The Dr Louise Newson Podcast - 179 - Advancing menopause care after breast cancer with Dr Sarah Glynne

Episode Date: November 22, 2022

GP and menopause specialist, Dr Sarah Glynne, joins Dr Louise Newson on the podcast this week to discuss menopause care after breast cancer.  The experts share more about the breast cancer steering group established as part of the Newson Health Menopause Society that is working towards producing a consensus statement to support clinicians and improve the quality of life for menopausal women who have had breast cancer. Dr Sarah Glynne discusses the importance of individualising the risk-benefit ratio for every woman when making decisions around treating the cancer and weighing this up with treating menopausal symptoms. Sarah emphasises the importance of talking through the implications of each of these considerations using a shared decision making process. Sarah’s three tips for women after breast cancer: Understand the risks and benefits of the drugs used to treat your breast cancer and what this means for you personally. Ask your oncologist for more information about your own breast cancer, if you are not sure. You can then use the PREDICT tool online for understanding more about your own cancer risks and what additional benefits any treatments may offer. Read about non-hormonal options to help your menopause symptoms and cancer recovery such as diet, yoga, or acupuncture. Try various approaches to find the ones that may bring some benefit to you. Vaginal moisturisers and lubricants may also help and these do not contain hormones, and there are other medications your GP may be able to prescribe for some of your symptoms such as hot flushes. If your menopause symptoms are severe and your quality of life is suffering, ask your clinician to explain the risks for you regarding your cancer prognosis if you decide to take HRT, versus the risks to your quality of life and long-term health if you choose not to take HRT. If you have genitourinary symptoms of soreness and dryness, vaginal hormones are very safe for improving these symptoms. Read information on the balance website and the book ‘Oestrogen Matters’ by Avrum Bluming, and make a choice that is right for you through discussion with your clinician using a shared decision making process.

Hello, I'm Dr Louise Newsome and welcome to my podcast. I'm a GP and menopause specialist and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-Bron-Avon. I'm also the founder of the Menopause charity and the menopause support app called Balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based, information and advice about both the perimenopause and the menopause. Today on the podcast, I'm very delighted, excited to introduce to you someone who I've known for a while and we've now got very close relationship academically and friendship as

well. So it's someone called Dr Sarah Glynn who has agreed to talk today about some of the work we're doing which we're really excited about. So welcome Sarah. Hi. So Sarah, you were introduced to me by your lovely husband, Paul, and my husband's called Paul. So there you go, a bit of a connection there. And you, like me, have got another degree as well as medicine, because obviously a medical degree isn't enough. For some of you who are listening, know that I've got a pathology and immunology degree, and you've got a degree in allergy. So there's a big overlap, actually, and I hope you don't mind me saying this, our geekiness, actually. Absolutely. Is that all right to say it? I'm very proud to be a fellow geek.

So we love seeing patients and, you know, medicine is a great privilege and both of us get a lot of satisfaction making people feel better. We both went into medicine to make a difference to help as many people as possible. But actually, with medicine, you have to understand what you're doing. And sometimes it's really hard, isn't it, to know what the best thing is for that patient sitting in front of you. And I know sometimes when I'm not sure, I will go back to the basics and look at the basic physiology, the pathology, what's going wrong in a disease. But think of it in the cellular level. And I think a lot of people don't have the luxury of that. Maybe because we've got degrees, we've had time to reflect and think and go back to basics almost, haven't we?

So tell us a bit about why you're doing what you're doing. and then we'll talk about the work we're doing together if that's all right. Yeah, sure. So, I mean, I'd started to develop an interest in the menopause, probably around about 2017-2018-ish. And the thing that led me to the menopause initially, which I've told you this before, was because I was having to start prescribing HRT for patients

that's a new practice that I'd moved to, and I didn't know how to do it. And I found your easy prescribing guide online, which just took all the fear out of prescribing HRT, and it's one of the most practice-changing documents that I think I'd ever read. And I think partly because I started to think about HRT more at work, partly because I'm in my mid to late 40s and all of my friends were coming up to me asking me about menopausal symptoms.

I just started to get interested in it. And then the pandemic struck, COVID, who knew that was around the corner. And in fact, it was a slide you put on Instagram quite early on in 2020 about the effects of estrogen on the different cells of the immune system. And I think it snagged my interest, obviously, because I've got this background in allergy. And that was acute COVID. This was before long COVID was even a thing. Nobody knew about it.

But I remember the slide was something to do with the effects of estrogen and the immune system and the fact that women were much less likely to die from COVID compared to men. Pre-menopause or women were much less likely to die compared to men. And it sort of went from there, really. As the pandemic progressed, my husband started to see long COVID patients. I was getting interested in the menopause and becoming aware of this link between hormones, estrogen. and COVID and long COVID. And as he started to see pages,

I was telling him about what I was learning. And then he was asking me and I was asking him. And, you know, we were both working from home, which is the first time that's ever happened. So we were able to, you know, bounce off each other a little bit. And it just grew from there, really. I thought that at this stage, I might be sort of learning how to paint and things like that.

But instead, I've become a manifold specialist. And now, alongside my interest in long COVID, I've also become very interested in breast cancer, which is my other area of interest. And thanks to you, I've got involved with this work that you're doing at the News and Health Menopause Society, which I'm just finding fascinating. And as you say, it's very exciting. And we hope that we're going to publish something next year that will start to make a difference for the many, many women

with breast cancer who are suffering in some cases terribly with menopause or symptoms. Yeah, because I've talked about breast cancer before on the podcast and I'm sure I will talk about it again. But, you know, breast cancer affects around one in seven women. And when I was at medical school, probably when you're at medical school as well, Sarah, breast cancer was actually less common. It was about one in 12 women when I was a medical student, then it was one in 11, and it's become more common. And actually, there's this big fear about HRT. We know it's the biggest reason why people don't take HRT. They're worried about the perceived risk of breast cancer associated with HRT, and we know the risk really isn't there. And it's certainly,

if it is there, it's not statistically significant anyway. However, we know that HRT prescribes has plummeted over the last 20 years, but the incidence of breast cancer has increased. So not everybody who takes HRT will develop breast cancer, but also a lot of breast cancer cases are nothing related to hormones at all. And this causes a lot of confusion to people because when someone has breast cancer, they look at it, don't they? And it's, is it estrogen receptor negative or positive? And so if a woman has an estrogen-referent or positive, and so if a woman has an estrogen receptor positive breast cancer, then it's presumed, and a lot of people say it's an estrogen driven and it's caused by estrogen, which isn't actually quite right, is it? So can you explain

before we talk about what we're doing what it means by having an estrogen receptor in a breast cancer? Yeah, it's really interesting. And again, we've spoken about this before. The analogy would be prostate cancer. So men with prostate cancer, inevitably, if you take a biopsy, from a prostate tumor, you will find testosterone receptors in it, which is not surprising. And one of the treatments for prostate cancer is anti-androgen or anti-testosterone therapy. But nobody thinks that testosterone causes prostate cancer. Whereas with breast cancer, because breast tissue also contains estrogen receptors, they're supposed to be there.

That's why we develop breasts at puberty. They're important. And because if you take a biopsy from a breast cancer, about, I think it's about two-thirds, 70, 75% of them will be estrogen receptor positive. And one of the treatments for breast cancer is anti-estrogen therapy. And somewhere along the line, that's been interpreted as meaningful. Therefore, estrogen causes breast cancer, which makes absolutely zero sense. As you say, in terms of HRT, the majority of women that develop breast cancer haven't taken

HRT, and the majority of women who take HRT don't get breast cancer, it would make no sense on one of our own hormones to cause breast cancer. I think a lot of the data that it was the WHOI study that was published 20 years ago that through the major spanner in the works and reported that there was this association, or rather causation between estrogen and breast cancer. And I think it's really important to remember that 20 years ago, they were prescribing synthetic hormones, HRT, and they were describing synthetic progesterone, synthetic estrogen.

In fact, in the WHOI study, it was conjugated equiore. estrogen, or Premarin, which is a cocktail of about 10 different estrogens, I think, that are not supposed to normally be in the human body. And those types of hormones are very different to the body identical hormones that we prescribe nowadays. And just because you've got estrogen receptors in your breast does not mean that your own estrogen has caused breast cancer. If that were the case, if it was that straightforward, all women would develop breast cancer. It doesn't make any sense. Yeah, and that's important to know actually because there might be people listening who've had breast cancer and they have taken HRT and then they're regretting that decision and there isn't good evidence that that's the case, of course.

But the other thing is there's a lot of other reasons why people get breast cancer and often it's bad luck actually. Sometimes it can be a genetic thing. But also there are other risk factors we know that obesity is one of the commonest risk factors for all types of cancer actually. and that's probably one of the reasons why the incidence has increased. Now, there are some people that say, well, obesity, fat cells produce estrogen, therefore that's why there's an increased risk. And it's not as simple as that because fat cells are very active, actually. They produce all sorts of chemicals and cytokines.

And they do produce a very weak type of estrogen called eustrone, which is very different to the estrogen. Our ovaries produce or the estrogen we prescribe in HRT. and whether that does have an inflammatory properties with respect to breast cancer, we don't know, but it's very different. And other risk factors such as drinking alcohol, not exercising, actually, are risk factors as well. And all these are small risk factors, but sometimes it's more than one risk factor people have as well.

So, but we've got estrogen receptors all over our body, haven't we? So if I chopped off the end of my nose or the end of my finger or my ear, I would have estrogen receptors in it. So sometimes now the more oncologists look for these receptors, the more they see them, and then they can cause confusion. So it's important to know that it doesn't mean, sometimes it does dictate how treatment is as well, though, isn't it for breast cancer?

So the estrogen receptor positive cancers, one of the treatments is to try and block the estrogen, isn't it? Yeah, I mean, I certainly believe that, estrogen can fuel breast cancer growth. I think if you've got a breast cancer for whatever reason and it's got estrogen receptors, then I do think estrogen is a growth factor and your tumour will grow quicker in the presence of estrogen. But that's not necessarily a bad thing. We know because there was a study that was published in 2016 that showed that women who develop breast cancer whilst taking HRT actually have a better prognosis and are less likely to diet.

from it compared with women who develop breast cancer that are not taking HRT. So paradoxically, because we don't quite understand so what's going on in breast cancer and it's probably very complicated because breast cancer is actually quite a heterogeneous group of diseases. It's not the same for every woman. But paradoxically, growing quicker in the presence of estrogen seems to be a good thing, maybe because it's detected sooner before it's spread and therefore women's prognosis will be better. So I think if you've already been diagnosed with a breast cancer, I can see why anti-estrogen therapy can be helpful to prevent the tumour growing quickly, i.e. to slow the growth of the tumour down. But even then, that's not straightforward,

because it doesn't stop breast cancers from developing. It's not as simple as if you take this treatment, you won't get breast cancer. Your breast cancer will not come back. It's going to prevent it from coming back. And in fact, for many women, especially those with early localised cancers, which are localized to the breast, which actually are the majority of women at that, some two-thirds of women present with early localized cancer that hasn't spread or hasn't spread to the lymph nodes, then actually the prognosis is very good. And those anti-endocrine treatments, I'm talking about things like tamoxifen, aromatophanaromatase inhibitors, so anastrasol, leptosol, etc, are only of very, very, in some cases, minimal benefits, which considering the side effects of the anti-estrogen treatments, I think it's really important that women understand

that if they've got an early localised breast cancer, they need to understand the absolute benefit and risk to them from their endocrine therapy in terms of if they wish to take it or not. So this is very important because this brings us to why we're doing what we're doing actually. So someone actually said to me a while ago, having breast cancer is very difficult. Being menopausal and having had breast cancer is even harder. But actually being a menopausal woman who's had breast cancer and not being listened to is really, really difficult.

And since I opened my clinic and I started having a dedicated clinic, I started, as many of you know, on my own seven years ago. And there was a lady that came in to see me and she'd had breast cancer a few years before. She had had a hysterectomy. And she was really struggling with her menopause. And for seven years, she had the most drenching awful sweats. and she had her hair cut very short because she couldn't do anything else. She'd had a few changes of clothes in her bag every day.

She couldn't sleep. She'd put on weight. She was just close to divorcing her husband and she'd given up her job. And she came to see me, a really lovely lady and she said, could I have some HRT? And I said, well, you've had breast cancer and she'd say, yes, I know, but my life is absolutely awful. I've tried antidepressants. I've tried to lose weight. I've tried other things.

and I've tried all the supplements that I can have and I'm just feeling awful. And my life is just really difficult. So I gave her a bit of gel, some estrogen gel. And I've never actually given a woman who's had breast cancer, HRT, before. And I went home and most nights I just couldn't sleep because I thought, what have I done? What have I done?

But she was central to the consultation. I told her that there was no good evidence and it might be at risk giving her some estrogen and I had no one really to talk to you because I was doing the clinic on my own. And so then three months later she came back. I saw her name on the records and I thought, oh my goodness, here goes. And she came breezing in and she had lost a stone in weight. She had divorced her husband, which she was very happy about and she had since had a new boyfriend. She'd grown her hair a bit and she said, Louise, I, well, she didn't say Louise, she actually said, Dr. News and I would like to thank you. And I said, oh, what for? She said, because you have transformed

my life. This is incredible. And I saw her again recently actually a few weeks ago and we were talking about this first consultation and she had no idea the enormity of what I'd done and the difficulty that I had faced knowing whether I was doing the wrong or right thing. But we learn from our patients every day. Our patients are such a privilege to us and I have grown and learned so much. And I thought then actually, who am I to say no to something that is transforming her life? And whenever I see women, whether they've had breast cancer or not, they know that they can stop their HRT in any day, and it will come out of their system, their half-life's about 18 hours or so. So it will, within a day, they're back to how they were before. So she was completely in control.

And she also knew her mother had had really bad osteoporosis. And she was worried about osteoporosis. and in fact she was more worried about having osteoporosis than she was her breast cancer coming back. And I really learned from her. And since then, obviously my clinic opened four years ago and we've had quite a few women. We've got over 500 women who have now come to the clinic who have had breast cancer

and they're wanting individualised consultations. And often that has ended in HRT and many women have said to me, Dr. News and I've had chemotherapy, I've had radiotherapy, I've had a mastectomy, I know how gruesome breast cancer treatments can be, but actually my life is horrendous and I really want to consider having some of my own hormones back.

And so, and then you look at the evidence and it's not very clear. And so this is where the work we're doing together, we've created, and you can explain more, a sort of clinical steering group really, where we've got together really key people who are sort of top of the game really, who are oncologists and breast surgeons and radiotherapists and us as GP specialists,

But we've also got a urologist who's been on the podcast before, Steve Payne. His wife was getting pino nephritis and infections because she had low estrogen as a result of her menopause. And she'd had breast cancer in the past. And even as a urologist, he didn't understand the enormity of how important hormones are for the urinary tract. And we've also got patients on our group. So just explain what we've been doing because you've been leading the groups there. And it's a huge amount of work. And we've been unpicking the evidence

of what scanty evidence there is. But we've been trying to work out how to take this conversation forward because women in the end are suffering because they've been given the treatments, which like you say can make a difference, but a small difference compared to the effect of their surgery or their chemotherapy, their initial treatment is obviously the most important. But we're just trying to help women,

and but also healthcare professionals about this area, which causes a lot of controversy, really. And because breast cancer is so common, and luckily the prognosis is so good, there's millions of menopause or women who have breast cancer out there who we hear from a lot just through other platforms who are not being listened to.

So we're hoping this work will improve. So explain what we've been doing then, Sarah. Yeah, I mean, essentially, I think sort of two, principles behind what we're doing are exactly, as you say, the risk-benefit ratio, which is different for every single woman. And it's the risks versus the benefits of the endocrine treatments used to treat cancer. And it's the risks versus the benefits of HRT used to treat menopausal symptoms in women who've had breast cancer in the past. And the second principle is this shared care and shared decision-making, which is absolutely fundamental.

and key to what we're trying to do. And we are absolutely not saying that all women who've had breast cancer can have HRT or should have HRT. And we are absolutely not saying that HRT is 100% safe for all women who've had breast cancer. And I think perhaps that's why we're meeting with some resistance in some quarters and why I think some people don't understand what we're doing because they haven't got that message from us before. But that is what underlies the work. We are saying that for every woman with breast cancer, the risk-benefit ratio will be different.

And unless she is counseled so that she can consider the risks and benefits specific to her, she will not be able to decide whether HRT is something that will benefit her or not. And so what we're trying to do is look at, as I say, the risks and benefits of the endocrine treatments. and chemotherapy, other treatments that are used for breast cancer. And then we're having a look at the evidence in breast cancer survivors that have been given HRT as to whether it increased risk of

recurrence, whether it increase or decreases mortality. And not just that, but what are the long-term risk of not giving HRT? So obviously in the short term, it's to do with quality of life and menopausal symptoms, which can be debilitating for many women. But also in the long term, exactly, as you said, and I've seen patients recently, but I've far more. concerned about their risk of osteoporosis than they are about their breast cancer coming back. Or they're more concerned. I saw a woman just a couple of weeks ago whose father had dementia and she's far more terrified, were her words, of getting dementia, then she has her breast cancer coming back, which makes perfect sense because actually breast cancer these days often has an

excellent prognosis. And the vast majority of women who get breast cancer will not die of their breast cancer, they'll die on something else. And the things they are dying from, the most common cause of death in breast cancer patients is cardiovascular disease and stroke and dementia. And we know that in patients without breast cancer, HRT can significantly reduce the risk of these long-term health conditions. And it stands to reason, although there's no work being done specifically looking at the long-term benefits of HRT and breast cancer survivors, but it stands to reason that if their symptoms and their long-term health risk and all-cause mortality is being caused by hormone and deficiency and giving women their hormones back will at least partially offset or mitigate

against those risks, then it stands to reason that actually, for many women, the benefits of HRT might outweigh the risks. So that's what we're doing. We're trying to produce a consensus statement that will support shared decision-making and prescribing of HRT to women who've had breast cancer if they want it, if the benefits outweigh the risks for them, and if they've been given enough accurate information to enable them to make a decision. That's what we're trying to do. Which is no mean feat, actually. And I think what's happening sometimes is that women with breast cancer are just grouped

together. You've had breast cancer, therefore you can't have hormones. And that's like saying, oh, you've had a car crash before, therefore you can never get in a car. It's, you know, you make choices all the time about what we do. And I hear, and I'm sure you hear a lot, that from our patients who say, say they are told they can categorically never have HRT. And I think in medicine you can never say never, that's one thing. But I think there's also different types of cancer.

We've already said there's estrogen receptor positive, but there's also estrogen receptor negative. And many experts feel that giving your hormones is less controversial, if you like, for women who've had an estrogen receptor negative cancer. But I see some women who have had breast cancer 20 years ago. And, you know, that's very different when, someone's had it 20 years ago to someone who's had it 20 days ago or 20 minutes ago. And with time makes the difference as well.

And then also it depends sometimes on their age. So I've got quite a few people who've had a double menopause. So they've had breast cancer when they're young. And then they've had treatment that's caused a menopause. Maybe they've had one of these estrogen blocking drugs or they've had their ovaries removed. And then the ones that have had the drugs, maybe if they've had them for five years, and then in their 40s their periods have come back and they've felt wonderful

because they've got their own internal hormones have worked and then in their late 40s their periods stop and they become menopause and they're told they can never have HRT but then all we're doing is giving them back what they've had for the last few years when they've been menstruating and so then those women, it's almost easier to make the decision because they've been exposed to hormones already

so every woman is different but like you say Sarah every woman has, every woman has different reasons for doing something and also they have different health risks as well. And when we've been looking at some of the studies looking at outcomes from people who've had breast cancer or the benefits of these treatments that block hormones, it's all been focused on breast cancer. Has there been a recurrence in this lady? Has there been a death from breast cancer in this lady? and what they haven't been looking at is what is about the risks for her future health, for heart disease and osteoporosis like you say, but also quality of life as well.

And I had a lady a while ago who's a paramedic, she's really bright, lovely lady who's really flawed with symptoms because of her breast cancer treatments. And she said to me, Louise, I've come to a crossroads. She said, I can either carry on with a treatment the oncologist want me to do and avoid hormones, but I will have to go and live with my mother and I can't work anymore and I might have a really long life. Or I'm going to have to consider taking hormones and that might enable me to get my job back and that might enable me to do the things I want to do and I might die at an earlier age, but that's my decision.

But I'd like to have that choice. So after a lot of discussion, she decided to take HRT and she's taking HRT and testosterone actually. and she's backworking not just as a paramedic, but she's also doing a PhD as well. And she's living at home. She's not with her mother. She's fiercely independent. In fact, she's quite scary because she's so bright.

But she's got her brain back and it's her decision. And I feel the work we're doing is to help facilitate a conversation. Not saying yes, you can, no, you can't, is it? I think that's really important to distinguish. No. And that's the interesting thing is that even if, if all women with breast cancer had the same risk benefit ratio, which obviously they won't. But even if they did, that ratio will have a different meaning for different women.

So I don't know. For example, let's say if you had a small localized breast cancer, maybe your risk of recurrence in the future would be, I don't know, I'm talking to 6% or something. And with HRT, it went up to 9%. So let's say you've increased your risk of breast cancer recurrence by 3% of making these numbers up. Now, some women would look at that and say, well, absolutely not. I wouldn't want to take HIV at any cost because my fear of my breast cancer coming back is the thing that I'm most terrified of and I will do whatever it takes and I will suffer

or maybe some women aren't having such bad menopal symptoms. I don't know. But they will not want to take that decision. Whereas another woman will look at that and think, well, hold on a minute, 3%. That's not worth it. I feel terrible. You know, my quality of life has gone down the drain. I'm no longer functioning normally. I can't work. I can't look after my children. I'm contemplating suicide. We've both seen patients. You know, and that, same risk benefit ratio will have a completely different meaning depending on what women are scared of and what I think everybody has a different threshold for what they would consider worthwhile. And obviously if the treatments of breast cancer didn't have any side effects and if women weren't

suffering from menopause or symptoms, then of course you take that 1% benefit or that 2% benefit because why wouldn't you? But the reality is that it's much more complicated than that. And women's quality of life is really suffering and their long-term health is really suffering. And And that's the other important thing in terms of timing. So, as you said, the risk-benefit ratio changes over time, and that's also really important. So as a general rule of thumb, and it's not my place to tell a woman whether she should suffer or not, but as a general rule of thumb, I probably wouldn't encourage somebody to take HRT if it was within a year or so of their diagnosis, at least without trying other things first. It's not my decision, but that would be what we would discuss.

but actually the risk of breast cancer recurrence decreases over time. So only about 7% of recurrences happen after 10 years. The vast majority of them happen in the first 10 years. And from about seven years after diagnosis, that's when your risk of dying from something else starts to increase. And that's when cardiovascular mortality and breast cancer survivors starts to increase. And in fact, women who've had breast cancer have double the risk of dying from, heart disease compared with women who haven't had breast cancer, which we think is related to the fact they've been hormone deficient for so long. In the past, we thought, well, maybe that's

because lots of risk factors of breast cancer are the same as the risk factors for cardiovascular disease, so it stands to reason if you've got breast cancer, you're also more likely to have a heart attack. But there's been some work recently that's looked at risk factors in women with and without breast cancer, and that doesn't appear to be the case. The other theory was that it was the treatments that were breast cancer were cardiotoxic, and therefore, again, that could explain the higher cardiovascular mortality in breast cancer survivors. But again, when they compared cardiovascular mortality before 2005 with cardiovascular mortality since 2005, because since then the treatments are less cardiotoxic, they're better, they're not so bad for women. And again,

it hasn't made any difference. So in fact, the only reason I can think of that would account for a higher cardiovascular mortality in women who've had breast cancer is because they've been deprived of their hormones for so long. And again, if you're coming up to sort of the five-year, seven-year mark, you're still within that 10-year window of opportunity that we talk about all the time, whereby if you start HRT within 10 years of the menopause, you can halve your future risk of cardiovascular disease, you can reduce your all-cause mortality, because, as I said, most women with breast cancer don't die with their breast cancer, they die of something else. And you can reduce that by up to 30%. You can reduce your risk of osteoporosis by about 50%

and about, I think, mortality after osteoprotic hip fracture is, what I say? It's a 20%. It's quite high, isn't it? Well, I learned last week it was as high as 30% actually. So, yeah, and I think, yeah, absolutely. And I think the most important thing from all of this is about choice. And it's about putting the patient in front foremost of the consultation, actually. And I really strongly feel, you know, we're advocates to help.

We're not doing any didactic. You have to, you must do. The only option is this. It's just about choice. And we're looking at the limited evidence we have, but also using expert voices as well. So I'm hoping, Sarah, that you can come back onto the podcast

and announce next year how it's all gone. But we're really striving forward with this. And I know I'm just publicly very grateful for the work that you're doing. We're using something called the Delphi process and it's taken hours and hours and hours. but we're really committed to making a difference. And so I want to thank you for that. But before we finish, I know you've done your homework

because you're so super organised. And your three take-home tips, actually, for women who are listening. And I know we've covered a lot of information in a short space of time. So some people might want to listen to this podcast more than once because I know there's a lot. But what are your three take-home tips on, Sarah, please?

So my first top tip would be to understand the risks and benefits of the drugs used to treat breast cancer and what this means for you personally. And what I mean by that is if you've been diagnosed with breast cancer and you're taking tomoxifen or an aromatase inhibitor like lectorzole to reduce the risk of recurrence, then make sure you speak to your oncologists and ask what the risks and benefits of that treatment are for you and your breast cancer. And there's something online called the Predict Breast Cancer Screaming tool that actually if you Google, you can find for yourself, you can plug in your own numbers. And it's quite a helpful online tool that you upload your own

tumour characteristics, whether it's spread to the lymph nodes, whether it's a future receptor, positive, negative, etc. And it tells you what your risk of dying, your long-term prognosis is, of breast cancer. And it tells you what your risk is if you don't take endocrine treatment, versus if you do take endocrine treatment. And I think many women will be surprised to learn that actually the benefits of endocrine treatment are small. In some cases, we're literally talking maybe one or two percent difference in terms of their breast cancer mortality. And as we've already said, every patient will have a different threshold of, you know, what's worthwhile, what's acceptable to them. But some women may decide that the benefit for them is too small to continue in view of the

side effects, in which case they could speak to their oncologists about either stopping their treatment or switching to a different treatment, you know. And that in itself might be enough to improve their quality of life, at least temporarily, you know, until a later. time. So that would be my first top tip. My second top tip would be to read about non-hormonal options that are available and to learn more about what you can do for yourself to improve your quality of life. So for example, there's evidence coming out all the time about dietary modification, breathing, yoga, exercise, acupuncture, all those kind of things. It's important to experiment with lots of different options because different things work for different people. Viginal moisturisers

and vaginal lubricants don't contain hormones. They can be very helpful to treat symptoms of vaginal dryness and soreness, which are common in breast cancer survivors. And there are other options. Your GP can prescribe medications, for example, such as antidepressants that will help to reduce the frequency and severity of hot flushes, etc. But if that's not enough, if your symptoms are severe and your quality of life is poor, which we're worried about your long-term health, as we've been discussing, then my final tip, tip three, would be to ask your doctor to explain the risks for you, you decide to take HRT in terms of the risk of breast cancer recurrence and your long-term prognosis versus the risks to your long-term health if you decide not to take HRT.

And vaginal hormones generally are very safe and most oncologists are happy to let their patients take vaginal hormones if they need it. But someone may choose to take HRT and that's fine. If the benefits outweigh the risk for them, then HRT is absolutely an option. And I don't believe that HRT is contraindicated for any woman. I think if the patient in consultation, conversation with the menopause specialist or the oncologist or the breast surgeon of the team around them deems that the benefits outweigh the risks, then HRT is absolutely an option. I think I certainly recommend arming yourself with information and there are lots of helpful excellent resources, of course, on the balanced website, lots of factutes and book fits and podcasts. I would recommend reading estrogen matters by Asin Blooming, and I know he's done a podcast as well with you on balance.

and then have that conversation with your menopause specialist because it's a very personal choice that a woman can only make once she's been given all the information about the relative risks and benefits and shared decision making is key and that's probably a really good note to leave it on. It's so important and there are nice guidance and shared decision making and that should be pivotal to everything that we do as a healthcare professional. So that's been really useful and I hope really useful for others to listen to and hear about the work that we're all doing

and a lot of us are really dedicated to make a huge difference to people going forwards and this will really help with that. So thank you so much for your time today. So I really appreciate it. Thank you. For more information about the perimenopause and menopause, please visit my website, balance hyphen menopause. Or you can download the free balance app, which is available to download from the app store or from Google Play. Thank you.