Hormone Therapy and Breast Cancer Risk

If you’re looking for relief from menopause symptoms like hot flashes, you’ve probably heard about menopausal hormone therapy (MHT), formerly known as hormone replacement therapy (HRT). MHT has numerous benefits, but what about the risks? Let’s dive into the research and see if MHT could be a good choice for you.

What is Menopausal Hormone Therapy?

During the menopause transition, your sex hormone levels drop, eventually leaving you with permanently low estrogen and progesterone levels. These hormone changes bring with them a multitude of unpleasant symptoms such as fatigue, hot flashes, weight gain, brain fog, vaginal dryness, and depression. Some of the changes can even be dangerous for your physical health, such as declining bone mass and losing elasticity in your blood vessels.

MHT refers to the use of supplemental hormones for women in perimenopause and menopause. The hormones that are prescribed depend on whether or not a woman has had a hysterectomy (surgical removal of the uterus).

Those who still have their uterus take combined estrogen and progesterone, while those who have had a hysterectomy are prescribed only estrogen.

Research has consistently shown that MHT is effective at treating hot flashes, night sweats, vaginal dryness and protecting against osteoporosis. It can be taken orally or applied to the skin via patches, gels and creams.

MHT and Breast Cancer

MHT offers many benefits, but also presents some risks. Although research findings have been mixed, most experts agree that combined progesterone/estrogen hormone therapy slightly increase the risk of developing breast cancer when taken for more than seven years. Estrogen-only therapy does not seem to significantly impact the incidence of breast cancer.

Understanding the Risks of MHT

So is MHT safe for you? This is not a simple question with a definite answer. Like most choices about your health, it comes down to the balance between benefits and potential risks. Numerous factors determine your potential risk.

Variables such as when you begin taking MHT, how long you take it, what kind you take, your age and your health history all need to be considered. Many factors outside of taking MHT also contribute to your breast cancer risk, including genetics and lifestyle factors such as diet and exercise.

Experts agree that based on current research, MHT is not recommended for most people who have had breast cancer as it appears that the risk of cancer recurrence is increased. If you have previously experienced blood clots, stroke, cardiovascular disease, or have a strong family history of breast cancer, MHT may also not be the best treatment for you.

You and your care provider will need to assess your unique health history and individual risks to determine if the benefits of MHT outweigh them. There is no one-size-fits-all answer when it comes to MHT.

If you’re looking to learn more and get support around MHT, request a virtual or in-person appointment with a Mayo Clinic menopause specialist.

Your Midday menopause coach is another great resource for learning more and having a conversation about your options. Reach your coach through the Midday website.

Alternatives to Hormone Therapy

If you decide that you aren’t comfortable taking MHT or have pre-existing conditions that prevent you from taking it, don’t be discouraged. Depending on the symptom you are trying to treat, you may have other effective options.

Vaginal Estrogen

Estrogen applied vaginally in cream, tablet, or ring form is effective for treating vaginal dryness and painful sex that come with menopause. Research shows it is a safe and effective therapy with no known systemic effects — the estrogen is local instead of being absorbed into the body like MHT.

Non-Hormonal Prescription Options

If you are not a good candidate for MHT, or if you prefer to avoid hormonal therapies, you have a few non-hormonal options. These medications have been shown to reduce the frequency and severity of hot flashes.

The FDA-approved non-hormonal medications to manage hot flashes:

• Fezolinetant (brand name Veozah). This is the newest FDA-approved non-hormonal medication to treat hot flashes. It’s a once a day oral medication that has been shown to reduce frequency and severity of hot flashes. Fezolinetant is not appropriate for those with kidney or liver disease. Users are advised to undergo regular liver function testing while taking the medication.
• Paroxetine (brand name Brisdelle). A selective serotonin reuptake inhibitor (SSRI) also used to treat depression

Sometimes prescribed but not FDA-approved to manage hot flashes:

• Gabapentin (brand name Neurontin). A drug for chronic nerve pain
• Clonidine (brand name Catapres). A blood pressure drug

Holistic Strategies

Gold standard alternative therapies for managing hot flashes include Cognitive Behavioral Therapy (CBT) and Hypnotherapy. These therapeutic options can yield results similar to MHT.

Other options like acupuncture, yoga, mindfulness, meditation, and self-guided hypnosis have mixed evidence but are generally considered safe with minimal risk. They may also offer other benefits, including lowering stress and anxiety, which may have a beneficial effect on sleep, hot flashes, and mood swings.

Don’t disregard the power of lifestyle changes to help you manage symptoms. Hot flashes, sleep disturbance, and mood swings can be triggered by what you eat and drink, stress and anxiety, and sleep habits.

You can track your hot flashes and triggers with the Midday app and get an analysis of your top triggers with personalized support. Tap on the yellow (+) button on the bottom navigation bar and start logging your hot flashes. Even a few days of tracking can provide insights to put you on the path to hot flash relief.

Safely Discontinuing Hormone Therapy

Until recently, women were encouraged to stop MHT after five years of taking it or at age 60. However, a 2017 research study showed no increase in all-cause mortality for women who took MHT longer than five years.

The North American Menopause Society (NAMS) has since updated its recommendations to state that women should not automatically be taken off of MHT at a certain age if they continue to have menopause symptoms.

If you do want or need to stop taking MHT, discuss the best strategy with your healthcare provider. Rather than stopping abruptly, your provider may lower your dose slowly and monitor for a recurrence of symptoms.

Questions to Ask Your Provider About Hormone Therapy

• Am I a good candidate for MHT based on my health history and my family history?
• Will MHT improve all of my menopause symptoms?
• What can I do to minimize my risk of cancer, heart disease, and osteoporosis in menopause?
• What’s the safest treatment option for me?
• Are bioidentical hormones safer than synthetic hormones?
• What other options can you recommend to me for symptom management?

Conclusion

Whether to take MHT or not is a complicated question, and there is no easy answer. In 2022, NAMS updated its position statement regarding MHT, calling it “the most effective treatment for vasomotor symptoms” (hot flashes and night sweats) in menopause but explicitly stated that treatment with MHT needs “periodic reevaluation.”

Use the tools in Midday to educate yourself and access support for decisions about your health. Work closely with your healthcare provider to ensure you are getting the most appropriate support for your menopause symptoms.