Nicole Smythe was overcome with anxiety for months before she finally tried a treatment that gave her back her life.
Smythe is a registered nurse who runs an appearance medicine clinic in Tauranga. She has survived breast cancer twice, but she’d never felt as bad as she did after turning 47.
She was plagued with anxiety. Migraines got worse, and she stopped sleeping well. Her doctor prescribed four types of antidepressants and anxiety pills – they didn’t make a dent.
“I even went to a psychiatrist and said, ‘None of this is working, what’s wrong with me?’
“The anxiety got so bad I didn’t want to leave the house, I didn’t want to go to work. That’s when I thought, ‘This cannot carry on. This is not the person I am, there is something wrong here.’”
At her worst, Smythe took two weeks off work, desperate to avoid her clients knowing how bad she was feeling.
“Even just hearing people complaining about things in their lives got me really down, and I would try and filter it out. But I just couldn’t. It’s like you’re not in your own body, it’s really weird.”
Yet those same clients switched on the lightbulb for her. They said they’d started MHT – menopause hormone therapy – and they felt like new people.
MHT – originally known as HRT, or hormone replacement therapy – replaces decreasing oestrogen in the body, alleviating symptoms of perimenopause and menopause, which are both physical and mental.
Smythe raised the topic with her GP, and consulted a local specialist, Dr Linda Dear, and together they suspected she may have entered perimenopause, the stage before periods stops altogether.
Within a week of using MHT, Smythe was feeling like herself again – more than that, she felt amazing.
“I used to wake up in the morning and feel exhausted, and dread the day. I started waking up earlier and earlier, and wanting to get up, exercise and throw myself into the day.
“I don’t think I had felt like that for probably five years.”
But as a survivor of breast cancer whose risk of the disease returning is high, taking MHT wasn’t an obvious decision.
The study that stopped MHT
Ever since the early 2000s, MHT and breast cancer are uttered in the same breath more often than they should be.
In 2002, a US$625 million (NZ $1B) landmark study in the United States of about 160,000 postmenopausal women aged 50 to 79 investigated MHT.
Called the Women’s Health Initiative (WHI), it was one of the largest ever studies of its kind. It reportedly found that long-term use of MHT – a type no longer prescribed – from the age of 60 slightly increased the risk of breast cancer.
The study was actually designed to look at any links between MHT and heart disease, so participants weren’t screened for breast cancer risk. Subsequent reviews of the WHI data found that the small number of women who developed breast cancer while taking MHT during the study was not higher than the statistical average.
Nonetheless, the breast cancer “link” dominated headlines globally.
For Auckland consultant obstetrician and gynaecologist Dr Michelle Wise, the news came smack in the middle of her residency training at a menopause clinic in Canada.
“I have never seen anything like it from one day to the next,” Wise said.
“The entire world just stopped prescribing hormone therapy. It was one of the biggest paradigm shifts that has ever been seen in medicine.”
The WHI began in the early 1990s, and included studies into cardiovascular disease, cancers and osteoporotic fracture in postmenopausal women, through three clinical trials.
One trial focused on whether hormone therapy could have long-term positive effects on cardiovascular health.
Even so, after researchers announced the breast cancer “findings”, the study was suddenly put on hold in 2002.
Parts of the study continued and some participants have been tracked ever since. More recent findings show that, rather than harming, MHT actually protects against osteoporosis and heart disease.
New Zealand endocrinologist Dr Susannah O’Sullivan said between the age of the women involved and the type of MHT given to the women, those cancer-mongering headlines don’t carry much weight.
For one, the people in the study was much older than the average age of those beginning MHT today. Those participants were in their 60s, whereas in New Zealand menopause begins at 52 on average.
Since the study, hormone treatments have also changed significantly. Today, with natural progesterones replacing synthetic progestin, and oestrogen being delivered via patches worn on the skin, the risk for people in their 40s and 50s is nowhere close to that suggested by the WHI study headlines.
“The population who may have an increased risk of breast cancer is quite different to your average young healthy woman starting hormone treatment around the age of menopause with modern treatments,” said O’Sullivan, who specialises in menopause and osteoporosis at Fertility Associates.
Consensus that MHT is safe
The consensus globally is that MHT is safe, and that any associated risks are outweighed by the benefits, especially for those under age 60 or within 10 years of the onset of menopause (a year after your last period).
O’Sullivan said there are myriad other factors that increase the risk of breast cancer – being overweight, smoking cigarettes and drinking alcohol all push up the odds.
So too does the combined contraceptive pill, which huge numbers of people use without a second thought.
According to a 2020 survey by Family Planning, 88% of respondents used the pill, which has a known slight increased risk of breast cancer of about 7% compared to people who have never taken it.
Wise, who is also Deputy Head of the Department of Obstetrics and Gynaecology at the University of Auckland said the WHI’s effects are palpable in Aotearoa today.
Doctors who were taught then to turn to MHT as a “last resort” are still wary of prescribing it, calling Wise for advice and permission to offer it.
“We’ve got a whole generation of women who have suffered symptoms who have not been empowered to get menopause hormone therapy. I want that to change,” Wise said.
Even so, prescriptions are made carefully. Wise said the general practice is to prescribe the lowest dose for the shortest amount of time.
Most important though is starting the right conversation about MHT, she said.
“If the doctor leads with ‘it increases your risk of breast cancer by 25%’ which is the 20-year-ago headline, and just stops there, then you’re not even getting to the conversation.
“How it should be led with is: tell me about how your symptoms are affecting your quality of life. There are probably a lot of people who want to come in because they are not sure if the symptoms they are having are menopause related or not. The first step is just to give space to the person to have that discussion and be heard.”
‘I can’t carry on like this’
Smythe was first diagnosed with breast cancer when she was 38, and had a lumpectomy and six weeks of radiotherapy. Four years later, the cancer returned and she had a double mastectomy.
When her perimenopause symptoms started, she was willing to try antidepressants because of her experiences with post-natal depression after the birth of her daughter, but quickly suspected it wasn’t enough.
After reading up on MHT, she wasn’t even sure her GP or specialist Dr Dear would agree to prescribe her MHT. While oestrogen has been used as a breast cancer therapy, her breast cancer was a type called oestrogen receptor positive, where the future risks of taking MHT are unknown.
“I honestly was at that point where I begged Linda, I said, ‘Please give it to me. If you don’t give it to me I can’t live any more. I can’t carry on like this.’ And I said the same to [my GP].”
Smythe talked to her mother, husband and daughter about the decision to start MHT and the potential return of breast cancer, but they all agreed that something had to change, telling her: “What quality of life have you got?”
In February 2022, Dr Linda Dear opened a clinic in Tauranga dedicated to menopause treatment, desperate to offer more than a rushed 15-minute GP appointment to people struggling with perimenopause and menopause symptoms.
She said she had faced a rough ride with those symptoms herself and barely recognised what was happening to her.
“I visited my GP repeatedly with various different symptoms and felt embarrassed about seeing her so much. I understood how confusing and scary this life phase can be for women and how rushed and overwhelming it can feel talking to your doctor.”
To help advance knowledge in Aotearoa, Dear is running an online survey for those who have gone through menopause, and hopes the data collected will reveal an accurate picture of the impact of menopause.
Professor Beverly Lawton (Ngāti Porou) is the founder and director of Te Tātai Hauora o Hine, the National Centre for Women’s Health Research Aotearoa at Victoria University of Wellington.
She also co-founded the Wellington Menopause Clinic, one of a handful of specialist centres nationally.
“Some people really can’t function because they’ve got this lack of oestrogen that causes them to have night sweats, hot flushes, anxiety. I don’t think the breast cancer risk is a major for some of these women,” she said
MHT still underprescribed
So exactly how many people are suffering in Aotearoa thanks to the impacts of the WHI study?
At the end of 2020, there were 487,470 women in New Zealand aged 50 to 65. Lawton said about 20% of menopausal people will experience significant symptoms that require intervention, so about 97,000 that year.
But only a fraction of that number – 29,283 people – were prescribed an oestradiol patch for oestrogen hormone therapy that year, according to the Ministry of Health’s pharmaceutical data.
The figures don’t offer much information about who exactly received these prescriptions. But it appears that less than 30% of people who might need MHT are getting it.
One positive step in recent months is that micronised progesterone will be fully funded by Pharmac from December 1, 2022.
The progesterone is an essential component of MHT – it thins the womb lining, which can be thickened by oestrogen. Before perimenopause, the body produces both hormones and manages this balance itself.
But if doctors’ prescribing habits don’t change, no amount of funded MHT will make a difference.
There will continue to be a lot more people out there needing help than getting it, Lawton said.
They face wary GPs, or months-long waiting lists at specialist clinics – but it shouldn’t be this way.
“This is not hard medicine.”
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