Questions about menopause that patients ask me most frequently – and what I tell them

When patients come to see me about their menopause, what they want most is information. Despite plentiful advice available online, questions remain. Some ladies find it difficult to comb through lots of online material, and they cannot tell which information is true, credible and based on evidence – and this is the kind of information they want. 

There are some questions that get asked more than others, and so I decided to share two common and interesting ones in this post, along with the answers. 

Let’s begin! 

Q1: I am menopausal, but I feel great, no symptoms whatsoever. All my friends take HRT, and they tell me I should too. Is this true? 

No. When doctors prescribe HRT, like any other medication, we consider so called benefit-risk balance. If the patient can gain significant benefit from medication, and this benefit is greater that any potential risk, then the drug should be prescribed.  

If you do not have any menopause symptoms, the benefit of HRT for you will not be as large as for patients with symptoms. You would still get some benefits, for example reduced risk of osteoporotic fracture, but these benefits may not sufficiently outweigh HRT risks. Please note that risks of serious side effects from HRT are very low (if there are no contraindications), but like any other drug it is not completely risk free and certainly not harmless. See this table from Medicines & Healthcare Regulatory Agency for details on benefits and risks of HRT. 

Q2: Will HRT give me breast cancer? 

This is a topic which has sparked a heated debate for many years running. As above, the main principle in prescribing HRT relates to the benefit–risk balance – and this balance might be quite different for different patients with varying family and medical histories. Any decision whether to start taking HRT need to be taken by an informed patient through a conversation with her doctor. 

I could never predict if my individual patient would develop breast cancer due to HRT, as I am just not able to foresee the future.  In medicine we can only inform the patients about the estimation of their risk, based on evidence from studies. 

Here are some facts:  

According to guidelines used by GPs: “HRT with oestrogen alone is associated with little or no increase in the risk of breast cancer.” But remember, this type of HRT is only suitable to patients without uterus, so might not be suitable for you. “Combined HRT with oestrogen and progestogen is associated with an increased risk of breast cancer that is dependent on duration of treatment.” 

So how big is this risk? 

If we look at women between 50-69 years old who are not taking HRT, some of them will develop breast cancer anyway.  If we take 1000 random women like this, 13 will develop breast cancer. If 1000 women of this age took HRT for up to 5 years, we would observe between 3-20 more women developing breast cancer, depending on the type of HRT they took. This means instead of 13 women out of 1000, we would have 16-23 women out of 1000 with breast cancer. 

More information can be found in this leaflet. 

References:

NICE CKS Guideline: Menopause, September 2022

Collaborative Group on Hormonal Factors in Breast Cancer. Type and timing of menopausal hormone therapy and breast cancer risk: individual participant meta-analysis of the worldwide epidemiological evidence. The Lancet. Published August 29, 2019.

Medicines and Healthcare Regulatory Agency. Drug Safety Update: Hormone replacement therapy (HRT): further information on the known increased risk of breast cancer with HRT and its persistence after stopping. Published August 2019.