Menopause has been getting some long overdue attention lately, focusing on evolving recommendations for hormone replacement therapy (HRT). Why is VBCF talking about menopause? A few good reasons: the risk for breast cancer increases after menopause; the use of HRT has long been connected with increased risk of breast cancer; and many people in treatment for breast cancer are thrust into early menopause or temporary menopause due to hormone-suppressing medications. We’ll break the menopause conversation down for you and give you some background on menopause, what led to the fear around HRT in the early 2000s, and how recommendations are evolving.
The medical definition of menopause is “the permanent cessation of menstrual cycles following the loss of ovarian follicular activity.”1 In English, that means that menstrual cycles stop because eggs are no longer maturing or being released from the ovaries. If there is no potential for a pregnancy, the body doesn’t have to prepare the uterine lining for implantation, and if there is no lining, then there is no need to shed it through menstruation. Someone can enter menopause naturally, just over the course of time, or can enter “secondary” menopause due to surgical removal of the ovaries/uterus or medical suppression of the ovaries.
Someone has officially entered menopause if they have gone one full year without a menstrual period. However, we culturally view menopause to include the perimenopause period, meaning the time when hormones start to fluctuate and can cause a variety of symptoms of differing degrees. Symptoms of menopause or perimenopause can include hot flashes, difficulty sleeping, fatigue, weight gain, brain fog, etc.2 And these are just the symptoms that people can feel and experience, there are also underlying effects on the heart that may be hidden.
The main culprit for these symptoms is the drop in levels of estrogen, which is why hormone-suppressing medication can cause symptoms and why hormone replacement therapy was historically and is now potentially considered as a way to treat the symptoms. One might ask “why are we considering medicating a natural process?” And the short answer is that sometimes symptoms are so severe that they impact a person’s life. Similar to how monthly menstrual cycles can vary from person to person in the presence and severity of symptoms, menopause behaves in the same way.3 Some people may take pain medication or sit with a heating pad for a day or two during their cycle, and some people have symptoms so severe they can’t go to work for a few days out of the month. Menopause symptoms can have a similar impact, from negligible to annoying to debilitating.
One major reason that doctors first started considering HRT, giving people in perimenopause low levels of estrogen, was to protect heart and bone health. This is why the landmark Women’s Health Initiative Study (WHI) began researching HRT in 1993. However, this study was stopped early and abruptly in 2002 due to an observed increase in breast cancer diagnoses and other negative health effects among the participants. This led to fewer and fewer women receiving treatment for severe menopausal symptoms and essentially being forced to suffer in silence or turn to herbal remedies with mixed success and little scientific evidence. So why are we talking about HRT again if a major study demonstrated serious risks? After the study was halted, other researchers picked up the question and changed the study design to determine the results. Numerous researchers have now found that women between the ages of 50-59, right in the average age for symptom onset, can get relief from their symptoms with minimal negative health impacts. WHI included many women over the age of 60, likely skewing the overall results and painting the effects of HRT with too broad a brush.4
With research over the past twenty years, we have learned that HRT can be valuable to people experiencing menopause, but like with most medications, it isn’t for everyone. For example, if you have a personal history of breast cancer HRT is likely not a good option. An HRT regimen will also likely affect you differently depending on whether you went through natural menopause or surgical menopause. If you want to talk to your provider about HRT, plan to share a detailed description of your menopause symptoms and your personal and family health history for a risk-benefit analysis. Are the potential benefits to your day-to-day life worth a slight increase in risk for certain cancers, including breast cancer, or heart disease? For people without those diseases in their personal or family history, it might be worth it. For others with a history of certain diseases, maybe not. The takeaway is, due to continuing and evolving research, there is again an evidence-based option to treat severe menopause symptoms that people can consider in consultation with their provider. VBCF urges people experiencing menopausal symptoms to talk to their provider about ways they treat their symptoms, whether it is HRT or other evidence-based options, because no one should suffer in silence.
To find a doctor certified by the North American Menopause Society, visit menopause.org.
For additional reading, check out this article from Breastcancer.org and one from UVA Health.
