Breast Cancer Survivors Benefit From Tailored, Team-Based Menopause Care

Menopause after breast cancer can cause symptoms that substantially impact quality of life, making individualized, multidisciplinary care and shared decision-making critical, experts noted during yesterday's session, "Balancing Act—Hormone Replacement Therapy in Breast Cancer Care," at the San Antonio Breast Cancer Symposium.¹

How Does Managing Menopause Symptoms in the General Population Differ From Patients With Breast Cancer?

Maryam Lustberg, MD, MPH, of Yale School of Medicine, set the stage with her presentation, “Beyond Hot Flashes: Addressing Unmet Needs in Menopause Care After Breast Cancer.” She defined natural menopause as no menstrual bleeding for 12 consecutive months, typically occurring around age 51. Lustberg also described early menopause, affecting patients aged 40 to 45, which can occur naturally or result from surgery for benign or malignant conditions.

Premature menopause, affecting those under age 40, may result from primary ovarian insufficiency or, in patients with genetic mutations that increase cancer risk, from risk-reducing bilateral salpingo-oophorectomy. Treatment-induced menopause, often caused by chemotherapy, endocrine therapy, or surgery, tends to occur abruptly and is more severe.

Menopause symptoms include vasomotor symptoms, brain fog, mood changes, sexual dysfunction, weight gain, bone loss, and hair thinning. Women experiencing menopause are also at increased risk for heart disease, diabetes, bone loss, and musculoskeletal issues. Lustberg noted that symptom severity varies among individuals.

Among patients with breast cancer, she underscored that many patients are receiving ovarian suppression treatments, endocrine therapy, and combination targeted therapies, which can worsen or complicate menopause symptoms. These symptoms are often under-addressed, yet they significantly affect quality of life and may impact treatment adherence.

“Our patients have a lot of symptoms, and they're not always being addressed,” Lustberg said. “I think as a community, we do need to own this and acknowledge this and strive to do better…. These quality-of-life issues are, of course, significant, but in addition to this, these consequences can actually impact adherence, where up to a quarter of our patients may discontinue their endocrine therapy agents due to unmanaged side effects.”

In the general population, she noted that the “gold standard” for managing vasomotor symptoms is menopausal hormone therapy. However, its use in patients with breast cancer is more controversial. Several FDA-approved non-hormonal options are also available, including elinzanetant (Lynkuet; Bayer), a newly approved neurokinin 1 and 3 receptor antagonist, as well as off-label FDA-approved options such as gabapentin and oxybutynin.²

How Have Perspectives on Menopausal Hormone Therapy Evolved?

Menopausal hormone therapy may be the “gold standard” now, but it was not always thought of that way.¹ In her presentation, “Menopausal Hormonal Therapy After Breast Cancer: Where Do We Stand Today?” Lisa Larkin, MD, of Ms.Medicine, discussed the evolving understanding of the treatment’s risks and benefits. She noted that the 2002 Women’s Health Initiative study created widespread fear by emphasizing relative risks of breast cancer, heart disease, and stroke, while largely ignoring benefits like reduced fractures, cognitive decline, and diabetes risk.³

As a result, the FDA placed a black box warning on these treatments in 2003, and there was a dramatic drop in menopause hormonal therapy use.¹ However, last month, the FDA announced it would be removing black box warnings on cardiovascular, breast cancer, and dementia risks for local vaginal and systemic estrogen treatments, citing updated scientific evidence and expert collaboration.⁴ Conversely, concerns about endometrial cancer associated with the treatment remain.

Larkin emphasized that risks vary by hormone type.¹ She noted that conjugated equine estrogen (CEE) plus medroxyprogesterone acetate is associated with higher breast cancer risk, but CEE alone may reduce breast cancer risk. In contrast, estradiol with micronized progesterone lacks robust randomized trial data, making interpretation and patient counseling more challenging.

Due to these varying risks, Larkin stressed the importance of individualized care and shared decision-making. Specifically, she instructed clinicians to consider a woman’s baseline breast cancer risk, age, early menopause status, and comorbidities before prescribing a treatment. Additionally, high-risk patients may require informed consent and longitudinal, multidisciplinary care.

“…what I hope for the future is longitudinal, comprehensive, multidisciplinary, integrated care, using the totality of data we have, including the patient and shared decision-making,” Larkin said.

How Menopause Care Can Be Individualized After Breast Cancer

Lustberg chimed in again to build on Larkin’s points with her presentation, “Rethinking Menopause and Breast Cancer: Is It Time to Change Practice,” further examining the evolving landscape of menopausal hormone therapy for patients with a history of breast cancer.

She highlighted that while the FDA black box warning was lifted, the American Society of Clinical Oncology underscored that systemic hormone therapy is generally not indicated for patients with prior breast cancer, particularly hormone receptor (HR)–positive disease. However, low-dose vaginal estrogen may be an option for those unresponsive to nonhormonal therapies.

Lustberg noted that recent research suggested no increased risk of recurrence with low-dose vaginal estrogen, though follow-up duration is limited and most data involve patients on tamoxifen rather than aromatase inhibitors. She added that systemic absorption with low-dose formulations is minimal, and hormone monitoring is generally not recommended unless clinically indicated.

Like Larkin, Lustberg emphasized the importance of shared decision-making for systemic menopausal hormone therapy, particularly for patients at higher risk, those in early menopause, or those with HR-positive disease within the first 5 years post-diagnosis. She highlighted that certain groups, including younger BRCA mutation carriers or patients with non-hormonally driven breast cancers, may be candidates for carefully considered systemic therapy, but data are limited. Similarly, innovative approaches, like short-term combination therapies, show promise in select non-invasive or HR-negative populations.

Lustberg concluded by underscoring that risk varies, so menopausal hormone therapy decisions should be individualized, balancing symptom burden, quality of life, and evolving evidence.

“Multidisciplinary care, good communication, and really listening to our patients and knowing that it’s not just symptoms and that we really need to take a look at all the quality of life effects that our cancer treatments cause [are essential],” she said.

References

1. Sanft T, Lustberg M, Kling JM, Larkin L, Brown TP. Balancing act—hormone replacement therapy in breast cancer care. Presented at: San Antonio Breast Cancer Symposium 2025; December 9-12, 2025; San Antonio, Texas.
2. McNulty R. FDA approves elinzanentant, a hormone-free option for hot flashes in menopause. AJMC^®. October 24, 2025. Accessed December 10, 2025. https://www.ajmc.com/view/fda-approves-elinzanetant-a-hormone-free-option-for-hot-flashes-in-menopause
3. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-333. doi:10.1001/jama.288.3.321
4. Shaw ML. FDA to remove black box warnings from HRT, debate ensues. AJMC. November 10, 2025. Accessed December 10, 2025. https://www.ajmc.com/view/fda-to-remove-black-box-warnings-from-hrt-debate-ensues