Can you have HRT after breast cancer?
And what should you do when doctors disagree?
The question of whether or not a woman can or should choose to have hormone replacement therapy after breast cancer is a controversial one, often fraught with conflicting medical advice.
This week, I was invited back on to Dani Binnington’s Menopause & Cancer podcast, which I’ve been on before to talk about my other favourite subject, mindful drinking. If you’re not familiar, this podcast is an indispensable resource for any woman thrown into early menopause by cancer treatment, and I’ve learned so much from it.
First, the facts: if your cancer is oestrogen-fed (or ER+), then HRT will increase your risk of recurrence and is unlikely to be recommended.
Around 75% of breast cancers in women are ER+, so that is the majority of cases.
However, it does leave 25% of women in more of a grey area.
HRT will always increase your risk, because cancer cells can mutate, so there is a chance that a non-oestrogen-fed cancer could change and become oestrogen-fed.
However, this chance is small, and sometimes there are other factors to consider.
Before I get into those, I should explain that my own experience of this is not something that I’ve talked about publicly before. I know that many women feel very strongly one way or the other, and I would hate for anyone to think that I’m saying the choice I’ve made is the right choice for anyone else.
Everyone is different. Every breast cancer diagnosis is different. And every woman’s experience of menopause is different.
But, since I talked about it with Dani on the podcast, I thought I’d explain it here, too…
The first thing to say is that I’m not one of those people who thinks I know better than the doctors. I’m a “good” patient: I trust in science and I do what I’m told. The difficulty arises when different doctors are telling me different things.
I was 40 when I began 16 rounds of chemotherapy over five months. My periods stopped instantly and, although I waited a year after treatment to see if my ovaries would recover, blood tests showed that my oestrogen levels were “on the floor” and I was, indeed, in early menopause.
Since my diagnosis was triple negative (ie. not oestrogen-driven), I asked my oncologist if I could have HRT. “No,” she said, “because if it comes back, it could be the other type.” That was all I needed to hear - I did not want to do anything to increase my risk of recurrence. As far as I was concerned, that was it, case closed.
However, a year after that, I had an appointment with a surgeon who wasn’t my usual surgeon. Looking through my notes, he said, almost absent-mindedly: “I assume you’re on HRT?”
Wait, what? “Obviously not,” I replied. “I’ve had breast cancer.”
I relayed what my oncologist had said about cells mutating, and he said that the risk of that is small. The further on you are from treatment, it becomes vanishingly small.
He explained that HRT can negate the impact of early menopause on the long-term health of the brain, heart and bones. The latter two of these were of particular interest to me, since my dad had just had heart surgery and I’ve already been diagnosed with early-onset osteoporosis.
He said that HRT should be prescribed after breast cancer if the following apply:
Your diagnosis is not ER+ ✔️
You’re under 45 ✔️
You’re at least two years clear of treatment ✔️
He recommended I have HRT only until I’m 51; the average age at which women go through menopause. Then it’s simply replacing the oestrogen that my body would naturally have had, had chemo not extinguished my ovaries at the age of 40.
Of course, that conversation was not the end of the story. He said to ask my GP to prescribe it, but they wouldn’t do that without hearing it from my oncologist, and my oncologist wanted me to be referred to the menopause clinic first - so there were still several hurdles to cross.
My point is: knowledge is power.
It’s why I will continue to share all of the latest evidence-based information that I can. For example, this week Jen Gunter has done a brilliant précis of what she learned at the 2024 Menopause Society meeting in Chicago.
And there is a lot that you can do to support your body through early menopause without HRT, which I’ve written about before.
One question that Dani asked during the podcast interview threw me: what would I say to anyone who has been given conflicting advice by different doctors?
The question brought back the feelings of overwhelm, uncertainty and vulnerability. I remembered feeling panicky and paralysed: if they couldn’t agree on this, then how the hell was I supposed to know what to do??
But Dani’s brilliantly calm, practical tip was simple: just focus on the next thing.
To quell those feelings of overwhelm, think only of the next conversation, the next bit of research, the next question to ask, the next oncologist appointment.
Another thing I’ve found extremely useful is this question: “What would you do, if you were me?”
When I’ve asked that of female doctors, I can see them shifting from the detached attitude of giving me the facts and waiting for my choice, to a more empathetic place of thinking what it would actually be like to be sitting in the patient’s chair.
When I asked this question of my oncologist, having explained to her what the surgeon had told me, she said something unexpected: “I hadn’t looked at it like this before.”
She explained that, as an oncologist, she’s so laser-focused on cancer that she hadn’t considered the overall impact of HRT on the long-term health of my heart, brain and bones. She agreed that the benefits would now appear to outweigh the risks.
If she was in my place, she said, she’d have the HRT.
So, yes, I have HRT after breast cancer. But it took time to reach that decision, and I’d advise anyone in the same boat to examine all of their options before making their own choice.
If you’re anything like me, you probably want someone with medical training to just tell you what is the best thing to do. But ultimately, it boils down to your decision, which can be extremely stressful.
I know women with the same diagnosis as me, who have chosen not to have HRT because they feel that their fear of recurrence outweighs any benefits.
Similarly, I know women who’ve had ER+ breast cancer but chose to have HRT despite the risks, because their menopausal symptoms were so debilitating.
No one should be judged for their choice, because the only way we can learn more about this is to talk about it openly - and feeling judged does not lead to open discussion.
This week I’m…
Watching Ruth Wilson and Michael Sheen face off as Emily Maitlis and Prince Andrew in A Very Royal Scandal on Prime Video.
Enjoying Gen Z’s dedication to the perfect night’s sleep (while I’m barely scraping my 7 hours)
Cooking from Dr Linia Patel’s Food for Menopause. She had me at ‘feta fried eggs’.
Well done for tackling this one, Ros. It’s really the elephant in the room as far as oncologists and breast surgeons are concerned. If I could take HRT again (I’m ER+ PR +) I’d be on it like a rat up a drainpipe. Asking the medics what they’d do if they were you is a powerful question, and one we should all employ. I used it when talking about Tamoxifen with my oncologist. One day I’ll tell you what she said. 😘
This is such an important and timely issue within the breast cancer community. Thank you for speaking so openly about your experience, Ros. I was diagnosed at 29 and have been in early menopause ever since. I've been on hormone suppression and have already developed osteopenia. I've actually just hit my five-year mark and been allowed to stop the medication, so I'm dearly hoping I'll come out of menopause, as I'd love to start a family. I do worry about my health in later life, though, especially my bones. Plus, now I know how awful menopause symptoms can be to manage! I don't relish the thought of going through it all again one day. Although, on the flip side, if I live long enough to experience menopause once more, I'll be very happy :)