H is for Hormones – A Feminist Issue

Dear Oestrogen,
It’s over. I know all about you and Breast Cancer. I always had my suspicions and now the doctors have told me everything, so don’t even think about trying to deny it. Apparently all Breast Cancer had to do was flutter her receptors in your direction and next thing you’re catering to her every cell-proliferating whim and TOTALLY SCREWING ME OVER.
Well if you think I’m standing for this then you’re obviously confused about the kind of woman you’ve made me into. This relationship is officially OVER you two-timing, good-for-nothing, cancer-chasing CHEMICAL!!!
Most definitively NOT yours,
Emma

Heaven has no rage like love to hatred turned

Nor hell a fury like a woman scorned

– William Congreve

I always had a vague sense that hormones might have something to do with cancer, thanks mainly to sensationalist “Pill of Doom” newspaper headlines about breast cancer and the contraceptive pill. What I didn’t realise until I actually got cancer is that hormones can have everything to do with it, from cause to cure. Suddenly, hormones were everywhere I looked, causing all manner of problems from diabetes to depression, cancer to chronic fatigue. Hormones, I realised, are the elixir of life; the chemical messengers that tell our bodies what to do, from breathing to sleep, movement to mood. If the nervous system is the heart that keeps us functioning then the endocrine system must surely be the soul. It is one of the most miraculous systems on the planet, and when they are good our hormones are bloody fantastic, but when they are bad they can do the Devil’s work. We underestimate them at our peril.

There are over 50 hormones in the human body, but the three musketeers of mischief – at least where some of the more common cancers are concerned – are the sex hormones: Oestrogen, Progesterone and Androgens (of which Testosterone is the bad boy leader of the pack). They are known to play a key role in breast, ovarian and womb cancer in women, as well as prostate cancer in men. Breast and prostate cancers can both contain special proteins called ‘receptors’. When hormones bind to the receptors it stimulates the cells to multiply. The hormones thereby fuel the growth of the cancer, which can be viewed as both a curse and a blessing. A curse, because the cancer has a ready source of sustenance innate within the body, but also a blessing because anything which causes cancer can theoretically be manipulated to treat it.

What’s oestrogen got to do with it?

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What’s oestrogen got to do with it? What’s oestrogen but a primary sex hormone?

120 years ago, George Beatson – the founding father of hormone therapy for breast cancer – published a pioneering paper reporting that the removal of ovaries in women with advanced breast cancer dramatically reduced tumour size. Removal of the ovaries subsequently became a standard treatment for advanced breast cancer, although it was only effective in a third of cases, and why it worked remained unclear. It was not until the late 1950s that the oestrogen receptor was discovered; in 1971 it became clear that breast cancers with higher levels of oestrogen receptors were more likely to respond to endocrine therapy¹; and in 1974 a method was developed to measure the concentration of oestrogen receptors in a tumour. During the same period a chemist – Dora Richardson – synthesised a drug called ICI-46,474, as part of an ICI research programme to develop the morning-after pill. As a contraceptive drug it proved useless, but the lead researcher, Arthur L. Walpole, recognised the drug’s potential as an anti-oestrogen breast cancer therapy. Like the quiet guy next door who you had dismissed as a bit of a loser, ICI-46,474 was about to prove itself the hero of the piece. Rebranded as ‘Tamoxifen’, the first clinical study was carried out at Manchester’s Christie Hospital in 1971 with convincing results for late stage breast cancer. Despite this, the development programme stalled – endocrine therapies for cancer were not a corporate priority, and the market for late stage palliative cancer treatments did not represent a goldmine. Fortunately for me and countless others, Walpole persevered. He elected to take early retirement if the drug was not marketed, and secured support for Dr V. C. Jordan to research tamoxifen’s anticancer potential². The rest, as they say, is a long and complicated history – in 1980 tamoxifen was proven to improve survival for patients with early breast cancer, by 2001 sales had exceeded $1bn (not such a dud after all, then), and hormone therapy is now established as an essential pillar in the treatment and prevention of breast cancer.

Today in the UK around 80% of breast cancers in the UK are oestrogen-positive. Hormone therapy focuses on shutting down access to oestrogen to starve the cancer cells out, either by blocking oestrogen from locking onto the cancer receptors, and/or by reducing the level of oestrogen in the body – i.e. kicking the offending hormone out of the house, and changing the locks.

It is the responsibility of each new generation to challenge the fashions in medicine created by the ruling dynasty. Progress by defying the dynasty can be profound and today we witness the results of an unlikely revolution in thinking that had its roots in the 1970’s³

– Professor V. Craig Jordan

It’s not me, it’s you

How you break up with your hormones depends to a large extent on the state of the relationship, and quite how badly they’ve misbehaved (or, how much oestrogen you have and how much of a love match it is with your tumour). Chemotherapy will indiscriminately give everything, including the ovaries, a good kicking with temporary or permanent effects, which is why younger patients are also offered measures to protect their fertility. Beyond this there are 3 specific and targeted types of hormone therapy:

Tamoxifen – the ‘we’re on a break’ break-up. The endocrine therapy of choice. Tamoxifen works like tetris – it binds with the hormone receptor in the cancer cell (like a jigsaw piece), thereby blocking oestrogen from attaching itself.
Aromatase Inhibitors – the ‘take out a restraining order’ break-up. For post-menopausal women where oestrogen doesn’t live in the ovaries anymore, aromatase inhibitors prevent the residual production of oestrogen in body fat
Ovarian Suppression – the ‘change your identity and leave the country without a forwarding address’ break-up. This treatment rids the pre-menopausal body of oestrogen, either by blocking the luteinising hormone which triggers oestrogen production in the ovaries, or through surgical removal of the ovaries.

Personally I have dabbled in all three; my cancer displayed a vulgar and voracious appetite for oestrogen, and my oestrogen drive is particularly potent – the Don Draper of my endocrine system; the consummate charmer who is officially Bad News. However much you love them, however pretty they look and talk, this relationship is toxic and you have no alternative but to kick them to the kerb in the interests of self-preservation.

The end of the affair

The end of the love-hate relationship with our oestrogen and progesterone is one every woman faces eventually. Usually it’s between the (relatively tender) ages of 45 and 55, and when it happens naturally it’s more of a gradual growing apart than a sudden betrayal. Hormones slowly recede as the biological clock ticks predictably down to zero, though that doesn’t necessarily make the process any easier to deal with. When it is induced – through a chemical or surgical intervention – it is the biological equivalent of being wrenched from your dreams and waking up disorientated and confused to the blaring sound of the alarm going off at 4 o’clock in the morning. It’s the break-up you never saw coming, and as anyone who has been there will know, break-ups take over your life. Normal service is suspended while you go through the motions of insomnia, comfort eating, alcohol as a crutch, and crying at everything from the Great British Bake Off to Question Time (“It’s just that tie that David’s wearing…(sob)…is exactly the same colour as his tie…(sob)” etc. etc.). It turns out the menopause is not much different…

In the heat of the moment

Hormone therapies for breast cancer either mimic, trigger or reinforce the natural menopause, which is why the side effects are the same, though they can be more intense. By far the most common symptom is the hot flush, and here I owe a sincere apology to every woman who has ever gone through the menopause because I just didn’t imagine that hot flushes could ever be that big a deal. In fact, when I read that 20% of women don’t experience them I resolved – with the arrogance of youth – that it was merely a case of mind over matter and I therefore wasn’t going to have any. Which is about as realistic as expecting that you will marry Ross Poldark simply because you have decreed it will be so.

I have so many issues with hot flushes that I’m not sure where to start, but let’s begin with the name. ‘Hot flush’ implies something mild, modest and possibly even fortuitous – a Royal Flush is after all the hand to beat all others. And what is ‘hot’, exactly, other than somewhere north of ‘warm’? Tropical, sultry, summery. A hot flush, then, could a brief and welcome abundance of summery warmth. Clearly it was named by someone who has never actually experienced one, because that definitely doesn’t convey the sheer intensity and cloying claustrophobia of being trapped in the steam engine room of your own body as coals are piled on the furnace and the flames rise until all that you are, and all that you can think about is pure, relentless hotness. You have ceased to be a functioning person, you are mercury smashing through the top of the thermometer, and this is not a ‘hot flush’, this is a blistering blaze of body heat. How you respond depends largely on where you are, and what level of nudity you can reasonably get away with:

Hot flush at home

SCENE: Kitchen, enjoying early morning coffee. Suddenly core body temperature rises.
Abruptly stand, shoving table, crockery and any other outstanding obstacles out of the way in land speed record rush towards balcony door
Wrestle hopelessly with door handle, screaming “Oh. My. GOD. How do I get out of this goddamned FORTRESS?!?”
Fall out of house into open air. Fling dressing gown off into herb garden
Assume starfish pose in the style of Michael Jackson’s Earth Song, arms and face outstretched to heaven with pyjamas flapping in the delicious and miraculous breeze…
…for 90 seconds until it is suddenly very cold and you notice the neighbours opposite staring at you wondering, presumably, if you have joined a cult
Sheepishly retrieve dressing gown and return inside

Hot flush at work

SCENE: Office, serious meeting. Suddenly, and without warning, core body temperature rises.
Sit very still and nod sagely, trying to disguise the fact that you don’t give a s**t what the powerpoint slides say because heat is rising to your face like molten lava erupting from Vesuvius
Pray that this is not one of those where your entire body starts dripping with sweat and your make-up slides down your face
Fantasise about opening the window
Fantasise about jumping out of the window
Quietly remove all garments that are surplus to requirements without actually becoming naked. Regret decision to wear tights this morning.
Estimate how much longer Tarquin’s ‘presentation’ is going to last. Consider desperately how you can practically flee the room and stick your head in a bucket of ice without obviously interrupting his monologue.
Breathe inward sigh of relief as temperature returns to normal. Stick head in handbag to ‘look for a pen’ whilst listening for clues as to what you are supposed to contribute next. Conclude, despairingly, that none of it makes any sense. Emerge from handbag exclaiming brightly  “That is SO true. Let’s roast this turkey people!” to general approval of the room.

In this messy divorce, hot flushes are those unpredictable moments where the emotions that you are endeavouring to keep a lid on overspill at will, like a swollen river bursting its banks. You have no control over where and when it will happen, and all you can do is ride it out, wipe the sweat from your brow, and get back to whatever you were doing before you were hijacked by your own body.

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“If any of you are having hot flashes like I am you deserve a f**king medal” – Samantha, Sex and the City

It’s no surprise then – if that’s the effect on body temperature – that the menopause can also cause severe sleep deprivation, anxiety, depression, memory loss, and a myriad of other side effects. You name it, and the menopause is probably responsible for it including, apparently, the disturbing possibility that you might find yourself a lot less interested in chasing boys (or girls). Personally I haven’t noticed this. On the one hand I haven’t stopped lusting after Joshua Jackson which I’ve been doing pretty consistently for the last 20 years, but on the other I don’t have any real uncontrollable urges to wrap myself in leather and strut around like a concubine in my best impression of an extra from Game of Thrones. So I’d say that hasn’t really changed…but then maybe I’ve just been too hot and tired to give the leather proper consideration.

Breaking up is hard to do

Any bona fide break-up scenario must culminate eventually in Rock Bottom where you find yourself bleakly surveying the wreckage that is ‘Your Life’ and resolving that no amount of dependency on Gordon’s gin, Lionel’s greatest hits, or Ben and Jerry’s cookie dough, is going to help you pull it back together. Deep in the depths of oestrogen cold turkey I found myself there and, being a logical person, I sought guidance from Science on the basis that if I could understand why the hot flushes were happening I might have half a chance of mitigating their effects and pulling myself back from the brink. Imagine my complete lack of surprise when I discovered that the sum total of all our understanding is “we don’t really know”. We, the human race, who have invented computers, sent spaceships to Mars, and developed Viagra, have basically NO IDEA what mysterious forces are at work to trigger hot flushes, or indeed how we might do anything about them short of drinking leaves (herbal tea), eating leaves (sage tablets), cutting down on alcohol, caffeine and chocolate and anything that’s vaguely enjoyable, and hoping for the best. I’ll leave it to you to wonder if that would still be the case if the other half of the human race had been having them instead.

This sounds desperate and, I won’t lie, it’s definitely not up there in my top 5 desert island enjoyable experiences of all time. It’s called the ‘change of life’ for a reason, and – like a second adolescence – it takes some getting used to, to adjust to a ‘normality’ that you don’t recognise, and let go of the expectations that you have taken for granted. But it’s not all bad. Like a healthy dose of single time, gaining your freedom from the hormonal rollercoaster can lend life a more serene predictability and a renewed knowledge of yourself. What I feel is what I say, and you’d better believe that what I say is what I mean, because it definitely isn’t my hormones doing the talking anymore…

A feminist issue

…So I really mean it when I say that I’m absolutely horrified that generations of women have been quietly and demurely enduring this life-altering event. Frankly, if I had to go through it all in a corset I would end up inflicting serious damage on something (and would no doubt have been diagnosed with ‘hysteria’ and locked up in a mental institution by the men in white coats). Except of course, whole generations of corset-wearing women haven’t had to endure it as we do today – it’s only in the last 100 years that women have lived long enough to experience it in any majority, and it’s only in the last 40 or so that they have increasingly worked through it during an ongoing career. Society doesn’t appear to have quite caught up with that reality. It seems that we’ve been so focused on women ‘having it all’ while their biological clock is still ticking, that we’ve neglected to consider what really happens after the clock stops. I’m sure that the women experiencing it are talking to each other about it, and the challenge of handling menopause in the workplace is now creeping slowly onto the agenda⁴, but – unless I’ve been attending the wrong sewing circles – the menopause still feels to me like the universal women’s issue that feminism forgot.

Facts of life

We draw reassurance, I think, from the idea that life unfolds in a neat and predictable straight line, from childhood through to adulthood, partnering to parenthood, work to retirement. Cancer doesn’t respect those expectations, and neither do our hormones. Which is why the vibrant career woman you work alongside could well be managing the menopause; your joyful new mother friend may be quietly drowning in post-natal depression; or the macho man next door might be grappling with the heightened emotions and body shock of hormone treatment for prostate cancer.

As a young woman with cancer you learn to accept that, instead of towing the established straight line, you will be the one towing the proverbial elephant into every room. Add a premature menopause into the equation and you are officially an ‘anomaly’ – one of the 1% of women who hit the hot flushes before they hit their 40s. Now there is a whole other elephant in the room, and it’s difficult to know the best way to handle that beyond referring vaguely to ‘hormone treatment’ and changing the subject as quickly as humanly possible. When I talk about my cancer I might get the sympathetic but slightly wary “you mentioned the C-word” rabbit-in-the-headlights look, but we are all familiar with this elephant, and we can push on through the cringeworthy conversation barrier. Were I to casually start chatting about the brutalities of a chemical menopause I don’t know what would happen, but I’m pretty sure it would involve a lot of excruciating silence and heads might actually explode, including mine.

It seems altogether the easier option not to say anything at all and to stoically (sweatily) march on whilst doing your best impression of a superhuman. But that’s exactly the kind of behaviour that perpetuates the issue. As I know from cancer, silence breeds fear and shame while openness breeds recognition and understanding; it normalises the anomalies, and sheds light on the realities that would otherwise be consigned to the shadows. That’s why I talk about my breast cancer, and that’s why H is for Hormones – because we can’t just ignore a major life event that happens to 50% of the population (no, seriously, we can’t). I can’t complain about it if I’m not prepared to put my money where my mouth is, and I’m certainly not prepared to sit silently self-combusting on the sidelines to protect us all from the not-so-embarrassing facts of female life. So I’m outing myself. I’m Emma. I’m 35. I’m positively, purposefully and unashamedly menopausal. And as far as I’m concerned it’s only made me hotter – in every sense of the word.