Two medical doctors specialising in gynaecology and obstetrics met up for a conversation - Skrinings.lv ambassador Laura Luse interviewed Elizabete Pumpure.
The topic of today's conversation is dedicated to hormone-dependent processes, including menstruation, menopause and breastfeeding, that can affect the risk of developing breast cancer. A commonly asked question is how can such factors, like the age of your first period or the start of menopause, impact this risk? It is important to emphasize that in discourse around hormonal risks of breast cancer, hormonal contraception is often singled out as a primary focus. It is important to acknowledge that this is not the only hormonal risk factor that women are exposed to. A woman's body goes through a variety of hormonal changes and fluctuations, beginning from starting the menstrual cycle up until menopause and after, hitting fundamental milestones of contraceptive use, pregnancy and breast-feeding in the middle.
L: We can begin this conversation by discussing the correlation that the longer a woman's menstrual cycle is, the longer she is exposed to hormonal fluctuations. How exactly does early-onset of menstruation or delayed menopause impact your risk of developing breast cancer?
E: The biggest risk factor for breast cancer remains the female gender, as women are approximately one hundred times more likely to develop breast cancer than men. This can be explained by the particularity of the female gender - women are exposed to drastic estrogen and progesterone hormone fluctuations. These fluctuations can contribute and impact the formation of hormone-dependent tumours, for example, breast cancer. A term called estrogen exposure explains this correlation - the more estrogen a woman receives, the larger her risk is. Unfortunately, we cannot determine the age that our menstrual cycle starts at, however knowing this to be a potential risk factor, we allow us to pay greater attention to it. Sensitivity towards hormonal fluctuations can manifest as pain and soreness in the breasts, which is a relatively common symptom for women before menstruation or during ovulation. These pains for the majority of times are not related to increased risk of breast cancer, however, if there are other noticeable changes it is imperative to visit a doctor. The pain can be attributed to drastic changes in hormonal concentration during menstruation, which is a normal occurrence. In addition, it is worth defining the age that qualifies as early-onset menstruation. Currently the age is set as below 12 years, however an observable worldwide tendency demonstrates that girls are starting their periods earlier and earlier, beginning from age of 11. On the other hand, the age that qualifies late-onset menopause is 55 years based on current standards. The average age in the population to exhibit the beginning of menopause is around 50. This is the age that sees a spike in breast cancer risk and women in Latvia receive official invitations for mammograms and other breast screenings. These factors are often inherited traits that are reflected in family history, meaning that if the mother has late-onset menopause or begins menstruating early, most likely this will be the same experience for the daughter.
L: Similarly it is important to mention, that early-onset menstruation or delayed menopause are only a few of the risk factors that impact the possible development of breast cancer. If we compare disease risk factors to a puzzle, this would just be a piece in the greater picture of illness development. Women, who have experienced early-onset menstruation or observed a delay in menopause, should not be alarmed but rather approach this information with caution. These are the factors that are worth mentioning during visits to the doctor or gynaecologist.
L: I also want to touch on the topic of hormone phobias. Women are often distrustful and at times exhibit fear over the use of artificial hormones that can impact the risk of breast cancer development. In clinical practice with patients, have You encountered any prejudices against the use of hormonal contraceptives?
E: Of course, my job as a gynaecologist guarantees involvement in a woman's life from the moment of birth to menopause and later. Many different women turn to me for the initial start of hormonal contraceptives, either because of irregularities in their menstrual cycle or as a method of birth control and prevention from unwanted pregnancies. The statistics in Latvia, compared to other countries, demonstrate that women are often hesitant in their use of hormonal contraceptives. To answer the question why, fear of breast cancer is not a common response. Most often this is attributed to fears of weight gain or the deterioration of ovary function. Fears connected to breast cancer are very rare. In my clinical practice I am guided by the UK developed UKMEC (UK Medical Eligibility Criteria for Contraceptive Use) scale to assess and get to know my patients, in order to accurately determine their risks - not only their breast cancer but blood clot risks as well. This allows for finding the most suitable form of hormonal birth control for every woman. One more important aspect to mention, is that hormonal contraception often decreases certain risks, including lowering the risk of ovarian cancer by around 50%, decreasing the likelihood of stomach and bowel cancer and cancer of the inner lining of the uterus otherwise known as endometrial cancer. Regarding breast cancer, the relative risk is 1,24, which is relatively low, however this does not imply an existing correlation that has currently been proven. It is important to mention that this relative risk evens out within ten years after stopping the use of hormonal birth control. Hormonal therapy during menopause has a slightly higher risk but as previously mentioned, this risk also evens out after stopping the use of the hormonal contraceptives. We cannot forget that age remains one of the most significant risk factors that affects everyone.
L: In addition to increasing age as a prominent risk factor, that becomes particularly relevant after the age of 35, genetic predisposition towards breast cancer starts playing a larger role at this stage of life. The result of these risk factors coming together, can often explain the unfortunately difficult and at times tragic diagnosis of breast cancer. The longer we live, the more we expose ourselves to various harmful forces and environments, including leading an unhealthy lifestyle. As gynaecologists we prescribe hormonal contraceptives to healthy women after carefully analysing all of the possible risks. It is the doctor’s duty to evaluate all of the contributing factors and provide guidance on the suitable choice based on the patient’s profile.
L: Is there a need to take a break after the long-term use of hormonal contraceptives, if you have no complaints?
E: So many speculations circulate around the necessity to take a break or a pause after taking hormonal contraception for a certain amount of time. What I say, is that if a woman does not wish to conceive and is using hormonal contraception as a form of birth control, she can use it long-term. Of course, other medical experts suggest taking a six month pause after eight to ten year use of hormonal contraception, however objectively this does not change much. Hormonal contraception as a method of birth control is reversible, meaning after stopping the intake of the pills, your hormonal axis recognises the lack of artificial hormones and begins the naturally occurring cycle. The reason why this particular question is often asked, comes from the speculation that long-term birth control use is associated with infertility or a woman’s inability to have children. I would like to turn your attention to the fact that if a woman has been using hormonal contraception for ten or more years, then the factor of age, reaching age 35 will be a more significant contributor in her ability to conceive. The length of the use of hormonal contraception will not be the deciding aspect here. With age the ovarian reserve diminishes, which directly impacts a woman’s reproductive abilities. There is no medical guidance that states the absolute necessity to take a break after the use of hormonal pills in the long-term. My suggestion with time would be to consider switching from birth control pills to a IUD perhaps, that requires no daily effort. In the end, it is absolutely a woman's personal choice to decide, which contraceptive is the most appropriate to their lifestyle and it is the gynaecologist’s responsibility to provide information on all of the possible choices.
L: The next life stage in a woman’s reproductive journey involves the planning of pregnancy and breast-feeding. How exactly are pregnancy and breast-feeding related to risk of developing breast cancer?
E: When a woman conceives and later begins breast-feeding her child, the woman’s body goes through a hormonal respite, otherwise understood as a resting period. During these few years, the persistent impact of estrogen is disrupted. Likewise, breast-feeding serves as a positive factor in reducing the risk of breast cancer as during this time breast tissue cells produce milk necessary to feed the child, the designated function of those cells. In effect, a pregnancy before the age of 35 carries protective qualities in regard to breast cancer development. However, beginning a pregnancy and breast-feeding after the age of 35, the risk of malignant cell division increases that can form the basis of a cancerous tumour. Overall, pregnancy and breast-feeding is associated with decreased risk of developing breast cancer granted it happens before a certain age.
L: Wrapping up this conversation, what takeaway message would You like to pass on to the readers related to the hormonal cycle, menstruation and breast cancer?
E: A lot of women after detecting changes in their breasts are afraid to turn to their doctors and seek help, which serves contradictory to receiving an early diagnosis and the ability to successfully treat breast cancer. We are a nation of strong women, which means prioritizing our health, especially when it comes to reproductive health. Health should always remain the top priority and it is essential to find time to at least respond to the letters inviting women to receive the necessary breast screenings and other examinations. Ideally, women would perform monthly self-examinations and report to trusted doctors in cases of abnormal changes or concerns. Performing breast screenings regularly guarantees improved quality of life, allowing women to feel confident in their health and live life fearlessly.
The full conversation in video format can be found on the Skrinings.lv Facebook page. There you will find out more about the impacts of emergency birth control as well as answers to other questions.