Breast Cancer and Menopause: Risks & Symptoms

Hormone replacement therapy (HRT) is an effective way to manage the symptoms of menopause. However, if you have a history of cancer, you may feel left out of the menopause conversation, particularly if you have been told that you cannot take HRT. You may also be ready to explore treatment options, but be worried about the risks of taking hormone-based medications.

The good news is that overall, HRT is safe to use, with the caveats that the client’s risks are assessed and optimal breast screening is recommended. For those who have had breast cancer, you may be able to use HRT under specialist guidance. If you can’t, there are alternative options available to you, which include optimising nutrition and lifestyle, non-hormonal medication, and complementary therapies.

A word from the founder of Menopause Care: “Please be reassured that - whatever the course of action – you will be supported along the way to making your own, informed decision.” – Dr Naomi Potter.

Menopause and breast cancer

HRT does slightly increase the risk of breast cancer, ovarian cancer, and sometimes, womb cancer. However, the association is moderately higher when using combined oestrogen and progesterone. Proportionately, there are lower risks for oestrogen-only HRT. There is no clear excess risk at 5 years after stopping HRT, if use is less than 5 years. In most instances, the benefits in relation to managing menopause symptoms far outweigh the minimal risks.

The risk of cancer from using HRT depends on several factors, including:

The type of HRT used
How long you take HRT for
Your age, which is a key factor
Your general health and medical history
Your detailed family history that includes types of cancers: breast, ovary, uterine, pancreas, prostate, thyroid, and colon
Understanding one’s individual breast cancer risks is important to inform decisions at any age.
Risk of breast cancer algorithms are used to inform specialist referrals to consultant geneticists, and guide consultant breast specialists in recommending personalised breast screening.

The risks explained

The relationship between HRT and cancer risk is complex and depends on several factors. Although small, the risk of cancer is slightly elevated with HRT, and it’s understandable if you want to understand the risks of this medication before you decide whether to start taking it.

The type of HRT used

There are different forms of HRT designed to replenish or balance out falling or fluctuating levels of oestrogen and progesterone. Some women will be prescribed oestrogen-only HRT, while others will be recommended a combined regimen of oestrogen and progesterone. There are also different forms of HRT, including tablets (progesterone, such as Utrogestan), patches (e.g., Estradot, Evorel), gel (Oestrogel, Sandrena), spray (e.g,. Lenzetto), pessaries, cream, and vaginal rings. The type of HRT medication and the way it is delivered to the body make a difference in the risk of cancer it creates:

Combined HRT (oestrogen and progesterone): This type of HRT can increase the risk of breast cancer, particularly with long-term use, defined as 5 to 10 years. However, the risk decreases after stopping HRT, but may persist for up to 10 years following cessation of HRT.
Oestrogen-only HRT: This is usually prescribed for women who have had a hysterectomy and is associated with a significantly lower risk of breast cancer (1 extra cancer in 100 users) compared to combined HRT from 50 years of age taken for 10 years (1 extra cancer in 25 to 30 users). However, it may slightly increase the risk of endometrial (uterine) cancer in women who still have a uterus.

NOTE: These specific risks relate to studies using synthetic types of HRT, dating from 1995 and 2005, respectively. The risks of using bio-identical or “modern” types of HRT are likely to be lower, although the evidence is evolving.

Localised (low dose) HRT: Vaginal creams, rings, or tablets used to relieve symptoms like dryness and discomfort tend to have minimal effects and don’t carry the same cancer risks as orally ingested HRT.

How long do you take HRT for

Generally, the risk of cancer, particularly breast cancer, increases with the duration of HRT use. Studies suggest that using combined HRT for more than five years may lead to a slightly higher risk, while shorter-term use under 5 years carries lower risks.

Your age

Starting HRT before or around the time of menopause (typically between 45 and 55 years of age) can have notable health benefits, such as reducing the risk of cardiovascular disease and osteoporosis. A detailed review of 13 studies showed that combined HRT use in women under 55 years may increase breast cancer risks by 18%, but it is important to note that these risks relate to historical studies (1995 to 2005) that are not comparable to the current use of “modern” or bio-identical HRT, and in particula,r safer forms of progesterone.

However, beginning HRT after age 60 may carry higher risks, especially for heart disease, stroke, and certain cancers. This is why it’s generally not recommended to start or continue taking HRT later in life unless there are compelling reasons.

Your general health and medical history

If you or a close family member has a history of breast, ovarian, or endometrial cancer, your doctor will carefully assess whether HRT is suitable. HRT may not be recommended in such cases due to potential increased risks.

Smoking, obesity, and lack of physical activity can also affect the risk of cancer and other serious side effects, with or without HRT. Maintaining a healthy lifestyle can help mitigate some of these risks.

Other conditions, like blood clots or heart disease may also affect whether HRT suits you. For some women, the benefits of symptom relief may outweigh the risks, while others may be advised against it.

HRT and breast cancer

HRT can slightly increase the risk of breast cancer. According to the NHS, in every 1000 women who take combined HRT for five years, there are around five extra cases of breast cancer. The risk increases the longer HRT is taken, but decreases once stopped.

This can make managing the symptoms of menopause and breast cancer more challengin,g given that HRT can increase the chance of breast cancer returning. That’s why if you have had breast cancer, you may be advised against taking it.

However, there are non-hormonal medications that can help manage the most common menopause symptoms. Hot flushes, for example, can be alleviated with Clonidine, Gabapentin, or Venlafaxine, including consideration of the newly approved drug called Fezolinetant (Veoza) that is non-hormonal and works by blocking brain receptors that control flushing. Vaginal dryness can be improved using vaginal moisturisers and lubricants.

HRT and ovarian cancer

Oestrogen-only and combined HRT can also increase the risk of ovarian cancer, particularly the two most common forms: serous and endometrioid. Again, the risk is small. It is thought that only 1% of all ovarian cancer cases are caused by HRT. An analysis of more than 50 studies found that women who took oestrogen and progestin (progesterone) after menopause did have an increased risk of getting ovarian cancer. However, when this risk was put into numbers, it equated to one extra case of ovarian cancer occurring in every 1000 women over 50 years of age, by using HRT for five years. As with breast cancer, the risk is reduced when HRT is stopped.

Oestrogen-only HRT can increase the risk of endometrial (womb) cancer, with the risk becoming greater the longer the medication is used. This is why in most cases, this type of HRT is only recommended for women who have had a hysterectomy.

Can you take HRT if you have a family history of cancer?

Having a family history of cancer doesn’t automatically mean you can’t take HRT, but it does require careful consideration and consultation. If you have a family history of cancer, whether or not you can take HRT usually depends on several factors, including the type of cancer involved, the specifics of your family history, and your personal health.

A family history of breast cancer, especially if it involves close female relatives (like your mother or sister), is an important point when deciding on HRT. Research suggests that combined HRT can slightly increase the risk of breast cancer; however, a woman’s lifetime risk of developing breast cancer is 1 in 7, which is determined by one’s population genetics (like shuffling a pack of cards), and other factors as described, regardless of whether one takes HRT or not.

If your family history suggests a specific genetic predisposition to breast cancer, such as BRCA1 or BRCA2 mutations (direct inheritance of a specific gene), but you have not had breast cancer and are going through early menopause, the Royal College of Obstetricians and Gynaecologists advise on taking HRT until the natural age of menopause. This is because HRT medication can help minimise the risks linked to early menopause. If you have a history of breast cancer, then whether HRT is the best form of treatment is decided on a case-by-case basis.

A family history of cancers like colon or lung cancer is less likely to influence HRT decisions directly, as these types of cancers are not as closely linked to hormone replacement therapy. However, if you have a genetic syndrome that increases your risk for multiple cancers, such as Lynch syndrome (CHEK2 mutation), your doctor will evaluate whether HRT is right for you.

Can you take HRT if you have previously had cancer?

Whether you can take HRT if you’ve previously had cancer will depend largely on what type of cancer you had. If you’ve had breast cancer, for example, you’ll usually be advised not to take HRT as it can increase the risk of recurrence. However, these risks are contingent on the clinical and pathological stage within a spectrum of risks. Drugs that block post-menopausal oestrogen production, called aromatase inhibitor,s are a contraindication to HRT use. In premenopausal high-risk breast cancers, suppression of ovarian function to induce menopause is also a contraindication to HRT use.

Fortunately, there are effective alternative therapies for menopause.

Ultimately, the decision to take HRT requires a highly individualised approach. Your healthcare provider will assess:

Any specific types of cancer in your family history
Whether you have any genetic predispositions, assessed using a blood test or a mucosal sample at a specialist genetics centre
The severity of your menopausal symptoms and how they impact your quality of life
Your general health, lifestyle, and any other risk factors

Seeking support for menopause after breast cancer

Knowing which doctor to consult for menopause can be invaluable in deciding how best to treat your menopause symptoms and whether HRT is right for you. At Menopause Care, we have a team of highly experienced menopause doctors and nurses who can talk you through your options and develop a personalised treatment plan based on your unique circumstances.

If you’d like help during this transitional life stage to focus on your well-being, book a consultation with a menopause doctor. We work closely with Consultant Breast Specialists and one-stop breast clinics.

DisclaimerAt Menopause Care, we ensure that everything you read in our blog is medically reviewed and approved. However, the information provided is not meant to replace professional medical advice, diagnosis, or treatment. It should not be relied upon for specific medical advice.

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