tag:theconversation.com,2011:/id/topics/oestrogen-8353/articlesOestrogen – The Conversation2024-02-26T01:47:21Ztag:theconversation.com,2011:article/2242372024-02-26T01:47:21Z2024-02-26T01:47:21ZWhat is Ryeqo, the recently approved medicine for endometriosis?<figure><img src="https://images.theconversation.com/files/577738/original/file-20240225-24-jk5b3s.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5991%2C3997&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/woman-suffering-from-a-stomach-pain-5938369/">Pexels/Sora Shimazaki</a></span></figcaption></figure><p>For women diagnosed with endometriosis it is often a long sentence of chronic pain and cramping that <a href="https://www.instagram.com/p/CP2i5xKl9tS/">impacts their daily life</a>. It is a condition that is both difficult to diagnose and treat, with many women needing either <a href="https://www.thewomens.org.au/health-information/periods/endometriosis/">surgery or regular medication</a>.</p>
<p>A medicine called Ryeqo has just been approved for marketing specifically for endometriosis, although it was already available in Australia to treat a different condition.</p>
<p>Women who want the drug will need to consult their local doctor and, as it is not yet on the Pharmaceutical Benefits Scheme, they will need to pay the full cost of the script.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/people-with-endometriosis-and-pcos-wait-years-for-a-diagnosis-attitudes-to-womens-pain-may-be-to-blame-179500">People with endometriosis and PCOS wait years for a diagnosis – attitudes to women’s pain may be to blame</a>
</strong>
</em>
</p>
<hr>
<h2>What does Ryeqo do?</h2>
<p>Endometriosis <a href="https://www.aihw.gov.au/reports/chronic-disease/endometriosis-in-australia/contents/how-common-is-endometriosis">affects 14% of women of reproductive age</a>. While we don’t have a full understanding of the cause, the evidence suggests it’s due to body tissue that is similar to the lining of the uterus (called the endometrium) growing outside the uterus. This causes pain and inflammation, which reduces quality of life and can also affect fertility.</p>
<p>Ryeqo is a tablet containing three different active ingredients: relugolix, estradiol and norethisterone. </p>
<p>Relugolix is a drug that blocks a particular peptide from releasing other hormones. It is also used in the <a href="https://www.mayoclinic.org/drugs-supplements/relugolix-oral-route/description/drg-20506394">treatment of prostate cancer</a>. Estradiol is a naturally occurring oestrogen hormone in women that helps regulate the menstrual cycle and is used in <a href="https://www.menopause.org.au/health-info/fact-sheets/what-is-menopausal-hormone-therapy-mht-and-is-it-safe">menopausal hormone therapy</a>. Norethisterone is a synthetic hormone commonly used in birth control medications and to <a href="https://www.netdoctor.co.uk/medicines/a8713/norethisterone/">delay menstruation and help with heavy menstrual bleeding</a>.</p>
<p>All three components work together to regulate the levels of oestrogen and progesterone in the body that contribute to endometriosis, alleviating its symptoms. </p>
<p>Relugolix reduces the overall levels of oestrogen and progesterone in the body. The estradiol compensates for the loss of oestrogen because low oestrogen levels can cause hot flushes (also called hot flashes) and bone density loss. And norethisterone blocks the effects of estradiol on the uterus (where too much tissue growth is unwanted).</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-new-government-inquiry-will-examine-womens-pain-and-treatment-how-and-why-is-it-different-221747">A new government inquiry will examine women's pain and treatment. How and why is it different?</a>
</strong>
</em>
</p>
<hr>
<h2>Is it really new?</h2>
<p>The maker of Ryeqo claims it is the <a href="https://www.gedeonrichter.com/au/-/media/sites/au/documents/media-release-c_ryeqo-tga-approval_gedeon-richter-australia_final.pdf?rev=1cc37d3726f84e9ca71d4c094c1e3dd6">first new drug for endometriosis in Australia in 13 years</a>.</p>
<p>But individually, all three active ingredients in Ryeqo have been in use since <a href="https://link.springer.com/article/10.1007/s40265-019-01105-0#:%7E:text=Relugolix%20received%20its%20first%20global,with%20uterine%20fibroids%20in%20Japan.">2019</a> or earlier. </p>
<p>Ryeqo has been available in Australia <a href="https://www.tga.gov.au/resources/artg/375414">since 2022</a>, but until now was not specifically indicated for endometriosis. It was originally approved for the treatment of <a href="https://www.ema.europa.eu/en/medicines/human/EPAR/ryeqo">uterine fibroids</a>, which share some <a href="https://www.medicalnewstoday.com/articles/fibroid-vs-endometriosis#similarities">common symptoms</a> with endometriosis and have related causes.</p>
<p>In addition to Ryeqo, current medical guidance lists other drugs that are suitable for endometriosis and some reformulations of these have also only been recently approved. </p>
<p>The oral medicine <a href="https://www.tga.gov.au/resources/artg/336684">Dienogest</a> was approved in 2021, and there have been a number of injectable drugs for endometriosis recently approved, such as <a href="https://www.tga.gov.au/resources/artg/401897">Sayana Press</a> which was approved in a smaller dose form for self-injection in 2023. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/577780/original/file-20240225-28-5t517.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="hands taking pill out of contraceptive blister pack" src="https://images.theconversation.com/files/577780/original/file-20240225-28-5t517.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/577780/original/file-20240225-28-5t517.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/577780/original/file-20240225-28-5t517.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/577780/original/file-20240225-28-5t517.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/577780/original/file-20240225-28-5t517.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/577780/original/file-20240225-28-5t517.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/577780/original/file-20240225-28-5t517.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">You can’t take the contraceptive pill with Ryeqo but the endometriosis drug could replace it.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/contraceptive-pill-174193232">Shutterstock</a></span>
</figcaption>
</figure>
<h2>How to take it and what not to do</h2>
<p>Ryeqo is a once-a-day tablet. You can take it with, or without food, but it should be taken about the same time each day.</p>
<p>It is recommended you start taking Ryeqo within the first five days after the start of your next period. If you start at another time during your period, you may experience initial irregular or heavier bleeding.</p>
<p>Because it contains both synthetic and natural hormones, you can’t use the contraceptive pill and Ryeqo together. However, because Ryeqo does contain norethisterone it can be used as your contraception, although <a href="https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent=&id=CP-2023-CMI-01327-1&d=20240224172310101">it will take at least one month of use to be effective</a>. So, if you are on Ryeqo, you should use a non-hormonal contraceptive – such as condoms – for a month when starting the medicine.</p>
<p>Ryeqo may be incompatible with other medicines. It might not be suitable for you if you take medicines for epilepsy, HIV and AIDS, hepatitis C, fungal or bacterial infections, high blood pressure, irregular heartbeat, angina (chest pain), or organ rejection. You should also not take Ryeqo if you have a liver tumour or liver disease.</p>
<p>The possible <a href="https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2022-PI-01955-1">side effects of Ryeqo</a> are similar to those of oral contraceptives. Blood clots are a risk with any medicine that contains an oestrogen or a progestogen, which Ryeqo does. Other potential side effects include bone loss, a reduction in menstrual blood loss or loss of your period.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/whats-a-tens-machine-can-it-help-my-period-pain-or-endometriosis-201389">What's a TENS machine? Can it help my period pain or endometriosis?</a>
</strong>
</em>
</p>
<hr>
<h2>It’s costly for now</h2>
<p>Ryeqo can now be prescribed in Australia, so you should discuss whether Ryeqo is right for you with the doctor you usually consult for your endometriosis. </p>
<p>While the maker has made a submission to the Pharmaceutical Benefits Advisory Committee, it is not yet subsidised by the Australian government. This means that rather than paying the <a href="https://www.pbs.gov.au/info/healthpro/explanatory-notes/front/fee">normal PBS price of up to A$31.60</a>, it has been reported it may <a href="https://www.9news.com.au/national/it-never-stops-new-drug-approved-to-treat-endometriosis-after-decade-of-pain/b51f0e92-6dd8-4812-800a-eadac0d55218">cost as much as $135</a> for a one-month supply. The committee will make a decision on whether to subsidise Ryeqo at its meeting next month.</p>
<hr>
<p><em>Correction: this article has been updated to clarify the recent approval of specific formulations of drugs for endometriosis.</em></p><img src="https://counter.theconversation.com/content/224237/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nial Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is a Fellow of the Royal Australian Chemical Institute, a member of the Australasian Pharmaceutical Science Association, and a member of the Australian Institute of Company Directors. Nial is the chief scientific officer of Vaihea Skincare LLC, a director of SetDose Pty Ltd a medical device company, and a Standards Australia panel member for sunscreen agents. Nial regularly consults to industry on issues to do with medicine risk assessments, manufacturing, design, and testing.</span></em></p><p class="fine-print"><em><span>Jasmine Lee does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A drug newly approved by the Therapeutic Goods Administration for endometriosis is available in Australia.Nial Wheate, Associate Professor of the School of Pharmacy, University of SydneyJasmine Lee, Pharmacist and PhD Candidate, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2121982023-12-20T00:14:19Z2023-12-20T00:14:19ZWhat happens to your vagina as you age?<figure><img src="https://images.theconversation.com/files/565380/original/file-20231213-23-r8q3y2.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3000%2C2276&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/realistic-3d-paper-cut-human-uterus-2210475317">Dedraw Studio/Shutterstock</a></span></figcaption></figure><p>The vagina is an internal organ with a complex ecosystem, influenced by circulating hormone levels which change during the menstrual cycle, pregnancy, breastfeeding and menopause.</p>
<p>Around and after menopause, there are normal changes in the growth and function of vaginal cells, as well as the vagina’s microbiome (groups of bacteria living in the vagina). Many women won’t notice these changes. They don’t usually cause symptoms or concern, but if they do, symptoms can usually be managed.</p>
<p>Here’s what happens to your vagina as you age, whether you notice or not.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/friday-essay-grey-haired-and-radiant-reimagining-ageing-for-women-182336">Friday essay: grey-haired and radiant – reimagining ageing for women</a>
</strong>
</em>
</p>
<hr>
<h2>Let’s clear up the terminology</h2>
<p>We’re focusing on the <a href="https://www.ncbi.nlm.nih.gov/books/NBK545147/">vagina</a>, the muscular tube that goes from the external genitalia (the vulva), past the cervix, to the womb (uterus). Sometimes the word “vagina” is used to include the external genitalia. However, these are different organs and play different roles in women’s health.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/565381/original/file-20231213-17-grlu25.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Diagram of female reproductive system including the vagina" src="https://images.theconversation.com/files/565381/original/file-20231213-17-grlu25.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/565381/original/file-20231213-17-grlu25.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=428&fit=crop&dpr=1 600w, https://images.theconversation.com/files/565381/original/file-20231213-17-grlu25.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=428&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/565381/original/file-20231213-17-grlu25.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=428&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/565381/original/file-20231213-17-grlu25.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=538&fit=crop&dpr=1 754w, https://images.theconversation.com/files/565381/original/file-20231213-17-grlu25.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=538&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/565381/original/file-20231213-17-grlu25.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=538&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">We’re talking about the internal organ, the vagina.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/female-reproductive-system-image-diagram-243154639">Suwin66/Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/vulvas-periods-and-leaks-women-need-the-right-words-to-seek-help-for-conditions-down-there-53638">Vulvas, periods and leaks: women need the right words to seek help for conditions 'down there'</a>
</strong>
</em>
</p>
<hr>
<h2>What happens to the vagina as you age?</h2>
<p>Like many other organs in the body, the vagina is sensitive to female sex steroid hormones (hormones) that change around puberty, pregnancy and menopause. </p>
<p>Menopause is associated with a drop in circulating oestrogen concentrations and the hormone progesterone is no longer produced. The changes in hormones affect the vagina and its ecosystem. <a href="https://www.ncbi.nlm.nih.gov/books/NBK564341/">Effects</a> may include:</p>
<ul>
<li>less vaginal secretions, potentially leading to dryness </li>
<li>less growth of vagina surface cells resulting in a thinned lining</li>
<li>alteration to the support structure (connective tissue) around the vagina leading to less elasticity and more narrowing</li>
<li>fewer blood vessels around the vagina, which <a href="https://pubmed.ncbi.nlm.nih.gov/2989746/">may explain</a> less blood flow after menopause</li>
<li>a <a href="https://www.nature.com/articles/s41564-022-01083-2">shift</a> in the type and balance of bacteria, which can change vaginal acidity, from more acidic to more alkaline. </li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/essays-on-health-microbes-arent-the-enemy-theyre-a-big-part-of-who-we-are-79116">Essays on health: microbes aren't the enemy, they're a big part of who we are</a>
</strong>
</em>
</p>
<hr>
<h2>What symptoms can I expect?</h2>
<p>Many women do not notice any bothersome vaginal changes as they age. There’s also little evidence many of these changes cause vaginal symptoms. For example, there is no direct evidence these changes cause vaginal infection or bleeding in menopausal women. </p>
<p>Some women notice vaginal dryness after menopause, which may be linked to less vaginal secretions. This may lead to pain and discomfort during sex. But it’s not clear how much of this dryness is due to menopause, as younger women also commonly report it. In <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6136974/pdf/nihms957122.pdf">one study</a>, 47% of sexually active postmenopausal women reported vaginal dryness, as did around 20% of premenopausal women.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/562316/original/file-20231129-21-kae382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two cut grapefruit, one drier than the other" src="https://images.theconversation.com/files/562316/original/file-20231129-21-kae382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/562316/original/file-20231129-21-kae382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/562316/original/file-20231129-21-kae382.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/562316/original/file-20231129-21-kae382.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/562316/original/file-20231129-21-kae382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/562316/original/file-20231129-21-kae382.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/562316/original/file-20231129-21-kae382.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Vaginal dryness is common but it can also affect younger women.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/fresh-grapefruit-stale-on-pink-background-1115302421">ECOSY/Shutterstock</a></span>
</figcaption>
</figure>
<p>Other organs close to the vagina, such as the bladder and urethra, are also affected by the change in hormone levels after menopause. Some women experience recurrent urinary tract infections, which may cause pain (including pain to the side of the body) and irritation. So their symptoms are in fact not coming from the vagina itself but relate to changes in the urinary tract. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-long-does-menopause-last-5-tips-for-navigating-uncertain-times-195211">How long does menopause last? 5 tips for navigating uncertain times</a>
</strong>
</em>
</p>
<hr>
<h2>Not everyone has the same experience</h2>
<p>Women vary in whether they notice vaginal changes and whether they <a href="https://www.flinders.edu.au/research/vitalmeno">are bothered</a> by these to the same extent. For example, women with vaginal dryness who are not sexually active may not notice the change in vaginal secretions after menopause. However, some women notice severe dryness that affects their daily function and activities.</p>
<p>In fact, <a href="https://www.imsociety.org/2021/06/21/a-core-outcome-set-for-vasomotor-symptoms-associated-with-menopause-the-comma-core-outcomes-in-menopause-global-initiative/">researchers globally</a> are taking more notice of women’s experiences of menopause to inform future research. This includes prioritising symptoms that matter to women the most, such as vaginal dryness, discomfort, irritation and pain during sex.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/vaginas-pheromones-and-tiktok-what-is-the-strange-new-trend-of-vabbing-187431">Vaginas, pheromones and TikTok: what is the strange new trend of 'vabbing'?</a>
</strong>
</em>
</p>
<hr>
<h2>If symptoms bother you</h2>
<p>Symptoms such as dryness, irritation, or pain during sex can usually be effectively managed. Lubricants may reduce pain during sex. Vaginal moisturisers may reduce dryness. Both are available over-the-counter at your local pharmacy. </p>
<p>While there are many small clinical trials of individual products, these studies <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8942543/">lack the power</a> to demonstrate if they are really effective in improving vaginal symptoms. </p>
<p>In contrast, there is robust evidence that vaginal oestrogen is <a href="https://www.cochrane.org/CD001500/MENSTR_use-postmenopausal-women-creams-pessaries-or-vaginal-ring-apply-oestrogen-vaginally-symptoms-vaginal">effective</a> in treating vaginal dryness and reducing pain during sex. It also <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005131.pub2/full">reduces</a> your chance of recurrent urinary tract infections. You can talk to your doctor about a prescription. </p>
<p>Vaginal oestrogen is usually inserted using an applicator, two to three times a week. Very little is absorbed into the blood stream, it is <a href="https://pubmed.ncbi.nlm.nih.gov/31913230/">generally safe</a> but longer-term trials are required to confirm safety in long-term use beyond a year. </p>
<p>Women with a <a href="https://www.menopause.org.au/hp/position-statements/the-use-of-vaginal-estrogen-in-women-with-a-history-of-estrogen-dependent-breast-cancer">history of breast cancer</a> should see their oncologist to discuss using oestrogen as it may not be suitable for them.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/your-vagina-cleans-itself-why-vagina-cleaning-fads-are-unnecessary-and-harmful-88150">Your vagina cleans itself: why vagina cleaning fads are unnecessary and harmful</a>
</strong>
</em>
</p>
<hr>
<h2>Are there other treatments?</h2>
<p>New treatments for vaginal dryness are under investigation. One avenue relates to our growing understanding of how the vaginal microbiome adapts and modifies around changes in circulating and local concentrations of hormones.</p>
<p>For example, a <a href="https://pubmed.ncbi.nlm.nih.gov/29381086">small number of reports</a> show that combining vaginal probiotics with low-dose vaginal oestrogen can improve vaginal symptoms. But more evidence is needed before this is recommended.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-should-healthy-people-take-probiotic-supplements-95861">Health Check: should healthy people take probiotic supplements?</a>
</strong>
</em>
</p>
<hr>
<h2>Where to from here?</h2>
<p>The normal ageing process, as well as menopause, both affect the vagina as we age.</p>
<p>Most women do not have troublesome vaginal symptoms during and after menopause, but for some, these may cause discomfort or distress. </p>
<p>While hormonal treatments such as vaginal oestrogen are available, there is a pressing need for more non-hormonal treatments.</p>
<hr>
<p><em>Dr Sianan Healy, from Women’s Health Victoria, contributed to this article.</em></p><img src="https://counter.theconversation.com/content/212198/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Martha Hickey previously received research funding for a study of an ultrasound device for vaginal dryness (Madorra)</span></em></p><p class="fine-print"><em><span>Louie Ye does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Dryness, irritation, or pain during sex can be managed. But not everyone has these symptoms or is bothered by them.Louie Ye, Clinical Fellow, Department of Obstetrics and Gynecology, The University of MelbourneMartha Hickey, Professor of Obstetrics and Gynaecology, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2085022023-09-05T12:56:59Z2023-09-05T12:56:59ZFive ways to take control of your menstrual cycle and improve your sports performance<figure><img src="https://images.theconversation.com/files/542580/original/file-20230814-25-aydj9i.jpg?ixlib=rb-1.1.0&rect=0%2C11%2C7360%2C4594&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Taking a proactive approach to your menstrual cycle can help promote your sports performance every day.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/fit-young-woman-lifting-barbells-looking-417189208">Ground Picture/Shutterstock</a></span></figcaption></figure><p>Menstruation is often seen as a negative experience, with symptoms that can be disruptive to daily life. Participation in sport and physical activity is particularly affected, with <a href="https://womeninsport.org/press-release/more-than-1-million-teenage-girls-fall-out-of-love-with-sport/#:%7E:text=Women%20in%20Sport's%20research%20found,them%20take%20part%20in%20activity.">78%</a> of teenage girls reporting they avoid exercise while on their period. </p>
<p>Elite athletes have also <a href="https://www.bbc.co.uk/sport/53705777">reported</a> their performance is negatively affected by their period. So, how do we reduce or manage period-related symptoms? The first step is understanding our menstrual cycle.</p>
<p>There are <a href="https://optimalperiod.com/menstrual-cycle-101/">phases of the menstrual cycle</a>, based upon hormonal fluctuations, where certain symptoms are more frequently experienced. The two main phases are the follicular phase and the luteal phase and they are divided by ovulation. A menstrual cycle should last between 21 and 35 days, with menstruation indicating day one of the cycle and the number of days until the next bleed. Ovulation is approximately half way through the cycle.</p>
<hr>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p><em>This article is part of <a href="https://theconversation.com/uk/topics/womens-health-matters-143335">Women’s Health Matters</a>, a series about the health and wellbeing of women and girls around the world. From menopause to miscarriage, pleasure to pain the articles in this series will delve into the full spectrum of women’s health issues to provide valuable information, insights and resources for women of all ages.</em></p>
<p><em>You may be interested in:</em></p>
<p><em><a href="https://theconversation.com/five-old-contraception-methods-that-show-why-the-pill-was-a-medical-breakthrough-207572">Five old contraception methods that show why the pill was a medical breakthrough
</a></em></p>
<p><em><a href="https://theconversation.com/the-orgasm-gap-and-why-women-climax-less-than-men-208614">The orgasm gap and why women climax less than men</a></em></p>
<p><em><a href="https://theconversation.com/science-experiments-traditionally-only-used-male-mice-heres-why-thats-a-problem-for-womens-health-205963">Science experiments traditionally only used male mice – here’s why that’s a problem for women’s health</a></em></p>
<hr>
<p>This is different for those taking hormonal contraceptives, as their natural hormone levels are suppressed by the synthetic hormones and any bleed is known as a “withdrawal bleed”, which is not equivalent to a period.</p>
<p>During the follicular phase, hormone levels are low to begin with. The first three to five days are the time of menstruation and an increase in oestrogen occurs prior to ovulation. For some, this phase provides many positive symptoms of increased confidence, energy and motivation. </p>
<p>After ovulation, hormone levels are higher, with a peak in progesterone and a secondary peak in oestrogen. It is during this time that the menstrual cycle is frequently associated with negative symptoms such as bloating, fatigue and changes in mood.</p>
<p>But we know that menstrual-related symptoms can be improved through diet, sleep, reducing stress and exercising. So taking a proactive approach can help to promote sports performance on every day of the menstrual cycle.</p>
<figure class="align-center ">
<img alt="A hand holds a smartphone which is displaying a menstrual calendar app." src="https://images.theconversation.com/files/541696/original/file-20230808-27-20hbe1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/541696/original/file-20230808-27-20hbe1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/541696/original/file-20230808-27-20hbe1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/541696/original/file-20230808-27-20hbe1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/541696/original/file-20230808-27-20hbe1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/541696/original/file-20230808-27-20hbe1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/541696/original/file-20230808-27-20hbe1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There are apps which can help you track your menstrual symptoms.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-tracking-periods-by-using-menstrual-1940658049">Kaspars Grinvalds/Shutterstock</a></span>
</figcaption>
</figure>
<h2>1. Track your cycle</h2>
<p>Tracking your menstrual cycle and related symptoms is crucial to taking a proactive approach. Note the first day of your period to check you are having a regular cycle. This is an <a href="https://pubmed.ncbi.nlm.nih.gov/32707266/">important marker</a> for both reproductive and holistic health. </p>
<p>Record any <a href="https://optimalperiod.com/menstrual-cycle-101/">symptoms</a> such as stomach cramps, fatigue and tiredness, changes in mood, anxiety and breast tenderness, along with life events. This helps to determine what’s caused by the menstrual cycle as opposed to other factors. </p>
<p>Complete this for at least three cycles to identify your own pattern. Everyone has a unique experience of the menstrual cycle and related symptoms. </p>
<p>See a doctor if your cycle consistently lasts less than 21 days, is longer than 35 days or absent for three months or more, after the first two years of having periods. If any symptoms are debilitating and affect your daily activities, this is not normal and you need to seek medical advice.</p>
<h2>2. Improve your diet and hydration</h2>
<p>Eat a <a href="https://www.nhs.uk/live-well/eat-well/food-guidelines-and-food-labels/the-eatwell-guide/">well-balanced diet</a>, because this will help give you the energy for training and sport, while also reducing bloating and managing <a href="https://optimalperiod.com/exploring-symptoms-3-what-causes-food-cravings-with-top-tips-on-management/">cravings</a>. </p>
<p>If you train hard, ensure you are <a href="https://optimalperiod.com/wp-content/uploads/2023/02/FAH-carbohydate.pdf">fuelling your training</a> appropriately to support your menstrual cycle. This changes according to what activity you’re participating in. For example, for high intensity workouts, you will need some quick releasing carbohydrate such as a banana or an energy drink during your session, as well as before and after.</p>
<p>If you can, don’t eat too many processed foods such as takeaways, sugary drinks and crisps. Try to eat at least five portions of fruit and vegetables every day. Batch cooking meals can help achieve this – have food prepared in the freezer ready for when you are tired, lacking motivation or short on time. </p>
<p>Drinking plenty of water is also important, as it will help to reduce bloating. </p>
<h2>3. Get better sleep</h2>
<p><a href="https://www.sciencedirect.com/science/article/abs/pii/S1087079200901382">Sleep</a> is vital because a lack of sleep or poor sleep quality can make many menstrual cycle-related symptoms <a href="https://www.semanticscholar.org/paper/The-Relationship-of-Premenstrual-Syndrome-Symptoms-A%C5%9Fc%C4%B1-G%C3%B6kdemir/cb2222a23d05cf64f804bbcab9a2d730437b6176">worse</a>. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6988893/">Sleep hygiene</a> strategies can help prevent symptoms. These include going to bed and getting up at a similar time each day, starting the day with sunlight and limiting your caffeine intake (especially in the afternoon).</p>
<h2>4. Reduce your stress</h2>
<p><a href="https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/feelings-and-symptoms/stress/">Stress</a> increases the severity and duration of symptoms related to the menstrual cycle and is therefore an important factor to manage. </p>
<p>This is individual and finding a strategy that works for you will differ from person to person. Some ways to reduce stress could include socialising with friends, or meditating. Plan these in advance to prevent stress rather than reacting once you are already stressed.</p>
<h2>5. Stay active</h2>
<p>Sometimes getting to training is the hardest part when experiencing menstrual-related symptoms. Consider other activities such as walking or yoga to manage symptoms like stomach cramps while you are implementing the above strategies. And if there are days when you have more energy and motivation, maximise them while you are getting to understand your menstrual cycle.</p>
<p>You can use heat and pain relief for symptoms such as stomach cramps. Have these to hand if stomach cramps are affecting your ability to train around the time of menstruation. You could also speak to your trainer to adapt a session if required.</p>
<p>The menstrual cycle has long been seen as a negative thing. And there has not been enough information on how to manage symptoms. But we must change that narrative. Symptoms can be managed or reduced so you can continue to participate in sports and other activities. Don’t feel ashamed of your period – take control and be proactive in managing it.</p><img src="https://counter.theconversation.com/content/208502/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Natalie Brown is affiliated with Arc'Teryx. </span></em></p>Understanding our menstrual cycle and taking a proactive approach to our periods is vital to improving sports performance.Natalie Brown, Research officer for the Welsh Institute of Performance Science, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2038642023-04-18T16:12:00Z2023-04-18T16:12:00ZBirth control study suggests oestrogen dosage could be drastically cut – here’s what you should know<figure><img src="https://images.theconversation.com/files/521575/original/file-20230418-26-e046v7.jpg?ixlib=rb-1.1.0&rect=0%2C16%2C5607%2C3715&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/contraceptive-pill-174199502">Image Point Fr/ Shutterstock</a></span></figcaption></figure><p>The amount of oestrogen the birth control pill currently contains is already <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3520685/">substantially lower</a> than it was when the pill was first licensed more than 60 years ago. But a new paper has suggested that the doses of both oestrogen and progestogen in the pill could be significantly reduced and <a href="https://journals.plos.org/ploscompbiol/article?id=10.1371/journal.pcbi.1010073#abstract0">still work to prevent pregnancy</a>.</p>
<p>Given the many <a href="https://www.plannedparenthood.org/learn/birth-control/birth-control-pill/birth-control-pill-side-effects">side effects</a> that can come from using contraceptives, researchers wanted to know whether birth control could still work even if hormone dosages were lower. </p>
<p>To conduct their study, the team of researchers developed a very complex mathematical model using data on hormone levels from 23 women with normal menstrual cycles. They were then able to use this information to calculate what effect altering the timing and doses of certain hormones could have in preventing ovulation. </p>
<p>The model predicted that giving a very short, moderate dose of oestrogen around the seventh day of a 28-day cycle – either with or without a low dose of continuous progesterone – was capable of stopping ovulation. This meant that the dose of oestrogen needed to stop ovulation could be reduced by over 92%, while the dose of progesterone in progestogen-only methods could be reduced by 43%. </p>
<h2>Hormone dosages</h2>
<p>As exciting as these findings may be, there are a couple of major caveats to this research when it comes to real-world application.</p>
<p>First, it’s important to understand that these findings are based on computer modelling – not real-world data. Most new contraceptive methods are tried first on <a href="https://slate.com/news-and-politics/2011/08/how-they-run-clinical-trials-of-contraceptives.html">animal models, then in human volunteers</a>. It’s very possible that these computer models will reflect real-world results, but much more research will be needed in order to understand whether very precise low-dose hormonal contraceptives actually work in humans. </p>
<p>Second, the model was built using a simulated 28-day menstrual cycle. But menstrual cycle length can <a href="https://www.nhs.uk/conditions/periods/fertility-in-the-menstrual-cycle/">vary greatly between women</a>. As such, it’s uncertain whether these results will be true for women who have different menstrual cycle lengths. </p>
<p>Another limitation of the model that the researchers point out is that reducing contraceptive hormone levels only appears to work for about four simulated menstrual cycles. After that, the model predicts that ovulation will start to happen again. </p>
<p>This is because stopping ovulation in the previous cycle adjusts the length of the next cycle and the hormone levels associated with it. This in turn affects the time that the next dose needs to be given. So, for very low doses to work in real life, it’s likely that women would need to constantly adjust the time they take hormone dosages to keep the contraceptive working.</p>
<figure class="align-center ">
<img alt="A woman uses a menstrual calendar on her phone to track stages of her cycle." src="https://images.theconversation.com/files/521578/original/file-20230418-22-x72wkx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521578/original/file-20230418-22-x72wkx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521578/original/file-20230418-22-x72wkx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521578/original/file-20230418-22-x72wkx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521578/original/file-20230418-22-x72wkx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521578/original/file-20230418-22-x72wkx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521578/original/file-20230418-22-x72wkx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The simulation found ovulation was only stopped for a few months.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-tracking-periods-by-using-menstrual-1940658049">Kaspars Grinvalds/ Shutterstock</a></span>
</figcaption>
</figure>
<p>The researchers suggest that if a device could constantly sample the blood of the user and adjust the timing of a dose of oestrogen each month, this would overcome this problem and the problem of varying cycle lengths between women. Such a device does not yet exist, however.</p>
<p>The oestrogen found in current combined contraceptive methods (such as the pill and patch) also helps to regulate bleeding, and is taken for at least 21 days in every month. We don’t know what effect taking a lower dosage of oestrogen during a specific, much shorter time of the month would have on bleeding in the rest of the menstrual cycle. This is something that future studies will need to investigate. </p>
<h2>The future</h2>
<p>Despite these caveats, these results are exciting because of the benefits that lowering hormone doses could have for those who use birth control. </p>
<p>When the combined contraceptive pill was first introduced in the 1960s, doctors quickly realised that the high doses of oestrogen in the pill <a href="https://peopleshistorynhs.org/encyclopaedia/birth-control-on-the-nhs/">were causing clots, strokes and heart attacks</a> in some women. This led to a reduction of the amount of oestrogen the pills contained. </p>
<p>But although hormone levels are significantly lower now than they were in the past, a small number of women still experience harmful side effects when they take birth control, such as clots in the leg, <a href="https://www.nhs.uk/conditions/contraception/combined-contraceptive-pill/">largely because of the oestrogen it contains</a>. Women at increased risks of clots, strokes or heart problems cannot use contraceptive methods involving oestrogen at all. </p>
<p>While many factors contribute to a woman’s risk of harmful side effects from the oestrogen and progestogen found in contraceptives (such as genetics, weight and whether she smokes), it’s generally assumed that some of this risk is due to the level of these hormones that contraceptives contain. That means that lowering the dose of hormones in contraceptive methods has the potential to reduce the small risk of harmful side effects in some women.</p>
<p>This is why the suggestion that the doses of both oestrogen and progesterone could be much lower and still stop ovulation is so interesting. If future research shows these findings to be true in human trials, the next step would then be developing technology that could help ensure women receive the precise hormone dosages at just the right time. This would ensure that her contraceptive worked but with the possibility of minimising the risk of side effects.</p><img src="https://counter.theconversation.com/content/203864/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Walker has previously received funding from Bayer PLC. </span></em></p>A computer modelling study suggests that oestrogen levels could get lowered by as much as 92%.Susan Walker, Reader in Contraception, Reproductive and Sexual Health, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1912962022-10-07T14:51:15Z2022-10-07T14:51:15ZBirth control pill linked to greater risk of blood clots in women with obesity – here’s what you need to know<figure><img src="https://images.theconversation.com/files/486508/original/file-20220926-21-vtaud.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5615%2C3724&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The combined pill contains both oestrogen and progestin. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/contraceptive-pill-174193232">Image Point Fr/ Shutterstock</a></span></figcaption></figure><p>Women who are obese and taking the combined oral contraceptive pill have 12 to 24 times greater risk of developing a leg-vein blood clot than those not taking the pill and who are not overweight, according to <a href="https://onlinelibrary.wiley.com/doi/10.1002/ehf2.14104">a recent review of research</a>. <a href="https://pubmed.ncbi.nlm.nih.gov/12624633/">Other studies</a> have found a lower but still increased risk.</p>
<p>This kind of blood clot, known as a <a href="https://www.nhs.uk/conditions/deep-vein-thrombosis-dvt/">deep venous thrombosis</a> (DVT), can cause pain, swelling and redness of the affected leg. Usually this pain happens in the calf or thigh. Fortunately, most DVTs aren’t fatal – but they are serious and need to be treated urgently. In a small number of cases, part of the clot can break off and travel to the lungs which can be life threatening. </p>
<p>This increased risk might seem scary, and could even put some women off using contraception altogether if they’re overweight. But it’s important to understand where that risk comes from. And that not all types of contraception carry this increased risk. </p>
<p>The first thing to understand about the evidence around blood clot risk and contraception is that it only applies to <a href="https://pubmed.ncbi.nlm.nih.gov/22027398/">contraceptive methods that contain oestrogen</a>. These are the <a href="https://www.nhs.uk/conditions/contraception/combined-contraceptive-pill/">combined oral contraceptive pill</a>, the <a href="https://www.nhs.uk/conditions/contraception/contraceptive-patch/">contraceptive patch</a> and the <a href="https://www.nhs.uk/conditions/contraception/vaginal-ring/">contraceptive vaginal ring</a>. </p>
<p>That means that for <a href="https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016-summary-sheets/">all other methods available</a> the evidence doesn’t show an increased risk of developing a clot in healthy women who are not obese and don’t smoke. Smoking can also increase a person’s overall risk of blood clots, both in the leg and in the blood supply to the heart and brain. </p>
<p>The second thing to look at is the risk for all women of developing a clot, either while using contraception or not using it. </p>
<p>In general, the risk of developing a clot in the leg varies with age. But in young women worldwide, who are not using hormonal contraception, <a href="https://www.gov.uk/drug-safety-update/combined-hormonal-contraceptives-and-venous-thromboembolism-review-confirms-risk-is-small">around two in every 10,000</a> will develop a blood clot each year. This is very low.</p>
<figure class="align-center ">
<img alt="A clinician wearing blue surgical gloves holds a copper IUD between their fingers." src="https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Contraceptives that don’t contain oestrogen (such as the copper IUD) don’t carry an additional risk of blood clots.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-holding-tshaped-intrauterine-birth-control-2074498042">New Africa/ Shutterstock</a></span>
</figcaption>
</figure>
<p>But the risk of developing a blood clot while on the combined oral pill is between <a href="https://pubmed.ncbi.nlm.nih.gov/22027398/">two and six times higher</a> than for women not using the combined pill. This works out at about five to 12 women per 10,000 each year – depending on the type of combined pill. Older pills containing <a href="https://pubmed.ncbi.nlm.nih.gov/22027398/">levonorgestrel have the lowest risk</a>.</p>
<p>The risk of developing a blood clot on the combined pill is about the same as the risk of developing a clot <a href="https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/treatment-of-venous-thrombosis-in-pregnancy-and-after-birth-patient-information-leaflet/#:%7E:text=it%20in%20pregnancy%3F-,Pregnancy%20increases%20your%20risk%20of%20a%20DVT%2C%20with%20the%20highest,including%20the%20first%203%20months.">during or immediately after pregnancy</a>. The <a href="https://www.bmj.com/content/344/bmj.e2990">patch and vaginal ring</a>, which both contain oestrogen, increase the risks by about the same amount as the combined oral pill. </p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6039863/">contraceptive injection</a> seems also to increase the risk by a small amount – but this risk is still less than oestrogen-containing birth control methods.</p>
<h2>Obesity and DVT</h2>
<p>Being overweight increases everyone’s chance of developing a DVT, and this seems to be <a href="https://www.amjmed.com/article/S0002-9343(05)00207-X/fulltext">especially the case in women</a>. People who are considered obese (a <a href="https://www.nhs.uk/live-well/healthy-weight/bmi-calculator/">BMI of over 30</a>) are at about a <a href="https://www.amjmed.com/article/S0002-9343(05)00207-X/fulltext">three to five times greater risk</a> of having a venous clot than those who have a healthy BMI. </p>
<p>There are two reasons that obesity increases risk of DVT. People who are obese have more abdominal fat, <a href="https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0031-1297369">which can slow the speed of blood flow</a> travelling from the legs and through the abdomen. This increases the chance of blood clotting. </p>
<p>Obesity also seems to cause <a href="https://www.webofscience.com/wos/woscc/full-record/WOS:000222655700008?SID=EUW1ED0AF0rjOMT19mVWZ8cXVTUpt">low-grade inflammation</a> in the body, which may make it easier for clots to form and may also make them <a href="https://onlinelibrary.wiley.com/doi/10.1002/ehf2.14104#ehf214104-bib-0019">less likely to be dissolved naturally</a>.</p>
<p>Oestrogen has a similar effect to excess weight, also making the blood <a href="https://onlinelibrary.wiley.com/doi/10.1002/ehf2.14104#ehf214104-bib-0019">more likely to form clots</a> and less likely to dissolve small clots when they happen. This is why obesity can put women taking oestrogen-containing contraceptives at even greater risk of DVT. </p>
<p>To lower your risk of a blood clot in general, it’s best to maintain as healthy a weight as possible, to avoid smoking and keep an eye on your blood pressure. Since both obesity and oestrogen can increase the likelihood of a blood clot in the leg, it’s not surprising the combination of these two factors increases blood clot risk substantially. </p>
<p>If you are worried about your risk of a blood clot, that doesn’t mean you can’t use contraception. There are still many safe contraceptives you can choose from which do not contain oestrogen, and therefore do not increase risk of a clot. This includes condoms, the copper IUD (which contains no hormones) or the progesterone-only pill, intrauterine system or implant (which only contain progestogen).</p><img src="https://counter.theconversation.com/content/191296/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Walker has receives funding from Bayer and NaturalCycles.. </span></em></p>Although the study found greater risk of blood clots for obese women taking the pill, the risk of developing one was still very low.Susan Walker, Reader in Contraception, Reproductive and Sexual Health, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1849912022-06-15T10:45:26Z2022-06-15T10:45:26ZPeriod delay tablets can help you temporarily skip your period – here’s how they work<figure><img src="https://images.theconversation.com/files/468962/original/file-20220615-24-6jm8ji.jpg?ixlib=rb-1.1.0&rect=17%2C0%2C5734%2C3828&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many women don't know period delay tablets are available to them.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cropped-illness-woman-blue-dress-holding-1150619087">ViDI Studio/ Shutterstock</a></span></figcaption></figure><p>There’s an underlying law of the universe which dictates a woman’s period will always arrive just in time to disrupt important plans. For any woman who’s ever had a special trip or event spoiled thanks to the arrival of her period, having a way of skipping it temporarily would be life-changing. </p>
<p>Users of the combined contraceptive pill are able to postpone or skip their period by starting their next packet of birth control instead of taking the break week. For women on different types of contraceptives (or no contraceptive at all), they’ve had no choice but to deal with their period and all its inconveniences – whenever it arrives. But recently, more and more high-street pharmacies have started selling period delay tablets on prescription – which may just be the solution many women have been waiting for. </p>
<h2>Delaying your period</h2>
<p>For many years, doctors have been able to prescribe a course of hormone tablets to delay a period. But more recently, retail pharmacists in the UK (such as Boots) have started selling the period delay tablet Utovlan via <a href="https://onlinedoctor.boots.com/period-delay">online consultation</a> with a doctor.</p>
<p>These tablets contain an artificial hormone, similar to the body’s progesterone, which helps to delay the end of a natural cycle – ultimately delaying a period. These pills are only designed to be used by women not already taking the combined oral birth control pill.</p>
<hr>
<figure class="align-right ">
<img alt="Quarter life, a series by The Conversation" src="https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p><em><strong><a href="https://theconversation.com/uk/topics/quarter-life-117947?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">This article is part of Quarter Life</a></strong>, a series about issues affecting those of us in our twenties and thirties. From the challenges of beginning a career and taking care of our mental health, to the excitement of starting a family, adopting a pet or just making friends as an adult. The articles in this series explore the questions and bring answers as we navigate this turbulent period of life.</em></p>
<p><em>You may be interested in:</em></p>
<p><em><a href="https://theconversation.com/people-with-endometriosis-and-pcos-wait-years-for-a-diagnosis-attitudes-to-womens-pain-may-be-to-blame-179500?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">People with endometriosis and PCOS wait years for a diagnosis – attitudes to women’s pain may be to blame</a></em></p>
<p><em><a href="https://theconversation.com/birth-control-what-to-expect-if-you-choose-to-come-off-it-182964?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">Birth control: what to expect if you choose to come off it</a></em></p>
<p><em><a href="https://theconversation.com/ivf-add-ons-why-you-should-be-cautious-of-these-expensive-procedures-if-youre-trying-to-conceive-180198?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">IVF add-ons: why you should be cautious of these expensive procedures if you’re trying to conceive</a></em></p>
<hr>
<p>The timing of periods is controlled by hormonal changes which take place every month. In simple terms, the hormone oestrogen – produced by the ovaries – causes the lining of the womb to thicken in the first two weeks of each month. After the woman has ovulated, progesterone (another hormone) maintains that womb lining for the next two weeks to prepare for the arrival of a fertilised egg. But if pregnancy doesn’t happen, progesterone levels drop steeply – causing the womb to shed its lining and the woman’s period to begin. </p>
<p>Period delay tablets contain norethisterone, an artificial version of progesterone. These work by keeping the progesterone levels in the body artificially higher for longer – ultimately delaying the arrival of a period. But there is a limit to how long the thickened womb lining can be maintained – so usually it’s only possible to delay a period using these tablets for about two weeks after it was due. </p>
<figure class="align-right ">
<img alt="A box of the period delay tablet Utovlan." src="https://images.theconversation.com/files/468965/original/file-20220615-19-d7lxvd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/468965/original/file-20220615-19-d7lxvd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/468965/original/file-20220615-19-d7lxvd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/468965/original/file-20220615-19-d7lxvd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/468965/original/file-20220615-19-d7lxvd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/468965/original/file-20220615-19-d7lxvd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/468965/original/file-20220615-19-d7lxvd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Utovlan is the period delay tablet available in the UK.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/144891950@N08/48671074198">Doctor 4U/ flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Anyone who wants to use a period delay tablet will need to start them about three days before their period is due. They will need to take the tablets three times a day for as long as they want their period to be delayed (up to a maximum of 17 days of tablets). The delayed period will arrive about two or three days after stopping the norethisterone tablets. Of course, each woman is different, so the effectiveness and timing of the delay can vary a little from person to person.</p>
<h2>Not a contraception</h2>
<p>While period delay tablets may temporarily delay your period, it is not a contraceptive method and cannot be used to prevent pregnancy. Women who don’t use contraception or use non-hormonal contraception (such as the copper IUD) will need to continue to taking measures to prevent pregnancy while using period delay tablets if they don’t want to become pregnant.</p>
<p>There’s virtually no evidence about what happens if a woman using progesterone-only contraceptive methods (such as <a href="https://www.nhs.uk/conditions/contraception/contraceptive-implant/">the implant</a> or progesterone-only pill) takes a period delay tablet. It’s likely that it won’t be harmful to combine these on a once-off basis – but it should be discussed first with the doctor who is prescribing them. </p>
<p>Women using combined oral contraception should not use norethisterone to delay periods. If they want to <a href="https://www.nhs.uk/common-health-questions/travel-health/how-can-i-delay-my-period/">delay their period</a>, they can skip their pill-free break and start the next pack. This is not harmful and does not affect how well the combined pill works as a contraceptive.</p>
<h2>Side effects and risks</h2>
<p>Like any medication, norethisterone can have some <a href="https://www.medicines.org.uk/emc/product/1717/pil">side effects</a>. The most common ones are acne, menstrual spotting (light bleeding), low mood, loss of libido, breast pain or nausea. Not everyone will experience these.</p>
<p>However there are some women who should not use norethisterone to delay a period. These are women who are or could be pregnant, women who have just given birth and women who are breastfeeding. They also aren’t suitable for women with liver tumours, breast cancer and some other uncommon medical conditions. </p>
<p>The way that norethisterone is metabolised in the body may also increase the likelihood of blood clots. So women who have had blood clots before or are at a higher risk of clotting should avoid using period delay tablets. For the same reason, it’s important for any woman who takes period delay tablets to stay hydrated and move around often, especially on long plane flights. Norethisterone can also interact with some prescribed drugs (such as anti-epileptic or anti-TB medication) and the doctor prescribing the period delay tablets will check what other medication is being taken. </p>
<p>Most women will want to delay a period from time to time, and period delay tablets are one way to do this. Because they are not suitable for every woman, and they still need to be prescribed after a consultation with a doctor. But the option to delay a period once in a while, and the convenience of doing this through a high-street pharmacist, gives women control of their menstrual calendar.</p><img src="https://counter.theconversation.com/content/184991/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Walker has received funding from Bayer PLC.</span></em></p>Period delay tablets may help you take control of your menstrual cycle – but only if used properly.Susan Walker, Reader in Contraception, Reproductive and Sexual Health, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1842482022-06-09T04:58:34Z2022-06-09T04:58:34ZThere’s convincing evidence the pill can cause depression, and some types are worse than others<figure><img src="https://images.theconversation.com/files/467409/original/file-20220607-13238-56mjcv.jpg?ixlib=rb-1.1.0&rect=47%2C0%2C5343%2C3551&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Anthony Tran/Unsplash</span></span></figcaption></figure><p>Since the 1960s, “the pill” has been a popular choice of contraception for many women around the world. On February 1 1961, Australia became the <a href="https://theconversation.com/freer-sex-and-family-planning-a-short-history-of-the-contraceptive-pill-92282">second country in the world</a> to enable access to the pill, thereby allowing women to have control over their fertility and separate sexual activity from reproduction, a major revolution. </p>
<p>Today, the pill is the <a href="https://theconversation.com/how-to-choose-the-right-contraceptive-pill-for-you-87614#:%7E:text=The%20combined%20oral%20contraceptive%20pill,types%20of%20oral%20contraceptive%20pills.">most popular choice of contraception</a> for Australian women.</p>
<p>The early pills caused many physical side effects such as nausea, vomiting and increased rates of blood clots – which were significant and concerning. </p>
<p>While newer generations of the pill have generally been improved in terms of physical side effects and safety overall, a neglected area of consideration is the impact of the pill on mood.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1380275089615249412"}"></div></p>
<h2>The hormones in the pill do affect the brain and mood</h2>
<p>The relationship between the pill and mood is an important area to consider in view of the high prevalence of depression in Australian women, particularly those of reproductive age. Women are more likely to experience high or very high levels of <a href="https://www.abs.gov.au/articles/first-insights-national-study-mental-health-and-wellbeing-2020-21">psychological distress</a> (19% of women compared with 12% of men), and <a href="https://www.abs.gov.au/statistics/health/mental-health/mental-health/latest-release">reproductive-aged women</a> (15-45 years) have high rates of depression.</p>
<p>We need to understand whether the pill could be to blame for some of this.</p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/22467147/">Laboratory neuroscience studies</a> have shown oestrogen and progesterone, the “female hormones”, which most versions of the pill contain, greatly influence neurochemistry, brain function and the activity of neurotransmitters such as gamma-aminobutyric acid (GABA), serotonin and dopamine. This can cause depression, behaviour changes and disturbances in cognition. </p>
<p><a href="https://www.tandfonline.com/doi/abs/10.3109/00048674.2011.583218?journalCode=ianp20">Brain imaging studies</a> have indicated oestrogen regulates the activation of brain regions implicated in emotional and cognitive processing such as the amygdala. Natural progesterone has been shown to have some anti-anxiety effects by acting on the GABA system.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/467412/original/file-20220607-16-gad9hd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman with tear-streaked face, holding up a smiling mouth on a piece of paper" src="https://images.theconversation.com/files/467412/original/file-20220607-16-gad9hd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/467412/original/file-20220607-16-gad9hd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/467412/original/file-20220607-16-gad9hd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/467412/original/file-20220607-16-gad9hd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/467412/original/file-20220607-16-gad9hd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/467412/original/file-20220607-16-gad9hd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/467412/original/file-20220607-16-gad9hd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Drawing conclusions from clinical trials on the pill and depression can be difficult.</span>
<span class="attribution"><span class="source">Unsplash/Sydney Sims</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Drawing conclusions from clinical trials on the pill and depression are hampered by the large number of different types of the pill and different hormones used, as well as the narrow definition of depression, that <a href="https://pubmed.ncbi.nlm.nih.gov/22467147/">mainly refers to severe major depressive disorder</a>. Depression can manifest as a spectrum of mood disorders, including mild and moderate depression that still impairs the enjoyment of life.</p>
<p>However, convincing findings come from a <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2552796">large Danish study</a>, with data from more than a million women. It concluded the use of hormonal contraception, especially among adolescents, was associated with depression requiring antidepressant treatment. This strongly suggests depression is a potential adverse effect of hormonal contraceptive use. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1432987781219815425"}"></div></p>
<h2>Are any types worse than others?</h2>
<p>Currently, the <a href="https://pubmed.ncbi.nlm.nih.gov/17688380/">data</a> suggest overall synthetic oestrogens appear to have a positive effect on depression, while the synthetic progesterones – called progestogens – have a varied effect including worsening depression (depending on the type and dose of progestogen). Most pills contain both hormones - for example, in a commonly used pill called Levlen.</p>
<p>Progestogen-only contraception, known as the “mini-pill”, seems to create a greater propensity for depressive disorders in vulnerable women. And users of the injectable progestogen contraceptive medroxyprogesterone acetate (brand name depo-provera) have more symptoms of depression than non-users. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/heres-whats-on-the-horizon-for-a-male-contraceptive-pill-but-dont-hold-your-breath-92509">Here's what's on the horizon for a male contraceptive pill – but don't hold your breath</a>
</strong>
</em>
</p>
<hr>
<p>It appears the addition of oestrogen in the hormone contraceptive improves mental health impacts, and the newer oral contraceptive pills containing the hormone estradiol (for example Diane 35) or estradiol valerate (for example Qlaira) may be less likely to cause mood changes. </p>
<p>The link between taking oral contraceptive pills and depression may be attributed to the amount and type of progestogen contained in oral contraceptive pills. </p>
<p>Our <a href="https://pubmed.ncbi.nlm.nih.gov/34630323/">recent research</a> showed a positive mental health response for some women taking a newer pill (called Zoely) containing a progestogen and a type of estradiol. This pill appeared to be better tolerated by women with a history of mood disorders. </p>
<p>Millions of women use hormone contraception without impact on their mental health. However, a significant number of women experience either first time depression or exacerbation of existing depression when taking particular types of hormone contraception. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/informed-consent-women-need-to-know-about-the-link-between-the-pill-and-depression-92424">Informed consent: women need to know about the link between the pill and depression</a>
</strong>
</em>
</p>
<hr>
<p>It’s therefore important for women to take note of their individual responses to hormone contraception and discuss this with their doctor, who should be able to <a href="https://www.nps.org.au/australian-prescriber/articles/hormonal-contraception-and-mood-disorders">discuss suitable options</a>. It’s not clear whether doctors are advising women of the risks and asking them to keep an eye out for these symptoms when they prescribe the pill.</p>
<p>As a community we all need to recognise and acknowledge hormones such as oestrogen, progesterone and their synthetic versions can have potent mental health effects.</p><img src="https://counter.theconversation.com/content/184248/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jayashri Kulkarni receives funding from NHMRC, Jansen, Servier pharmaceutical industries for clinical trials. This article received no funding and there are no conflicts to declare in relation to it</span></em></p>The hormones in the pill can cause or exacerbate depression, and the type you use is an important factor.Jayashri Kulkarni, Professor of Psychiatry, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1552532021-02-23T15:05:04Z2021-02-23T15:05:04ZBreast cancer: is milk a risk factor?<figure><img src="https://images.theconversation.com/files/385838/original/file-20210223-22-56pbn6.jpg?ixlib=rb-1.1.0&rect=17%2C8%2C5734%2C3819&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some studies have linked drinking milk with higher risk of oestrogen-receptor positive breast cancer.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-drinking-milk-362409509">Summersky/ Shutterstock</a></span></figcaption></figure><p>Breast cancer has now overtaken lung cancer as the world’s <a href="https://www.who.int/news/item/03-02-2021-breast-cancer-now-most-common-form-of-cancer-who-taking-action">most commonly diagnosed</a> cancer, and as the <a href="https://pubmed.ncbi.nlm.nih.gov/30207593/">leading cause</a> of cancer-related deaths for women in many countries. While genetics can certainly increase risk of the disease, for most women <a href="https://www.cancerresearchuk.org/about-cancer/breast-cancer/risks-causes/risk-factors">lifestyle factors</a>, such as alcohol or being overweight or obese, are bigger influences on developing breast cancer. Now, two separate studies, both published in 2020, have identified cow’s milk as another possible risk factor for breast cancer.</p>
<p>The <a href="https://pubmed.ncbi.nlm.nih.gov/33004231/">first study</a>, which looked at 33,780 Swedish women since 1997, found that about 300 millilitres of cow’s milk per day (the equivalent of a large mug) increased breast cancer risk by about a third compared to women who did not drink milk. </p>
<p>The <a href="https://academic.oup.com/ije/article-abstract/49/5/1526/5743492?redirectedFrom=fulltext">second study</a>, from the US, looked at 52,795 over a period of nearly eight years and found that women who drank about 300 millilitres of milk per day had a 50% increased risk for breast cancer compared with those who drank very little milk.</p>
<p>Both studies found that the risk was mostly limited to post-menopausal women who developed a type of breast cancer stimulated by oestrogen, called <a href="https://www.cancer.org/cancer/breast-cancer/understanding-a-breast-cancer-diagnosis/breast-cancer-hormone-receptor-status.html">oestrogen-receptor positive</a> breast cancer. There was no increased risk of other types of breast cancer which rely on other growth factors (such as <a href="https://www.breastcancer.org/symptoms/diagnosis/her2">HER2 positive</a> breast cancer). </p>
<p>But because of their design, the studies could only conclude that there was an association between milk consumption and breast cancer – they could not prove that drinking milk caused cancer. The authors of the studies took into account other known causes of breast cancer that might have explained their results, such as the woman’s age when she had her first period and menopause, and alcohol consumption. But the authors could still not completely discount all other possible explanations for their findings. So how important is milk as a cause of this type of breast cancer?</p>
<p>To understand why cow’s milk might increase risk of oestrogen-receptor positive breast cancer, it’s important to look at biological studies, which can help us see which mechanisms are taking place in the body. Cow’s milk naturally contains stimulants for cell growth and division. These stimulants act in the body by raising levels of a growth factor called IGF1 (insulin-like growth factor 1). Studies show that in humans, it’s these raised levels of IGF1 that are <a href="https://pubmed.ncbi.nlm.nih.gov/25743390/">strongly implicated</a> in increasing breast cancer risk, which may be why drinking milk is linked <a href="https://pubmed.ncbi.nlm.nih.gov/16900085/">to greater risk</a>. </p>
<p>Interestingly, fermented dairy products (yogurt and cheese) did not increase breast cancer risk in either of the earlier studies. This may be because yogurt and cheese <a href="https://pubmed.ncbi.nlm.nih.gov/31089868/">do not increase</a> IGF1 levels in the body. This could be because the IGF1-stimulating factors present in milk are lost during the making of cheese and yogurt.</p>
<figure class="align-center ">
<img alt="Bowl of plain yoghurt with wooden spoon." src="https://images.theconversation.com/files/385839/original/file-20210223-24-chayb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/385839/original/file-20210223-24-chayb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/385839/original/file-20210223-24-chayb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/385839/original/file-20210223-24-chayb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/385839/original/file-20210223-24-chayb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/385839/original/file-20210223-24-chayb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/385839/original/file-20210223-24-chayb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Fermented dairy products don’t increase IGF1 levels.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/homemade-yogurt-sour-cream-wooden-bowl-515797933">DONOT6_STUDIO/ Shutterstock</a></span>
</figcaption>
</figure>
<p>IGF1 does not increase breast cancer risk on its own. Rather, its ability to stimulate cell growth is <a href="https://pubmed.ncbi.nlm.nih.gov/33364239/">greatly magnified</a> by oestrogen. This could explain why in the two studies, high milk consumption increased the risk for oestrogen-receptor positive breast cancer, but not for other types. It may be that both oestrogen and IGF1 are needed for breast cells to become cancerous – and that this can only happen in cells that respond to oestrogen as well as to IGF1.</p>
<h2>Other risk factors</h2>
<p>As well as milk, many other factors that increase the risk for breast cancer also act by raising levels of IGF1 or oestrogen in the body. Obesity raises levels of both <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2639294/">IGF1 and oestrogen</a> in post-menopausal women. And an early menarche, a late menopause and drinking alcohol <a href="https://www.wcrf.org/breast-cancer-2017">all increase</a> the duration and amount of breast cells’ exposure to oestrogen.</p>
<p>Since many risk factors influence oestrogen and IGF1 levels, it’s too simplistic to point the finger of blame for breast cancer at only one food, such as milk. Many factors need to be considered. This may help explain why, for example, Belgium, the Netherlands, and Luxembourg occupy the <a href="https://www.wcrf.org/dietandcancer/cancer-trends/breast-cancer-statistics">top three spots</a> in the world for breast cancer incidence. <a href="https://worldpopulationreview.com/country-rankings/milk-consumption-by-country">Milk consumption</a> is high in the Netherlands, but it’s not particularly high in Belgium or Luxembourg. And while <a href="https://www.oecd.org/els/health-systems/Obesity-Update-2017.pdf">obesity rates</a> for women in these countries is high, they are certainly not the highest in the world. Neither is their <a href="https://ec.europa.eu/jrc/en/page/alcohol-daily">alcohol consumption</a> especially high. So it’s probably the coming together of many risk factors elevating oestrogen and IGF1 levels that contributes to the especially high incidence of breast cancer in the Benelux countries.</p>
<p>It’s equally important to consider protective factors. Physical activity lowers the risk of breast cancer and improves survival in breast cancer patients, and this is linked to <a href="https://pubmed.ncbi.nlm.nih.gov/27562357/">lowering IGF1 levels</a>. Diet can also protect against raised levels of oestrogen and IGF1. Some foods contain substances called phytoestrogens that block the action of oestrogen. For instance, extra virgin olive oil is an <a href="https://pubmed.ncbi.nlm.nih.gov/23332727/">exceptionally rich</a> source. This may also partly explain why women who eat a Mediterranean diet (which traditionally doesn’t include cow’s milk) are at a <a href="https://pubmed.ncbi.nlm.nih.gov/26365989/">lower risk of breast cancer</a>. So while cow’s milk may be a risk factor for breast cancer, it acts alongside many other risk factors.</p><img src="https://counter.theconversation.com/content/155253/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Hoffman has previously received funding from NIHR. He is the author of two books on the Mediterranean diet: The Mediterranean Diet: Health and Science (2011) and More Healthy Years - Why a Mediterranean Diet is best for you and for the planet (2020).</span></em></p>Cow’s milk naturally raises levels of a growth factor strongly implicated in breast cancer risk.Richard Hoffman, Associate lecturer, Nutritional Biochemistry, University of HertfordshireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1194662020-04-30T16:00:18Z2020-04-30T16:00:18ZHot flashes? Night sweats? Progesterone can help reduce symptoms of menopause<figure><img src="https://images.theconversation.com/files/310383/original/file-20200116-134772-19ak44u.jpg?ixlib=rb-1.1.0&rect=140%2C118%2C4744%2C3086&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Progesterone doesn't seem to cause the blood clots, heart diseases and breast cancer associated with estrogen-dominant menopausal hormone therapy</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Intense and frequent night sweats zapped my vitality during perimenopause, <a href="https://www.mayoclinic.org/diseases-conditions/perimenopause/symptoms-causes/syc-20354666">the transition to menopause</a>. I would wake in the night feeling suddenly anxious — then a wave of heat would sweep over me — a <a href="https://www.health.harvard.edu/blog/menopause-related-hot-flashes-night-sweats-can-last-years-201502237745">night sweat</a>.</p>
<p>What I needed to keep these symptoms in check was the <a href="https://www.hormone.org/your-health-and-hormones/glands-and-hormones-a-to-z/hormones/progesterone">hormone progesterone</a>. I took it for seven years because I needed it, it worked, and I believed it was safe. </p>
<p>As the founder of the <a href="https://www.cemcor.ca/">Centre for Menstrual Cycle and Ovulation Research</a>, I have been researching perimenopause and menopause for more than 30 years. In medical school and during post-medical training, I learned that perimenopause and menopause were about dropping, dwindling and deficient estrogen levels. What I found in my research, by contrast, was that <a href="https://www.cemcor.ubc.ca/resources/life-phases/perimenopause">estrogen levels are often elevated and unpredictable in perimenopause</a>. </p>
<p>It is important for women to know that many perimenopausal miseries are because estrogen is too high and extremely variable, not because it is low or deficient. </p>
<h2>When does menopause occur?</h2>
<p>Things got much better for me when I became menopausal.</p>
<p>What women know about menopause often involves a mix of myth and marketing, rather than scientific fact. Ask three different people about menopause and you may get three different perspectives. </p>
<p>Many women may tell you that menopause means everything changing and becoming miserable in midlife and that it includes a transition called perimenopause.</p>
<p>For a gynecologist, menopause means the <a href="https://www.ncbi.nlm.nih.gov/pubmed/22343510">last menstrual period in a women’s reproductive timeline</a>. </p>
<p>Finally, an epidemiologist will tell you menopause begins one year after the final menstruation. </p>
<h2>Vaginal dryness and trouble sleeping</h2>
<p>In reality, menopause is normal, natural and inevitable. Perimenopause begins between ages 35 and 57, and menopause occurs around the age of 52 for most Canadian women (usually between 45 and 60). </p>
<p>Menopausal women cannot become pregnant and, beyond that, many are pleased to be free of unpredictable and sometimes flooding blood flow that one-third of women experience in perimenopause. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/284604/original/file-20190717-147295-1a38eqe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/284604/original/file-20190717-147295-1a38eqe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=357&fit=crop&dpr=1 600w, https://images.theconversation.com/files/284604/original/file-20190717-147295-1a38eqe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=357&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/284604/original/file-20190717-147295-1a38eqe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=357&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/284604/original/file-20190717-147295-1a38eqe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=448&fit=crop&dpr=1 754w, https://images.theconversation.com/files/284604/original/file-20190717-147295-1a38eqe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=448&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/284604/original/file-20190717-147295-1a38eqe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=448&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">When estrogen drops during menopause, this is not a deficiency, but part of every woman’s natural life cycle.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The night sweats and hot flashes that begin in perimenopause may last as long as 10 to 12 years. In general, menopausal women experience daytime sweating, which is less disruptive. </p>
<p>Menopausal women who don’t have sex regularly will likely notice some vaginal dryness, some may have more trouble sleeping soundly and, for a few, a sudden urgency to pee may make it a race to get to the washroom on time. </p>
<h2>Forget estrogen deficiency</h2>
<p>Some have promoted the idea that menopausal women are old, wrinkly, unattractive and senile to boot. These are lures to get women to ask for estrogen or hormone “replacement” therapy. But decreasing estrogen levels do not signal a deficiency, as the estrogen-marketing lobby would have us believe. </p>
<p>Research shows women need a break from the high demands of estrogen, which stimulates cellular growth and poses a risk for cancers. Giving menopausual women estrogen alone — without progesterone or its synthetic knock-off progestin — led to <a href="http://www.dx.doi.org/10.1056/NEJM197606032942303">increased rates of endometrial cancer</a> in the 1970s. </p>
<p>The language of estrogen deficiency and hormone or estrogen “replacement” still dominates the medical literature even 17 years after a <a href="https://www.whi.org/SitePages/WHI%20Home.aspx">huge randomized study called the Women’s Health Initiative (WHI)</a> showed taking a combination of <a href="http://www.dx.doi.org/10.1001/jama.288.3.321">estrogen-progestin caused more harm than benefit</a> (two-thirds of the women were over 60). The same was also true for women who had had <a href="http://www.dx.doi.org/10.1001/jama.291.14.1701">hysterectomies and received estrogen-alone</a> (all were over 50 and more than two-thirds older than 60). </p>
<h2>Breast cancer risks of estrogen therapy</h2>
<p>Does that mean menopausal women with vasomotor symptoms such as hot flashes and night sweats must just suffer? </p>
<p>Estrogen, whether <a href="https://doi.org/10.1002/14651858.CD002978.pub2">on its own or combined with progesterone/progestin</a>, can treat vasomotor symptoms. But there are downsides to estrogen-based hormonal therapy. It can, for example, <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31709-X/fulltext">increase breast cancer risk</a>. </p>
<p>When a woman stops menopausal hormone therapy, she often experiences rapidly worsening vasomotor symptoms. About a quarter of women find they <a href="https://abcnews.go.com/Health/story?id=116654&page=1">can’t stop therapy because the withdrawal symptoms are so severe</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/310387/original/file-20200116-134777-lkmjhi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/310387/original/file-20200116-134777-lkmjhi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/310387/original/file-20200116-134777-lkmjhi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/310387/original/file-20200116-134777-lkmjhi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/310387/original/file-20200116-134777-lkmjhi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/310387/original/file-20200116-134777-lkmjhi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/310387/original/file-20200116-134777-lkmjhi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Estrogen withdrawal can exacerbate vasomotor symptoms.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<h2>The benefits of progesterone</h2>
<p>It turns out that <a href="https://www.abingtonhealth.org/healthy-living/health-news/library/articles-related-to-womens-health-/sleeping-hot-how-to-sleep-well-during-menopause/">estrogen withdrawal leads to hot flashes and night sweats</a>. In other words, the brain gets used to higher estrogen levels and reacts to the decrease by releasing the stress hormone norepinephrine, which causes altered temperature responses. </p>
<p>Progesterone can ease this response. It <a href="https://www.dx.doi.org/10.1097/gme.0b013e318247f07a">treats hot flashes and night sweats</a>, causes <a href="https://doi.org/10.3109/09513590.2012.705390">no rebound when stopped</a> and, importantly, it significantly <a href="https://www.ncbi.nlm.nih.gov/pubmed/18676087">helps menopausal women with sleep problems</a>.</p>
<p>Although progesterone has not been tested in a large controlled trial, progesterone also doesn’t seem to cause the blood clots, heart disease or breast cancer associated with estrogen or estrogen-progestin menopausal hormone therapy. </p>
<p>In our randomized trial of progesterone or placebo for the treatment of vasomotor symptoms we also measured changes in weight, blood pressure, waist size, fasting glucose, blood lipids, a marker of inflammation and one of blood-clot risks. The changes with progesterone <a href="https://doi.org/10.1371/journal.pone.0084698">did not differ from changes on placebo</a>, meaning that it had neither positive or negative effects on these factors.</p>
<h2>Steps to healthy aging</h2>
<p>Women should look forward to healthy aging. Perimenopause may be difficult, but we all survive and eventually graduate into menopause. This is our break from the 30 to 45 years of demands made by our reproductive hormones. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/310392/original/file-20200116-134802-1evqtrl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/310392/original/file-20200116-134802-1evqtrl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/310392/original/file-20200116-134802-1evqtrl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/310392/original/file-20200116-134802-1evqtrl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/310392/original/file-20200116-134802-1evqtrl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/310392/original/file-20200116-134802-1evqtrl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/310392/original/file-20200116-134802-1evqtrl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Moderate physical activity is important during the menopausal transition/perimenopause.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Menopausal women who are waking with night sweats more than twice a week may find that moderate physical activity (brisk walking for 30 minutes every day), adopting stress-reducing strategies (relaxation, mindfulness meditation, cognitive behavioural therapy) and quitting smoking can help.</p>
<p>If night sweats continue, she could ask her health-care provider for progesterone therapy (taken at bedtime). If vaginal dryness is an ongoing problem despite regular and gentle sex, vaginal estradiol in very low doses is effective and safe. </p>
<p>Most important of all is that perimenopausal or menopausal women remain active learners and continue to importantly contribute to their communities.</p><img src="https://counter.theconversation.com/content/119466/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jerilynn C. Prior has received research funding from the Canadian Institutes for Health Research and a donation for research to complete a CIHR-funded study from Besin Healthcare International. She is the Founder and Scientific Director of the not-for-profit University of British Columbia Centre for Menstrual Cycle and Ovulation Research. </span></em></p>Science shows that many perimenopausal miseries — such as hot flashes, night sweats and trouble sleeping — are caused by excess or variable estrogen, not by “estrogen deficiency.”Jerilynn C. Prior, Professor of Endocrinology and Metabolism, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1240842019-11-17T19:21:31Z2019-11-17T19:21:31ZMaking sense of menopausal hormone therapy means understanding the benefits as well as the risks<figure><img src="https://images.theconversation.com/files/301208/original/file-20191112-178502-c0svif.jpg?ixlib=rb-1.1.0&rect=4%2C0%2C3296%2C2197&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Grappling with the pros and cons of menopausal hormone therapy can be confusing.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>At menopause, a woman’s ovaries lose their reproductive function. Eggs are no longer released and the production of the hormones oestrogen and progesterone falls. It’s the lowered levels of oestrogen after menopause that gives rise to troublesome postmenopausal symptoms.</p>
<p>Most women experience menopause between the <a href="https://www.nature.com/articles/nrdp20154">ages of 45 and 55</a>. It’s a natural event, but for many women it has significant health consequences.</p>
<p>The fortunate few have minimal symptoms, but at least <a href="https://www.ncbi.nlm.nih.gov/pubmed/25706184">three-quarters</a> of women will have some symptoms. <a href="https://www.ncbi.nlm.nih.gov/pubmed/25706184">One-third of all menopausal women</a> are moderately to severely affected.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-perimenopause-and-how-does-it-affect-womens-health-in-midlife-122186">What is perimenopause and how does it affect women's health in midlife?</a>
</strong>
</em>
</p>
<hr>
<p>Typical symptoms include hot flushes, night sweats, anxiety, low mood, disturbed sleep, joint pain and vaginal dryness. These symptoms <a href="https://www.ncbi.nlm.nih.gov/pubmed/26115590">can be debilitating</a>.</p>
<p>The fall in oestrogen also leads to bone loss and an increased risk of fragility fractures. And women going through menopause have increased central abdominal fat, even without an increase in weight. This contributes to <a href="https://www.nature.com/articles/nrdp20154">a heightened risk</a> of diabetes and heart disease. </p>
<p>An absence of symptoms doesn’t mean bone loss and other metabolic changes aren’t occurring, as these develop silently.</p>
<p>Menopausal hormone therapy (MHT) – which used to be known as hormone replacement therapy, or HRT – is <a href="https://www.ncbi.nlm.nih.gov/pubmed/26444994">the most effective treatment</a> we have for menopausal symptoms. Yet many women and health-care providers remain confused about the benefits and risks of MHT.</p>
<h2>What is menopausal hormone therapy?</h2>
<p>MHT replenishes oestrogen supplies in the body to treat the symptoms of menopause. Taking oestrogen causes thickening of the lining of the uterus, so progestogen (which acts like progesterone) is added to MHT to stop this. </p>
<p>This is important because a thickened uterus lining may undergo <a href="https://www.ncbi.nlm.nih.gov/pubmed/8569016">cellular changes</a> that have the potential to develop into uterine cancer. For a woman who has had a hysterectomy (surgery where the uterus is removed) MHT will be oestrogen-only.</p>
<p>Oestrogen is usually taken in tablet form, but can be applied as a skin patch or skin gel, or as a vaginal pessary. Progesterone is taken as a capsule. There are a range of single formulations and combinations, so the dose and formulation of MHT should be tailored to each woman’s health profile and personal preferences.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-shift-in-social-attitudes-can-make-menopause-a-positive-experience-46742">A shift in social attitudes can make menopause a positive experience</a>
</strong>
</em>
</p>
<hr>
<p>Women shouldn’t take MHT if they have a malignancy sensitive to oestrogen, like breast cancer, or have undiagnosed vaginal bleeding.</p>
<p>Unless there’s a specific reason they can’t, it’s especially important women with early menopause take MHT to optimise their health. This is true regardless of how severe their symptoms are.</p>
<p>Menopause before age 45 is classified as early menopause. Prematurely menopausal women are at <a href="https://www.ncbi.nlm.nih.gov/pubmed/27627190">significantly greater risk</a> of osteoporosis and fracture, heart disease and premature death.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/301700/original/file-20191114-77305-1m1bc8k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/301700/original/file-20191114-77305-1m1bc8k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/301700/original/file-20191114-77305-1m1bc8k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/301700/original/file-20191114-77305-1m1bc8k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/301700/original/file-20191114-77305-1m1bc8k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/301700/original/file-20191114-77305-1m1bc8k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/301700/original/file-20191114-77305-1m1bc8k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Menopause normally happens between age 45 and 55.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
</figcaption>
</figure>
<p>For women going through menopause at the usual time, the choice may be less clear-cut.</p>
<p>Importantly, MHT cannot be seen in one dimension; that is, as only having one benefit or one risk. To make an informed choice, it’s essential to evaluate the total effects of MHT, including how it influences the risk of premature death, heart disease, fracture, other cancers, and of course, well-being and quality of life.</p>
<h2>Balancing the risks and the benefits</h2>
<p>Clinical trials have found specific formulations of oral oestrogen with progesterone result in a small increase in breast cancer risk. One study reported roughly a <a href="https://jamanetwork.com/journals/jama/fullarticle/195120">1.25-fold increase in risk</a>. This is equivalent to about four extra cases of breast cancer per 1,000 women per year in women who were taking this specific MHT formulation before and during the study period. </p>
<p>However, this risk estimate may be incorrect as the women in this study who had never used MHT prior to starting the study had no increased breast cancer risk compared with the placebo group. So some degree of uncertainty as to the risk remains.</p>
<p>There was <a href="https://jamanetwork.com/journals/jama/fullarticle/198540">no increase in risk</a> for oestrogen-only therapy, and whether these risks apply to non-oral therapies is not yet known.</p>
<p>These risks should be balanced with the benefits. Women who take MHT gain less abdominal fat and are <a href="https://www.ncbi.nlm.nih.gov/pubmed/16440209">less likely to develop diabetes</a>.
MHT prevents bone loss and therefore the risk of fragility fracture, an effect that continues <a href="https://www.ncbi.nlm.nih.gov/pubmed/20711081">after treatment is stopped</a>. Oestrogen alone is associated with <a href="https://www.ncbi.nlm.nih.gov/pubmed/24084921">reduced heart disease risk</a>, while oestrogen plus progestogen also <a href="https://www.ncbi.nlm.nih.gov/pubmed/24084921">lowers the risk</a> of colon and uterine cancer.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/chemical-messengers-how-hormones-change-through-menopause-56921">Chemical messengers: how hormones change through menopause</a>
</strong>
</em>
</p>
<hr>
<p>The most comprehensive summary of the safety of MHT is from the Women’s Health Initiative study in which 27,347 participants were randomised to receive MHT or a placebo for five to seven years. The researchers followed up to see <a href="https://www.ncbi.nlm.nih.gov/pubmed/28898378">if death rates differed</a> between women who had taken MHT compared with the placebo.</p>
<p>After 18 years, cancer mortality and death overall from any cause did not differ between the groups, irrespective of whether the MHT was oral oestrogen-only or oral oestrogen plus progestogen. </p>
<p>So if we add symptom relief to the equation, the benefits of MHT will outweigh the potential risks for most symptomatic women who start MHT within ten years of menopause (the time frame measured in this study).</p>
<p>Some women using MHT will continue on the treatment for five or ten years to manage their symptoms. <a href="https://www.ncbi.nlm.nih.gov/pubmed/25706184">More than 40%</a> of women aged 60 to 65 still have hot flushes and night sweats, and one in seven of these women describe their symptoms as “severe”.</p>
<p>The <a href="https://www.tandfonline.com/doi/abs/10.3109/13697137.2015.1129166?journalCode=icmt20">length of time</a> a woman uses MHT for will depend on her symptom severity and individual needs, which should be re-evaluated alongside her risk profile every year with a health professional.</p>
<h2>The alternatives aren’t evidence-based</h2>
<p>Claims over-the-counter or internet-purchased nutritional supplements or herbal tablets will “balance your hormones” and relieve symptoms <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001395.pub4/full">cannot be substantiated</a>.</p>
<p>Studies have consistently <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6419242/">failed to show meaningful benefits</a> of nutritional supplements or herbal tablets over placebo for hot flushes. And these treatments do not prevent bone loss or protect against heart disease.</p>
<p>Further, unproven therapies can also have side effects. Women considering herbal or naturopathic remedies should have a face-to-face consultation with a qualified therapist (as opposed to internet-based communication) to ensure their full symptom and health profile, as well as medication use, are documented to minimise adverse effects.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dont-count-on-freezing-ovarian-tissue-to-delay-menopause-or-stop-your-biological-clock-121496">Don't count on freezing ovarian tissue to delay menopause or stop your biological clock</a>
</strong>
</em>
</p>
<hr>
<p><em>For more information about treatment options visit the <a href="https://www.menopause.org.au/">Australasian Menopause Society</a> website and view the International Menopause Society <a href="https://www.youtube.com/playlist?list=PLAjwoYuItHS-4jvjL6gJgM7o-vpr0PVk6">YouTube videos</a>.</em></p><img src="https://counter.theconversation.com/content/124084/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Davis consults with Que Oncology. She receives funding from NHMRC and the Grollo Ruzzene Foundation and her institution has received funding from Que Oncology. She has received honoraria from Besins Healthcare and Pfizer Australia for unrestricted presentations to health practitioners on menopause. She is affiliated with the International Menopause Society.</span></em></p>While evidence has indicated women who take menopausal hormone therapy have a marginally increased risk of breast cancer, it’s equally important we talk about the benefits of the treatment.Susan Davis, Chair of Women's Health, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1054242018-10-23T12:48:17Z2018-10-23T12:48:17ZStudy shows equality frees women to follow traditional gender choices – or does it?<figure><img src="https://images.theconversation.com/files/241837/original/file-20181023-169801-18k952m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/beautiful-african-american-woman-her-daughter-590562002?src=zyFpU8UMQOG2kT0p0un9Rw-1-0">Tijana M/Shutterstock</a></span></figcaption></figure><p>If you want gender equality, get rich. Research shows that men and women tend to be more equal in <a href="http://reports.weforum.org/global-gender-gap-report-2015/the-case-for-gender-equality/">more developed countries</a>. You might expect that the more equal opportunities in these countries might reduce other differences between the genders, such as what kind of jobs people are more likely to have, or personality traits such as kindness or a tendency for risk-taking. But a new study <a href="http://science.sciencemag.org/cgi/doi/10.1126/science.aas9899">published in Science</a> argues the opposite, that greater equality actually widens these kind of gender differences.</p>
<p>Cleverly, the study doesn’t claim that gender preferences are culturally learnt or biologically driven. Instead, it simply describes them as “intrinsic” and says you can be agnostic about their origin. In avoiding the discussion about where these differences come from, the article simply treats gender preferences as a black box that economists and others shouldn’t open.</p>
<p>Yet while the study looked at data from all over the world to build its case, I believe it reaches the wrong conclusions simply by assuming that men and women have different preferences that are free to be expressed in more developed countries. Removing legal barriers to equal opportunity isn’t the same as removing <a href="https://theconversation.com/would-gender-differences-exist-if-we-treated-all-people-the-same-from-birth-68181">the social pressures</a> that help shape traditional beliefs about gender roles.</p>
<p>There are two ideas that could explain whether traditional gender roles and preferences are likely to increase or decrease as a country gets richer. The <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/9781118663219.wbegss183">social role hypothesis</a> says that gender roles defined by unequal opportunity instil differences in preferences. So when women have the same opportunities as men, these differences should disappear.</p>
<p>On the other hand, the resource hypothesis says that gender preferences <a href="https://pubsonline.informs.org/doi/abs/10.1287/mnsc.2015.2244?journalCode=mnsc">aren’t created by gender roles</a>. And once men and women have similar opportunities they are freer to express their “natural” inner differences.</p>
<h2>What the study shows</h2>
<p>Drawing on data from 80,000 people in 76 countries, the new research provides evidence to support the second hypothesis. In countries where economic growth had helped create more equal opportunities, men were more likely to take risks. Meanwhile, women were more likely to be trusting and kind, and less willing to postpone rewards to get more in the future. Because these results follow greater economic and social freedom, they supposedly show that these gender differences are intrinsic, and explain why men are more focused on their careers and women on their families.</p>
<p>The problem hidden in the logic of the study is that attitudes and preferences are not intrinsic. They are not characteristics we are born with, that we can simply add as a variable in an economic model correlating them with economic growth. We develop attitudes from an early age over the whole course of our lives, learning from <a href="https://eige.europa.eu/gender-mainstreaming/resources/european-union/you-are-who-you-know-network-approach-gender">everyone we interact with</a>. This includes family members, teachers and other role models, as well as other children in our schools and later colleagues in our workplaces.</p>
<p><a href="http://aris.ss.uci.edu/%7Elin/52.pdf">In this way</a>, we learn that women should be caring and men successful, that girls should be altruistic and boys risk-taking. These gender stereotypes are then reinforced throughout our lives because society is structured to make women more likely to look after children and so tend to interact more with teachers and other mums. Men are more likely to spend more time on their careers and their social networks are more varied and offer more opportunities.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/241839/original/file-20181023-169807-1w88bez.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/241839/original/file-20181023-169807-1w88bez.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/241839/original/file-20181023-169807-1w88bez.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/241839/original/file-20181023-169807-1w88bez.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/241839/original/file-20181023-169807-1w88bez.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/241839/original/file-20181023-169807-1w88bez.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/241839/original/file-20181023-169807-1w88bez.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Tradition holds men are naturally more aggressive and risk-taking.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sao-paulo-brazil-june-19-2004-317336375?src=DOGlEvKq57g4gRsVHwN1-w-1-21">Alf Ribeiro/Shutterstock</a></span>
</figcaption>
</figure>
<p>These differences result in what we call <a href="https://www.sup.org/books/title/?id=1416">horizontal segregation</a>, where women end up in so-called “pink collar” jobs because they are more likely to find out about vacancies from other women. When women do end up in male-dominated jobs, they have to face <a href="https://www.emeraldinsight.com/doi/abs/10.1108/03090590110407191">vertical segregation</a>, making it almost impossible for them to reach leading roles. We see this in the well-documented lack of female leaders <a href="https://www.weforum.org/agenda/2017/11/women-leaders-key-to-workplace-equality/">in many industries</a>.</p>
<p>A counter-argument would be that these gender differences really are intrinsic because they depend on biological factors, such as the different levels of sex hormones men and women tend to have. There is now a solid stream of research that looks at how hormones such as testosterone and oestrogen may explain gender behaviour.</p>
<p>Evidence shows that hormones may well influence <a href="https://www.ncbi.nlm.nih.gov/pubmed/21334362">sexual identity</a>, the likelihood of developing <a href="http://journals.sagepub.com/doi/10.2190/PM.46.2.g">certain diseases</a>, and <a href="https://www.sciencedirect.com/science/article/pii/S0306453012001588">male aggression</a> (although results are controversial). But there is no evidence that this is directly related to gender preferences in risk-taking, patience, trust and reciprocity. Interestingly, <a href="https://www.ncbi.nlm.nih.gov/pubmed/19699203">some studies</a> show that while hormones seem to suggest an influence on male behaviour, the same effect is not found in females.</p>
<p>Studies that have looked at these biological factors also stress that they don’t fully explain gender differences in behaviours and preferences, because these are reinforced <a href="https://link.springer.com/article/10.1007/s11199-012-0120-z">in boys</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/20604606">and girls</a> by society. In other words, no biological or genetic study has concluded that nature is stronger than nurture.</p>
<h2>How free are we really?</h2>
<p>The researchers behind the new study explain their results by referring to the <a href="https://www.hse.ru/data/2013/02/20/1306830406/Inglehart&Norris_Rising%2520Tide.pdf">theory of post-materialism</a>. This says that once material needs are satisfied, human beings are free to make their own decisions and express themselves however they want. In poorer countries, men and women are more equally involved in simply making enough money to get by so they aren’t free in this way. In rich countries, more resources supposedly provide more scope for expressing intrinsic gender preferences and behaviour.</p>
<p>What I think the study actually shows is that economic equality leaves men and women freer to express the gender differences that have been created in them by social pressures. This is the same conclusion recently reached by Paul Polman, chief executive officer of Unilever, <a href="https://www.weforum.org/agenda/2017/11/why-is-gender-equality-in-decline-and-how-can-we-reverse-it/">when discussing</a> the <a href="http://www3.weforum.org/docs/WEF_GGGR_2017.pdf">2017 World Economic Forum Global Gender Gap report</a> (the same report used as a measure of gender equality in the new study).</p>
<p>If we really want to understand what drives gender inequality we should ask people who they think are the most caring and most successful people they know. Then we should count how many times women and men are named in these respective roles, by men and women respectively. They will show us how much traditional beliefs about gender roles are still in place, even more in supposedly rich and equal countries.</p><img src="https://counter.theconversation.com/content/105424/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elisa Bellotti does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Gender differences in jobs and attitudes are wider in countries with more equality, but that’s not the end of the story.Elisa Bellotti, Senior Lecturer in Sociology, University of ManchesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/924242018-05-15T03:37:26Z2018-05-15T03:37:26ZInformed consent: women need to know about the link between the pill and depression<figure><img src="https://images.theconversation.com/files/217683/original/file-20180504-153888-i3w8ij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some women are very sensitive to small shifts in oestrogen and progesterone; others aren't.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p><em>ON THE PILL: In this <a href="https://theconversation.com/au/topics/pill-series-52834">seven-part series</a> we explore the history, myths, side-effects and alternatives of the pill, and why it’s the most popular form of contraception in Australia.</em></p>
<hr>
<p>The introduction of the contraceptive pill in the 1960s was a major milestone for female empowerment. It allowed women to separate sex from procreation, and to increase their participation in work outside the home.</p>
<p>Now, <a href="https://www.k4health.org/sites/default/files/l13.pdf">more than 100 million women worldwide</a> use the oral contraceptive pill to prevent pregnancy or control their menstruation.</p>
<p>But the pill and other hormone contraceptives are not without side effects. We usually focus on the physical health effects of the pill, yet the <a href="https://www.ncbi.nlm.nih.gov/pubmed/15236788">most common reason</a> women stop or change the pill is mental health side effects. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/chemical-messengers-how-hormones-affect-our-mood-42422">Chemical messengers: how hormones affect our mood</a>
</strong>
</em>
</p>
<hr>
<p>Depression is one of the most prevalent and debilitating mental disorders in Australia, and <a href="https://www.researchgate.net/publication/50866070_McLean_CP_Asnaani_A_Litz_BT_Hofmann_SG_Gender_differences_in_anxiety_disorders_prevalence_course_of_illness_comorbidity_and_burden_of_illness_J_Psychiatr_Res_45_1027-1035">affects twice as many women</a> as men. It is estimated that one in four women will experience depression in her lifetime. </p>
<p><a href="http://www.abs.gov.au/AUSSTATS/abs@.nsf/2f762f95845417aeca25706c00834efa/e50a5b60e048fc07ca2570ec001909fb!OpenDocument">One in four Australian women</a> between the ages of 18 and 49 use the pill, at any one time. But few are aware of the link between the pill and depression.</p>
<h2>Types of contraceptive pill</h2>
<p>There are many oral contraceptives available in Australia, with different types and doses of the hormones oestrogen and progesterone. </p>
<p>The most commonly prescribed is a combination pill, which contains an oestrogen to prevent ovulation, and a progesterone to reduce the chance of a fertilised egg implanting into the wall of the uterus. </p>
<p>Most combined oral contraceptives have a similar dose and type of oestrogen, but the progesterone types and doses vary widely. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Different types of contraceptive pills contain varying doses of oestrogen and progesterone.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
</figcaption>
</figure>
<p>There are also several <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1728-4465.2005.00038.x">progesterone-only contraceptives</a> that do not contain oestrogen. These are known as the “mini-pill”, or injected contraceptive (“depot provera”), or the skin implanted “straw” (Implanon or Norplant).</p>
<h2>Hormones and mental health</h2>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pubmed/25222701">recent review</a> has shown that sex hormones have significant impact on brain areas related to emotional and cognitive functioning. Progesterones <a href="https://www.ncbi.nlm.nih.gov/pubmed/2725334">have been shown to induce depression</a>, particularly in <a href="https://www.ncbi.nlm.nih.gov/pubmed/1846872">vulnerable women</a>. </p>
<p>Synthetic progesterone (more than natural progesterone) has <a href="https://www.ncbi.nlm.nih.gov/pubmed/9044441">significant effects</a> on the brain chemicals serotonin and monoamine oxidase, resulting in depression, irritability and anxiety.</p>
<p>There is a great deal of variation in the effects of hormone shifts on mood and behaviour. Some women are very sensitive to small shifts in oestrogen and progesterone; others aren’t.</p>
<h2>What does the research say?</h2>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/17688380">Our research</a> has involved measuring the clinical impact of various types of oral contraceptive pill on mood and anxiety. Overall, <a href="https://www.ncbi.nlm.nih.gov/pubmed/24856205">we found</a> woman taking the oral contraceptive pill were more likely to be depressed than non-pill users. </p>
<p>Women taking the pills with low amounts of oestrogen had more depression than those taking higher oestrogen dose pills. </p>
<p>Certain types of progesterone were more “depressive” than other progesterones, but the progesterone-only contraceptives were the most depressive of all the contraceptives.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/biology-is-partly-to-blame-for-high-rates-of-mental-illness-in-women-the-rest-is-social-75700">Biology is partly to blame for high rates of mental illness in women – the rest is social</a>
</strong>
</em>
</p>
<hr>
<p>A <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2552796">2016 Danish study</a> of more than one million women supports our clinical findings. The researchers found that, compared to non-users, women aged 15-34 who took the combined oral contraceptive pill were 1.23 times more likely to be diagnosed with depression and prescribed antidepressant medication.</p>
<p>Adolescents aged 15-19 who used combined oral contraceptives had an even higher rate of depression than older women. They were 1.8 times more likely to be diagnosed with depression than the non-pill using peers, and this increased to 2.2 times among adolescents using progesterone-only contraceptives. </p>
<p>The study concluded that depression is a significant potential side effect of hormonal contraceptive use, especially in adolescents.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Adolescents taking the pill appear to be at higher risk of depression than women in older age groups.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
</figcaption>
</figure>
<h2>It’s not all bad news</h2>
<p>Emerging research <a href="https://www.ncbi.nlm.nih.gov/pubmed/24856205">by our group</a> and others suggests the combined contraceptive pill may improve “verbal memory” or memory for words and language. This is thought to be driven by oestrogen, which has been shown to positively influence memory-related brain regions. </p>
<p>Research also suggests that pills containing progesterones that are structurally more like testosterone improve visual-spatial skills (traditionally, a male-dominant skill) and pill types containing other progesterones may worsen visual-spatial skills.</p>
<h2>Finding the right contraception</h2>
<p>There are many types of hormone contraceptives and their use needs to be tailored carefully for the individual, especially among adolescents. Women and their doctors need to be aware that hormone contraceptives can contribute to mental health problems, and women should return to their GP if they experience mental health side effects. </p>
<p>The development of new hormone contraceptives that don’t impact adversely on brain chemistry is well overdue. Women must have the right to control their fertility without compromising their enjoyment of life.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/chemical-messengers-how-hormones-change-through-menopause-56921">Chemical messengers: how hormones change through menopause</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/92424/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jayashri Kulkarni conducts many clinical trials and has received funding from the National Health and Medical Research Council of Australia, is on the Swisse Scientific Advisory Board, has received research grants from pharmaceutical companies – Jansen Cilag and Servier. The work presented in this article on the contraceptive pill was not funded by any external funding agencies and is completely independent research. No makers of any contraceptive pill or device has been involved in any way with this research.
</span></em></p><p class="fine-print"><em><span>Caroline Gurvich has received funding from the National Health and Medical Research Council of Australia. </span></em></p>We usually focus on the physical health effects of the pill, yet the most common reason women stop or change the pill is mental health side effects.Jayashri Kulkarni, Professor of Psychiatry, Monash UniversityCaroline Gurvich, Senior Research Fellow and Clinical Neuropsychologist, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/842242017-10-10T13:22:26Z2017-10-10T13:22:26ZWhat’s behind the huge increase in breast cancer rates in China?<figure><img src="https://images.theconversation.com/files/186839/original/file-20170920-16414-18qqy8r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/289309139?size=medium_jpg">Guschenkova/Shutterstock</a></span></figcaption></figure><p>Breast cancer is the most common cancer among women in China, according to the <a href="http://onlinelibrary.wiley.com/doi/10.3322/caac.21338/full">latest data</a> from China’s national cancer registry. An analysis of the data reveals that the cancer has increased at a rate of around 3.5% a year from 2000 to 2013, compared with a <a href="https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2015/cancer-facts-and-figures-2015.pdf">drop of 0.4% a year</a> over the same period in the US. </p>
<p>The analysis also reveals that breast cancer rates are higher in urban areas of China than in rural areas. And the higher the population density, the higher the rate. For small cities (population below 500,000), the incidence of breast cancer is 30 per 100,000. For medium-sized cities (population between 500,000 to 1,000,000), it is 40 in 100,000. And for large cities (population above 1m), the incidence rate is 60 per 100,000 women. </p>
<p>With the rapid development of China’s economy, more and more people have moved from rural areas and towns to large cities. As a result, many “megacities” have sprung up. By 2014, China had six megacities with populations above 10m. It is very likely that urbanisation is having a big impact on breast cancer incidence in China.</p>
<p>Here is a list of some of the factors that may be behind the rise in breast cancer incidence in China: </p>
<p><strong>Childbearing</strong>: Having <a href="https://www.ncbi.nlm.nih.gov/pubmed/8178795">more than one child</a> lowers breast-cancer risk. With the <a href="https://en.wikipedia.org/wiki/One-child_policy">one-child policy</a> in place since 1979, most women – especially if they worked in the city – had to strictly follow the policy in order to avoid being fined. Although the one-child policy rule was replaced in 2015 with a two-child policy rule, the possible benefit on breast cancer incidence will probably take <a href="http://www.thelancet.com/journals/landia/article/PIIS0140-6736(16)31405-2/abstract">15 to 20 years to show</a>.</p>
<p>Research also shows that the women who have their first child at age <a href="https://www.ncbi.nlm.nih.gov/pubmed/2145231">35 or younger</a> tend to have a protective benefit from pregnancy. However, in China, many women have chosen to delay having a child as a result of <a href="https://books.google.co.uk/books?isbn=0739180460">work pressure and cultural change</a>. </p>
<p>Women are also less likely to breastfeed than previous generations, which may be another contributing factor. Research has shown that both pregnancy and breastfeeding reduce a woman’s risk of developing cancer, because they reduce the lifetime number of menstrual cycles. As a result, women are exposed to less oestrogen. (<a href="http://www.nhs.uk/Conditions/Cancer-of-the-breast-female/Pages/Causes.aspx">Oestrogen</a> can stimulate breast cancer cells to grow.) It has also been <a href="https://www.ncbi.nlm.nih.gov/pubmed/15987443">hypothesised</a> that breast cells need to mature in order to produce milk and mature cells are more resistant to becoming cancer cells.</p>
<p>Researchers in China have found <a href="https://link.springer.com/article/10.1007%2Fs11670-012-0009-y">associations</a> between these “reproductive factors” – including oral contraceptives and hormone replacement therapy (HRT) – and the rise in breast cancer incidence in China. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/189359/original/file-20171009-6971-y2fb9r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/189359/original/file-20171009-6971-y2fb9r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/189359/original/file-20171009-6971-y2fb9r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/189359/original/file-20171009-6971-y2fb9r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/189359/original/file-20171009-6971-y2fb9r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/189359/original/file-20171009-6971-y2fb9r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/189359/original/file-20171009-6971-y2fb9r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">China’s one-child policy was in place till 2015.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/136834085?src=sSE4cT7ho1Le5Tmei7Q4Yw-1-13&size=medium_jpg">TonyV3112/Shutterstock</a></span>
</figcaption>
</figure>
<p><strong>Stress</strong>: Stress – which is more likely to be experienced in large cities – has been linked to <a href="https://www.ncbi.nlm.nih.gov/pubmed/16476222">increased risk</a> of developing cancer. Although stress may not directly cause cancer, it does <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3079864/">affect the levels of various hormones</a> and it <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3341916/">suppresses the immune system</a>. And, once cancer has developed, stress is believed to aid its <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3037818/">progression</a>. </p>
<p><strong>Lifestyle</strong>: In modern China, women are generally less physically active than they were in previous generations. A <a href="https://www.biomedcentral.com/about/press-centre/science-press-releases/20-04-2016">study</a> published in the International Journal of Behavioral Nutrition and Physical Activity, shows that levels of physical activity for adults in China fell by nearly half between 1991 and 2011, and they declined more rapidly for women than for men. </p>
<p>An unhealthy diet is also increasingly common in urban China, with a proliferation of fast food outlets. This has resulted in an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3951516/">increase in obesity among Chinese women</a>. </p>
<p>Increased <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3832299/">alcohol assumption</a> has long been associated with the increased risk of developing breast cancer and a <a href="http://www.who.int/bulletin/volumes/91/4/12-107318/en/">World Health Organisation bulletin</a> notes that, in China, alcohol consumption is increasing faster than in other parts of the world.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/189358/original/file-20171009-6979-wj18ep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/189358/original/file-20171009-6979-wj18ep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=406&fit=crop&dpr=1 600w, https://images.theconversation.com/files/189358/original/file-20171009-6979-wj18ep.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=406&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/189358/original/file-20171009-6979-wj18ep.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=406&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/189358/original/file-20171009-6979-wj18ep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=510&fit=crop&dpr=1 754w, https://images.theconversation.com/files/189358/original/file-20171009-6979-wj18ep.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=510&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/189358/original/file-20171009-6979-wj18ep.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=510&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">McDonalds in Shenzhen, China.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/178962470?src=508M7CTswR5w9nlFCZKuvg-1-7&size=medium_jpg">ArtWell/Shutterstock</a></span>
</figcaption>
</figure>
<p><strong>Ageing</strong>: <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2626623/">Ageing</a> is the biggest risk factor for breast cancer. Women are <a href="http://www.worldlifeexpectancy.com/china-life-expectancy">living longer in China</a>, which is a <a href="http://onlinelibrary.wiley.com/doi/10.3322/caac.21338/full">key factor</a> related to the increased incidence of breast cancer in the country. As people get older, there is more genetic damage and <a href="https://www.omicsonline.org/molecular-basis-of-aging-and-breast-cancer-1948-5956.1000187.pdf">less ability to repair the damages</a>.</p>
<h2>Small improvements</h2>
<p>Even though the prevalence of breast cancer among women in China is lower than in many <a href="https://theconversation.com/uk">developed countries</a>, the rapid increase in incidence of the disease – which is also being <a href="https://theconversation.com/confronting-breast-cancer-is-crucial-to-indias-economic-development-81717">witnessed in India</a> – is cause for great concern. </p>
<p>Because of China’s large population, even with a small percentage of improvement on cancer prevention, a sizeable number of women’s lives could be saved. There are many risk factors that can be reduced by raising cancer awareness and having better education on diet, exercise, stress reduction as well as improving breast cancer screening. Public health authorities in China <a href="http://www.who.int/tdr/publications/documents/health-research-china.pdf">can play a crucial role</a> in developing well-defined strategies to tackle the issue and reduce the breast cancer burden in China.</p><img src="https://counter.theconversation.com/content/84224/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jin-Li Luo does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Breast cancer rates in China are rising, and are expected to continue rising for the next three decades.Jin-Li Luo, Senior Bioinformatician, University of LeicesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/735962017-03-19T19:26:59Z2017-03-19T19:26:59ZHow obesity causes cancer, and may make screening and treatment harder<p>Today, almost <a href="https://theconversation.com/mapping-australias-collective-weight-gain-7816">two in every three</a> Australian adults are overweight or obese, as are one in four children. Obesity is a disease itself and a risk factor linked to ischaemic <a href="https://www.healthdata.org/sites/default/files/files/country_profiles/GBD/ihme_gbd_country_report_australia.pdf">heart disease</a> (the leading cause of premature deaths today in Australia), stroke (the third leading cause), and musculoskeletal conditions (the <a href="http://www.aihw.gov.au/burden-of-disease/">second major</a> cause of disability), among others. </p>
<p>This rising obesity burden is the outcome of a <a href="https://theconversation.com/mapping-australias-collective-weight-gain-7816">host of factors</a>, many of which are <a href="https://theconversation.com/your-fault-youre-fat-i-dont-buy-it-33513">beyond the control</a> of the individual. It is having a devastating impact on the health of the nation. What’s often overlooked, though, is the link between obesity and cancer.</p>
<p>Cancer is a disease of altered gene expression that originates from changes to the DNA caused by a range of factors. These include inherited mutations, DNA damage, inflammation, hormones, and external factors including tobacco use, infections (for example, viruses such as HPV), radiation, chemicals and carcinogenic agents in food.</p>
<p><a href="http://www.bmj.com/content/356/bmj.j477">Strong evidence</a> also links obesity to a number of cancers. These include oesophageal adenocarcinoma, bowel cancer (the third leading cause of preventable death in Australia), cancer of the liver, gall bladder and bile ducts, pancreatic cancer, postmenopausal breast cancer, endometrial cancer, kidney cancer, and multiple myeloma (cancer in the plasma in the blood). </p>
<p>This is just the tip of the iceberg. Highly suggestive evidence exists for a further eight cancers.</p>
<h2>How does obesity increase cancer risk?</h2>
<p>There are <a href="http://www.aicr.org/assets/docs/pdf/reports/Second_Expert_Report.pdf">many complex ways</a> obesity is thought to cause or increase the risk of cancer.</p>
<p>Increased body fat is associated with increased inflammation in the body, increased release of oestrogens (in part from the fat cells themselves) and decreased insulin sensitivity associated with raised insulin production. </p>
<p>Insulin, “insulin-like growth factor-1” (IGF1) and leptin are all elevated in obese people and can promote the growth of cancer cells. </p>
<p>Secretion of the hormone insulin is usually tightly controlled and a healthy part of our body’s sugar-regulation processes. But it can be significantly elevated in people with obesity-related pre-diabetes or diabetes due to insulin resistance. </p>
<p>This state of elevated insulin levels in the blood can act as a growth signal for tumour cells. This <a href="http://www.nature.com/nrc/journal/v4/n8/full/nrc1408.html">increases the risk of cancers</a> of the colon and endometrium (the lining of the uterus), and likely of the pancreas and kidney.</p>
<p>Insulin-like growth factors (IGFs) regulate cell growth, differentiation and death, and <a href="https://www.ncbi.nlm.nih.gov/pubmed/15110491">IGF-1</a> has been associated with prostate, breast and bowel cancers. </p>
<p>Leptin, a hormone implicated in hunger and satiety, can stimulate proliferation of many pre-cancer and cancer cells. Increased leptin levels in obese people are associated with <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Stattin+P%2C+Lukanova+A%2C+Biessy+C%2C+et+al.+Obesity+and+colon+cancer%3A+does+leptin+provide+a+link%3F+Int+J+Cancer+2004%3B109%3A149-52.">bowel</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/11170133">prostate</a> cancers.</p>
<p>Sex steroid hormones, including oestrogens, testosterone and progesterone, are crucial to healthy body development and sexual function, but are also likely to play a role in obesity and cancer. Increased levels of sex steroids are strongly associated with risk of developing endometrial and postmenopausal breast cancers, and may contribute to other cancers such as bowel cancer. </p>
<p>Fat tissue is the main site of oestrogen production in the body for men and postmenopausal women (in premenopausal women the ovaries are the major producer). Obesity can predispose premenopausal women to polycystic ovarian syndrome, which causes elevated testosterone and therefore could contribute to cancer risk.</p>
<p>Obesity also causes inflammation in the body. This means the body’s immune system is consistently more active than is normal in healthy weight people. </p>
<p><a href="http://www.nejm.org/doi/full/10.1056/NEJMsr1606602#t=article">Evidence</a> for a role of sex hormones and chronic inflammation in the relationship between obesity and cancer is strong. Evidence for a role of insulin and IGF is moderate. A range of other mechanisms are still under investigation. </p>
<h2>Where does obesity lie on cancer-risk scale?</h2>
<p>Overall, obesity-associated cancers represent <a href="http://www.sciencedirect.com/science/article/pii/S1877782116000059">up to 8.2% of all cancers</a> in the UK. For comparison, smoking is <a href="http://www.cancerresearchuk.org/health-professional/cancer-statistics/risk/tobacco">responsible for about 19%</a>. </p>
<p>Of all deaths from cancer in the USA, excess body weight is close behind smoking as the attributable cause, at <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2515569/">20%</a> versus <a href="http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2571615">30%</a>. </p>
<h2>Does obesity affect the screening and detection of cancer?</h2>
<p>Focusing on just two types of cancer, breast cancer in women and prostate cancer in men, some evidence suggests that obesity can delay the identification of cancer through screening. This does not reduce the importance or accuracy of screening tools or programs.</p>
<p>For breast cancer, the most common form of cancer in women in Australia, the good news is that screening accuracy is similar across weight status. The Swiss national health survey found the accuracy of mammography is maintained in obese women - with similar ability of the tests to detect cancers, but reduced ability to ensure the positive result definitely means cancer. This meant obese women had a <a href="https://www.ncbi.nlm.nih.gov/pubmed/15159273">20% higher</a> false positive rate than normal weight individuals, but does not suggest any cancers were missed. </p>
<p>The troubling news, though, is <a href="http://link.springer.com/article/10.1245/s10434-012-2320-8">studies</a> suggest obese women with breast cancer detected through mammogram tend to present to their doctors later, and when the cancer is more serious, than their healthy weight counterparts. The exact reasons for this are not clear, but may include difficulties in breast self-examination and <a href="http://www.nature.com/bjc/journal/v86/n7/abs/6600209a.html">delayed health-seeking</a>. <a href="http://link.springer.com/article/10.1245/ASO.2006.03.049">Such findings</a> reinforce the crucial importance of strategies to encourage appropriate cancer screening and timely medical follow-up among overweight and obese women. </p>
<p>For prostate cancer, the most common form of cancer in Australia, large <a href="http://www.sciencedirect.com/science/article/pii/S0302283807006641">studies</a> suggest a link between obesity and decreased risk of low-grade or early prostate cancer, but increased risk of advanced disease. </p>
<p>The reasons are again thought to be numerous, but one potential reason may be linked to greater difficulty in diagnosing prostate cancer in overweight men. While this is thought to possibly delay diagnosis and treatment, it is unlikely entirely to explain the links between obesity and prostate cancer risk.</p>
<h2>What risks does obesity pose in the treatments of cancer?</h2>
<p>Obesity can impact cancer treatments and their success. Obese patients have a <a href="https://www.ncbi.nlm.nih.gov/pubmed/16957821">significantly higher risk</a> of heart attack following surgery, as well as risk of wound infection, nerve injury and urinary infection. Obesity alone increases the risk of poorer health outcomes following surgery, and morbid obesity increases the risk of death.</p>
<p>In cancer treatments, <a href="https://www.ncbi.nlm.nih.gov/pubmed/26643515">one study</a> has shown significantly increased surgical complications and prolonged hospital stay with morbid obesity in bowel cancer. <a href="http://meetinglibrary.asco.org/content/145468-156">Another suggests</a> obesity may reduce chemotherapy efficacy in breast cancer, with lower disease-free survival rates.</p>
<h2>Is this risk reversible?</h2>
<p>By 2025 <a href="http://www.nature.com/ijo/journal/v41/n1/abs/ijo2016165a.html">it’s estimated</a> that more Australians will be obese than normal weight. At the same time, cancer is a <a href="https://www.healthdata.org/sites/default/files/files/country_profiles/GBD/ihme_gbd_country_report_australia.pdf">leading contributor</a> to early deaths and disability in Australia and the major cause of <a href="http://www.aihw.gov.au/burden-of-disease/">years lost</a> from people’s lifespans. </p>
<p>The question is not whether obesity can cause cancer; it is how we can better prevent or mitigate this important risk factor. Reassuringly, <a href="http://www.nejm.org/doi/full/10.1056/NEJMsr1606602#t=article">evidence suggests</a> that weight loss may reduce or reverse many of the above processes and their associated risks.</p>
<p>While obesity is just one of the drivers of the cancer burden in Australia, it is preventable and doing so would bring other enormous health benefits.</p><img src="https://counter.theconversation.com/content/73596/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Alessandro Demaio works for the World Health Organization in Geneva. This post was written by Dr Alessandro Demaio in his personal capacity. The views, opinions and positions expressed in this article are the author’s own and do not reflect the views of any third party. Additionally, those providing comments on this blogs are doing so in their personal capacity, and do not necessarily reflect the views, opinions or positions of the author. </span></em></p><p class="fine-print"><em><span>Anna Beale does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Obesity is linked with a host of health outcomes. Both a disease itself and a risk factor linked to many others, we explore the linkages between obesity and cancer.Sandro Demaio, Medical Doctor, Associate Researcher, University of CopenhagenAnna Beale, Medical doctor; PhD candidate in cardiology, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/597872016-12-06T02:22:26Z2016-12-06T02:22:26ZWhat women with breast cancer should know about estrogens<figure><img src="https://images.theconversation.com/files/146450/original/image-20161117-18113-kc2bjl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Doctors and patients should appreciate the many roles estrogens play in the body.</span> <span class="attribution"><span class="source">Doctor and patient image via www.shutterstock.com.</span></span></figcaption></figure><p>One of every eight women in the United States <a href="http://www.breastcancer.org/symptoms/understand_bc/statistics">will develop invasive breast cancer</a> over her lifetime. <a href="http://www.breastcancer.org/symptoms/diagnosis/hormone_status/read_results">Eighty percent of those cancers</a> are fueled in part by estrogens.</p>
<p>One treatment for women whose breast cancer is fueled by estrogen – or what is often called estrogen receptor (ER)-positive breast cancer – is for them to take drugs that block estrogens. But estrogens have benefits that should be considered.</p>
<p>This particularly affects postmenopausal women who have gone through the trauma of surgery for invasive breast cancer. They are typically faced with a very difficult decision. Should they take estrogen blockers or not? Is the treatment worth it, balancing the risk of recurrence of the cancer with potential quality-of-life issues?</p>
<p>When prescribing a particular drug for postmenopausal, ER-positive, breast cancer survivors, physicians often consider the effects of estrogen blockers on <a href="http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-treating-hormone-therapy">bone and the uterus</a>.</p>
<p>However, they also need to consider the effects on other aspects of women’s health. Estrogens also have many positive effects on mental health, cognitive function, libido and protection of the brain, possibly even slowing the onset of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2728624/">Alzheimer’s disease</a>.</p>
<p>I am a neuroendocrinologist, and I have studied the effects of hormones, including estrogens, on the brain, behavior and mental health for over 40 years. Not only is the fact that “estrogen” is actually a class of hormones <a href="http://press.endocrine.org/doi/pdf/10.1210/en.2008-0396">not well understood</a>, but so are the many positive functions of estrogens. As with any health treatment, the potential negative effects should be weighed against the potential positive effects. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/146451/original/image-20161117-18128-5citjp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/146451/original/image-20161117-18128-5citjp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/146451/original/image-20161117-18128-5citjp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/146451/original/image-20161117-18128-5citjp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/146451/original/image-20161117-18128-5citjp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/146451/original/image-20161117-18128-5citjp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/146451/original/image-20161117-18128-5citjp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">It’s estrogens, not estrogen.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-263085500/stock-photo-papers-with-hormones-list-and-tablet-with-words-estrogens-.html?src=a3HUbVzTGdtnmxelDI09Bw-1-44">Estrogens image via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>There is no hormone called estrogen</h2>
<p>First, a primer on what exactly “estrogen” is. There is actually <a href="http://press.endocrine.org/doi/pdf/10.1210/en.2008-0396">no hormone called</a> “estrogen.” Estrogens are a class of hormones. There are three different forms of estrogens in the body: estradiol, estriol and estrone. Although they are all pretty similar in function, they vary in potency. Estrogens found in plants, like soy, are also sometimes simply called “estrogen,” although their effects may differ from those of the estrogens produced in the body.</p>
<p>Estradiol is the dominant estrogen circulating prior to menopause. It is produced mainly in the ovaries. In most cases, this is the most potent form of estrogen. During pregnancy, the dominant form is estriol, produced by the placenta. And during menopause, when the levels of estradiol decrease, the dominant estrogen is estrone, produced in fat tissue. </p>
<p>The ovaries stop producing estrogens during menopause, resulting in lower levels of estrogens in the body. Yet other organs, including fat and the brain, continue to produce them. There are still estrogens doing whatever they were doing before, but because their levels are lower, they are not doing their work as effectively.</p>
<p>One class of estrogen blockers that is often prescribed for women with estrogen receptor-positive breast cancer does its job by blocking estrogens from getting to the receptors of the cells in the body, including cancer cells. The body still produces estrogens, but their effects are blocked in some cells. </p>
<p>A second class, called aromatase inhibitors, blocks the production of estrogens. Both types of estrogen blocker act in the brain as well as the breast, ovaries, vagina and many other parts of the body. </p>
<p>Since these drugs block the effects of estrogens, we should expect that, besides blocking the negative effects of estrogens on the breast cancer, they will block the positive effects on the brain and on mental health.</p>
<p>Unfortunately, many experiments directly assessing the effects of these drugs in breast cancer survivors are missing essential controls. It would not be ethical to give one group of women with a high risk of recurrence of breast cancer a placebo. </p>
<p>However, although much more research on the effects of anti-estrogens in postmenopausal women with breast cancer is needed, by considering what we know about the effects of estrogens <a href="http://www.sinauer.com/an-introduction-to-behavioral-endocrinology-864.html">from animal studies</a>, all that we know about the <a href="https://www.ncbi.nlm.nih.gov/pubmed/27680875">effects of estrogens in women without breast cancer</a> and what we know from some studies about the <a href="https://www.ncbi.nlm.nih.gov/pubmed/26786934">effects of anti-estrogens</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/25906766">in breast cancer survivors</a>, we can conclude that anti-estrogens are likely to compromise quality of life in some women.</p>
<h2>What are the positive effects of estrogens?</h2>
<p>The many positive functions of estrogens and their effects on health are often underestimated. </p>
<p>Estrogens are responsible for the development of reproductive tissues and female secondary sexual characteristics (like breasts) at puberty. They also maintain bone density and decrease the risk of osteoporosis, which can result in brittle bones that break easily. But the role estrogens play in women’s health goes far beyond reproductive health and bone density.</p>
<p>Some of the most profound effects of estrogens are in the brain. For instance, hot flashes, which many women experience while going through menopause, are due to the loss of estrogens acting on brain areas involved in temperature regulation. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/146452/original/image-20161117-18138-5axe5n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/146452/original/image-20161117-18138-5axe5n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=691&fit=crop&dpr=1 600w, https://images.theconversation.com/files/146452/original/image-20161117-18138-5axe5n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=691&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/146452/original/image-20161117-18138-5axe5n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=691&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/146452/original/image-20161117-18138-5axe5n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=868&fit=crop&dpr=1 754w, https://images.theconversation.com/files/146452/original/image-20161117-18138-5axe5n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=868&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/146452/original/image-20161117-18138-5axe5n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=868&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Estrogen may have a protective role in the brain.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/pic-100336682.html">Brain image via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<p>They can also influence <a href="http://press.endocrine.org/doi/10.1210/er.2001-0016">cognitive function</a> – <a href="https://www.ncbi.nlm.nih.gov/pubmed/25205317">how we think</a>, particularly
verbal memory and fluency, which is the memory of words and how we express ourselves in language. And around the time of menopause in many women, they are believed to have an <a href="https://womensmentalhealth.org/posts/proving-the-estrogen-withdrawal-hypothesis-of-perimenopausal-depression/?doing_wp_cron=1478622920.9318621158599853515625">anti-depressive effect</a>. </p>
<p>Sleep disturbances during menopause are believed to be caused by absence of the estrogens acting on sleep centers in the brain. The decreased actions of estrogens on the brain during menopause may also <a href="http://www.sciencedirect.com/science/article/pii/S0018506X15301677">influence sexual desire</a>.</p>
<p>And finally, estrogens may be protective in the brain. This has been demonstrated in nonhuman primates. In women, estrogens may decrease the <a href="https://www.ncbi.nlm.nih.gov/pubmed/27327261">incidence of Alzheimer’s disease</a> if <a href="http://jama.jamanetwork.com/article.aspx?articleid=195464">hormone replacement begins soon after menopause</a>. </p>
<p>After menopause, the level of estrogens drops to low amounts. Appreciable amounts are still produced in fat tissue. We now believe that the brain also produces some estrogens as well, a topic that is being studied right now.</p>
<h2>Weighing the pros and cons of estrogen blockers</h2>
<p>Should women with estrogen receptor-positive breast cancer take inhibitors of estrogens? The decision of whether or not to use estrogen blockers is a complex one that each woman must make in consultation with her oncologist. </p>
<p>The potential negative effects of these blockers on the brain and quality of life should be weighed against the potential positive effects on recurrence of the cancer. The answer to this will depend on the absolute risk of recurrence of the cancer. </p>
<p>In making a decision about a treatment that could impact quality of life, it would be most helpful to speak with an oncologist who is fully aware of the potential negative, as well as positive, effects of these drugs.</p><img src="https://counter.theconversation.com/content/59787/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeffrey D. Blaustein does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Estrogens also have many positive effects on mental health, cognitive function, libido and protection of the brain, possibly even slowing the onset of Alzheimer’s disease.Jeffrey D. Blaustein, Professor of Psychological and Brain Sciences, UMass AmherstLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/473492015-11-15T19:17:29Z2015-11-15T19:17:29ZHow cancer doctors use personalised medicine to target variations unique to each tumour<figure><img src="https://images.theconversation.com/files/99119/original/image-20151021-32235-1gvxijl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Understanding the DNA of tumours allows researchers to target treatment to each individual.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/akire_yrko/3573644189/in/photolist-6rMRUZ-kaeMjj-ks75Wi-o8Dufm-kh2cVC-6Zq5td-o5GPqG-ng8ZAw-nS9kB1-nTc5iy-nDDUYf-o8Dujj-dZrRbo-yQcADM-nM4fy9-4BYXRj-dieVW6-oowrrL-rwZo4C-eeZ2WB-bvxDXq-dyu3pu-vcFhob-5pqov9-qebnFQ-fzysmy-8ZRGME-mEN11z-aLKn6M-bJsqVH-nBBh4w-omZoFq-nBBgMu-ivf5Mn-o5GPdY-Fg2yY-cwU2o7-o5GNXq-ooXhPB-7BJjf8-GTqKj-okaA4u-4sCW6q-omV8e8-ooXoQp-ooXqQM-o5HRcc-nJGuCU-nS9z4Q-4CH7rh">Erika/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>The Children’s Cancer Institute in Sydney <a href="http://www.smh.com.au/national/health/australianfirst-program-aims-to-eliminate-childhood-cancer-deaths-20150901-gjcqkt.html">recently launched</a> an ambitious program. From early next year, scientists will analyse the unique cancer cells of 12 children diagnosed with the most aggressive forms of the disease to find the best treatment for each child. </p>
<p>By 2020, they aim to have these individualised treatment options available to all children diagnosed with cancers that have a less than 30% survival rate. This way of tailoring treatment to each person is known as personalised medicine, and advances in DNA sequencing have paved the way for a new era in cancer management. </p>
<h2>Tailoring treatments</h2>
<p>The modern use of the term “personalised medicine” is based on the idea that by understanding the specific molecular code of a person’s disease, and particularly its genetic makeup, we can more accurately tailor treatment to them. This approach is also referred to as precision medicine.</p>
<p>Cancer is fundamentally a disease of altered genomics – genetic material making up the structure of cells. Because these alterations are different in each person, every tumour is programmed differently with genes made up of varying sequences of DNA. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/99135/original/image-20151021-15424-1sn93sn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/99135/original/image-20151021-15424-1sn93sn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/99135/original/image-20151021-15424-1sn93sn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/99135/original/image-20151021-15424-1sn93sn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/99135/original/image-20151021-15424-1sn93sn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/99135/original/image-20151021-15424-1sn93sn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/99135/original/image-20151021-15424-1sn93sn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Cancer cells are programmed with a unique code.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>This is why not everyone will respond the same way to a given treatment. Determining the DNA sequence that makes up the genome of each tumour (genomic sequencing) helps doctors understand how the tumour may be effectively targeted.</p>
<p>Traditionally, identifying effective cancer treatments relied on large clinical trials involving thousands of patients. This approach successfully identifies drugs effective for general cancer features, but these may miss the unique Achilles heel in some people’s cancers.</p>
<p>Because personalised medicine is customised treatment for individuals, clinical trial designs are moving from population-based to <a href="http://www.nature.com/news/personalized-medicine-time-for-one-person-trials-1.17411">one-person trials</a>. Here, a person with a specific genomic makeup is given targeted therapies and the responses are tracked over time. </p>
<h2>Genomic framework</h2>
<p>While the Sydney children’s program has been described as the first of its kind in Australia, the concept of personalised medicine is not new. Cancer doctors have always managed each person’s cancer by using all the available information about the tumour and other pre-existing medical conditions. </p>
<p>But there are important differences in the development of personalised medicine today. </p>
<p>Breast cancer treatment is one example. For the last 40 years, a large factor dictating the clinician’s choice for breast cancer therapy was the <a href="http://www.biomedcentral.com/content/pdf/s12916-015-0369-5.pdf">presence or absence of oestrogen receptors</a> in the tumour. Oestrogen receptors receive signals from the hormone oestrogen, which then generates a reaction. Without them, oestrogen wouldn’t have any affect. </p>
<p>If a woman’s tumour didn’t have these receptors, then doctors wouldn’t give them drugs that affected oestrogen as there would be no point. </p>
<p>But now it has become apparent that having oestrogen receptors is not the only criteria for the use of these drugs, as not all women who have oestrogen receptors will benefit from them.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/99138/original/image-20151021-15440-tfxxk8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/99138/original/image-20151021-15440-tfxxk8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/99138/original/image-20151021-15440-tfxxk8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/99138/original/image-20151021-15440-tfxxk8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/99138/original/image-20151021-15440-tfxxk8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/99138/original/image-20151021-15440-tfxxk8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/99138/original/image-20151021-15440-tfxxk8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A personalised approach to treatment can prevent having to undergo a therapy that isn’t working.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>So researchers have gone deeper to see that this is due to the <a href="http://www.biomedcentral.com/content/pdf/s12916-015-0369-5.pdf">different way oestrogen receptors function</a> in cancer cells. </p>
<p>Understanding the genomic framework of the tumour can determine this function and thus predict the types of women who, despite having the receptor, would likely not benefit from such hormonal therapy.</p>
<h2>Different classifications</h2>
<p>This understanding of a tumour’s genomic makeup has also led scientists to expand the way cancer is classified. Where previously we categorised cancers by their organ of origin (breast, pancreas etc), findings like the above mean we can now also use a genomic definition. </p>
<p>This has positive implications for optimising cancer treatment.</p>
<p>For instance, one of the most aggressive forms of breast cancer is HER2-positive cancer (human epidermal growth factor receptor 2). The subtype accounts for about 15% of breast cancers, and occurs when the tumour has extra copies of the HER2 receptor gene that promotes cancer cell growth.</p>
<p>Drugs targeting the HER2 protein have shown <a href="http://canceraustralia.gov.au/publications-and-resources/cancer-australia-publications/recommendations-use-trastuzumab-herceptin%C2%AE-treatment-her2-positive-breast-cancer">dramatic success in improving outcomes</a> for people with this subtype. They have become standard treatment.</p>
<p>But it has <a href="http://www.ncbi.nlm.nih.gov/pubmed/25896973">recently been discovered</a> that excessive HER2 is also present in about 8% of gastric cancers and 3% of pancreatic cancers. This means a therapy successful in one location has the potential to work in another, because the tumour types are similar.</p>
<p>Clinical <a href="http://www.garvan.org.au/news-events/news/potential-treatment-for-a-specific-kind-of-pancreatic-cancer">trials are currently assessing</a> whether HER2-targeted drugs can then also be effective against these pancreatic tumour types. </p>
<h2>Cost and benefit</h2>
<p>Most major cancer hospitals in Australia have trials investigating personalised medicine at some level. But genomic analyses aren’t widely performed on an individual patient basis.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/99139/original/image-20151021-15414-1ney30d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/99139/original/image-20151021-15414-1ney30d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/99139/original/image-20151021-15414-1ney30d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/99139/original/image-20151021-15414-1ney30d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/99139/original/image-20151021-15414-1ney30d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/99139/original/image-20151021-15414-1ney30d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/99139/original/image-20151021-15414-1ney30d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Understanding a tumour’s genome can dramatically improve outcomes.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>It is likely examining each tumour in this way will become routine treatment in the near future. There are already international providers who will (for a fee) sequence tumours and suggest treatments based on this information.</p>
<p>For instance, the <a href="http://www.mycancerisunique.com">Foundation Medicine test</a> profiles some 400 known cancer driver genes and can be purchased for $US5,800 (approximately $A8,000). This type of test is not routine in Australia, but internet-savvy patients who have the financial means can arrange to have their tumour analysed with the help of their doctor.</p>
<p>Further to that cost of sequencing is the actual treatment, which may sometimes be an expensive drug not listed on the Australian Pharmaceutical Benefits Scheme for this particular use.</p>
<p>But there are advantages to the personalised approach that transcend cost. </p>
<p>Besides the potential of finding the right treatment, it can lead to stopping a therapy that isn’t working. Or result in a therapy not being undertaken at all; therapies that in many cases are themselves expensive and often have the added burden of side effects.</p><img src="https://counter.theconversation.com/content/47349/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth Williams receives funding from Movember Foundation and the Prostate Cancer Foundation of Australia through a Movember Revolutionary Team Award.</span></em></p><p class="fine-print"><em><span>Rik Thompson receives funding from the National Breast Cancer Foundation, the NHMRC and Princess Alexander Hospital Foundation</span></em></p>Personalised medicine is based on the idea that by understanding the specific molecular code of a person’s disease, and particularly its genetic makeup, we can more accurately tailor treatment.Elizabeth Williams, Associate Professor, School of Biomedical Sciences, Queensland University of TechnologyRik Thompson, Professor of Breast Cancer Research, Institute of Health and Biomedical Innovation and School of Biomedical Sciences,, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/424222015-10-01T20:13:31Z2015-10-01T20:13:31ZChemical messengers: how hormones affect our mood<figure><img src="https://images.theconversation.com/files/95483/original/image-20150921-19274-2bzqjv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some women are very sensitive to small shifts in hormones, others aren't. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/gagilas/8117584487/">Petras Gagilas/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>“It’s that time of the month – stay away from her!” </p>
<p>The process of shedding the uterine lining with vaginal bleeding every month has an obvious reproductive focus, but it has also long been linked with changes to mood and behaviour. Unfortunately, this has often been an attempt to consign women to a “biologically” determined place of inferior mental functioning.</p>
<p>In recent times, we have learnt more about the connections between the “reproductive” or gonadal hormones and the brain, and how they affect not only women but men as well. </p>
<p>Gonadal hormones (oestrogen, progesterone and testosterone) are produced by the gonads (the ovaries and testes) in response to other precursor hormones found in the pituitary gland and other brain areas. These gonadal hormones impact brain chemistry and circuitry, and hence influence emotions, mood and behaviour. </p>
<h2>Women’s hormones</h2>
<p>Oestrogen appears to be a “protective” agent in the brain. This may in part explain why some women feel worse, in terms of their mental state, in the low-oestrogen phase of their monthly cycle. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/96894/original/image-20151001-5869-1ke5waq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/96894/original/image-20151001-5869-1ke5waq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=301&fit=crop&dpr=1 600w, https://images.theconversation.com/files/96894/original/image-20151001-5869-1ke5waq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=301&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/96894/original/image-20151001-5869-1ke5waq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=301&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/96894/original/image-20151001-5869-1ke5waq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=378&fit=crop&dpr=1 754w, https://images.theconversation.com/files/96894/original/image-20151001-5869-1ke5waq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=378&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/96894/original/image-20151001-5869-1ke5waq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=378&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A ‘classic’ 28 day cycle – though many women have shorter or longer cycles.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-162580289/stock-vector-menstrual-cycle-hormone-level-average-menstrual-cycle-follicular-phase-ovulation-luteal-phase.html">Tefi/Shutterstock</a></span>
</figcaption>
</figure>
<p>Oestrogen appears to have direct impacts on dopamine and serotonin, the key brain chemicals associated with the development of depression and psychosis. In fact, animal and <a href="http://www.ncbi.nlm.nih.gov/pubmed/18678800">clinical studies</a> show that administering oestradiol (the most potent form of oestrogen) can improve symptoms of psychosis and depression. </p>
<p>The concept of PMS (premenstrual syndrome) has its believers and non-believers. But essentially, there is a group of women who experience significant mental and physical symptoms in the low-oestrogen phase of their cycle every month. </p>
<p>Then there are women with crushing depression once per month that is known as <a href="http://www.med.unc.edu/psych/wmd/mood-disorders/menstrually-related#md_pmdd">premenstrual dysphoric disorder</a> (PMDD). PMDD is a serious, real depression that can rob a woman of her functioning every month. The tricky part is that it’s not always exactly the week before bleeding, nor does it last exactly a week since many women do not have the “classic” 28-day cycle with ovulation at day 14, and bleeding for five days. If life were that simple!</p>
<p>The impact of gonadal hormones on mood is apparent at many other life stages. Around puberty, a time of major hormonal change, many girls experience various mood swings and other changes in mental health. Some women who take certain types of the combined oral contraceptive experience depressive symptoms with irritability, loss of enjoyment and even suicidal thoughts.</p>
<p>Postnatal depression and <a href="http://www.blackdoginstitute.org.au/public/depression/inpregnancypostnatal/postnatalpuerperalpsychosis.cfm">psychosis</a> are key mental illnesses related to childbirth and have a major hormonal component to the onset and course of illness. This is thought to be triggered by the sudden, rapid drop in the high levels of pregnancy hormones shortly after birth.</p>
<p>During the transition to menopause, women experience major hormonal shifts. At this time, they are 14 times more likely than usual to experience depression. This is known as <a href="http://www.med.unc.edu/psych/wmd/mood-disorders/menstrually-related#md_perimen">perimenopausal depression</a>. It affects women differently than other types of depression, causing anger, irritability, poor concentration, memory difficulties, low self-esteem, poor sleep and weight gain.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/95488/original/image-20150921-20435-16zhcu2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/95488/original/image-20150921-20435-16zhcu2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=487&fit=crop&dpr=1 600w, https://images.theconversation.com/files/95488/original/image-20150921-20435-16zhcu2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=487&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/95488/original/image-20150921-20435-16zhcu2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=487&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/95488/original/image-20150921-20435-16zhcu2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=612&fit=crop&dpr=1 754w, https://images.theconversation.com/files/95488/original/image-20150921-20435-16zhcu2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=612&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/95488/original/image-20150921-20435-16zhcu2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=612&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hormones can influence our moods at different stages of life.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-174361181/stock-photo-happy-together-grandmother-with-her-daughter-and-her-granddaughter-outdoor-in-nature.html?src=bf_Yt7mjBIgcJusVoRA0WQ-1-4">Martin Novak/www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Perimenopausal depression isn’t well recognised and is often poorly treated with standard <a href="https://theconversation.com/some-antidepressants-work-better-than-others-now-we-know-why-17850">antidepressant therapies</a>. Women with this type of depression generally respond better to hormone treatments, but the link between depression and hormones is not often made.</p>
<p>It’s also important to note that trauma and violence can lead to <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181836/">chronically elevated levels</a> of the stress hormone cortisol, causing significant mental ill health at any time in a woman’s life. High cortisol levels have huge impacts on many brain regions, resulting in rage, suicidal thoughts, obesity and infertility.</p>
<p>There is a great deal of variation in the effects of hormone shifts on mood and behaviour. Some women are very sensitive to small shifts in gonadal hormones; others are not. </p>
<h2>Men’s hormones</h2>
<p><a href="http://www.sciencedirect.com/science/journal/10432760/12/10">Recent research</a> investigating cognition in men suggests that, just like in women, gonadal hormones influence mood and behaviour. In particular, low levels of testosterone can lead to an age-related condition called andropause. </p>
<p>Andropause is sometimes described as the “male menopause”. This is not strictly accurate since unlike female fertility, male fertility does not end abruptly with a fixed hormone decline. Andropause is caused by a significant decline in testosterone levels to below the normal range for young men. This <a href="http://www.growthhormoneigfresearch.com/article/S1096-6374(03)00061-3/abstract">can result</a> in erectile problems, diminished libido, decreased muscle strength and decreased bone mass. </p>
<p>To complicate matters, testosterone is converted to oestradiol (the most potent form of oestrogen) in men. Altered testosterone/oestradiol ratios can cause problems with memory function, depression, irritability, sleep, fatigue and occasionally even <a href="http://www.npjournal.org/article/S1555-4155(08)00522-9/abstract">hot flushes</a>.</p>
<p>There is controversy about how much of these changes are a normal part of ageing. Many other factors such as obesity, diabetes and excessive alcohol consumption can also cause low testosterone levels. So andropause should not be viewed as a disease, but as a clinical syndrome with a great deal of variability. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/96895/original/image-20151001-5873-k73jgi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/96895/original/image-20151001-5873-k73jgi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/96895/original/image-20151001-5873-k73jgi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/96895/original/image-20151001-5873-k73jgi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/96895/original/image-20151001-5873-k73jgi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/96895/original/image-20151001-5873-k73jgi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/96895/original/image-20151001-5873-k73jgi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Testosterone levels reduce with age.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-303241304/stock-photo-senior-hands-resting.html?src=GZ9pbd1c2opZCvLnDXfSrg-1-97">carballo/Shutterstock</a></span>
</figcaption>
</figure>
<p>In some men, testosterone-replacement has been used successfully to treat andropause. But this needs to be done under strict medical supervision because of the many potential side effects including prostate problems, elevated cholesterol and increased rage. </p>
<p>A great deal more research is required in both men and women on the role of gonadal hormones and mental health. But the era of splitting the mind from the body should be long gone. </p>
<p><em>This article is part of an occasional series, <a href="https://theconversation.com/au/topics/chemical-messengers">Chemical Messengers</a>, on hormones and the body.</em></p><img src="https://counter.theconversation.com/content/42422/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jayashri Kulkarni receives funding from the NHMRC, ARC, several pharmaceutical companies for clinical trials research. This article is independently written and has no source of funding and no conflict of interest.</span></em></p>In recent times, we have learnt more about the connections between the “reproductive” or gonadal hormones and the brain, and how they affect not only women but men as well.Jayashri Kulkarni, Professor of Psychiatry, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/282952014-06-27T14:27:37Z2014-06-27T14:27:37ZCutting oestrogen could lead to fewer women undergoing preventative mastectomy<figure><img src="https://images.theconversation.com/files/52372/original/wfyn2kdx-1403803075.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Keeping hold of them.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/caitlinator/2913727846/sizes/l/">Caitlinator</a></span></figcaption></figure><p>Angelina Jolie made the decision to have a double mastectomy after discovering she <a href="https://theconversation.com/panicking-about-breast-cancer-heres-what-you-need-to-know-14256">carried a faulty copy</a> of the hereditary gene BRCA1 and was told she had an 87% chance of developing breast cancer. Jolie was a high-profile case, but many other women face this very difficult dilemma.</p>
<p>Women who inherit a faulty copy of the breast cancer gene BRCA1 have a 55-65% <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1180265/">lifetime chance</a> of developing breast cancer, compared <a href="http://www.ncbi.nlm.nih.gov/pubmed/21296855">with about 7%</a> in average women in the developing world. The risk of ovarian cancer is also increased by about 40%.</p>
<p>Although a damaged copy of BRCA1 only accounts for <a href="http://www.ncbi.nlm.nih.gov/pubmed/10952774">about one in 50</a> of the breast cancer diagnoses each year, women who have this genetic fault often face a decision: whether or not to have surgery to remove their breasts and/or ovaries. Many factors will be considered such as her age, whether there is a family history of hereditary cancer and whether she is planning to have children, but for many who don’t want to run the risk of developing cancer, surgery is currently the only treatment available. </p>
<h2>DNA damage caused by oestrogen</h2>
<p>Although women with inherited BRCA1 faults have this mistake in every cell in their body, they mainly develop breast and ovarian cancers. This has been of major interest to researchers since BRCA1 <a href="http://www.sciencemag.org/content/266/5182/66">was discovered</a> in 1994. In <a href="http://www.ncbi.nlm.nih.gov/pubmed/24638981">a recent study</a>, published in Cancer Research, we found evidence that oestrogen is the driving factor behind these cancers and our finding could pave the way for a new therapy that leads to fewer preventative surgeries. </p>
<p>We found that oestrogen and oestrogen metabolites (created when natural oestrogen breaks down) cause a severe type of damage to DNA called double strand breaks. The accumulation of this type of damage often leads to genetic mutations and cancer. It is interesting because although oestrogen caused these breaks in both normal and defective BRCA1 cells, it was the defective cells that couldn’t fix the damage. </p>
<p>It is already known that BRCA1 is very important in the repair of double strand breaks. But the damage driven by the oestrogen metabolites was so severe to the faulty BRCA1 cells that it caused dangerous changes in the cell’s chromosomes (DNA bundles), which often leads to cancer development over time. </p>
<p>In addition to this, we also discovered that BRCA1 regulates the levels of some key enzymes that convert oestrogen into the toxic oestrogen metabolites. Cells with faulty BRCA1 had lost the control of these enzymes, meaning their level was increased and more oestrogen metabolites were being produced. This led to more damage that wasn’t being repaired in these BRCA1 faulty cells. </p>
<p>Taken together, the research suggests that exposure to oestrogen and its subsequent metabolism in defective BRCA1 breast cells can drive DNA damage and instability, an early event in breast cancer development.</p>
<h2>Potential in reversible drugs</h2>
<p>Our research also suggests that suppression of oestrogen production may be an exciting therapeutic option. One <a href="http://clinicaltrials.gov/ct2/show/study/NCT00673335">US trial</a> is currently enrolling postmenopausal women for treatment with an aromatase inhibitor, a drug which inhibits oestrogen production, to prevent breast cancer in patients carrying a BRCA1 mistake. The trial is also testing this for faults in another gene called BRCA2 which carries a 45% risk of developing breast cancer and 15% risk of developing ovarian cancer. </p>
<p>Our results would support this approach. However, these inhibitor drugs would not be suitable for premenopausal women, in whom most BRCA1-linked cancers develop, because in these women oestrogen is produced in the ovaries in a process that doesn’t involve aromatase – a key enzyme that helps the body produce oestrogen. There is, however, a group of drugs called luteinizing hormone-releasing hormone (LHRH) agonists, which cause a reversible suppression of oestrogen production in the ovaries and which are currently used to treat women with other oestrogen-dependent premenopausal cancers. These drugs could be effective in premenopausal women with the faulty BRCA1 gene who have chosen not to undergo preventative surgery.</p>
<p>This could be an opportunity because instead of major surgery, we could use drugs that are already available to chemically reduce oestrogen production in women. It also has the potential to “pause” treatment for women to have children, if desired, before resuming treatment. Our group plans to launch a clinical in the next 12 months to test this approach as a novel, reversible treatment.</p><img src="https://counter.theconversation.com/content/28295/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kyle Matchett received funding from Cancer Research UK</span></em></p>Angelina Jolie made the decision to have a double mastectomy after discovering she carried a faulty copy of the hereditary gene BRCA1 and was told she had an 87% chance of developing breast cancer. Jolie…Kyle Matchett, Research Fellow, Queen's University BelfastLicensed as Creative Commons – attribution, no derivatives.