The Hormone replacement therapy debate

In all societies doctors are encountering an increasing number of women surviving breast cancer. How the menopause of these women should be treated is still an open ended question and is the subject of much debate in medical circles.

Use of Hormone Replacement Therapy (HRT) may, at least in theory, increase the risk of the recurrence of breast cancer. However, its categoric refusal is a double-edged sword because it also denies these women all the indisputable health benefits that HRT provides. This is particularly so, because the very drugs used to treat breast cancer and prevent its recurrence also enhance the troublesome symptoms of menopause.

Most chemotherapists and surgeons are highly opposed to the use of HRT in breast cancer survivors. This is driven by the underlying fear of recurrence in survivors themselves, the lack of international uniform guidelines for doctors and the possibility of litigation should a woman develop a recurrence while taking HRT. The situation is further compounded by the fact that research focusing on the use of HRT in breast cancer survivors is often confusing and conflicting.

So what is the evidence?

In medical circles, various methods are used to analyse data. Observational studies and randomised controlled trials are the main study types that have been used in an attempt to answer the question of safety of HRT in breast cancer survivors. The latter type of trial carries more scientific weight and can be seen as the most accurate if performed correctly.

The existing observational studies to date, do not support that HRT increases cancer recurrence, or even the risk of dying from breast cancer. The randomised controlled trials however, conflict these results. There have been three trials to date, two of which were stopped before the planned end date,

due to the increased recurrence of breast cancer in survivors who subsequently went onto HRT. Although worrying, experts who have analysed the data from these trials were not truly convinced of the validity of these findings.

So where does that leave the multitude of doctors and patients, who, on a daily basis, need to address these health and quality of life issues?

And are there alternatives to HRT then?

Yes there are. These are usually not in the form of one single treatment that can address all the menopausal symptoms, but consist of multiple therapies that often need to be combined and that are targeted at specific problems. In general, lifestyle factors such as increasing exercise, not smoking and maintaining a healthy Body Mass Index (BMI) will all help to reduce symptoms.

Hot flushes

The alternative drug therapies are all moderately effective in treating this problem and their efficacy can vary from person to person. Side effects can include nausea, dizziness, weight gain and sexual dysfunction. Some examples:


• Venlafaxine (Effexor/Venlor)

• Paroxetine (Paxil)

• Fluoxetine (Prozac)

These medications are also used to treat depression and/or anxiety.


• Gabapentin  (Neurontin) anti-siezure medication especially for night flushes.

• Clonidine (Dixirit) to treat high blood pressure.


Calcium and vitamin D supplementation are effective strategies. Weight bearing exercises can be beneficial as well. Drugs like Fosamax, Evista, Protos or Aclasta are reserved for those with proven osteoporosis on a bone scan.

High cholesterol levels

Reduced saturated fats in the diet help here. The Statins e.g. Crestor is also beneficial.

Vaginal dryness

Studies have shown that vaginal insertion of estrogen twice a week does not increase the risk of breast cancer recurrence in survivors and is certainly very effective in treating vaginal dryness and consequent painful intercourse.

Cancer brings with it a huge amount of emotional and physical strain resulting in significant impairment of quality of life. Many survivors report little, or no relief from the solutions offered above. In this select group of patients HRT can be considered provided it is fully discussed first and consistently monitored by an expert in the field. One thing clearly emerges though: we need more research on this topic.


Dr Sumayya Ebrahim is a gynaecologist in private practice in Johannesburg. She is also a blogger. Check out her blog “vaginations by Dr E” on