Menopause, Breast Cancer, and Hormone Replacement Therapy: What to Know

Traditionally, hormone replacement therapy has not been recommended to people who have had breast cancer, though research is evolving. Common menopausal symptoms can also be managed in other ways.

However it happens, menopause is a fact of life for most people born with a uterus. In conversations about menopause, you’ll likely hear discussion of hormone replacement therapy (HRT).

Are you wondering where the cancer community currently stands on the safety of HRT after breast cancer treatment? Read on to get the latest to help you make an informed, shared decision with your team.

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What is HRT or menopausal hormone therapy?

Hormone replacement therapy is the use of external hormones to replace or supplement the body’s natural hormones, usually estrogen or estrogen with progestin, a form of progesterone.

Though still commonly used, HRT is considered a misnomer because the medication doesn’t technically replace hormones. The more accurate term is “menopausal hormone therapy,” or “MHT” for short, says Alyssa Dweck, MD, a gynecologist.

Specifically, medicines usually contain estrogen to compensate for lower ovarian production and progesterone because a person is ovulating less (or not at all).

MHT is available in various forms, including:

• pills
• patches
• vaginal rings
• topical creams and gels

As for the acceptance of MHT? It’s evolving, too.

A 2002 Women’s Health Initiative study noted a link between MHT treatment and breast cancer. However, the conversation has become more nuanced since then.

Research from 2022 indicated that MHT could reduce the odds of cardiovascular disease and death. The data suggested that people who began the medications in their 50s, continued for at least 5 years, and started using them within 10 years of their last period, had the most benefit.

Importantly, this research was not specific to people with breast cancer.

Hormone therapy after breast cancer treatment

While the conversation around MHT is changing, the general recommendation for people who have completed breast cancer treatment remains the same: it’s not recommended.

It’s generally not recommended

“MHT is generally considered contraindicated in those with active or recurrent breast cancer and in survivors,” Dweck says. “The risk outweighs the benefit, particularly since there are many nonhormonal options available to manage symptoms.”

According to Bhavana Pathak, MD, research is inconclusive, and there is some evidence that MHT may increase the risk of breast cancer recurrence.

For instance, one 2021 review and meta-analysis indicated that HRT was linked to an increased likelihood of breast cancer coming back among women who had hormone receptor-positive cancer.

“Few studies have been done in cancer survivors, but those that exist show an increase in the incidence of breast cancer, particularly with systemic, nontopical formulations,” said Pathak. “The use of combination HRT can increase the risk of breast cancer, especially continuous formulations.”

But research is mixed

A 2021 review indicated that the evidence didn’t definitively rule out MHT as a possible approach for treating menopausal symptoms in people who have had breast cancer. The researchers called for shared decision making and informed consent. 

Indeed, the decision is personal.

“I would consider the age of menopause, because early onset can be associated with increased risk of osteoporosis and cardiovascular disease,” Pathak says. “I generally take each woman on a case-by-case basis, particularly based on the severity of her symptoms. It’s important to have a good quality of life, and I will consider hormonal therapy to fit an individual woman’s needs.”

Dweck echoes these sentiments, noting that it should come down to a nuanced conversation with shared decision making between you and your healthcare professional.

Some are at more risk than others

There’s also a difference in the risk of HRT if someone experiences hormone-sensitive breast cancer versus triple-negative breast cancer (TNBC). Those with hormone-sensitive breast cancer are known to be at risk, while the data on safety for TNBC patients is inconclusive.

Other ways to manage menopausal symptoms after breast cancer

People who undergo menopause after breast cancer treatment may experience a range of symptoms, just like those who never had breast cancer.

Hot flashes

You may have experienced hot flashes as a side effect of treatment. It’s also common for them to return during menopause.

Potential ways to manage symptoms include:

• cognitive behavioral therapy
• hypnosis
• acupuncture

Medication therapies include Wellbutrin, venlafaxine, and Veozah (fezolinetant)

Vaginal dryness

Mindy Goldman, MD says people who undergo menopause as a result of treatments may be prone to vaginal dryness because of estrogen-sensitive tissue in the vagina. It’s also a common symptom of perimenopause and menopause more generally.

“Dryness and irritation can occur with declining estrogen levels,” Goldman said. “No cancer survivor should feel that they have to suffer from vaginal dryness.”

Over-the-counter remedies may be helpful, such as:

• oils
• moisturizers
• lubricants

Pathak also recommends exploring sex therapy to adjust to your new sex life after treatment.

Fatigue

The root cause of fatigue can vary. For instance, night sweats may be interrupting sleep.

Goldman’s preferred approach is to “fix what you can” and treat the whole person to address factors that could be contributing to fatigue. Some remedies may include:

• treating bladder issues to reduce frequent urination
• treating hot flashes
• adding protein to the diet, particularly plant-based sources
• eating plenty of fruits and vegetables
• regular exercise
• utilizing social and emotional supports, like community groups and therapy

Bone loss

Goldman says bone loss can occur during cancer treatment and during menopause. Post-cancer therapies like aromatase inhibitors may also contribute. Some ways to manage include:

• getting enough vitamin D and calcium
• monitoring with frequent bone density
• medications like Fosomax for people with significant loss or osteoporosis
• weight-bearing exercises

Brain fog

Missed sleep is a common culprit for brain fog.

Solutions may involve:

• cognitive behavioral therapy for insomnia (CBT-I)
• managing stress with meditation, therapy, and self-care
• regular exercise
• a balanced diet including fruits and vegetables
• maintaining a regular sleep and wake schedule
• practicing sleep hygiene, like turning off screens 30 minutes before bed

Dweck adds that cognitive exercises like puzzles and reading can also help calm the mind before sleep.

Emotional issues

“Cancer is hard and can throw people off balance,” Goldman said.

Your mood and outlook may change during and after treatment, and that’s understandable. Support is available to manage emotional issues, such as:

• therapy
• support groups
• churches or community centers
• addressing the pillars of health, including sleep, nutrition, social support, mindset, and exercise
• medication

Pathak adds that mindfulness exercises may also be useful. These can include yoga, breathing practices, and more.

Takeaway

Although HRT has been linked with an increased recurrence of breast cancer, newer research contradicts this. The conversation is nuanced, and considering whether HRT is right for you is a personal choice.

It’s important to discuss your options with your doctor with open communication and shared decision making. That way, you can weigh the risks and benefits for your unique situation to determine what’s best for you.