Daily Mail - 30.08.2019

Page 7

ST FOR 15 YEARS

Daily Mail, Friday, August 30, 2019

F

or years I have been

telling my patients: ‘If I

was a woman with trou-

bling menopausal symp-

toms, I would take HrT

for at least five years.’ Does

this latest study change my

view? Absolutely not.

Day after day, patients tell me

how their lives are being dread-

fully affected by their menopau-

sal symptoms: they cannot sleep,

they cannot think straight, they

have no energy, their skin and

hair is brittle and dry, they are

finding it hard to cope at work

and home due to constant hot

flushes. Their sex life might be

suffering too.

These kinds of symptoms can put

them under enormous stress. In fact

I have seen women who are under

such stress because of the meno-

pause that they run the risk of devel-

oping an illness as a result – but a

study can’t factor in things like that.

So I think it would be a tragedy if

women decided not to try HrT

because of these findings.

That is not to say that the research

doesn’t raise interesting issues; it

does, and by involving 100,

women it is bringing together an

impressive amount of data.

Put bluntly, what it shows is that

at most two in every hundred women

who take HrT will develop breast

cancer as a result. The other 98 will

have had the benefit of an increased

quality of life, freed from the distress

of their menopausal symptoms, and

will not get cancer as a result.

It is a trade-off – and for many

women their symptoms are so dis-

tressing that they are prepared to

take the associated risks

What the study does not show is

the mortality rate of the breast can-

cer that HrT causes – that is to say

how many die as a result.

Because if you do develop breast

cancer, but can be cured, then that

is an important distinction.

Besides, there are ways you can

mitigate the risks – not least by tak-

ing the right type of HrT. I find it

distressing that many doctors con-

tinue to prescribe outdated forms

that leave women in increased dan-

ger when there are safer options.

HrT usually involves a combina-

tion of a form of oestrogen, which

works on the central nervous system

and improves symptoms such as

hot flushes, the texture of skin

and hair and increases the efficiency

of mitochondria in cells to help

improve energy.

It also improves memory and joint

health. However, taking oestrogen

alone can increase the risk of womb

cancer, which is why it is given in

combination with progestogen, a

synthetic form of progesterone. This

COMMENTARY

by Professor

Kefah Mokbel

hormone also helps with sleep qual-

ity, and can have other benefits such

as helping to reduce blood pressure.

The trouble is that when you take

oestrogen orally it travels through

the system and is broken down in

the liver into numerous byproducts

called metabolites – and it is these

that cause problems such as blood

clots, stroke and potentially breast

cancer. But if you have oestrogen in

patch form or gel then it goes

straight into the blood stream.

G

Iven this fact, I cannot

understand why doctors con-

tinue to give out HrT as a

pill. I favour taking a form of

oestrogen called estradiol as a patch

• although unfortunately some of
  these patches are out of stock or
  running low due to shortages. It is
  accompanied by natural progester-
  one taken orally on an intermittent
  basis, with a break each month as
  advised by your doctor. You cannot
  take it as a patch as well because
  there is no evidence that it is
  absorbed in sufficient quantities to
  reduce the risk of womb cancer when
  given this way.
  This is a more natural way of hav-
  ing HrT, and some studies find that

taking it this way does not increase

the risk of breast cancer at all.

The other way to modify the risks

of HrT is to take it for the shortest

time possible. This study has found

that the shorter the duration the

lower the risk of breast cancer.

It mentions that the risk of cancer

remains elevated for ten years after

you have stopped taking HrT, but

in fact this was already established.

And let’s not lose sight of how big

that risk is – the answer being, as

previously stated, still small.

If women experience no troubling

symptoms and find they can cope

with their menopause without medi-

cal assistance then all well and good.

But those who feel they do need help

should not be afraid to seek it.

At the moment I have a set of twins

as patients – one of them took HrT

and one didn’t. Both have ended up

with breast cancer and the only dif-

ference between their individual sit-

uations now is that the one who was

taking HrT looks years younger and

has had a much better quality of life

thus far.

The sad truth is some people will

develop cancer irrespective of their

lifestyle; nothing in life is without

risk. It’s the size of the risk com-

pared to the benefit that you always

have to weigh up. That is what

women need to remember.

n Professor Kefah Mokbel is chairman

of the multidisciplinary breast cancer

programme at the London Breast

Institute and a consultant oncoplastic

breast surgeon at the Princess Grace

Hospital in the capital.

Interview by Lucy Elkins

Crippling

symptoms:

Kirsty Lang

Q&A

Haven’t we heard this before?

In 00 and 003 two major studies

showed that HRT increased the risk of

cancer. In the following years prescriptions

for it plummeted.

But isn’t HRT back in favour?

The balance has swung back in favour of

HRT, with experts stressing the risk of

cancer is low. NHS watchdogs in 015 said

that doctors should explain the risks and

allow women to decide.

What has happened now?

Yesterday the Oxford academics behind

the 00 study reviewed the evidence –

using data from 58 studies involving 100,

women. They said the results vindicated

their findings and even showed the cancer

risk persists for longer than thought.

How big is the danger?

A woman who takes HRT for five years has

a risk of breast cancer about a third

greater than a woman who doesn’t. But in

absolute terms, the risk is small – the vast

majority will never get cancer. For every

100 women who take HRT, eight will get

breast cancer rather than six. Drinking

alcohol or being obese are equivalently

risky. Smoking, however, carries a vastly

bigger breast cancer risk.

Should all women avoid HRT?

Experts stress that it is a personal decision.

The impact of the menopause can be very

severe and HRT is a lifeline for many. But

the cancer risk – although relatively small

• is real. Women should talk to their GP
  about these pros and cons and make an
  informed decision.

How can I minimise my risk?

Use as small a dose as possible, for as short

a time as possible. The longer the duration

of use, the greater the cancer risk. The

danger is doubled for women who use HRT

for ten years instead of five. And there is no

increase in risk for less than a year’s use.

The latest Oxford study showed that

oestrogen-only HRT carries a smaller

danger than combined HRT. And a combined

treatment that has intermittent

progesterone, rather than daily

progesterone, is safer still. HRT vaginal gel

treatments carry no greater risk because

they do not enter the bloodstream.

ONCOPLASTIC BREAST SURGEON

Yes, there

are risks...

but I’d still

prescribe it