HRT - Susan Flavin
The alarm shrieks me awake at 0345. -
“OUCH”, I think to myself as I rise to standing, and wonder (once again) if I have stress fractures in my feet. It is SO painful to stand when I arise. I gather the pile of damp t-shirts that I’ve gone through during the night (4, to be exact), a night of 6 hours’ sleep, punctuated by periods of wakefulness lasting 10-25 minutes. I’m grateful no one is monitoring my REM sleep, because I think that would be zero. I look in the mirror and am grateful for dental implants, and the one that replaced my front tooth which just broke off – all on its own. Good times. Good times I tell ya. I wonder what my bones look like, if my tooth misbehaved like that! I already know I’ve osteopenia, from my bilateral sacral fractures sustained during a fall in 2020; has it progressed to osteoporosis? And did I remember to take my cholesterol pill last night? (I can’t remember a bloody thing, anymore, or so it seems). Irrespective of a healthy diet, that bugger was 170 mg/dL the last time it was assessed – on medication. Pre-med, it was 230 mg/dL.
That’s a “morning in the life” of an endurance athlete struggling with the irritations of menopause.
For context, I am a 58 y.o. woman and a breast cancer “thrivor” x 15 years. I had Stage 1 DCIS (ductal carcinoma in situ), and was treated via a lumpectomy, followed by radiation. About 5 years post-op, I underwent breast reconstruction, to make the irradiated breast equal in size to the radiated breast. When I started swimming, and getting my upper body toned, the difference was very, very noticeable. I was still getting my period regularly at the age of 53, when a suspicious abdominal mass was observed on an MRI of my hip (which I had gotten because of some nagging hip pain). I had an oophorectomy (removal of my one ovary) and a bilateral salpingectomy (both fallopian tubes removed), and the mass was benign. However – my catapulting into menopause wasn’t benign!
Although I thought I had escaped unscathed, as I had only a few symptoms, they soon became more pronounced: more frequent and more irritating. I wanted so badly to explore HRT (hormone replacement therapy), but as someone with a history of breast cancer, everything I read said absolutely NOT. I had my annual appointment with my oncologist, and brought it up (shaking in my boots). Her response was “you had breast cancer 15 years ago. You were still menstruating then. You were still menstruating ten years out. You still had estrogen and progesterone circulating. I’m ok with us trying it as long as you are carefully monitored”.
WHAT??!!
Next up – my ob/gyn. Lovely, lovely woman. I’ve known her for 30 years. I was SO nervous about raising this topic, my BP was 180/100! (For context, it is normally 115/70 – talk about “white coat syndrome”!). You’d have thought I was drug-seeking (okay, maybe in some way I was!). We talked about it; she informed me of updated ACOG guidelines (American College of Obstetrics and Gynecology) which do allow for HRT in women with a history of breast cancer under certain conditions1. In 2016, updated guidelines were promulgated which stated:
“….According to the new Committee Opinion, for women with estrogen-dependent breast cancer or a history of estrogen-dependent breast cancer, non-hormonal options for vaginal atrophy should be the first choice. However, health practitioners may now consider topical estrogen therapy for patients with a history of estrogen-dependent breast cancer who are unresponsive to non-hormonal remedies. Although there is controversy related to the risk of topical estrogen therapy and breast cancer recurrence, the Committee Opinion notes that data show there is no increased risk of cancer recurrence with the use of topical vaginal estrogen…..”
- ACOG Committee Opinion No. 659 Summary: The Use of Vaginal Estrogen in Women With a History of Estrogen-Dependent Breast Cancer. Obstet Gynecol. 2016 Mar;127(3):618-619. doi: 10.1097/AOG.0000000000001349. PMID: 26901332.
It’s been about 8 months since I started therapy. No more phantom stress fracture pains in my feet. The night sweats have lessened by about 80% (nothing is perfect). I still don’t sleep through the night, but I’m trying different non-narcotic approaches to manage it. The forgetfulness is still there, to some degree. My moods aren’t quite as labile as they were. I’ve embraced serious strength training since July in an almost-all women gym. The owner refers to weight training as the “secret sauce’, and I think she’s right! My goal is to increase bone density as well as increase strength.
The moral of this long and sordid tale is to not be afraid to ask. This piece is in no way advocating for or against HRT, in survivors or none. It remains my personal experience. Find a good practitioner (or in my case, series of), advocate and ask “why”. Be compliant with what they ask, if it involves risks. Always consider sound medical opinion, and refer to published guidelines, when you can. Of course, there are always outliers, and exceptions to every rule!