Family history of breast cancer: Should I take HRT?
This factsheet is for you if you have a family history of breast cancer and are wondering whether HRT poses any particular risks for you. If you would like to know more about your personal risk of inheriting breast cancer because you have a family history, speak to your doctor.
HRT stands for Hormone Replacement Therapy and this is the umbrella term for hormonal treatments that work to relieve symptoms of the perimenopause and menopause. HRT replaces the ‘missing’ hormones that decline in the years around the time of the menopause. Low levels of hormones can cause symptoms such as hot flushes, night sweats, anxiety, mood swings, brain fog, and vaginal dryness and discomfort.
Living for years with low hormones increases your risk of the bone weakening disease osteoporosis, and heart disease, as well as other conditions such as type 2 diabetes, dementia, bowel cancer and depression. HRT helps improve symptoms of the perimenopause and menopause, and it also helps prevent the diseases mentioned from developing in the future.
There are different types of HRT and different ways to take it. The two main hormones that make up HRT are estrogen and progesterone.: If you have a strong family history of breast cancer, or have had breast cancer yourself in the past, you might still be able to take some types of HRT. It is best to discuss your options with your GP, or a doctor who specialises in the menopause.
- Estrogen is the key hormone to help improve your symptoms (as most of them are usually caused by a lack of estrogen). The preferred way to take estrogen is through the skin in a patch, gel or spray.
- Progesterone (or a progestogen) is usually recommended for women who still have their womb and are taking estrogen, this is to help keep the lining of the womb thin and healthy (as estrogen can thicken it). You can take this hormone in tablet form or have a Mirena coil inserted into your womb, which can remain for 5 years.
- Testosterone is a third hormone, which some women will need for additional help with symptoms of low libido, lack of energy and poor concentration.
What are the risks of HRT for all women?
For the vast majority of women, the benefits from taking HRT outweigh any risks. The risks of HRT depend on the type you are given and also other factors such as your age and general health. Because there are different factors at play in determining an individual’s risk of breast cancer, it’s so important to have a personalised consultation with your doctor to discuss your actual risks.
Many women worry about breast cancer when taking HRT, but most types of HRT do not actually increase the risk of breast cancer. Some studies have shown that women taking combined HRT containing both estrogen and a progestogen (which is a synthetic progesterone) may be associated with The increased risk is related to the type of progestogen in the HRT and not the oestrogen.
Taking micronised progesterone (the body identical progesterone) has not been shown to be associated with an increased risk of breast cancer. Even for women taking the synthetic progestogen, the risk is very low and is actually less than the increased risk of breast cancer associated with drinking a couple of glasses of wine each night, or from being overweight.
No studies have shown that any type of HRT increases the risk of a woman’s death from breast cancer. If you have had a hysterectomy in the past, and are just taking estrogen without a progestogen, you actually have a lower risk of breast cancer than if you did not take HRT at all.
There is also no increased risk of breast cancer in women who take any type of HRT when they are under the age of 51 years. If you take oestrogen in tablet form, you have a small increased risk of developing a blood clot, but this risk is not present if you take oestrogen through the skin in a patch, gel or spray.
Should I take HRT if I have a family history of breast cancer:
Because mood changes during the perimenopause and menopause are caused by altered hormones, the most effective treatment is to stabilise hormone levels by taking replacement estrogen (and for some women, testosterone as well). The right dose and type of estrogen can really help improve low mood and other psychological symptoms related to the menopause. Many women find that they feel calmer, their motivation and interest in things returns, along with a greater sense of energy, and they are generally much happier after a few months of being on HRT. There will usually be an improvement in other menopausal symptoms as well, such as hot flushes and night sweats, insomnia, vaginal dryness and many other symptoms.
Research has shown that if women are given HRT when they are perimenopausal, this can reduce the incidence of clinical depression developing. Many women who start HRT and have been incorrectly given antidepressants in the past, find that their depressive symptoms improve on the right dose and type of HRT, to the extent that they can reduce and often stop taking their antidepressants.
Most women will have history of breast cancer in their family because it is a relatively common disease. However, it is estimated that only about 10% of the breast cancers that are diagnosed every year have a genetic or familial cause. Women with a family history of breast cancer should discuss it with their doctor if they are considering HRT.
A woman’s lifetime risk of getting breast cancer is 1 in 7. This means that 1 in 7 women taking HRT will get breast cancer – not because of the HRT, but because they would have developed it anyway. There is no strong evidence that having a family history of breast cancer puts you at any higher risk of getting breast cancer if you take HRT, compared a very small increased risk of breast cancer to women who do not have a family history of breast cancer.
There is some evidence that women with a family history of breast cancer who take HRT actually have a lower future risk of developing breast cancer compared to women not taking HRT. This means that women with a family history of breast cancer, including those women with a BRCA gene, can still usually take HRT safely.
As there are many health benefits of taking HRT, women can usually take HRT for ever, so do not have to stop taking it at a certain age or after a specific length of time. Most women who have a family history of breast cancer do not go on to develop breast cancer, regardless of whether they take HRT or not.
Some final advice to remember…
To lower your risk of breast cancer: Stay a healthy weight Take regular exercise Don’t smoke Limit alcohol to as little as possible And remember to look at and feel your breasts regularly, for anything that’s different to normal.
Preparing for your appointment
If your local surgery offers double appointments it’s a good idea to book one of these so that you’ll have enough time discuss your symptoms and concerns. Before your appointment, take a look at the symptoms list to record the menopausal symptoms that you’re experiencing.
Make a note of any changes to your periods, and bring a list of any medications that you’re taking, including herbal supplements. It’s also wise to jot down any questions or concerns, so that you don’t forget to mention them during your appointment. If you’re feeling anxious, you can bring along a friend or family member for moral support.
Your first appointment
According to the 2015 NICE menopause guidelines, your doctor should discuss the following:
- the stages of menopause
- common symptoms of the menopause
- how the menopause is diagnosed
- lifestyle changes that can help your health and wellbeing
- benefits and risks of treatment
- how the menopause can affect your future health
Your doctor may want to carry out blood tests to check your hormone levels, but this isn’t usually necessary as these can vary by the hour. Most women can start HRT without needing any investigations or blood tests.
Sometimes your doctor may want to carry out blood tests to rule out other underlying issues, such as an underactive thyroid, and they will also check your blood pressure.
If you would like to take HRT and you feel you would benefit from taking it then you should ask at your first appointment for a prescription of HRT. The majority of women benefit from taking HRT and women can start taking HRT during their perimenopause. No women is usually too old to start taking HRT, even if it is many years since your menopause then you should still be able to take HRT.
Try to leave the room with as many questions answered as possible, ask if your doctor has any leaflets or information they can share with you, and check if you need a follow-up appointment. NICE guidelines recommend a review three months after your first appointment, but you should ask for an earlier review if you are experiencing side effects or the treatment doesn’t seem to be working.
A second opinion
Unfortunately, some doctors and healthcare professionals still believe outdated reports that HRT is linked to cancer, blood clots and heart problems, so they may be reluctant to prescribe HRT. If there’s no medical reason why HRT is unsuitable for you, then it’s important to speak up and, if necessary, ask for a second opinion.
You could ask to speak to another healthcare professional at your surgery, or ask to be referred to a specialist. Alternatively, you could refer yourself to a private menopause clinic. In the UK, the British Menopause Society has a register of recognised menopause specialists at thebms.org.uk. If you live outside the UK, you can contact the International Menopause Society.
What happens if my doctor / nurse won’t give me HRT?
- Informing your doctor about what you are wanting to discuss prior to the appointment or at the start of your consultation will help to ensure you get the most out of your consultation.
- Know your rights as a patient. Doctors will be more likely to consider your views if you can show you are fully informed and understand what any risks are and explain clearly why you still wish to have that treatment option because of the benefits to your life and health you believe it would bring.
- Be persistent but polite. If you do not get the desired outcome at the first appointment, try again another time. You can ask to see another doctor within your practice.
In general, your best approach when talking to your doctor about your menopause is to clearly state your reasons for what you would like, explain what information has led you to this decision, and that you know what the associated risks might be but that it is still what you choose to do. This information may need repeating on several occasions, to several doctors or nurses, but persistence often pays off when you can give a clear and rational argument that shows careful consideration of the evidence of the benefits to your health.