Mrs E. Jane Macaskill, Consultant Breast Surgeon and Honorary Clinical Senior Lecturer, Department of Breast Surgery, Ninewells Hospital & Medical School, Dundee.
NICE have recently updated their guidance on diagnosis and management of menopause, sparking again the animated discussion regarding risks and benefits of hormone replacement therapy (HRT), and how these can be communicated to patients. [1, 2]
The guidelines state that the risk of developing breast cancer is higher in current users of combined HRT preparations, with increasing risk with longer durations of treatment, but reducing to the same risk as never-users after 405 years of stopping. [3, 4, 5]
There are, however, data from the Women’s Health Initiative randomised trial of combined HRT versus none, showing that there was still an increase in breast cancer risk at 12 years follow-up despite most women having stopped at least 4 years prior to this, and 42% of women having stopped treatment when the early trial results showed an excess of breast cancers in the HRT arm.
There are risks related to being diagnosed with breast cancer while taking HRT: not only are patients at increase risk of developing breast cancer, they are also almost twice as likely to die from breast cancer if current users while diagnosed.  Mammographic sensitivity in reduced, resulting in more patients having cancer picked up by presenting with symptoms out with screening, and this later presentation and stage of disease, with increased likelihood of node positive disease and poorer prognosis. [7, 8, 9]
There are alternative options for management of menopausal symptoms. 10 While the proven benefits of HRT at reducing vasomotor (hot flush) symptoms of menopause are compelling, no difference in overall quality of life has been detected in women on HRT compared with never-users.  While HRT has been shown to reduce osteoporosis and fractures, there are other treatments available for this that do not ave inherent risk of cancer, and this should not be a sole indication for the use of HRT.
For women trying to come to a decision about whether to use HRT and concerned about the risk of breast cancer, the beast advice would be in agreement with the NICE conclusion that for women with troublesome vasomotor symptoms, HRT can be used inthe hsort term, at as low a dose as possible and using oestrogen only based preparations, and that women should be fully informed about the breast cancer risks.
This article was originally published in the SCPN Newsletter Volume 7, Issue 2. Read the full issue here, or read the digital edition below (great full screen on mobiles).