Preventing endometrial cancer - is it possible?

Endometrial cancer (cancer of the womb lining) is known to be associated in many cases with being overweight, since an imbalance of hormones and growth factors which then stimulate the womb lining can be produced in fat cells. But can maintaining a healthy weight prevent this common disease? According to a new report, it is estimated that 59% of the cases of endometrial cancer (about 29,500 annually in the United States) could be prevented if women engaged in physical activity for at least 30 minutes per day and maintained a healthy body weight, with a body mass index (BMI) from 18.5 to 25.0 kg/m².

The Endometrial Cancer 2013 Report, which was published by the American Institute for Cancer Research (AICR) and World Cancer Research Fund International (WCRF), also notes that coffee consumption reduces the risk.

Increasing evidence has suggested a link between cancer risk and physical activity and body weight. Physical activity and a healthy body weight have been associated with a reduced risk for a number of cancers, including breast, prostate, and colon.

But in the case of endometrial cancer, the relation is quite striking. Currently it is thought that 7 of 10 American women are overweight or obese, and more than half do not get enough exercise to protect themselves against endometrial cancer.

The researchers also found that a high glycemic load, a diet rich in sugar-laden drinks and processed foods high in carbohydrates boosted the risk of developing the disease; it seems that diets that contain a lot of processed foods and sugary drinks can make a difference in the metabolic environment.

Coffee consumption is also associated with a reduced risk for endometrial cancer. Although too much caffeine can affect sleep quality and have other detrimental effects such as on bone health, this study shows that moderate amounts of coffee can be part of a healthy diet, and drinking decaffeinated coffee was also protective.

However, despite the increasing number of studies linking lifestyle and weight to cancer risk and the subsequent media coverage, many people are still unaware of the connection. Surveys have shown that while many people are aware that being overweight increases the risk of type 2 diabetes and heart disease, about half do not see it as a risk factor for cancer.

For someone who is sedentary and overweight, change can be a daunting task. Weight loss should be viewed as a long-term effort, not something that needs to be done immediately. Changes should be made gradually both for weight loss and for increasing exercise. This report did find that activity of all types is important, not just recreational but occupational as well. Physical activity can be done in short bursts of time, even during the work day - go for a 15-minute walk, get up from your desk periodically, take the stairs instead of the lift. It is possible to work physical activity into daily life, even if you have a sedentary job.

It's All About The Ovaries

Through Menopause Matters website and magazine, we have told many personal stories, covered many aspects of the menopause, and hopefully helped many women steer their way through the tangled web which is the transition from reproductive years to the stage of post-reproduction.

The key aspect is the activity of the ovaries. Ovaries working normally release an egg each month and produce the hormones estrogen and progesterone, which affect many systems of the body - this is the normal state in the reproductive years. Ovaries failing to release eggs and failing to produce estrogen and progesterone, whether due to the natural running out of eggs, the removal of ovaries surgically, or the damage to ovaries from other drugs, is the state in the post-reproductive years.

Although emphasis is frequently given to the Menopause, the last menstrual period, the Menopause is in fact only one part of the inevitable process. A term which much more accurately reflects the process is Estrogen deficiency, or, in medical terms, Hypo-estrogenism, not unlike the term Hypo-thyroidism which refers to thyroid failure.

One of my missions is to encourage women and healthcare professionals to think more broadly than just “Menopause” and its early consequences such as hot flushes, and to think more in terms of estrogen deficiency and its early, intermediate and long term consequences.

Only then can the true effects of estrogen deficiency be more widely recognised, so that women can be better prepared to cope with the next phase of their lives as healthily as possible.

To find out more about menopause, and how to improve symptoms, visit Menopause Matters.

Menopause in the Workplace

Women currently make up a huge proportion of the workforce. For those of us who are 'baby boomers' and are now experiencing the hormonal changes of the perimenopause and of the menopause, demands of work can become even more challenging. Many women report great difficulties coping with what was previously manageable due to sleep disturbance and hence tiredness and, in some cases, exhaustion, difficulty concentrating, lack of confidence, anxiety, joint aches, not to mention the embarrassment of the well-known flushes and sweats. Throw into this the demands from teenage children and elderly relatives, and one might wonder how women cope at this stage at all!

The sad truth is that some really struggle and need help, yet often try to get through in the knowledge that for many, these symptoms will pass. The problem is that there is no way of predicting how long the 'early' symptoms of estrogen deficiency of the menopause will last. Many women report sad tales of significant symptoms which they openly admit have affected their ability to do their job necessitating changes in their role, time off work and even early retirement. Not all have received appropriate support and there appears to be a lack of awareness of the impact that menopausal symptoms can have - “isn’t it just about a few flushes?”!

So what can we do? As a doctor working in the field of menopause, I would wish that all women could receive appropriate advice and information about the effects of estogen deficiency, what simple changes women can make to reduce symptoms and improve long term health and what specific treatments are available. Sadly, this vision is a long way off but meanwhile, if symptoms are affecting you and your work, do seek help; ask your GP or Practice Nurse, make an appointment with Occupational Health, and above all, do not battle on alone!

For more information and for support, visit Menopause Matters and the Menopause Matters Forum.

Please let us know below if menopausal symptoms have affected your working day, and what support you've received from health professionals or colleagues.

Renewed Confidence in HRT

Since July 2002, there has been a huge downturn in the confidence of, and use of HRT. The concern about risks of HRT followed publication of results the Women's Health Initiative trial in 2002 and of the Million Women study in 2003. The massive publicity around the apparent risks shown by these studies understandably led to HRT being viewed as dangerous and that it should rarely be used.

Both these studies have since been reviewed and reanalysed and the revised outcomes, along with new studies which have now been published paints a much different picture - when used appropriately, HRT provides more benefits than risks for most women. Yet this message has not yet been widely circulated and I continue to hear of women who have distressing menopausal symptoms, have read thoroughly, weighed up the pros and cons and know that HRT is the best option for them but have to battle with their doctor to be allowed to take it.

To sort out the ongoing confusion, a global team of representatives of Menopause Societies and organisations associated with Women's Health met in November 2012 and have published a global consensus statement. The conclusions are clear:

• HRT is the most effective treatment for symptoms related to the hormonal changes of the menopause, and is beneficial for bone health and may decrease mortality and cardiovascular disease.

• Risks are acknowledged, but benefits will generally outweigh the risks for women under sixty, or within ten years of the menopause. The risks are generally small.

• Taking HRT is a decision which needs to be individualised, in consultation with a suitably qualified physician.

This statement is extrememly important and must be widely circulated and discussed. Women should be able to be access accurate, non-biased information so that they can make informed choices and in managing the consequences of the hormonal changes of the menopause, HRT should once again be considered as a safe option.

Full statement on menopausal hormone therapy.

Read more about hormone replacement therapy.

What do you think? Have you encountered problems with getting your doctor to prescribe you HRT? Please let us know below.

Vaginal Dryness - Lube or Hormones?

Many women experience vaginal changes and vaginal problems due to the lack of estrogen after the menopause. Initially, this can be in the form of dryness during sex. At this stage, lubricants can be used and many effective preparations are available. Some are applied just during sexual activity, others can be applied regularly to maintain the moisture. It is often a case of trial and error to find what works best.

While lubricants and moisturisers can reduce the dryness and ease the discomfort, to treat the underlying problem of the lack of estrogen and consequent changes in vaginal blood flow, secretions, thickness, elasticity and support of the vaginal skin and acidity level, consideration should be given to replacing estrogen which can either be in the form of HRT (hormones which circulate throughout the body and would be used if other generalised menopausal symptoms are also present) or vaginal estrogen.

The debate around the risks and benefits of HRT continues, but it should be understood that vaginal estrogen provides a very low dose of estrogen which is concentrated in the vagina and bladder with minimal absorption around the body. Therefore, vaginal estrogen can be used by women who either do not want to take HRT, or have been advised not to take HRT.

Various types of vaginal estrogen treatments are available and again, it may require trial and error to find which suits best. Preparations include small vaginal tablets inserted by an applicator, vaginal creams, pessaries and a three monthly vaginal ring. Vaginal tablets, creams and pessaries are used every night for two weeks, during which time there may be a little absorption and some women may notice breast tenderness. This should not cause concern. After the first two weeks, the maintenance dose is twice weekly, during which the absorption is minimal and any breast tenderness should settle. The vaginal ring is changed every three months and produces a small regular amount of vaginal estrogen. Vaginal estrogen used at the maintenance doses can be used long term, there being no known risks with many years of treatment. Indeed, we know that if vaginal estrogen is stopped, the symptoms frequently return and long-term treatment is recommended.

Whatever you choose, be aware of menopausal effects on the vagina and look after your vagina in the happy, healthy years ahead!

See more at Menopause Matters.

What do you think? Is this a problem you've encountered yourself? If so, what impact has it had on your relationship and sex life?

Why Do We Flush?

Flushes and sweats are the classic, well-known menopause symptoms, or can be caused by estrogen deficiency. We have all heard of them, yet we still know relatively little about why they happen and why there is such variation in their severity and duration. From what we do know, it seems that we have a thermostat in the brain which regulates our body temperature. If our core temperature rises, as happens if we have an infection, a fever, then our thermostat triggers cooling down mechanisms such as opening up surface blood vessels (the flush) and switching on sweat production. These measures ensure that our body organs do not become too hot. In the reverse situation, if our core body temperature falls, our thermostat switches on heating up mechanisms such as shivering, in order to maintain temperature.

During every day, our core temperature fluctuates by a few degrees but our thermostat works within a buffering zone, so that we don’t spend the whole day flushing, sweating or shivering. Even additional changes in temperature as brought about by hot or cold drinks, being outside or inside, emotion or stress do not normally lead to triggering by the thermostat. However, with estrogen deficiency of the menopause, the thermostat changes in action so that even the normal daily temperature changes and additional ones described, can lead to unnecessary flushes, sweats and shivers - the thermostat thinks that the body is over-heating, or over-cooling when it is not.

While it appears that estrogen deficiency is a cause of changing thermostat function, it is clearly not the only factor since menopausal women, with the same changing and low levels of estrogen, can have very different levels and duration of symptoms. Diet and lifestyle factors are involved with being overweight, drinking alcohol and caffeine, and smoking leading to worse symptoms. Other chemicals such as serotonin, noradrenaline and gamma aminobutyric acid are also likely to be involved and the recognition of their involvement has led to the development of other non-hormonal drugs which can be prescribed to reduce symptoms in women who are not able or willing to take HRT.

So while research continues into the mechanisms and treatments for flushes and sweats, we should try to maintain a healthy weight, eat a healthy, balanced diet, minimise alcohol and caffeine, not smoke, take plenty of exercise, wear loose layered clothing, and generally look after ourselves whilst considering treatments to minimise symptoms of the menopause and the impact that they may have on our lives.

See more at Menopause Matters.

Breast Cancer and HRT - Fact or Fiction?

While the role of HRT for treatment of menopausal symptoms, treatment of premature menopause and beneficial effect on bones should now be well established, the debate about HRT and breast cancer risk continues.

Following a massive drop in use of HRT after publication of the Women’s Health Initiative (WHI) trial in 2002 and Million Women Study (MWS) in 2003, an apparent drop in rates of breast cancer was claimed to provide further evidence that HRT did indeed cause breast cancer. However, researchers from Cape Town University, writing in the journal of Family Planning and Reproductive Healthcare, state that it is impossible to establish a causal link. Breast cancer rates actually started to fall in 1999, before the drop in use of HRT, and the drop seen in 2002 to 2004 was far too early to be due to the fall in use of HRT.

The same journal, in 2012, published reviews by Shapiro et al of both the WHI trial and the MWS and concluded that these studies did not in fact prove a link between HRT and breast cancer.

So, can we be completely reassured that HRT does not cause breast cancer, and can women go back to using HRT without any fear that it will increase their risk of this tragic disease? It seems that it is extremely unlikely that HRT causes breast cells to become cancerous. But it is possible that, if certain types of HRT (combined HRT containing estrogen and progestogen, rather than estrogen alone) are taken for more than five years after the age of fifty, there may be promotion of cancer cells which are already present in some women, but not in the majority. To add to the complexity, even within types of combined HRT, it appears that different progestogens have differing effects, some types appearing to be “breast-friendly”.

Finally, to try to understand the level of risk, it is known that drinking two or more units of alcohol per day, or being overweight after the menopause both provide a far greater level of risk than taking HRT for five years. Read more about the effects of diet, exercise and lifestyle on menopause.

No medicine is perfect and everything that we do carries some level of risk. It is essential that women who are considering taking HRT, and healthcare professionals who are considering prescribing HRT, should access accurate information to help them make informed choices. Currently, many women are missing out on the benefits of HRT because of fear of risk. But for the majority, when HRT is used appropriately,  the benefits outweigh the risks.

You can see more about balancing the risks and benefits of HRT at http://www.menopausematters.co.uk/pdf/breastCancerRisklinks.pdf