your own estrogen has caused breast cancer. If that were the case, if it was that straightforward, all women would develop breast cancer. It doesn’t make any sense.

Dr Louise Newson [00:08:23] Yeah, and that’s important to know actually, because there might be people listening who’ve had breast cancer and they have taken HRT and then they’re regretting that decision. And there isn’t good evidence that that’s the case, of course. But the other thing is there’s a lot of other reasons why people get breast cancer, and often it’s bad luck actually. Sometimes it can be a genetic thing, but also there are other risk factors. We know that obesity is one of the commonest risk factors for all types of cancer, actually, and that’s probably one of the reasons why the instances increased. Now, there are some people that say, well, obesity, fat cells produce estrogen therefore that’s why there’s an increased risk. And it’s not as simple as that because fat cells are very active, actually. They produce all sorts of chemicals and cytokines and they do produce a very weak type of estrogen called estrone, which is very different to the estrogen our ovaries produce or the estrogen we prescribe in HRT. And whether that does have an inflammatory properties with respect to breast cancer, we don’t know. But it’s very different. And other risk factors such as drinking alcohol, not exercising actually are risk factors as well. And all these are small risk factors. But if sometimes it’s more than one risk factor, people have as well. So but we’ve got estrogen receptors all over our body, haven’t we? So if I chopped off the end of my nose or the end of my finger or my ear, I would have estrogen receptors in it. So sometimes now the more oncologists look for these receptors, the more they see them, and then they can cause confusion. So it’s important to know that it doesn’t mean… sometimes it does dictate how treatment is as well, though, isn’t it, for breast cancer. So, the estrogen receptor positive cancers, one of the treatments is to try and block the estrogen isn’t it?

Dr Sarah Glynne [00:10:14] Yeah. I mean, I certainly believe that estrogen can fuel breast cancer growth. I think if you’ve got a breast cancer for whatever reason and it’s got estrogen receptors, then I do think estrogen is a growth factor and your tumour will grow quicker in the presence of estrogen. But that’s not necessarily a bad thing. We know because there was a study that was published in 2016 that showed that women who develop breast cancer whilst taking HRT actually have a better prognosis and are less likely to die from it compared with women who develop breast cancer that are not taking HRT. So paradoxically, because we don’t quite understand what’s going on in breast cancer and it’s probably very complicated because breast cancer is actually quite a heterogenous group of diseases, that it’s not the same for every woman. But paradoxically, growing quicker in the presence of estrogen seems to be a good thing. Maybe because it’s detected sooner before it spreads and therefore women’s prognosis will be better. So I think if you’ve already been diagnosed with a breast cancer, I can see why anti-estrogen therapy can be helpful to prevent the tumour growing quickly, i.e. to slow the growth of the tumour down. But even then, that’s not straightforward because it doesn’t stop breast cancers from developing. It’s not as simple as if you take this treatment, you won’t get breast cancer. Your breast cancer will not come back. It’s going to prevent it from coming back. And in fact, for many women, especially those with early localised cancers, which are localised in the breast, which actually are the majority of women, about two thirds of women present with early localised cancer that hasn’t spread or hasn’t spread to the lymph nodes, then actually the prognosis is very good and those anti- endocrine treatments – I’m talking about things like Tamoxifen, or aromatase inhibitors so Anastrozole, Letrozole, etc. – are only a very, very, in some cases, minimal benefit which considering the side effects of the anti-estrogen treatments, I think it’s really important that women understand that if they’ve got an early localised breast cancer, they need to understand the absolute benefit and risk to them from their endocrine therapy in terms of whether they wish to take it or not.

Dr Louise Newson [00:12:26] So this is very important because this brings us to why we’re doing what we’re doing, actually. So someone actually said to me a while ago, ‘having breast cancer is very difficult. Being menopausal and having had breast cancer is even harder’. But actually being a menopausal woman who’s had breast cancer and not being listened to is really, really difficult. And since I opened my clinic and I started having a dedicated clinic, I started, as many of you know, on my own seven years ago. And there was a lady that came in to see me and she had breast cancer a few years before. She had had a hysterectomy and she was really struggling with her menopause. And for seven years she had had the most wrenching, awful sweats and she had her hair cut very short because she couldn’t do anything else. She had a few changes of clothes in her bag every day. She couldn’t sleep. She put on weight. She was just close to divorcing her husband and she’d given up her job and she came to see me, really lovely lady. And she said, ‘Could I have some HRT?’ And I said, ‘Well, you’ve have breast cancer.’ And she said, ‘Yes, I know, but my life is absolutely awful. I’ve tried antidepressants, I’ve tried to lose weight, I’ve tried other things, and I’ve tried all the supplements that I can have and I’m just feeling awful and my life is just really difficult’. So I gave her a bit of gel, some estrogen gel, and I’d never actually given a woman who’s had breast cancer HRT before and I went home and most nights I just couldn’t sleep because I thought, what have I done? What have I done? But she was central to the consultation. I told her that there was no good evidence and it might be a risk giving her some estrogen. And I had no one really to talk to because I was doing the clinic on my own. And so then three months later, she came back, I saw her name on the records and I thought, ‘Oh my goodness, here goes’. And she came breezing in and she had lost a stone in weight. She divorced her husband, which she was very happy about, and she had a new boyfriend. She’d grown her hair a bit and she said, ‘Louise’, well she didn’t say Louise she actually said, ‘Dr I would like to thank you’. And I said, ‘Oh, what for?’ She said, ‘Because you have transformed my life. This is incredible’. And I saw her again recently, actually a few weeks ago, and we were talking about this first consultation. And she had no idea the enormity of what I had done and the difficulty that I had faced knowing whether I was doing the wrong or right thing. But we learn from our patients every day. Our patients are such a privilege to us and I have grown and learnt so much and I thought then actually, who am I to say no to something that is transforming her life? And whenever I see women, whether they’ve had breast cancer or not, they know that they can stop their HRT on any day and it will come out of their system. The half life’s about 18 hours or so. So it will, within a day they’re back to how they were before. So she was completely in control. And she also knew her mother had had really bad osteoporosis and she was worried about osteoporosis. And in fact, she was more worried about having osteoporosis than she was her breast cancer coming back. And I really learnt from her. And since then, obviously my clinic opened four years ago, and we’ve had quite a few women – we’ve got about over 500 women who have now come to the clinic who’ve had breast cancer and they’re wanting individualised consultations. And often that has ended in HRT. And many women have said to me, ‘Dr Newson I’ve had chemotherapy, I’ve had radiotherapy, I’ve had a mastectomy. I know how gruesome breast cancer treatments can be, but actually my life is horrendous and I really want to consider having some of my own hormones back’. And so… and then you look at the evidence and it’s not very clear. And so this is where the work we’re doing together we’ve created and you can explain more…. the clinical steering group really where we’ve got together really key people who are sort of top of the game really, oncologists and breast surgeons and radiotherapists and us as GP specialists. But we’ve also got a urologist who’s been on the podcast before, Steve Payne, his wife was getting pylonephritis infections because she had low estrogen as a result of her menopause and she’s had breast cancer in the past. And even as a urologist, he didn’t understand the enormity of how important hormones are for the urinary tract. And we’ve also got patients on our group. So just explain what we’ve been doing, because you’ve been leading the group Sarah, and it’s a huge amount of work and we’ve been picking the evidence of what scanty evidence there is. But we’ve been trying to work out how to take this conversation forward because women in the end are suffering because they’ve been given the treatments, which, like you say, can make a difference, but a small difference compared to the effect of the surgery or the chemotherapy. They’re initial treatments, obviously the most important. But we’re just trying to help women and but also healthcare professionals about this area, which causes a lot of controversy, really. And because breast cancer is so common and luckily the prognosis is so good, there’s millions of menopausal women who’ve had breast cancer out there who we hear from a lot just through other platforms who are not being listened to. So we’re hoping this work will improve. So explain what we’ve been doing then, Sarah.

Dr Sarah Glynne [00:17:53] So yeah, I mean, essentially, I think sort of two principles behind what we’re doing are exactly as you say, the risk-benefit ratio, which is different for every single woman. And it’s the risk versus the benefits of the endocrine treatments used to treat cancer. And it’s the risks versus the benefits of HRT used to treat menopausal symptoms in women who’ve had breast cancer in the past. And the second principle is this shared care and shared decision making, which is absolutely fundamental and key to what we’re trying to do. And we are absolutely not saying that all women who’ve had breast cancer can have HRT or should have HRT. And we are absolutely not saying that HRT is 100% safe for all women who’ve had breast cancer. And I think perhaps that’s why we’re meeting with some resistance in some quarters and why I think some people don’t understand what we’re doing because they haven’t got that message from us before, but that is what underlies the work. We are saying that for every woman with breast cancer, the risk-benefit ratio will be different and unless she is counselled so that she can consider the risks and benefits specific to her, she will not be able to decide whether HRT is something that will benefit her or not. And so what we’re trying to do is look at, as I say, the risks and benefits of the endocrine treatments and chemotherapy are the treatments that are used for breast cancer. And then we’re having a look at the evidence in breast cancer survivors that have been given HRT as to whether it’s increased risk of recurrence, whether it increases or decreases mortality. And not just that, but what are the long term risks of not giving HRT? So obviously, in the short term, it’s to do with quality of life and menopausal symptoms, which can be debilitating for many women, but also in the long term, exactly as you said. And I’ve seen patients recently that are far more concerned about their risk of osteoporosis than they are about their breast cancer coming back or they’re more concerned – I saw a woman just a couple of weeks ago whose father had dementia and she’s far more ‘terrified’ were her words, of getting dementia than she was of her breast cancer coming back, which makes perfect sense, because actually breast cancer these days often has an excellent prognosis. And the vast majority of women who get breast cancer will not die of their breast cancer, they’ll die of something else. And the things they are dying from, the most common cause of death in breast cancer patients is cardiovascular disease and stroke and dementia. And we know that in patients without breast cancer, HRT can significantly reduce the risk of these long term health conditions. And it stands to reason, although there’s no work being done specifically looking at the long term benefits of HRT in breast cancer survivors, but it stands to reason that if their symptoms and their long term health risk, that all cause mortality, is being caused by hormone deficiency and giving women their hormones back will at least partially offset or mitigate against those risks, then it stands to reason that actually, for many women, the benefits of HRT might outweigh the risks. So that’s what we’re doing. We’re trying to produce a consensus statement that will support shared decision making and prescribing of HRT to women who’ve had breast cancer, if they want it, if the benefits outweigh the risks for them, and if they’ve been given enough accurate information to enable them to make a decision – that’s what we’re trying to do.

Dr Louise Newson [00:21:26] Which is no mean feat, actually. And I think what’s happening sometimes is that women with breast cancer are just grouped together. You’ve had breast cancer, therefore you can’t have hormones. And that’s like saying, ‘oh, you’ve had a car crash before, therefore you can never get in a car’. It’s you know, you make choices all the time about what we do. And I hear, and I know I’m sure you hear a lot, that from our patients who say they’re told they can categorically never have HRT. And I think in medicine you can never say never, that’s one thing. But I think there’s also different types of cancer. We’ve already said there’s estrogen receptor positive but there’s also estrogen receptor negative. And many experts feel that giving more hormones is less controversial, if you like, for women who’ve had an estrogen receptor negative cancer. But I see some women who have had breast cancer 20 years ago. And, you know, that’s very different when someone’s had it 20 years ago to someone who’s had it 20 days ago or 20 minutes ago. And with time, that makes a difference as well. And then also it depends sometimes on their age. So I’ve got quite a few people who have had a double menopause. So they’ve had breast cancer when they’re young and then they’ve had treatment that’s caused a menopause. Maybe they’ve had one of these estrogen-blocking drugs or they’ve had their ovaries removed. And then the ones that have had the drugs, maybe if they’ve had them for five years and then in their forties, their periods have come back, and they felt wonderful because they’ve got their own internal hormones have worked and then in their late forties, their periods stop and they become menopausal and they’re told they can never have HRT. But then all we’re doing is giving them back what they’ve had for the last few years when they’ve been menstruating. And so then those women, it’s always easier to make the decision because they’ve been exposed to hormones already. So every woman is different. But like you say, Sarah, every woman has different reasons for doing something. And also they have different health risks as well. And when we’ve been looking at some of the studies, looking at outcomes from people who’ve had breast cancer or the benefits of these treatments that block hormones, it’s all been focused on breast cancer. Has there been a recurrence in this lady? Has there been a death from breast cancer in this lady? And what they haven’t been looking at is what is about the risks for her future health, for heart disease and osteoporosis, like you say, but also quality of life as well. And I had a lady a while ago who’s a paramedic, really bright, lovely lady who’s really floored with symptoms because of her breast cancer treatments. And she said to me, ‘Louise, I’ve come to a crossroads’. She said, ‘I can either carry on with the treatment the oncologists want me to do and avoid hormones, but I will have to go and live with my mother and I can’t work anymore and I might have a really long life or I’m going to have to consider taking hormones and that might enable me to get my job back and that might enable me to do the things I want to do and I might die at an earlier age, but that’s my decision. But I’d like to have that choice’. So after a lot of discussion, she decided to take HRT, and she’s taking HRT and testosterone, actually. And she’s back working not just as a paramedic, but she’s also doing a PhD as well. And she’s living at home. She’s not with her mother. She’s fiercely independent. In fact, she’s quite scary because she’s so bright. But she’s got her brain back and it’s her decision. And I feel the work we’re doing is to help facilitate a conversation. Not saying ‘yes, you can’, ‘no, you can’t’ is it? I think that’s really important to distinguish.

Dr Sarah Glynne [00:25:08] No. And that’s the interesting thing is that even if all women with breast cancer had the same risk-benefit ratio, which obviously they won’t, but even if they did, that ratio will have a different meaning for different women. So I don’t know, for example, let’s say if you had a small localised breast cancer, maybe your risk of recurrence in the future would be, I don’t know, 6% or something. And with HRT it went up to 9%. So let’s say that you’ve increased your risk of breast cancer recurrence by 3% – I’m  making these numbers up. Now some women would look at that and say, ‘well, absolutely not, I wouldn’t want to take HRT at any cost because my fear of my breast cancer coming back is the thing that I am most terrified of and I would do whatever it takes and I would suffer’. Or maybe some women aren’t having such bad menopause symptoms, I don’t know, but they will not want to take that decision. Whereas another woman would look at that and think, ‘well, hold on a minute, 3%, that’s not worth it. I feel terrible. You know, my quality of life has gone down the drain. I’m no longer functioning normally. I can’t work. I can’t look after my children. I’m contemplating suicide’. We’ve both seen patients, you know, that same risk-benefit ratio will have a completely different meaning depending on what women are scared of and what, I think everybody has a different threshold for what they would consider worthwhile. And obviously, if the treatment of breast cancer didn’t have any side effects and if women weren’t suffering from menopausal symptoms, then of course, you take that 1% benefit or that 2% benefit, because why wouldn’t you? But the reality is that it’s much more complicated than that. And women’s quality of life is really suffering and their long term health is really suffering. And that’s the other important thing in terms of timing. As you said, the risk-benefit ratio changes over time and that’s also really important. So as a general rule of thumb – and it’s not my place to tell a woman whether she should suffer or not – but as a general rule of thumb, I probably wouldn’t encourage somebody to take HRT if it was within a year or so of their diagnosis, at least without trying other things first. It’s not my decision, but that would be what we would discuss. But actually, the risk of breast cancer recurrence decreases over time. So only about 7% of recurrences happen after ten years. The vast majority of them happen in the first ten years. And from about seven years after diagnosis. That’s when your risk of dying from something else starts to increase, and that’s when cardiovascular mortality in breast cancer survivors starts to increase. And in fact, women who had breast cancer have double the risk of dying from heart disease, compared with women who haven’t had breast cancer, which we think is related to the fact they’ve been hormone deficient for so long. In the past, we thought, well, maybe that’s because lots of risk factors for breast cancer are the same as the risk factors for cardiovascular disease. It stands to reason if you’ve got breast cancer, you’re also more likely to have a heart attack. But there’s been some work recently that looked at risk factors in women with and without breast cancer, and that doesn’t appear to be the case. The other theory was that it was the treatments that were being used for breast cancer were cardiotoxic. And therefore, again, that could explain the higher cardiovascular mortality in breast cancer survivors. But again, when they compared cardiovascular mortality before 2005 with cardiovascular mortality since 2005, because since then, the treatments are less cardiotoxic. They’re better, they’re not so bad for women. And again, it hasn’t made any difference. So, in fact, the only reason I can think of that would account for a higher cardiovascular mortality in women who’ve had breast cancer is because they’ve been deprived of their hormones for so long. And again, if you’re coming up to sort of the five year, seven year mark, you’re still within that ten year window of opportunity that we talk about all the time, whereby if you start HRT within ten years of the menopause, you can half your future risk of cardiovascular disease. You can reduce your all cause mortality because as I said, most women with breast cancer don’t die of their breast cancer. They die of something else. And you can reduce that by up to 30%. You can reduce your risk of osteoporosis by about 50%. And about… I think mortality associated with a hip fracture was it 20%? It’s quite high, isn’t it?

Dr Louise Newson [00:29:02] Well, I learnt last week it was as high as 30% actually so yeah. And I think yeah absolutely. And I think the most important thing from all of this is about choice and it’s about putting the patient in front foremost of the consultation actually. And I really strongly feel, you know, we’re advocates to help. We’re not doing any didactic, ‘You have to…’ ‘You must do…’ ‘The only option is this…’ It’s just about choice. And we’re looking at the limited evidence we have, but also using expert voices as well. So I’m hoping, Sarah, that you can come back onto the podcast and announce next year how it’s all gone. But we’re really striving forwards with this. And I know I’m just publicly very grateful for the work that you’re doing. We’re using something called the Delphi process, and it’s taken hours and hours and hours, but we’re really committed to making a difference. And so I want to thank you for that. But before we finish, I know you’ve done your homework because you’re so super-organised and your three take home tips actually for women who are listening and I know we’ve covered a lot of information in a short space of time, so some people might want to listen to this podcast more than once because I know there’s a lot, but what are your three take home tips then Sarah, please?

Dr Sarah Glynne [00:30:21] So my first top tip would be to understand the risks and benefits of the drugs used to treat breast cancer and what this means for you personally. And what I mean by that is if you’ve been diagnosed with breast cancer and you’re taking Tamoxifen or an aromatase inhibitor like Letrozole to reduce the risk of recurrence, then make sure you speak to your oncologist and ask what the risks and benefits of that treatment are for you and your breast cancer. And there’s something online called the PREDICT breast cancer screening tool. But actually, if you Google, you can find for yourself, you can plug in your own numbers. And it’s quite a helpful online tool that you upload the… your own tumour characteristics, whether it spread to the lymph nodes, whether it’s estrogen receptor positive, negative, etc. and it tells you what your risk of dying, your long term prognosis is of breast cancer. And it tells you what your risk is if you don’t take endocrine treatment versus if you do take endocrine treatment. And I think many women will be surprised to learn that actually the benefits of endocrine treatment are small. In some cases, we’re literally talking maybe one or 2% difference in terms of their breast cancer mortality. And as I’ve already said, every patient will have a different threshold of what’s worthwhile, what’s acceptable to them. But some women may decide that the benefit for them is too small to continue in view of the side effects in which case, they should speak to their oncologist about stopping their treatment or switching to a different treatment. And that in itself might be enough to improve their quality of life, at least temporarily, until a later time. So that would be my first top tip. My second top tip would be to read about non-hormonal options that are available and to learn more about what you can do for yourself to improve your quality of life. So for example, there’s evidence coming out all the time about dietary modification, breathing, yoga, exercise, acupuncture, all those kind of things. It’s important to experiment with lots of different options because different things work for different people. Vaginal moisturisers and vaginal lubricants don’t contain hormones. They can be very helpful to treat symptoms of vaginal dryness and soreness, which are common in breast cancer survivors. And there are other options. Your GP can prescribe medications, for example such as antidepressants that will help to reduce the frequency and severity of hot flushes, etc.. But if that’s not enough, if your symptoms are severe and your quality of life is poor, and you’re worried about your long term health, as we’ve been discussing, then my final tip, tip three would be to ask your doctor to explain the risks for you if you decide to take HRT in terms of the risk of breast cancer recurrence in your long term prognosis, versus the risks to your long term health if you decide not to take HRT. And vaginal hormones generally are very safe and most oncologists are happy to let patients take vaginal hormones if they need it. But some women may choose to take HRT, and that’s fine. If the benefits outweigh the risks for them, then HRT is absolutely an option. And I don’t believe that HRT is contraindicated for any woman. I think if a patient in consultation, conversation with the menopause specialist or the oncologist or the breast surgeon, or the team around them deems that the benefits outweigh the risks, then HRT is absolutely an option. I think I’d certainly recommend arming yourself with information and there are lots of helpful, excellent resources, of course, on the balance website, lots of factsheets and booklets and podcasts. I would recommend reading ‘Oestrogen Matters’ by Avrum Bluming and I know he’s done a podcast as well with you on balance. And then have that conversation with your menopause specialist because it’s a very personal choice that a woman can only make once she’s been given all the information about the relative risks and benefits and shared decision making is key, and that’s probably a really good note to leave it on.

Dr Louise Newson [00:33:59] It’s so important and there are NICE guidance in Shared Decision Making and that should be pivotal to everything that we do as a healthcare professional. So that’s been really useful and I hope really useful for others to listen to and hear about the work that we’re all doing and we’re… a lot of us are really dedicated to make a huge difference to people going forwards and this will really help with that. So thank you so much for your time today Sarah I really appreciate it.

Dr Sarah Glynne [00:34:27] Thank you.

Dr Louise Newson [00:34:30] For more information about the perimenopause and menopause, please visit my website balance-menopause.com. Or you can download the free balance app which is available to download from the App Store or from Google Play.

END.

The post Advancing menopause care after breast cancer with Dr Sarah Glynne appeared first on Balance Menopause & Hormones.

Dani Binnington was diagnosed with breast cancer as a young mum at 33. For the next few years her life did not feel under her own control amidst countless medical appointments, treatments and surgeries. After discovering she carried the genetic BRCA1 mutation, Dani chose to have a double mastectomy and at 39 she opted to have both her ovaries removed as several family members had died from ovarian cancer.

Previously a jewellery designer, Dani then embarked on a change of direction towards yoga and healthy living, and she now offers programmes for women on menopause after cancer. Dani is on a mission to empower women to learn about their choices, seek out specialist menopause care and her goal is for every women to have the conversations with healthcare professionals that they deserve.

Dani’s tips for women after cancer:

1. Talk about it with the right group of people that understand what you’re going through
2. Make time for yourself to check and understand your symptoms
3. Continue conversations with your healthcare team and ask for specialist menopause care
4. Learn all your treatment options, including hormonal and non-hormonal treatments, complementary therapies, lifestyle management, and how to avoid triggers.
5. Don’t sit back, show up for yourself and be empowered. Be active in your own recovery.

Visit Dani’s website.

And follow her on social media:

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The Menopause And Cancer podcast:

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Episode Transcript:

Dr Louise Newson [00:00:09] Hello. I’m Dr Louise Newson and welcome to my podcast. I’m a GP and menopause specialist and I run the Newson Health Menopause and Wellbeing Centre here in Stratford upon Avon. I’m also the founder of The Menopause Charity and the menopause support app called balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence based information and advice about both the perimenopause and the menopause.

Dr Louise Newson [00:00:46] Today on the podcast, I am very delighted to introduce to you Dani Binnington, who some of you might have seen or heard before. She’s doing some incredible work, really allowing women to make more choices and also to learn more actually about the menopause, the perimenopause, especially for women who’ve had breast cancer. So welcome, Dani.

Dani Binnington [00:01:08] Thank you for having me, Louise.

Dr Louise Newson [00:01:09] Oh, it’s great. So I first met you. I don’t know how long ago, maybe a couple of years or so ago. And I remember looking at your website, which is so lovely and calm and really inspirational actually, and thinking, wow, you just look the picture of health because I know you do look after yourself and it is really important that we all look after ourselves and you are very holistic in the way you look after yourself, which indeed we all should be. Looking at your diet, looking at exercise and looking at your hormones as well. But things haven’t always been quite so healthy. I know that and not quite so easy. So are you able to just talk us a bit about your journey, if you like, and why you’re doing what you’re doing?

Dani Binnington [00:01:47] Yeah, of course. So I think I kind of like ended up almost in this situation when I thought my journey with breast cancer would come to an end. And when I thought, this is sort of the last bit in terms of my treatment, a whole new other chapter had opened up, and that was my early menopause and I had really good care Louise, it was fantastic. All my care was under the NHS, it was brilliant and at the same time I realised the exact opposite is true for most women I speak to. And I became so outraged and infuriated that I thought, right, I’ve got to do something about it. But before I was diagnosed with breast cancer, I was a jewelry designer. And so in my case, my cancer diagnosis has really totally changed, not just how I live my everyday life, but it’s changed my career. I’m now also a yoga teacher, I run programmes for women in menopause after cancer. And so everything around me and about me has changed and people will say, ‘Oh, you’re so positive. I love that about you’. But I wasn’t always like that. A lot of hard work and years and showing up for myself and looking into the right direction has gone into my journey for it to unfold the way it does. I think in the early years and months after my breast cancer diagnosis, I was so riddled with fear. I was so, so scared of a cancer recurrence. Our kids were tiny, you know, they hadn’t even started school. And I wasn’t waking up feeling amazing and I wasn’t looking great for sure. And it was just all a big malarkey, really. And then I think the added pain for me was that I realised I’m a BRCA1 carrier and so that gave me more decisions I had to make for my own health and for my future health, and partly that it meant a double mastectomy for me and it also meant me removing my ovaries when I was 39. So hence the early onset menopause.

Dr Louise Newson [00:03:44] Yeah. So how old were you then, Dani, when you were diagnosed with breast cancer?

Dani Binnington [00:03:48] So I was 33. I found a lump. Everyone around me sort of said, ‘it’ll just be a benign thing. Don’t worry. You’re so young’. And so I even went to the appointment for my results on my own because I just thought, there is no way this can be cancer. I’ve just stopped, you know, not long ago, I’ve stopped breastfeeding my twinnies. There is no way I thought my life would go that way. And when we did get the diagnosis after that, it felt like life was happening to me and to us as a family. And I would say it took years to regain a little bit of control back into my life. And then when it came to me having my oophorectomy, so letting go of my ovaries, by then I was so empowered I was the total opposite. It took a lot of work to get there. And partly that’s what I want to teach women today. That you can get from that feeling of being totally, almost desperate, not knowing what to do, to a more empowered state of being. And often that’s not even so much about getting rid of your symptoms. That might just be of teaching women how to navigate their health professionals and the healthcare and telling them what’s available to them.

Dr Louise Newson [00:04:59] Yes, and I think that’s really important, isn’t it? Choice. I think it’s a really powerful word choice in everything that we do. We do have choices. Sometimes they’re taken away from us. And obviously, you know, you didn’t choose to have breast cancer for sure. And there is no way that you were expecting it at such a young age. But then you have become a sort of advocate for yourself and for your future treatment choices as well, actually. And I think that is really important in any area of medicine actually, that we do the homework, if you like, and work out what is best for us. And certainly, knowing that our treatment choices can change as well, because certainly at the beginning, you probably didn’t really think much about menopause, did you? And understandably it was thinking about breast cancer and your children and what the treatment involved and how you are going to watch your children grow up and you know, all those things.

Dani Binnington [00:05:55] Yeah. And also everything that has happened in my past has influenced and will always influence my decision making process now and what will happen in the future. And the same is true for all of us, which is why even if you are a scientist or a doctor like you, there is no right or wrong because whoever is in front of you will have such a different sort of baggage and experience that we bring in. So in my family, we’ve got a very strong link of ovarian cancer, we’ve lost many women before they turn 60. To ovarian cancer, some have left children, teenagers, so so sad and one aunty, my last one to pass, was also diagnosed with ovarian cancer and her medical team has always said to her, for a long time I’ve said to her, ‘you’re postmenopausal. It’s best to get rid of your ovaries. You’re probably at risk’. But her worry about being and becoming menopausal was too much for her, so she never let go of her ovaries. And we lost her to cancer a few years after that. And Louise, all I want to say to people, it’s a real rubbish place to be. No one wants to be in the cancer and menopause group. It’s a rubbish camp to belong to. I understand. And at the same time, we mustn’t fear it because life can be beautiful and life can be so much and we might not always feel the same. Like, I know I don’t feel the same as I do before I was diagnosed, but life would be different and it can be good. And that’s really, really what I want to get across to women to not fear it quite so much.

Dr Louise Newson [00:07:30] Yeah, I think that’s that is really important because a lot of people think that the more awareness that’s been done about the menopause, the more that scary stories are being spread. And a lot of people have heard me talk about the mental health aspects and suicide and really disabling symptoms for a lot of women. And so I’m sometimes told off for talking like that and saying, well, actually we’re making people feel worse because they’re expecting something really bad. But actually, a lot of people don’t have severe symptoms. But those that do, it’s really important to know that there is treatment as well. And I think it’s also, as you know, it’s not even always thinking just about symptoms. It’s thinking about future health as well. And that’s what’s really important. And someone who’s young and has an early menopause has longer without the hormones and actually often has a higher risk of heart disease, osteoporosis, diabetes and so forth. So it is looking at the bigger picture and having the right tools to make the right choices, knowing what the risks are as well, if you see what I mean, so a lot of people I speak to have had cancer or are really worried about their bone health, but they don’t know how to improve their bone density. They don’t even know about vitamin D. And a lot of people think it’s either hormones or nothing. There’s nothing else. And, you know, hormones is one part of treatment for the menopause. Whether you’ve had cancer or breast cancer or no cancer, it has to be given in conjunction with looking at lifestyle and looking at exercise and wellbeing and sleep and everything else as well, doesn’t it?

Dani Binnington [00:09:02] Mm. I always thought when I was first diagnosed with the BRCA1 mutation that could give me more cancers, more ovarian cancers, more breast cancers. Initially, I was so shell-shocked by that because I really didn’t want to have that knowledge. And it took quite a lot of mindset work to then understand, I can use this in my favour. And it’s a little bit like that, I think with all the awareness work you’re doing, sometimes you’re on the receiving end and I’ve heard you talk about lots of stuff online in the last many years and sometimes you receive it and you hear the negatives because our mind has the tendency to go to the negatives. Is when I think back of my last week, if I don’t watch it, my mind will attach to what hasn’t gone well for me and so it takes a little bit of retraining and changing our mindset to think, okay, so these are my risks, this is what could happen to me. And then thinking, I’m glad I know because now I know I can do something about it. Rather than just sort of absorbing the facts and thinking it’s all terrible. I remember when I was preparing for my oophorectomy, I was walking down the street after an appointment so I saw two or three different surgeons – because by then, remember, I was empowered. I was that difficult patient. And this one doctor said to me, ‘Well, if you have this early onset menopause that young, your risk of cardiovascular disease and bone problems is almost going to be as high that you die of one of those things than if you get ovarian cancer. I was floored. I can still remember the roads, the pavement and almost my world around me crumbling to pieces, thinking whatever I’m going to do, it’s going to be rubbish. I also remember on the same day thinking that is not going to be me. It’s not going to be my future. I refuse to just hear this without being given real options. And that’s when my spark got ignited to look into everything from supplements to diet, to exercise to HRT, whatever it might be, to cognitive behaviour therapy. And I suddenly realised, wow, there are thousands of things – no, that’s exaggerated – but loads of things that we can do at different points that can help us feel better and feel good.

Dr Louise Newson [00:11:27] And that’s so important, isn’t it? And I think sometimes it’s not until something bad has happened that it makes us have a wake up call and think, actually, come on, I’ve got to take control of this, because otherwise you’re going to be controlled by something else. And, you know, you don’t want to be defined by your cancer or your BRCA status. You want to be defined as who you are and look at the whole of you. And so I think for those of you that don’t know, let’s just talk a bit about BRCA. So what does BRCA mean and can you just explain a bit?

Dani Binnington [00:11:56] Yeah. So because of our strong family history with ovarian cancer and because of the type of cancer I’ve had and because of my age, the doctor said, we should get you tested. If you just have a mum who’s got breast cancer, for example, it doesn’t necessarily mean you might be at risk of having the BRCA mutation. And so this genetic testing involves counselling and you go through a whole protocol and in my case there’s a BRCA1 and BRCA2 mutation. And when you have that mutation, it means the repair in your cells doesn’t work quite as much and you’re more likely to have ovarian cancer or breast cancer. But again, Louise, you know, you can have breast cancer to say 60%, you might not for 40%. It’s always going to be 100% for you, for each individual. And I never thought I’m unlucky or why me? I always just thought, and what do I do now?

Dr Louise Newson [00:12:52] So the whole thing about risk is really difficult. Isn’t it really hard when you know that you know you’ve got a high risk, doesn’t mean it’s 100% risk. And so with BRCA gene, if people have this gene then like you say, there’s an increased risk of breast and ovarian cancer. So a lot of women have their ovaries removed because they obviously then don’t have a risk of ovarian cancer if they haven’t got their ovaries. But one of the problems is when people have their ovaries removed, they become menopausal on that day. And a lot of people, even some doctors sometimes think that the reason that people with the BRCA gene are having their ovaries removed is because they don’t want estrogen in their body. And that’s not true, actually. It’s more because of the risk of ovarian cancer. So we see and speak to a lot of women who haven’t had breast cancer, but they’ve got this risk of ovarian and possibly breast cancer. So they have their ovaries removed, they become menopausal, and many are told they can’t have HRT because of the perceived risks with breast cancer. Well, women with BRCA have an increased risk of breast cancer, but there hasn’t been any good quality studies showing that those women do have an increased risk of breast cancer from taking HRT. And a few studies, small studies in this area have shown that women who take HRT following oophorectomy actually have a lower risk of breast cancer. And if women have a hysterectomy at the same time and only need estrogen, then studies have shown these women do have a lower risk of diagnosis of breast cancer, but also dying from breast cancer. So it’s very interesting. And in fact, somebody told me yesterday that she’d seen a lady in a clinic who’d been told she couldn’t have HRT because she was adopted. And the doctor didn’t know whether her family had a history of BRCA or not. So she was refused HRT for that reason, which I think is really absolutely sad and barbaric actually.

Dani Binnington [00:14:47] From day one of having had the cancer diagnosis, I feel like it was always a risk assessment of anything. Like in the early days, I had a second consultation about my initial surgery and I opted to have all my lymph nodes removed and I had to sign a disclaimer saying at one point you could get a lymphedema or complications of that. And it happened to me. And so even when I think back to all these years ago, of my surgery, I was assessing the risks. There were benefits and risks to each of the surgeries proposed by my surgeons, and both had quite different opinions. When I had my port fitted in through which I received chemotherapy, again I had to sign a disclaimer to say they might rupture my lungs. It happened to me 6 hours after my first dose of chemotherapy, my left part of my lung totally collapsed. And I was in intensive care for 12 days. Where I had promised my children to be home that night. And again, the risks and benefits for me then were do I have a port fitted? I know there is a small risk of this happening. Or will I have my chemo through my veins, which again brings risks with it? And so I feel in a very odd way, I’ve all along been managing my risks. And they’ve always been really difficult and I never thought it was a very positive risk management situation but you don’t have a choice. And so many women who have the BRCA genetic mutation and are tested, they don’t choose to have a double mastectomy. They don’t choose to have the ovaries removed. And so they’re managing their risks differently, with the history they’ve had, with the belief system they’ve got. And we’ve got to value and respect all of that. I opted to let go of my breasts. I opted to let go of my ovaries. I knew what that meant and I knew I was going to have to manage the risks of that forever, whether it’s the surgery or my long term health. And so I feel don’t we all just manage risks all the time? And I give you a very funny example of another risk assessment. The first few years after chemo, I threw myself into healthy eating and I probably got it all wrong. I excluded all main food groups. I was… sugar became a villain, all carbohydrates. I became vegan, like I was so extreme because I just needed something to hold onto, right? Now I know I just needed to replace the control a little bit. Anyway, I was cycling to the theatre with my friends and one friend, a very good friend, looked at me and said, Dani, why aren’t you wearing a helmet? You’re so worried that sugar is going to give you cancers, more cancer, but you’re not wearing a helmet. Like, if I was going to evaluate your risks for you, I’d have the muffin and wear a helmet!’ And it just showed. It was so good for her to be that honest with me, because it just showed me that managing our risks is such a personal decision, isn’t it, so personal.

Dr Louise Newson [00:17:52] That’s a really great story because I think it’s really difficult. And for those of you, some of you listening might realise that there is some controversial work regarding giving women HRT who’ve had breast cancer. And some people are really taking the whole conversation to extreme and, you know, thinking that all women who’ve had breast cancer should have HRT or women who’ve had breast cancer should not take HRT. And there’s nothing, 100%, nothing that we all do exactly the same every day. And when we don’t know answers – or even if we do know answers – it’s still about individualised choice. And we have some really good guidelines actually, that NICE brought out last year on shared decision making. And I think these are really pivotal for everything I do as a doctor actually, about sharing any potential risks and benefits of having treatment, but also of not having treatment as well. And I think we really need to understand that. And I think, you know, you’ve been very open Dani, in saying to people that you have taken HRT and that was a choice that you made. But also, you were aware that there are risks to your future health of avoiding HRT because of not having hormones in your body. So a lot of women actually, or several women certainly that I’ve spoken to, are more scared of the risk of osteoporosis or heart disease than the risk of their breast cancer coming back. And they want to minimise that risk as much as possible with lifestyle, of course, but also the choice of hormones. And actually they know that that might be increasing their risk of breast cancer recurrence or even metastatic disease, we don’t know. But for them, their main concern is, you know, their health and their heart risk and their bone risk. And actually that needs to be taken into consideration. It’s about like you, you know, your diet was more important to you than your risk of falling off your bike.

Dani Binnington [00:19:47] Or being knocked off my bike!

Dr Louise Newson [00:19:48] Knocked off your bike. So but also risk, you know, how we perceive risk can change with time. So on day one, after having a diagnosis of breast cancer, it would have been completely inappropriate to start thinking about HRT and menopause and everything else. But further down the line things change, and you know what you need and what you think about changes. And I think that’s what’s really important, that when we look at consent, we’re not consenting for a lifetime of something. We’re not, even if we decide to take HRT, doesn’t mean we’re signing up for a lifetime of HRT. Nothing is irreversible. Certainly having ovaries taking out is irreversible. We can’t put them back in. Diet, you’ve already changed your diet from what your extreme diet before, you know how you choose to exercise, but also how whether you take hormones. Some people decide to take them for a few months and then they can make a better decision on informed choice whether they want to continue or not. And what saddens me is there’s a lot of people that are refused treatment because their doctors or their nurses or their pharmacist or whoever they see don’t feel comfortable. And I think that’s really difficult because it’s not for me to say, ‘yes you should have HRT’, ‘no you can’t have HRT’. It’s about deciding together. And then I think the whole conversation about consent is really important. You know, you’ve had procedures and have been consented and you signed the consent form. A lot of time in our consultations, we use something called implied consent. You know, the fact that a patient is sitting in front of me means that she’s consented to have the consultation, otherwise she wouldn’t have turned up. And we do that with a lot of treatment as well. But actually when we give women who’ve had breast cancer HRT, there is a conversation that we started talking quite seriously with some of our peers about, you know, should women be consenting? So they’re more in control, actually. And for those of you who don’t know, we’ve set up a clinical steering group through my education work, which is involved by people who don’t work with me in the clinic, but they are oncologists and radiotherapists and breast surgeons and patients and Dani is kindly one on the steering group and also GPs with a special interest in menopause, and we’ve got some other patients as well. And it’s a great group where we’re trying to come together to talk about some consensus, to try and help with some of this uncertainty and we’re making some great progress. But one of the things we’ve been talking about recently is about the consent and how we can allow a better consent process for women who do want to take treatment. And I think this is going to be really important because I think it will help allow our patients to be in control. Because I feel very strongly with all my consultations that I’m led by patients rather than me leading the consultation. And certainly – this is a generalization – but a lot of women who’ve had cancer but especially breast cancer, are very empowered, they’re very knowledgeable. And they often know what they want, quite rightly so, they’ve been through a lot. And, you know, you learn a lot every time you’re a patient. Every time I’ve been a patient or my children have been patients, I learn so much and I reflect a lot as well about myself, my future, my fragility and what we want out of our lives. And so I feel that allowing women to be able to consent to something that they want that might have risks is actually quite good because then it puts them in control. What do you think?

Dani Binnington [00:23:22] And I learnt so much as well over the last few years because I can really clearly remember that you put a post out about a couple and I think on your Instagram it’s a couple on there. And you talked about the woman starting HRT after her estrogen receptive cancer. And when I read the short blurb, it sat really quite uncomfortable with me and I thought, wow, is Louise saying women should be on HRT after cancer? Because it’s a short message and it sort of did something with me. I had an emotional response to it, and so I became really inquisitive and only after speaking to this lady’s husband, who said she nearly died of sepsis several times because the symptoms of her menopause were so badly. And so our decision was so difficult, but we had to make it. And this is only one example, and I now speak to so many women who are pondering over these really difficult decisions. And for me, it’s really important to sort of stay judgement free and really understand the person like you say, and accept that they’ve all got their reasons for it. My decision happened quite a few years ago now, before the conversation was even available on social media, and I’m quite glad. And so partly my whole decision making process was within the NHS with the consultants at my hospital where I had my menopause specialist treatments, with my oncologist, with my surgeon, and all along, for years they’ve been saying because of the type of cancer, because you’ve had a double mastectomy, because by the time I chose to remove my ovaries, I was quite a few years on from my initial cancer diagnosis. They all were happy to talk to me about the use of HRT. I didn’t feel I had to fight for it. And I think what’s really important and key here is that all women deserve the conversation. That’s what’s important to me, regardless of what they do with the information. We deserve the conversation. And I feel that so many women, if they’re being told you mustn’t, then we’re always going to feel, oh my gosh, I’m really deprived of this treatment. And all my friends are swinging down the road and they’ve got glorious hair and they say HRT is just the best thing ever. And so it’s going to make us feel even more excluded from the greater menopause conversation. If someone says ‘You must not’ or ‘there is no way’. And I think if we just changed the conversation and gave every woman specialist care, which is what I’d so desperately like to work towards, as part of her oncology treatment or as part of her breast care nurses follow up. If every woman had the conversation with a specialist team to talk through all of our choices, all of our treatments, whether they’re complementary herbal treatments, whether that’s hormonal or non-hormonal treatments, I think that moves, I think, to an empowered patient situation. Rather than a ‘you mustn’t have this and we’re not going to give you any options’ because that’s the reality at the moment. People are being told, no, you can’t. And then they’re left. And that, to me is just not good enough.

Dr Louise Newson [00:26:37] Yeah. And I hate to compare genders, but, you know, men who’ve had prostate cancer get a lot more advice and help and support and treatment. Actually, often they are offered their own hormone back – that’s in testosterone in low doses and they are given a lot of support. So I feel that, you know, for women to just say ‘sorry, no’ is actually not good enough and also to be allowed to be part of this conversation and not just even the women on their own. You know, the woman can be supported by her friends and family. And, you know, no decision has to be made overnight. And it’s not an instant decision. And also, I think I have said it before, that people are allowed to change their mind. I think some people think that once they’ve decided one way or another, that’s it, they can’t change or because one doctor has said one thing, they can’t go and get an opinion from another doctor or another healthcare professional. And I think that is actually really important to allow us all to have choices based on different levels of information sometimes is really key and not taking things out of context. And I think your comment about what you read on sort of my social media is very easy to just take something out and not see the bigger picture and not see the concepts. And, you know, like you say, for this lady who’d had recurrent sepsis due to pyelonephritis infection, her kidneys and she wasn’t even given any vaginal estrogen was actually really affecting her ability to function. And her husband, who was a urologist, he’s now retired, didn’t even recognise that even just some local vaginal estrogen could be and actually was transformational for her. So there’s a lot that we need to do isn’t there?

Dani Binnington [00:28:25] Yeah. And you know even if that one doctor who had given me such dire statistics about my choices and my options, even if he had then said, ‘but that doesn’t mean this is your future’. There is so much you can do by consistently showing up for yourself every day, by moving well, by eating well, by jumping down and up the stairs, by supporting your bone health, by taking a vitamin D supplement, like you’ve mentioned earlier. I would have walked down that road feeling, Oh, there is something I can do, at least research. And I think sometimes it’s just how we talk about things as well that can open doors for people or close doors and we want them open, don’t we? We want them all open!

Dr Louise Newson [00:29:04] There’s always something in medicine that we can always do. And it doesn’t always mean that it’s medication, but it is really, really important that people are felt, listened to. And for those of you that listen to the podcast, I hope there’s been lots of information and just some food for thought really. We’re not here giving any answers. It’s really just an open discussion. And I’m really grateful to you Dani, for spending your time just being so open about your experience and what you’ve learnt and become a lot stronger and different person with your experiences in the past. So before we finish though, three tips. So I’d be really keen for you to just share three ways that women could really move forward in their conversation. So if women who are listening or people who are listening know of women who have been really, like you say, have the door closed on them and said no, what would you say? You know, how could they try and help this conversation move forward so they can be offered and listened to really for treatment that’s right for them. So I’m not saying about whether they want HRT or not, just any treatment that’s right for them. What would be the best thing to do if people feel quite hopeless?

Dani Binnington [00:30:12] I’m going to be a rebel and add a few more to your three. I’ve got a manifesto here for you. I think the first thing is we need to talk about it and we need to find the right groups to talk about it. If we, after cancer, always follow a normal menopause conversation, we’re always going to feel on the periphery. So it’s important to find your group and share your experiences with the right people to understand what you’re going through. Then it’s important to make time for yourself and fill in a symptom checker. Even if you are in the middle of surgically onset menopause or if you’re on Tamoxifen or something like that, is take time out to understand what is going on for you. Which are your worst symptoms, which would you like addressed? And then we need to persist with our healthcare team. It’s really key to go back to our GP and say we need and deserve specialist care. Most of the women I work with, I sent them to their GP and say ask for a referral for a menopause specialist and many GPs don’t know menopause specialists exist. So it’s really important to empower ourselves and be quite persistent with your healthcare team. They will be able to talk you through your treatment options, whether they are hormonal, non-hormonal medical options, complementary therapies, lifestyle, all the way to avoiding triggers. This deserves specialist attention, and then we need to empower ourselves every single day because it’s no good to wait and sit for an appointment that might turn up in six months time. Until then, we’ve got the opportunity that we can show up for ourselves every single day. And if that is reducing our stress levels or having the extra apple or walking up and down the stairs, whatever that might be, we can do so much by feeling we are active in our recovery at whatever point that is. So, yes, sorry, I’ve added a few too many, but here you go.

Dr Louise Newson [00:32:03] No, because it’s all really important and really empowering stuff. So thank you ever so much. And I know you do your own podcast as well and we’ll put links out there with the notes so people can hear more about your pearls of wisdom and great advice. So thanks ever so much today Dani.

Dani Binnington [00:32:19] Thank you for allowing us all to have the conversation.

Dr Louise Newson [00:32:24] For more information about the perimenopause and menopause, please visit my website balance-menopause.com. Or you can download the free balance app which is available to download from the App Store or from Google Play.

END.

The post Learning to make empowered choices after cancer with Dani Binnington appeared first on Balance Menopause & Hormones.

Medical oncologist, Dr Avrum Bluming makes a welcome return to the podcast this week to re-visit the hot topic of menopause hormone therapy after breast cancer. Avrum has spent decades studying the research on the benefits and risks of HRT in women with a history of breast cancer and is passionate about giving women clear, evidence-based information that dispels myths and combats the misinformation that has unnecessarily frightened women and clinicians for over 20 years.

In discussion with Dr Louise Newson, Avrum clearly explains what his recent review of the literature reveals about the safety of HRT and the benefits it brings for your future health. The experts highlight the gender disparities that are commonplace in how women with cancer are treated with regard to their hormones compared to men, and they also discuss the importance of patient-centred medicine and giving women choice.

Avrum’s 3 tips for women interested in exploring their menopause treatment options after breast cancer:

1. Speak to your oncologist. Tell them about your menopause symptoms, ask to discuss the possibility of starting HRT and have a conversation about the benefits and risk for you individually.
2. When it is available, take Avrum’s article that will be published, The Cancer Journal in May/June 2022, and show it to your oncologist and GP. Don’t accept a dismissal of your views – engage them in discussion.
3. ‘Oestrogen Matters’ (2018, published by Little Brown) is a book co-authored by Avrum that is for women and clinicians, including a chapter on HRT after breast cancer, and it is heavily referenced to show all the evidence behind the information given.

Links to Avrum Bluming’s upcoming journal article will be published on the balance-menopause.com website when it is released.

Episode Transcript

Dr Louise Newson [00:00:09] Hello. I’m Dr Louise Newson. And welcome to my podcast. I’m a GP and menopause specialist and I run the Newson Health menopause and Wellbeing Centre here in Stratford Upon Avon. I’m also the founder of the Menopause Charity and the menopause support app called balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence based information and advice about both the perimenopause and the menopause.

Dr Louise Newson [00:00:46] Today, I’m very excited, delighted and thrilled to introduce back to the studio today, Avrum Bluming, who hopefully a lot of you have heard the previous podcast we did together. Avrum is an emeritus clinical professor of medicine at the University of Southern California, and he’s also Master of the American Colleges of Physicians, which he’s going to say what that means because that’s quite a mouthful, but it’s a real honour that he was awarded. So I’m very honoured to have you here today, Avrum it’s incredible.

Avrum Bluming [00:01:17] I am honoured as well.

Dr Louise Newson [00:01:20] So and today on the podcast, we’re really going to concentrate talking about breast cancer and women’s choices following breast cancer.

Avrum Bluming [00:01:29] OK. I think first, it’s important to recognise that as human beings, we are risk averse if we’re given the option of a good gain with an associated risk we will almost always decide in favour of avoiding the risk, even if it means not getting the gain.

Dr Louise Newson [00:01:48] Yeah.

Avrum Bluming [00:01:48] And in the world we currently live in, most of the benefits of HRT have now been endorsed, not just by people like you and me and other medical practitioners, but by the Women’s Health Initiative, which is responsible for the dramatic decline in HRT that we’ve seen over the last 20 years. And the benefits include reduced risk of cardiovascular disease, and reduced hip fractures, and improved cognition, and obviously avoiding the symptoms of menopause, and even longevity. And it’s very important to note, and I think I sent you this, there was a paper by one of the senior investigators of the Women’s Health Initiative that was just published last month, Rowan Chlebowski, that says that we have missed the fact that even though we thought that women who took combination hormone replacement therapy had an increased risk of breast cancer, we omitted stating that they don’t have an increased risk of death from breast cancer. And in fact, estrogen decreases the risk of breast cancer when given alone and improves longevity. And we can talk about whether their thought that the combination increases the risk of breast cancer is still valid. There are articles that you’ve seen, that I’ve seen, that say it’s no longer valid. So even for women without any history of breast cancer, the movement is clearly in the direction of ‘let’s look at the benefits and stop waving this red risk flag of breast cancer’, which is a false red flag.

Avrum Bluming [00:03:30] OK. Having said that, we then have to look at what about women who have had breast cancer? And as you know, you and I can both talk indefinitely on this subject. So cut me off any time you want to. I’ve just finished a literature review of giving hormone replacement therapy, either estrogen or the combination, to women with a history of breast cancer, to see what it tells us. And what I found is there are 25 primary studies in the medical literature of giving hormone replacement therapy to women with a history of breast cancer. Of the 25, one has reported an increased risk of recurrence. The one is called the HABITS trial and, as you know, HABITS is an acronym for hormones after breast cancer, is it safe? And they conclude that there is an increased risk of recurrence amongst women who are given hormone replacement therapy after a diagnosis of breast cancer. That’s one out of 25. The other 24 do not show any increased risk of recurrence. And in fact, some show a decreased risk of recurrence and improved longevity, decreased mortality. So it’s important to look at that one. The HABITS study – and HABITS is the only one that’s quoted by many reviewers – and HABITS is a randomised, prospective study. It’s not double blind, but it’s randomised prospective. And that’s why everybody says, ‘Well, this is the one we have to pay attention to because it’s randomised.’ Well, there are three other randomised studies, and they don’t show any increased risk of recurrence. So it’s important to look at HABITS and see what we can learn from it. First, although it was randomised, the particular hormones used were left up to the individual practitioners. In addition, it wasn’t one institution, it was a variety of institutions around Sweden who participated in this study. Fair enough.

Avrum Bluming [00:05:53] If you’re going to do a study of hormone replacement therapy and breast cancer survivors, it’s very, very important to be sure that at the time women enter the study, they have no evidence of recurrent breast cancer. Well, they say none of them had evidence of recurrent breast cancer, but there was no imaging study of the breast that was required before entry into the study. And the recurrences that they found increased amongst women who got the hormones were only localised or contralateral breast cancer, which are also localised. There was no increased risk of distant metastases. There was no increased risk amongst women whose primary breast cancer included involvement of lymph nodes, which would be the group we would think would have the highest risk. And there was no increased risk of breast cancer deaths in this study.

Avrum Bluming [00:06:59] They proposed to do a study of 1300 women over five years, and what they found is after two years, not five years, because they found this increased risk of local recurrence, they stopped the study. And when they stopped the study, they only had a little over 400 women, not 1300 women. It’s important to note that the difference that they found is of 221 women randomised to hormones, 39 of the 221 (that’s 18%) had a local recurrence or a contralateral tumour. Of the 221 in the control, 17 (or eight%) had a local recurrence. The difference between 17 patients and 39 patients is 22 patients. Those 22 patients have yielded a practise guideline that prevents millions of women who are survivors of breast cancer from getting hormone replacement therapy. And by the way, they operated on the principle of intent to treat, which means that even within their groups, the women randomised to hormone replacement therapy didn’t all get hormone replacement therapy. In fact, 11 of them chose not to take hormone replacement therapy, but they were calculated as if they had. And 43 of the women who were randomised to receive nothing took hormone replacement therapy. And with that, there was still a 22-person difference in recurrences, which were not lethal recurrences, they were local or contralateral recurrences. And I’m not diminishing the importance of that. I don’t want women to get local or contralateral tumours, but they didn’t die of their tumours and they had a much better life and some of them lived longer. And that’s one of 25 studies. 24 showed no increased risk of recurrence. So in addition to the 25 studies, I found 18 studies that reviewed the studies that were already published. So these were analysis, not primary studies. And of the 18, the only study that any of them cite that reports an increased risk of recurrence is the HABITS study.

Dr Louise Newson [00:09:57] Yeah.

Avrum Bluming [00:09:57] Oh my God. And to show you where our minds are of the 18 reviews, 15 conclude, ‘Well, there’s really no harm in giving hormones.’ Three, including one that I wrote the letter about that was just published a few days ago by Poggio et al from Italy says, ‘Well, there’s an increased risk of recurrence.’ Well, wait a minute. They include the HABITS study. They include two other studies that don’t show an increased risk of recurrence, and they include one study by Kenemans, which is the study of tibolone. Well, tibolone isn’t estrogen or progesterone. It’s a form of progestin, but it has no known effect on either the breast or the uterus. And to include that as part of an analysis of hormone replacement therapy, especially since the number of patients in that study was 75% of the total number that this review article reviewed and concluded that hormones are dangerous, is disingenuous at best. It’s dishonest at worst, and there were two other review studies that misquote the results. They misquote the results, and that’s going to be in an article that I’ll be publishing in May on this review that I’ve done of the totality of the literature that I could see.

Dr Louise Newson [00:11:33] That’s amazing. I mean it’s… There’s so many words I want to use Avrum because we try don’t we as physicians, as healthcare professionals to practise evidence based medicine. But sometimes the evidence isn’t clear. Sometimes it is clear, but it’s ignored. And there’s a lot of bias in everything that we do isn’t there? And this area of medicine is something that affects so many people.

Dr Louise Newson [00:11:59] So when I was at medical school in the 80s, 1 in 12 women had breast cancer. We’re now in 2022, and the most recent figures are about 1 in 7. So it’s become far more common. But since I graduated from medical school, the use of HRT has declined since 2002, since the WHI study. So I mean, you were saying earlier only 5% of women in the USA take HRT. Around 14% of women in the UK take HRT, who are menopausal. So HRT can’t be causing all the breast cancers can it, because it’s so common. Yet so few women take HRT.

Avrum Bluming [00:12:37] That’s important to state that the overwhelming majority of women who develop breast cancer never took HRT, and the overwhelming majority of women who take HRT never get breast cancer. And by the way, getting pregnant after being treated for breast cancer has no negative prognostic effect on the outcome of your breast cancer. And by the way, taking in-vitro fertilisation (IVF) has no effect on the prognosis of breast cancer.

Dr Louise Newson [00:13:07] And that’s very important because the levels of estrogen in women who are pregnant are so much higher aren’t they, than the levels in women who take HRT? So, you know, I think sometimes with medicine, we run this sort of hamster wheel where we’re very, very busy and we learn by rote and we just sort of go through what we’ve been taught. And we don’t have the luxury sometimes of being able to take a step back and review the literature. But also, we don’t sometimes, when I say we I’m saying a lot of healthcare professionals including myself, sometimes get so wrapped up with the risks or the worry that we forget about what patients want as well.

Dr Louise Newson [00:13:45] And so I really had lots of reasons in my work, the stories I hear in my clinic and social media and so forth. But one of the stories that really I found very sad is these women, so 1 in 7 women, and the majority of them now who’ve had breast cancer have a good life expectancy, don’t they? It’s a disease where the majority do very well, and actually the majority of women who have had breast cancer in the past don’t actually die from their breast cancer, they die from heart disease or dementia. And so a lot of women are given treatments that block their hormones, which might be a temporary menopause. Sometimes they’re advised to have their ovaries removed and therefore they won’t have any hormones. And then a lot of women, because they live so much longer, will then enter a natural menopause. So I think – I don’t know if I’m right here – but the majority of women who’ve had breast cancer in the past will become menopausal at some stage, and a lot of them will be menopausal earlier.

Avrum Bluming [00:14:41] With a reported 90% cure rate of newly diagnosed breast cancer, that means that over several years 1.4 million women in the United States alone will be entered into the ‘breast cancer survivors’ population, and unless the guidelines are changed, will be denied even a discussion of hormone replacement therapy.

Dr Louise Newson [00:15:07] Yeah, we did a survey just to some of our patients recently, and the vast minority had ever been involved in any discussion about menopause or their treatment. And so a lot of women I speak to think that their symptoms are related to their chemotherapy or their treatment that they had in the past, like the brain fog or the bone pains or whatever. Some of the symptoms are due to their estrogen-blocking treatments, such as aromatase inhibitors, because it’s squeezing every bit of estrogen out of their body. But a lot of women, like you say, are just told ‘well you can’t have HRT’, end of. And a lot of women I speak to actually have vaginal symptoms, so they have vaginal dryness or soreness or irritation. Sometimes that means they can’t wear underclothes or they can’t sit down because the pain is so severe or they get recurrent urinary symptoms. Yet these women are told they can’t even have vaginal, which is localised estrogen. So people are so scared. Whereas my patients, I’m never going to stop them rock climbing or skydiving or driving very fast if they want to so, so it just doesn’t quite seem right, Avrum.

Avrum Bluming [00:16:13] Well, I think there are two issues. The first is the one we started with at the beginning, which said that if you want to prevent people from doing something, frighten them. And people are inherently risk averse. What we now know is that women who take hormones, not breast cancer survivors, but the general population of women who take hormones have a 50% reduced risk of heart disease and 50% reduced risk of hip fracture, a probably reduced risk, (although there haven’t been any randomised studies) of cognitive decline, and they live an average of 3.3 years longer. And yet they don’t want to go near hormones because of just the environment that you’re talking about. If we think for a minute, what would the situation be like if we were talking about men and not women? Of course you laugh, because it is so preposterous that we seem to be almost plotting against women’s wellbeing. And that’s so unfair. Do you think men would tolerate hot flashes, difficulty sleeping, loss of sex drive, forget trying to get an erection? And by the way, if you do have sex, it’s going to be painful. Increased risk of heart disease, increased risk of bone fracture, and you prevent them from taking something that you know can treat that. Just get out of the way. Men won’t allow that.

Dr Louise Newson [00:17:43]  No. And I think women thinking about breast cancer as well. I’ve got a very good friend who’s an oncologist, and he does a lot of work for men who have prostate cancer. And as you know, some people, not all, but some of men who have had prostate cancer have hormone-blocking treatments. And he was saying to me recently, ‘Oh, we’ve reduced a lot of men only have three years of treatment rather than five because the symptoms are so severe, the long term health risks are so severe of blocking their hormones so we’ve reduced it.’ Whereas a lot of women I see now are telling me that they’re told they have to not take five years of hormone blocking drugs, but 10 years. And there’s so much that’s wrong that is a gender disparity, there’s no doubt about it. The more I do this work, the more I think it definitely is, some sort of female suppression. But why is it that we worry about men who have hormone-blocking drugs after prostate cancer, yet we don’t seem to worry about the future health of these women who have hormones blocked and then the others who will become menopausal and then not allow their own hormones back?

Avrum Bluming [00:18:46] And incidentally, the link between testosterone and prostate cancer is considerably stronger than the link between estrogen and breast cancer. And the data that we have right now suggests that estrogen reduces the risk of breast cancer. And although you and I can banter about this, I think it’s important to realise that neither of us, nor is anybody, certain of what all this means. And Carlo Rovelli is an Italian physicist, a quantum physicist who is the easiest quantum physicist to read, and I read everything he writes in. And he wrote, ‘the search for knowledge is not nourished by certainty, it is precisely the openness of science, its constant putting of current knowledge in question that guarantees that the answers it offers are the best so far available.’ And that’s what we’re trying to do without being didactic.

Dr Louise Newson [00:19:47] Yeah, and I think that’s so important and I think it’s also looking… People forget the pathophysiology, but they also forget the basic biology of estrogen. And when I say estrogen, I mean estradiol, which is our natural estrogen that we produce when we’re still ovulating. And how anti-inflammatory it is in the body and it can do amazing things. And that’s why we know women who take HRT for many years have a reduced risk of different types of cancers, don’t they? And also, like you say, reduction in risk of death from breast cancer because it can actually induce something called apoptosis, which is programmed cell death. It can modulate the way our immune cells work, which is very good for fighting infections, but it’s also very good for reducing disease as well. And it used to be used as a treatment for breast cancer, didn’t it, many years ago?

Avrum Bluming [00:20:36] It was the first treatment we had besides surgery. Yes. And it had a 44% response rate when high dose estrogen was used. And so what people who are opposed to HRT (and I specifically identify them as people who are less than open minded) say is ‘Well, those are high doses, but low dose estrogen would be dangerous.’ Well, Craig Jordan is the father of tamoxifen, and he found that when women become resistant to tamoxifen, many of them become sensitive to low dose estrogen in its ability to control their breast cancer. We still have a lot to learn, but absolute statements have no place in this discussion.

Dr Louise Newson [00:21:24] Yeah, which is so important. And then the other thing just to really touch on is testosterone, obviously, is another female hormone. We produce even more testosterone than estrogen before the menopause or when we’re younger. And there is some work to suggest that women who’ve had breast cancer and take testosterone actually don’t increase their risk of it further.

Avrum Bluming [00:21:44] That’s true. But here we get into selective citing of literature, there were articles that suggest that testosterone might be a risk. It’s not a clear picture. And so it’s just important to tread very carefully through this minefield of data and share what you know with your patient, looking at benefits and risks, so that the best possible decision is reached between the two of you.

Dr Louise Newson [00:22:13] Yeah, I think that’s so important. So before the NICE guidance came out for menopause, so before 2015, I was a GP seeing lots of women for all sorts of reasons, but obviously menopause women as well. And I would never, ever, ever have given HRT to women who have had breast cancer. And then I set up my clinic, I became a specialist. And I remember that three weeks after I started, this gorgeous lady came in to see me and she’d had breast cancer. She wanted some HRT and I was there on my own thinking, ‘Oh my goodness, what do I do? What can I do?’ So she’d had a hysterectomy a long time ago, so she only wanted a bit of estrogen. And she said to me, ‘Look Dr Newson, I had breast cancer eight years ago. In those eight years, I have really struggled, but I’ve given up my job because I can’t work. My husband’s left me. We had lots of arguments because my mood was so bad. We weren’t having any sex. The sex we had was so painful and my life is really miserable. I’ve put on two stone in weight. I’m only 61. I do not know how I’m going to end the rest of my days. Some of my friends take HRT and they really feel better, have got more energy and motivation and so forth, but I’ve been told ‘no’ by every single doctor, including my breast surgeon and my oncology team. I was wondering if you could help me?’

Dr Louise Newson [00:23:24] So I was there thinking… And I didn’t know you. I didn’t have the luxury of knowing you at that stage Avrum. And I really didn’t know what to do actually, but I felt she’d come a long way actually. She had travelled for three hours to come and see me. And I just said to her, ‘Look, there is no strong data either way. I actually don’t know what to do, but let’s talk through the worst-case scenario is whether you take estrogen or not, your breast cancer might come back.’ And she said, ‘But Dr Newson I’ve had chemotherapy, I’ve had radiotherapy, I’ve had a mastectomy. I know how awful breast cancer treatment is, but I also know how awful my life is now, and I want anything I can do to improve it. I’ve tried anti-depressants, I’ve tried clonodine, I’ve tried sage, I’ve tried acupuncture. I don’t know what else I can do.’ So I said, ‘Well, look, I can give you some gel, some estrogen gel. We can start with a very low dose. You are in control, you can have half a pump, a quarter of a pump, gradually increase. See how you feel, but you can stop at any time. And when you do stop, it will take a day or two to come out of your system. You’re likely to have more estrogen in your body than you had eight years ago because you’ve put on weight as well, and our fat cells produce quite a nasty type of estrogen. So I’m prepared to take this risk if you’re prepared to try and so we had a very shared consultation and she went away with her gel and I just didn’t sleep for weeks afterwards, I was very worried what I’d done.

Dr Louise Newson [00:24:45] Anyway, she came up to see me three or four months later. She had lost a stone in weight. She had a massive smile on her face and she said, ‘Oh my God, I’m never coming off this. This is transformational. I’m so happy. I’m looking at a job now. I’ve now started dating someone. I cannot thank you enough.’ And my shoulders just probably went down about a foot because I thought, ‘This is what medicine is about actually.’ This is not textbook medicine. This is a bit risky medicine, but actually it’s about patient centered medicine. And you know, I’ve learnt so much since that lady first came to see me, and I’m now very grateful for her teaching me actually how I can push boundaries a little bit and listen to the patients.

Avrum Bluming [00:25:27] As you know, I’m a medical oncologist, so I am the doctor who was responsible for catapulting many women into menopause. I used chemotherapy that can induce menopause in many of the premenopausal women I saw. And when the women would complain to me, I would say, ‘Well, you’re well, you’re alive and you know, basically deal with it. And I had to learn to listen to these women. I’m also a physician who counselled pregnant women who came to me with breast cancer that they get an abortion because if estrogen is bad, we thought the pregnancy while you have breast cancer is terrible. And many women followed my advice, and we now know that that’s not true, that pregnancy does not adversely affect the prognosis of breast cancer. So like you, I’ve been learning carefully, trying very carefully not to overstep what I know, but sharing what I know both with peers like you and with the patients who come to me for advice.

Dr Louise Newson [00:26:44] Which is pivotal. I remember a while ago you said to me really, ‘You know, as healthcare professionals we’re here as advocates for our patients’ and I really strongly feel, not just in women who’ve had breast cancer, of course not, with every single patient I see it is crucial that they are put number one, and every consultation I have is different. And every need of a woman or a person is different as well, and their expectations are different. And we now as you know, have a lot of physicians that work with us in the clinic and a lot of them are very scared and nervous about seeing their first breast cancer patient. And actually a lot of women just come because they want to talk. They don’t want to go away with a gel or whatever. They just want to know that there are options available to them actually and the door is open to them. And I think that’s really crucial, as well isn’t it?

Avrum Bluming [00:27:32] Perfect, I couldn’t agree more.

Dr Louise Newson [00:27:34] So we need to do more work in this area don’t we Avrum? We really need to do a really good study and I think women would really love to do it actually, because they want to help others. And that’s something that I’m hearing more and more actually. Women who are suffering, don’t want others to suffer. But I think there’s a lot of women who would be really keen to be in a study that we need to initiate something don’t we?

Avrum Bluming [00:27:56] As you and I have discussed, where do we go from here? You and I agree. And there are many people out there, still the majority of practising physicians who don’t agree. And so what do we do when you say the word study? Obviously, the gold standard for study is a prospective, double blind, randomised trial, which means we have placebo pills or placebo gel. We have medicine, and women are randomised to receive either the controlled placebo or the gel. That is never going to work.

Avrum Bluming [00:28:34] We have 25 studies. At least three of them did that. And that’s just not going to be repeated. We have all the information we’re going to get. I can critique every study that’s been done. But if 24 of the 25 show no increased risk of recurrence and no study shows an increased risk of metastatic recurrence and no study shows an increased risk of death. Perhaps we can follow a less strict study, for example. Yes, women want to go on hormones, but we shouldn’t just do it in an uncontrolled way. Let us follow all women who were put on this treatment after breast cancer. We should be able to amass huge numbers of women, even if it isn’t controlled. We have very good control data. We know the prognosis of women at each stage of breast cancer, how they’re going to do based on their treatment and the characteristics of their tumour. And we can compare the outcome with the women who we follow. And what’s required is an informed consent form so that your colleagues who are concerned about medico-legal ramifications of giving hormones can share the risk with their patients and protect themselves legally. And it also requires some form that can be used that is relatively simple but will allow follow up of these patients on hormones, so they’re not simply lost to follow up. And that way, we can at least get more information while providing the service that you and I and many other people around the world are straining to do as effectively as possible.

Dr Louise Newson [00:30:34] Yeah, and certainly that’s something we’re going to work on. Avrum very kindly is part of our advisory board for the Menopause Society that we have just set up through my not-for-profit. And we have some amazing people, but we’re having a steering group to go forward in this, and I’m hoping over the next few years we’ll have a lot more to report back.

Avrum Bluming [00:30:54] Wouldn’t that be nice.

Dr Louise Newson [00:30:55] Wouldn’t it be nice! We’ve got to start somewhere and I’m very keen to really work and we’ve got some amazing people, actually, but obviously you’re on this group, but we’ve got a breast surgeon, we’ve got a few other oncologists, we’ve got oncology nurse and actually we’ve got some other menopause specialists. But crucially, we’ve got a patient. One of my patients is coming on the group as well, who has had breast cancer and has fought to actually keep her HRT going, and she was suicidal without her HRT. So we need to learn from women as well. That’s really important with any research we do.

Avrum Bluming [00:31:28] And you and I aren’t holding hands in the wilderness, Louise. There are physicians around the world who feel as we do, even though they’re outnumbered, many of them, highly respected physicians in their own countries and in their field, both primary care physicians, breast cancer surgeons, medical oncologists, who really want to see this happen.

Dr Louise Newson [00:31:56] Yeah, absolutely. And we make it happen because we’re not going to stop. So I’m very grateful for your time today Avrum. Before we end, I always do three take-home tips and so you can’t be excluded from me asking those. And I know what’s going to happen. We’ll put out this podcast and women will contact you or me, or they’ll put out on social media to say, ‘But that’s easy for you to say that I don’t know how to get help. What should I do?’ So are there three things that you would suggest that women who have had breast cancer in the past who just want to explore options, including HRT, what they could do?

Avrum Bluming [00:32:29] Well, first speak to your medical oncologist. Second, I told you, I’m writing this article, which will be published in The Cancer Journal in the May-June edition of this year. And anyone who wants a copy of that article can contact you or me.

Dr Louise Newson [00:32:47] Yeah, we’ll put it up. We’ll put it out. As soon as it’s out, we can circulate it.

Avrum Bluming [00:32:51] And bring it to your physician. And if your physician disagrees, instead of just dismissing you, discuss the disagreement, what is the concern? And both you and I are available not to give specific advice over the phone, but to provide whatever additional information any patient or physician wishes.

Avrum Bluming [00:33:14] As you know, I published a book three years ago called Oestrogen Matters, and I really wasn’t going to plug the book, but I can’t not do that.

Dr Louise Newson [00:33:24] Aw you have to!

Avrum Bluming [00:33:24] .. with that question. Oestrogen Matters was written both for the lay audience and for medical practitioners. It is heavily referenced so that you don’t take my word for it. Everything that’s stated in that book, which talks about the benefits and downsides of hormones, including a chapter on HRT for breast cancer survivors, is referenced so that it can be challenged. And since it was published three years ago, and this is something my parents would get pleasure from, and sadly, neither of them are alive, but I mention it just because it gives me some pleasure. Amazon rates books by how well they are selling, and they rate 8 million books an hour. They follow 8 million books, and they re-rate them every hour. And for the past three years since this was published, Oestrogen Matters has been rated in the top one half of 1% of the eight million books that Amazon carries, which means that people are reading it. Doctors and patients and we get calls from around the world asking for more information, which we gladly supply. And one of our major information resources, Louise, is your website and obviously the information you post. And I have to mention that if I were to write the book alone, it would be very informative and heavily referenced and very dry and probably boring. And fortunately, I had a co-author, Carol Tavris, a social psychologist who is a rocket, and Carol makes the book so easy to read, even funny in places. And so it’s called Oestrogen Matters. It’s published by Little Brown.

Dr Louise Newson [00:35:26] Yeah, and we’ll put a link to it in the notes at the end. And certainly we recommend – well most of our patients have read it – and we now get to the stage where we recommend it, certainly to our patients who have had breast cancer, and they look and they say, ‘Don’t worry, I’ve already read it.’ Whereas just around the time it came out, obviously they hadn’t heard of it. So it’s our Bible and it’s just fantastic for everyone. And so I’m very grateful for your time today Avrum, and I hope I can invite you back with some more news and updates as to what we’re getting up to behind the scenes. So thanks very much.

Avrum Bluming [00:35:53] It would be my pleasure.

Dr Louise Newson [00:35:55] Thank you.

Avrum Bluming [00:35:56] Take care.

Dr Louise Newson [00:35:59] For more information about the perimenopause and menopause, please visit my website balance-menopause.com or you can download the free Balance app, which is available to download from the App Store or from Google Play.

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