HRT is a lifeline for many menopausal women but what are your options if that is taken away after a breast cancer diagnosis? Here, one survivor shares her experience and advice, as does a breast cancer doctor who's had the disease

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“In Spring 2022, after the routine three-year mammogram visit, I was diagnosed with stage 1 tubular breast cancer,” says Mars Webb, a successful PR consultant.

“It’s a type of invasive cancer that grows in the milk ducts but doesn’t present itself as a lump or thickening – so I hadn’t felt anything at all before my diagnosis came in.

“At the time, I felt damn lucky. Three of my dearest friends had all undergone the full horrendous months of cancer treatment ranging from lumpectomies or mastectomies, to chemotherapy, radiation and hormone therapy. In comparison, I got off lightly with just a lumpectomy, radiotherapy and hormone treatment.

“Having worked in the field of health and wellness for over 20 years, I had access to amazing doctors and nutritionists who I could talk to, but the thing I didn’t bank on was how I would feel having to come off HRT. It was advised by my doctors because of my type of breast cancer, which was oestrogen recepter (ER) positive. It meant my cancer would be responsive to any oestrogen in my body, meaning I should not supplement it in any way.”

Image: Mars Webb

No two breast cancers are the same, which means no two treatment plans are either. How it is treated will depend on a range of factors including what stage it is picked up at (from 0-4), whether there a family history of it, your general health and what kind of cancer is it.

Why can’t women who have had breast cancer take HRT?

Liz O’ Riordan, a former consultant breast surgeon who has also had breast cancer twice explains: “Three-quarters of all breast cancers are hormone-sensitive and fuelled by oestrogen,” she days. “They can effectively be targeted with drugs like tamoxifen and letrozole which block the hormones from reaching cancer and reduce the risk of a future recurrence.”

The downside to these treatments, along with chemotherapy, is that if you haven’t reached menopause yet, they can trigger early menopause. If you are already menopausal like Mars, have an oestrogen-driven tumour and you are taking HRT, the advice is to stop the HRT. And this can be far from easy.

“I’d been on Femoston HRT for seven years, since the age of 47,” says Mars. “I had wanted to manage my menopause naturally, but after a year of trying various supplements for menopause - black cohosh, red clover, soy -  I was still left with the most awful hot flushes, horrendous fatigue, brain fog, low mood, anxiety and joint pain. It was hugely impacting on my life, with the hot flushes in particular affecting my sleep and confidence when I was in meetings or presentations. But when I went on HRT, I was back on my A-game within a month.”

Coming off HRT: what happened to me

“At my cancer diagnosis, I was given lots of leaflets about the importance of coming off HRT, but barely any advice about how to do it, apart from weaning yourself off it with progressively smaller doses. Maybe this sounds awful but I dreaded quitting the HRT more than the actual breast cancer. I was really worried about managing my career, life, marriage and confidence without the support of HRT - I'm the family’s main breadwinner, with the kids in university, and, like many people, was feeling financial pressures and the need to maintain my energy levels for work.

“The breast cancer surgery and radiotherapy were the relatively easy part, and they were successful. But the menopause symptoms started to come back as soon as I reduced my HRT dosage, with the hot flushes being easily the worst part. After the surgery, I was told by my oncologist to stop taking HRT altogether, which led to more than six months of hellish symptoms. And through it all, everyone - and I mean everyone - was suddenly talking about the menopause and championing the holy grail of HRT.”

The case for HRT after breast cancer

“Every day, I had to hear about how oestrogen replacement doesn’t just deal with menopausal symptoms, but minimises the risk of osteoporosis, Alzheimer’s, cardiovascular disease and diabetes and even keeps your skin in good nick. With all those important benefits, were there really no circumstances under which women recovering from breast cancer could take it, I wondered?

“I had had a very early type of breast cancer, no genetic history, I didn’t drink or smoke and my weight was normal and had always been. And I was aware of vocal doctors who indicated that some breast cancer survivors could indeed use HRT again.”

Menopause specialist Dr Louise Newson suggested on ITV’s This Morning in 2022 that for most cancers other than breast, HRT can be taken and that for breast cancer, things weren't clear cut.

With breast cancer, the approach is more careful, but it depended on the type of breast cancer and when you had it, she explained. “We haven't got good evidence to say it's safe. We haven't got good evidence to say it's dangerous. Most of the studies have been done show that it's either neutral or safe.”

It’s a complex issue and more research is needed. “Through my not-for-profit [organisation] we've got a whole steering committee of really eminent oncologists, radiotherapy, breast surgeons, breast nurses, patients and medical specialists trying to tease out what women can and can't have,” she said. “None of this is about yes or no options, it’s about choice.”

She released a full statement on HRT and breast cancer on her website and a video to explain the nuances of her view.

Around the time of Newson’s comments, a study from Odense University Hospital in Denmark suggested breast cancer survivors who’d been given HRT did not have an increased risk of recurrence - although the authors of the study, and other cancer experts, were quick to point out more research was needed.

The case against HRT after oestrogen-positive breast cancer

But for every argument in favour of using HRT post-breast cancer treatment, there is one against. Liz O’Riordan says, “I would dearly love it if HRT was an option, but it’s not. The majority of specialists advise against it for good reason. There are trials that show it can increase the risk of the cancer coming back,” she says.

She points to a meta-study from 2021 that concludes this. Meanwhile, the British Menopause Society, the Royal College of Obstetricians & Gynaecologists and the Society for Endocrinology have put out a statement saying that if a woman has had breast cancer, she should not be given HRT except in "exceptional cases".

It says: “A history of breast cancer should be considered a contraindication to systemic HRT. The risk of breast cancer recurrence with HRT is higher in women with oestrogen receptor-positive cancer, but women with oestrogen receptor-negative breast cancer are also considered to have an increased risk of recurrence with HRT. HRT may, in exceptional cases, be offered to women with breast cancer with severe menopausal symptoms if lifestyle modifications and non-hormonal treatment options are not effective. This should be done after discussion with the woman, her menopause specialist and her breast/oncology team.”

O’Riordan understands the dilemma and helplessness these women feel better than most, describing her own treatment-triggered menopausal symptoms as "excruciating". But for her, it’s outweighed by the other side of the coin: “I have looked after women who have died from the disease,” she says.

Embracing alternative treatments for menopause symptoms

So where did that leave Mars? “With the experts contradicting each other, I pushed on, trawling through books and websites but getting no definitive answers. In the end, I spoke to gynaecologist Ms Tania Adib with whom I had worked with for years and who I trusted. She, in a nice way, broke it to me that I was on a mission for someone to tell me that taking HRT was perfectly safe for me, because that’s what I wanted to hear. But, she said ,‘Right now, there just is no way of knowing whether it is’.”

Mars’ personal choice was to try to find a way to manage her symptoms without HRT.  “I found that devising an HRT-free, menopause-subduing routine is no picnic. My old staples of phytoestrogens such as red clover and hormone supplements such as DHEA help the body naturally make oestrogen, so are no longer allowed. Even collagen supplements are a matter for debate right now, although plant oestrogen-rich foods like soy do get the green light.

“Still, I had options, and I’ve outlined them below. These are the things I will stick to in the foreseeable future to give me a quality of life that is hopefully as good as it can be, but I am not going to rule out not going back on HRT.”

Mars' personal HRT-free way to manage menopause after breast cancer

  • Vaginal oestrogen
    "One chink of HRT hope Miss Adib gave me was that I could take vaginal oestrogen, which she prescribed for me. It’s non systemic, meaning it doesn’t absorb into the bloodstream and is not linked to breast cancer. It helps prevent vaginal dryness and painful sex.
  • Exercise
    An inspiring friend told me to get strong and now I do a mixture of weights (twice a week), running (about 5k every other day) and Pilates once a week – I’d do more if I had the time. I enjoy exercise for the first time in my life, and love my body feeling stronger and more toned.
  • Breathwork
    I do Breathpod sessions with breath coach Stuart Sandeman. I follow him on Instagram and do a 15-minute breathing session at the end of every working day, or I just dip in when I feel a bit stressed.
  • A. Vogel Menoforce Sage Tablets, £13.50 for 30
    It’s the only supplement I know that really does help with hot sweats and I think it helps my mood as well.
  • Vitamin D and calcium combined
    "I take OsteoComplete, £18.96 for 240, for bone support. A lack of oestrogen increases the risk of bone loss, and I have pre-osteoporosis.
  • ·Energy boosters
    Healthspan Vitamin B Complex £7.95 for 180, Ubiquinol,£34.95 for 60, help with my energy levels which were beyond awful.
  • Probiotics
    I eat yoghurt daily, with fruit for breakfast.
  • Vegetarian omegas
    I snack from a big pot of mixed nuts (the magnesium in them also helps me sleep) and have a handful of seeds on my yoghurt or in my porridge to help joint pain, heart health and brain health. These are huge concerns for me now that I have no oestrogen in my body.