Can menopause treatment cause cancer?

Jonathan Bailey, MD

Obstetrics and Gynecology

Many of us have some idea of what menopause is, how it’s treated and the risks related to that treatment, but are these preconceived notions accurate? OB/GYN Jonathan Bailey, MD, said much of what we believe might be outdated or simply not true. He shared what we need to know about menopause, treatment options and any potential risks associated with those treatments.

What is menopause?

Menopause is a time in a woman’s life when her ovaries cease to ovulate, her estrogen levels drop dramatically, and she can no longer become pregnant. If you have gone through 12 consecutive months without a period, not due to any other medical condition or medication, you are considered menopausal.

The average age of menopause is 52. Menopause before age 40 is considered premature ovarian insufficiency, and from age 40 to 45, it is early menopause. Perimenopause is usually a three-to-five-year window before menopause when people start to experience symptoms.

“It’s not like you go from being 51 and having a year of normal periods to waking up at 52 and suddenly you’re menopausal,” Dr. Bailey said. “What usually happens is, in the years before, people will often begin to experience some menopausal symptoms, even though they’re not technically defined as menopausal yet.”

He said understanding menopause is important because it can occur during such a large portion of a woman’s life.

“The average life expectancy of a woman is 83,” Dr. Bailey said. “If you begin menopause at age 50, you could live up to a third of your life menopausal.”

What causes menopause?

For most people, menopause occurs naturally as part of the aging process. It can also occur for other reasons, such as surgery of the ovaries due to severe endometriosis or cancer, medicines, such as chemotherapy for cancer treatment, pelvic radiation, a genetic predisposition to early menopause and certain autoimmune conditions.

What are the symptoms of menopause and perimenopause?

A big sign that you’re on the road toward menopause is irregular bleeding, either closer together or farther apart.

Other symptoms of menopause include:

• Hot flashes
• Trouble sleeping
• Night sweats
• Anxiety/depression
• Abdominal weight gain

“Hot flashes and night sweats occur in 60 to 80% of people, and they can occur for an average of seven to 10 years, including five years after periods have ended,” Dr. Bailey said. “For most people, these vasomotor symptoms go away as you get older.”

Vaginal dryness is a symptom that tends to present later in menopause.

“It doesn’t usually occur early on, but it can,” he said.

How do I know if I’m menopausal?

Your doctor can make a clinical diagnosis based on your symptoms and age. Lab tests aren’t usually needed unless you’re young for menopause and don’t quite fit the clinical criteria. In this case, your doctor may order labs to evaluate your ovarian function as well as your thyroid and prolactin levels.

Blood work may also be needed if you’re unable to track your periods, such as if you’ve had a hysterectomy or endometrial ablation, or if you have a progesterone IUD. In these cases, labs may be drawn to check your FSH and estradiol hormones.

“During the perimenopause window, those hormones fluctuate,” Dr. Bailey explained. “I could check them every week and they would bounce around. Checking them can be helpful in certain situations, but normally you don’t have to do it.”

He said going to outside testing centers to check progesterone, testosterone or salivary hormone levels is also not clinically indicated or overly helpful.

What is the best treatment for menopause?

The main and most effective treatment option for menopause is hormone management using hormone replacement therapy. HRT has been approved by the FDA for:

• Treatment of hot flashes
• Osteoporosis prevention
• Treatment of vaginal atrophy
• Treatment for people with premature ovarian insufficiency

A key factor in determining which of the two HRT treatment options will be recommended for you is whether you still have a uterus. If you don’t have a uterus, estrogen alone can be used. But if you still have a uterus and you’re going to be on estrogen, you must also be on progesterone.

“If you don’t take both and you have a uterus, estrogen can cause your uterus lining to be overstimulated over time, and that can be a risk factor for bleeding problems and even endometrial cancer,” Dr. Bailey said.

HRT can be taken orally, through the skin via a patch, gel, cream or spray, or by using a vaginal ring. Hormones also can come in different forms, including natural, bioidentical and synthetic.

“Bioidentical has gotten to be somewhat associated with compounded hormones and it’s not,” Dr. Bailey said. “There are commercially available FDA-approved bioidentical hormones, so you don’t have to go through a compounding pharmacy. If you choose to use a compounding pharmacy, be sure to discuss it with your doctor beforehand so you go to a reputable one.”

If you have premature ovarian insufficiency, meaning menopause prior to age 40, hormone therapy is recommended until age 52, the average age of menopause, to prevent issues such as fracture, cardiovascular disease, heart disease, diabetes and death. Higher doses of HRT are usually required.

Is HRT safe?

There are situations when hormone replacement therapy would not be recommended, such as for people with:

• A history of heart attack or stroke
• A history of pulmonary embolus or a deep venous thrombosis
• A known hormone receptor positive cancer
• Unexplained bleeding
• Ongoing liver disease

For others, the risk is a little different depending upon age and the hormone preparation used (estrogen only versus estrogen and progesterone).

“Treating women during the time period where they’re mostly symptomatic, which is ages 45 through 60, tends to be that critical window where we see the lowest risk and the most benefit,” he said.

A study looking at risks of hormone replacement therapy among 10,000 women aged 50-60 showed that taking estrogen alone slightly increased the risk of a blood clot in the leg (5 out of 10,000 women) or a clot in the lung (3 out of 10,000 women).

“Those numbers are a lot lower than the risks of those things happening on birth control pills or during pregnancy,” Dr. Bailey said.

Taking estrogen alone also had a benefit if taken during that “critical window.” The study showed there were fewer cases of heart disease, as well as fewer strokes, cancer diagnoses, breast cancer diagnoses, diabetes diagnoses and fewer deaths.

Taking estrogen with progesterone (a lower dose synthetic progesterone similar to Depo Provera) showed a slight increased risk of heart disease and breast cancer – five more per 10,000 women.

“Once again, those are slightly increased risks, but they’re very, very low,” Dr. Bailey said.

And, among people taking estrogen with progesterone, there was a decreased risk for fractures, diabetes, death, colon cancer and other cancers.

Is there a long-term risk to taking HRT?

The study has followed participants for about 18 years and shown no long-term risk if HRT is taken only during that critical window. Many particpants were on HRT for an average of six to seven years.

However, initiating HRT with estrogen and progesterone in patients 65 and older has been shown to potentially have negative effects on heart health, breast cancer risk, stroke and dementia. Dr. Bailey said it is incredibly uncommon to need to use systemic hormone replacement therapy in this age group and should generally be avoided.

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

“Minus a true genetic predisposition like a BRCA carrier or other genetic predispositions for breast cancer, it does not appear that hormone replacement therapy confers a greater risk than family history in those patients,” Dr. Bailey said. “I think, for the most part, doctors would be comfortable treating that patient with HRT and helping them get through that time. You don’t have to be on HRT long term.”

Can breast cancer survivors use HRT?

The data is limited and conflicting, so it’s generally not advised for breast cancer survivors to take HRT. However, non-hormonal treatment options can be used. For vaginal symptoms, there are topical treatment options that don’t raise estrogen levels.

Is there a risk for endometrial or ovarian cancer if you take HRT?

As long as you’re taking estrogen with progesterone, there’s not an increased risk of endometrial cancer on hormone replacement therapy. People who had endometrial cancer can be on hormone replacement therapy, except for those who have had more advanced stage uterine cancers or uterine cancers with hormonal receptor positivity, which is relatively uncommon.

There’s also no link between hormone replacement therapy and ovarian cancer.

“In fact, we know that birth control pill use when you’re younger can help decrease your lifelong risk for ovarian cancer,” Dr. Bailey said.

Also, people who have had their ovaries removed younger in life for an atypical ovarian cancer can be on hormone replacement therapy, unless it was a rare hormone receptor positive cancer.

If you can’t take HRT, what other treatment options are available?

If someone can’t take hormone replacement therapy or if they don’t like it and want to try something different, there are two FDA-approved options. One is Brisdelle, a low dose of Paxil that been shown to decrease hot flashes by 25-45%. Similar medications, such as Effexor Lexapro, Celexa and Pristiq, can help too.

“You’ll know in about two weeks if it’s going to help,” Dr. Bailey said. “It tends to be not as dramatic as hormone replacement therapy, but it’s certainly a welcome help to someone who can’t be on hormone replacement therapy.”

The other FDA-approved medicine is called Veozah. Although it hasn’t been shown to be as effective as HRT, Veozah has been shown to reduce hot flashes and night sweats by up to 60%. It’s important to track liver enzyme levels during treatment.

After stopping HRT, how are symptoms like vaginal dryness managed?

Vaginal atrophy, which includes symptoms such as vaginal dryness, burning and discharge, can occur later in menopause. It’s usually something that occurs gradually.

“You’ll see it in people who have been on hormones for a few years for hot flashes and come off,” Dr. Bailey said. “The following year they say they’re having dryness and sexual intercourse is uncomfortable. I always tell people to call right away so we can start treatment.”

Topical estrogen creams are effective in treating vaginal atrophy, and most doctors feel comfortable prescribing them even for breast cancer survivors.

“We know that the systemic absorption of estrogen from those is really only present much the first couple of weeks,” he said.

There’s also a new oral medicine called Osphena. It’s a pill taken every day that acts like estrogen on the vaginal lining, but it doesn’t really act like estrogen anywhere else.

“It’s not really recommended in people who have had a history of breast cancer because I don’t think we really know enough about it yet in that group, but is a fine treatment for vaginal atrophy,” Dr. Bailey said. “It takes few weeks to see an effect with a peak effect at three months. If you stop it, you’ll gradually go back to where you were.”

About 15% of people on Osphena will have new onset of hot flashes.

Are phytoestrogens, such as soy, an alternative to HRT?

“There have been numerous things through the years from soy products to black cohosh that looked promising, Dr. Bailey said. “The problem is, when these were put to clinical tests and studied, they haven’t really shown to be all that beneficial.”

He said if you’re taking it and you feel like it’s helping, it’s fine to continue.

The bottom line about menopause treatment

Dr. Bailey said if you’re suffering with menopause symptoms, don’t assume you have to just power through them. Talk to your doctor.