Menopause management, hormone replacement therapy, and shared decision-making

While the live webinar is over, join us through this self-directed continuing education activity for a practical discussion that combines the latest clinical evidence with the real questions we’re hearing from the breast cancer community. Together, we’ll explore hormonal and non-hormonal approaches to symptom management, considerations for hormone replacement therapy, lifestyle approaches, and communication strategies that help patients understand their options and make decisions that reflect their individual needs, concerns, and priorities.

Learn together

After this webinar, you’ll be able to:

• Describe the role of HRT in managing breast cancer-related menopausal symptoms.
• Identify hormonal and non-hormonal options for symptom management.
• Identify the relative contraindications and cautions for HRT use with patients.
• Explain patients’ practical and emotional concerns about coping with menopause.
• Apply strategies for shared decision-making with patients.

Continuing education available

Earn up to:

• 1.0 AMA PRA Category 1 Credit™ (Physicians)
• 1.0 ANCC contact hour (Nurses)
• 1.0 ASWB ACE continuing education credit (Social Workers)

The Live Learner Notification includes important information about the program, including how to submit your evaluation after the live webinar and claim your certificate. If you attended the live program on August 19, please be sure to click on the “Live” event link when you begin the evaluation process (based on the instructions in the Live Learner Notification at the end of p. 2). You must complete your evaluation and obtain your certificate by November 20, 2026.

This project is supported by Grant/Cooperative Agreement Number NU58DP007913 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.

Transcript

Michelle Bronzo, MA, LPC, LCPC, LMHC, CT, FT (00:00:09):

Hello, everyone, and welcome to today’s healthcare provider program, Menopause management, hormone replacement therapy, and shared decision-making. We’re glad you could join us.

(00:00:19):

My name is Michelle Bronzo. I’m pleased to serve as your moderator today. I’m a licensed professional counselor specializing in grief, loss, and oncology, and I serve on the Living Beyond Breast Cancer Medical Advisory Board.

(00:00:32):

In case you’re just getting to know Living Beyond Breast Cancer, or LBBC, they’re a national nonprofit organization that offers trusted information and a community of support to people affected by breast cancer. This program falls under LBBC’s grant or cooperative agreement with the Centers for Disease Control and Prevention. Since 2011, LBBC’s initiatives under this agreement have focused on addressing the needs of two very important groups: young people with breast cancer and people living with metastatic breast cancer.

(00:01:04):

We know that your patients are asking really important questions about menopause. Some of the things they’re wondering may be similar to what our patient audience asked in a recent LBBC webinar about menopausal symptom management. They’re looking for safe, practical symptom relief, especially for sexual and vaginal symptoms, along with clarity about hormone safety and who should coordinate their care.

(00:01:28):

Our speakers today, Dani Binnington and Dr. Corinne Menn, will help us explore hormonal and nonhormonal approaches to symptom management, considerations for hormone replacement therapy, lifestyle approaches, and communication strategies that help patients understand their options and make decisions that reflect their individual needs, concerns, and priorities. You can see our learning objectives now on the screen. We thank both of our speakers for sharing their time and insights with us today.

(00:01:58):

Before we begin, I’d like to share some information about today’s program. Please use the chat to connect and the Q&A feature to submit questions at any time. We ask that you frame your questions so that they can be helpful to all participants. Our speakers will respond to as many questions as possible after the presentation.

(00:02:16):

Today’s session is being recorded and will be posted on the program event page. Continuing education is available for physicians, nurses, and social workers who attend the entire live session today. You can see more details on the slide. Also related to continuing education is the live learner notification. This document provides important details about the program, including accreditation, disclosures, a link to the evaluation form, and how to claim your certificate after the webinar. The evaluation and certificate instructions can be found at the end of the document. We’ll add the link to the live learner notification to the chat. It was in your webinar reminder email, and you’ll also receive a message after the webinar with the link to this document. Please be sure to submit your evaluation and claim your certificate as soon as possible and no later than November 20.

(00:03:07):

It’s now my pleasure to introduce our speakers for today’s program. Dani Binnington is the founder of Menopause and Cancer. Her organization reaches millions through workshops, digital resources, and healthcare training and is dedicated to supporting and educating women about their options. Dani is a sought-after speaker who combines professional expertise with her personal experience of breast cancer at 33 and sudden early menopause. She recently presented during an LBBC webinar for the patient community, Menopause and breast cancer: understanding symptoms and finding support. We’ll share a recording of this webinar in a follow-up email to pass along to your patients.

(00:03:45):

Dani’s talk blends compassion and knowledge, and she has been featured widely in national media, appeared as a guest on many podcasts, and shared her story on ITV’s This Morning.

(00:03:56):

Dr. Corinne Menn is a board-certified OBGYN and Menopause Society-certified practitioner. A person treated for breast cancer in premature menopause, she brings together clinical expertise and lived experience in her work focused on menopause, sexual health, and cancer survivorship. Dr. Menn is a leading breast cancer advocate and serves on the council of advisors for the Young Survival Coalition and is a medical advisor to the nonprofit Menopause and Cancer. Through her medical practice, teaching, and national speaking, Dr. Menn is dedicated to advancing evidence-based, patient-centered care.

(00:04:32):

Welcome, Dani and Dr. Menn. We’re happy to have you with us today. Dani, please join us on screen to share your presentation. I will now turn things over to you.

Dani Binnington (00:04:40):

Hi, everyone. I am so excited to be here. I’ve just been in the chat, and there are so many people from all over the U.S. and it’s a real privilege. I feel a little bit like the support act for our amazing Dr. Menn, who is going to speak after me.

(00:04:56):

I’m just going to share my slides with you now, and then we can go straight into the presentation. I hope you can see my screen, and I hope you can hear me. I’ve got 10 minutes, and then I’ll hand over to Dr. Menn.

(00:05:11):

Let’s go and start with a figure. By 2050, an estimated 16.3 million women will be diagnosed with cancer globally each year. And we know that with cancer treatment often triggering the menopause, about 40% of women under 40 and 70% to 90% of women over 40 enter permanent menopause as a result of their cancer treatment. So I think it’s fair to say we’ve got a little bit of a global pandemic of menopausal cancer survivors happening out there.

(00:05:42):

I’m Dani Binnington. I’m just one of those millions of people. And since my own diagnosis, I founded a not-for-profit organization, Menopause and Cancer. We’re the only organization, I think globally still, dedicated to menopause after cancer support.

(00:06:00):

It is our mission to bring people together, experts but also patients, to help improve the lives of people experiencing menopause after cancer by bringing together this clinical expertise, which is what you’re going to hear from Dr. Menn today, with lived experience and of course evidence-based support to drive better care, much better education, and much better understanding. I think we’re in a situation at the moment where patients want more answers, but you guys, amazing healthcare professionals, also want more education. And so we’ve got to find the experts that can help us always skill up so that we can learn together and drive change forward together as patients and clinicians.

(00:06:44):

I think you’ll all agree that the menopause conversation has grown globally, and we have so many amazing people turning to social media and really driving the conversation forward. But this is the normal menopause conversation, and I know our conversation here today is very different. We talk about menopause after cancer. But before we dive into the ins and outs, I really just want to explain to you, just so we are all on the same page, what is menopause and what is perimenopause, and why is menopause after cancer different. And you’ll all know now, and apologies if I’m repeating what you know. Perimenopause is this lead up to menopause and it can last for several years. Hormones fluctuate. It’s really difficult for people to navigate perimenopause. It feels like a woman’s hormones are on a roller coaster. And of course, symptoms and the type of symptoms people have, severity, and duration can vary significantly between individuals.

(00:07:42):

And then we’ve got menopause, and that’s really just a moment in time. When we look back and a person hasn’t had a period anymore for 12 months, we look at that day being menopause, and then we’re postmenopausal for the rest of our lives. Premature menopause before the age of 40 affects around 1 in 100 women though — so it’s important to think of that as well — with around 1 in 1,000 experiencing menopause before the age of 30.

(00:08:10):

Within all of those people, there is a forgotten group, and it is menopause after cancer. It is the long-term side effect of cancer treatment that remains largely unspoken.

(00:08:21):

Let’s look at why treatment-induced menopause is so different to the perimenopause roller coaster or that moment-in-time menopause that I’ve just explained. It can occur as a result of chemotherapy, surgical removal of the ovaries, pelvic radiation, endocrine therapies, tamoxifen, aromatase inhibitors for all of our breast cancer survivors. And no one really even knows how immunotherapy is going to impact ovarian function. We’ve got very little data. Menopause after cancer can occur at any age, including in very young people, teenagers, and, of course, premenopausal patients.

(00:08:58):

When menopause after cancer happens due to cancer treatment, symptoms can begin quite suddenly, often without this gradual transition of maybe up to 10 years that we see in natural perimenopause. And that’s why patients often report more severe and persistent symptoms. Many people say to us they haven’t been prepared for menopause as a consequence of the cancer treatment. And we also know that menopause after cancer and symptoms may be more difficult to manage.

(00:09:28):

This is how our patients feel. They feel that everyone celebrates the end of their cancer treatment, but actually when menopause symptoms go on, it can feel incredibly difficult and isolating and people feel very lonely and they don’t know where to turn to for help.

(00:09:43):

We’ve done some research. It’s on our website, menopauseandcancer.org, and I’m just going to pick out one study. In over 1,300 people, 3 in 4 found menopause-related symptoms to be worse or somewhat worse than the active cancer treatment altogether. And if we think that, at the moment within oncology services, there is no menopause support woven into oncology services, it seems there are a lot of people who are falling through the gaps. But I’m sure you know all of that, and that is why we’re here together to learn from one another and with one another.

(00:10:19):

I’m just one of those millions of people. I was a triple-negative breast cancer survivor. I have three children, but my twins, I could never photograph all of them together. So here you’ve got my eldest daughter, she was 4, and my twins were 2 at the time. I was going through active cancer treatment. And then afterwards, my doctors told me that I was the carrier to a genetic mutation, which then meant that I had a double mastectomy and I also had my ovaries removed to reduce my risks of ovarian cancer. And I thought I’m just the only one. No one in this normal menopause revolution that I addressed earlier spoke about people like me. Everyone talked about how brilliant and important hormone replacement therapy is, and I had no idea whether I could or should take it. No one talked to me about it.

(00:11:09):

I didn’t know what to do. I set up a Facebook group, and within weeks, hundreds of people from all over the world joined it. We’re now thousands of people. And all we talk about is menopause after different types of cancer.

(00:11:22):

People came in from all over the world with all these different symptoms. And I am sure you’re very, very aware of all of the different symptoms that people can experience as a result of their medical-induced menopause. As I was reading and connecting with people and really listening to their story, I thought, Wow, everyone is so different. But some of the same stories and narratives came really through these hundreds of people that I was engaging with.

(00:11:49):

“Why did no one tell me this could happen?”

(00:11:52):

“I have no options.”

(00:11:54):

“I don’t know where to go for help.”

(00:11:56):

“No one mentioned this could be menopause.”

(00:12:00):

Many say, “I can’t take hormone replacement therapy, so what are my options?” Many had to stop hormone replacement therapy overnight, and their symptoms were overwhelming. And many said this feels harder than active cancer treatment itself.

(00:12:16):

So my next step was a logical step for me then. I just thought I’m going to find some amazing experts to help me, myself, and help the people in my group. I set up a podcast. And so I just gave this microphone to amazing experts like Dr. Menn, she’s been on the show several times, so that they could share their knowledge with the people in my community to fill this information void.

(00:12:39):

What can be done is quite amazing. From when I thought, “I’m on my own, I have no options,” we’ve now developed the Menopause and Cancer Toolkit, which is holistic and evidence-based. It doesn’t mean that we have to do one thing or another. It’s never a this-or-that approach. Our holistic tool kit encompasses lifestyle options, nonhormonal options, hormonal options, community connections, and complementary therapies.

(00:13:07):

And of course, when you zoom in even more, and Dr. Menn will talk about this in more detail, people have many options. So all of the millions of people that said to us, “I have no options. How can I manage my menopause after my particular type of breast cancer?” Suddenly they are presented with a whole variety of options.

(00:13:28):

I had an issue though, because more and more people said, “Dani, I love your podcast, but …” And I had hundreds of emails of people saying, “I love the podcast, but I still don’t know where to go for help.” And that is when I set up Menopause and Cancer, our not-for-profit organization. We now run lots of free practical support services from a fully funded menopause clinic, which is an amazing initiative, all the way to free resources. And if you feel your patients want to learn more, send them our way, and they can start their learning journey on a written fact sheet or maybe by listening to a podcast or watching one of our YouTubes.

(00:14:07):

This is the website. So if you go onto menopauseandcancer.org, you will see this is what it looks like. And I think for you too, as a healthcare professional, if you have questions that come up every single day in your practice, go and find one of our resources. See what you think are beneficial. And if you think they’re beneficial, please do share them with your wider community of doctors, nurses, other clinicians, but also with your patients.

(00:14:33):

Thank you so much. I absolutely believe that we can only do better together, and you are all now part of this menopause and cancer revolution and movement. And I’m very, very excited we all get to do this together because I really believe it’s the only way forward. Thank you.

Michelle Bronzo, MA, LPC, LCPC, LMHC, CT, FT (00:14:50):

Thank you so much, Dani. I really enjoyed learning about your personal story and such a unique contribution to this field. And I’m thinking, for all your providers out there, you’ll have so many patients to see and sometimes limited time to be giving a tremendous amount of information. I also think patients have a ceiling for how much they can take in on any given visit. And so it seems like your podcast and the Menopause and Cancer Toolkit would be great resources to share so that patients can absorb that on their own time when they have the bandwidth to take it in. I also think that the community support feature would be really fantastic for people who are feeling isolated in their experience that they probably feel they might not be able to talk to their friends and family about. So I’m just so pleased to learn about what you offer.

(00:15:49):

And now we’ll turn things over to Dr. Menn for her portion of the presentation.

Corinne Menn, DO, FACOG, MSCP (00:15:53):

Thank you, Dani, for setting that up. Let me share my slides, and we will get going into all the details.

(00:16:03):

I’d like to give you a warning. I often refer to Taylor Swift references. So my talk, I’m titling “In my hot flash era: What you need to know about premature menopause, early menopause, and breast cancer,” which I’m going to focus on. And I applaud that Dani is addressing the elephant in the room, that it’s more than just breast cancer out there. All cancers are on the rise, and menopause after cancer happens with all cancer subtypes.

(00:16:37):

A little bit about me so you know where I’m coming from. You’ve heard that I’m an OBGYN. I’m a long-term menopause specialist. Everything I present, I present evidence-based content from the menopause and OBGYN perspective, but I also can’t help but weave in my own perspective, which has really deeply informed my career path and my advocacy.

(00:17:02):

I’ve had multiple eras. I was diagnosed as a second year OBGYN resident in New York City. I was only 28 years old. I was newly married. I was shell shocked with my stage IIA ER-positive, PR-positive, HER2-negative breast cancer diagnosis only 6 weeks after my mom died of ovarian cancer. We did not know that we carried the genetic mutation of BRCA2. I didn’t find that out till years later because I was initially tested negative. But to make a very long story short, I was plunged into menopause three separate times. Two temporarily due to treatments, and then the third time when I had my ovaries removed. And I realized I was not equipped to help the average woman in menopause, much less somebody like myself with a complicated and early menopause.

(00:17:55):

Dani alluded to this menopause revolution. We joke around on social media, – I do a lot of patient education and clinician education there, that there’s a “menoposse” of doctors and advocates talking about access to menopausal hormone therapy, et cetera. But the reality is, and the New York Times just had this article, millions of women are left out of the menopause movement. They feel like they’re left out. And this is our invitation to you all as clinicians and advocates. You are part of the menoposse and so are the patients. It’s very important that we differentiate that menopause after young breast cancer or breast cancer in general is unique. It’s not menopause. It’s something entirely different. And premature menopause impacts your health span. We’re going to talk about genitourinary syndrome of menopause and how we can be proactive and not reactive. You deserve to have a happy and healthy sex life. We’ve got pillars of lifestyle medicine. We have a whole toolbox, and we need to empower our patients to be the CEOs of their menopause care because it’s not happening at the cancer centers in our country.

(00:19:08):

This is not in my slides, but just, I think yesterday or this week, the International Menopause Society just published a new paper that’s open access, which I’ll be sharing on social media later this week, but I just want to read a quote from it. It says, “A new paradigm for healthy aging. Premature and early menopause should no longer be managed as earlier variants of natural menopause. They’re not natural. They’re not normal. They’re chronic conditions and sentinel events for accelerated aging.” So I think this is the first thing we have to recognize as clinicians. We have to give the hard truths about premature early menopause or long-term estrogen deprivation. We can’t tie this pretty pink ribbon around it and just call it, “You might have some hot flashes and a little dryness. Oh, don’t worry, welcome to the club.” I mean, that’s what people are told by their doctors.

(00:20:03):

Just setting up the stage, estrogen, progesterone, and testosterone, they affect every cell in your body. We’ve got receptors on every tissue of your body. So it’s more than hot flashes and night sweats. And we’ll go through all of these things here, but this gives you an overview of all of the places where these hormones are biologically active. I’m going to refer a lot to premature menopause, but everything I’m saying about premature menopause also applies to a degree to earlier menopause and of course to women who are menopausal at the time of their diagnosis but are then having estrogen deprivation with things like aromatase inhibitors or having their ovaries removed even in post-menopause. Because even a postmenopausal ovary is biologically active. But the most severe and concerning issues happen when women are under the age of 45 and under 40.

(00:21:05):

So it’s more than just symptoms. Early loss of ovarian function is 50% to 90% increase in cardiovascular disease, double the risk of osteoporosis, up to 70% increased risk of cognitive decline and dementia and neurocognitive disorders, mood disorders—huge increase, sexual dysfunction, and sleep disorders.

(00:21:28):

It’s important for us to know. Let’s start with the most common symptom though. The hot flash, vasomotor symptoms. It’s more than just a hot flash, and it’s very important that clinicians know where hot flashes are originating from. They’re originating from the hypothalamus in the brain. There are these cute little candy neurons, not so cute, but estrogen positively feeds back onto these neurons. And when we lose that feedback, these neurons fire away at these other neurons that cause vasomotor symptoms.

(00:22:00):

But I think it’s very important that we recognize that vasomotor symptoms include hot flashes that can be bothersome, night sweats — it’s temperature dysregulation. But these things are more than just that. They’re directly associated also with patients feeling like palpitations, feeling anxious, insomnia, which then leads to daytime fatigue, mood changes, decreased energy.

(00:22:25):

When I explain patients this, I say treating your hot flash is super important, whether we do it hormonally or nonhormonally, because the downstream effects of unmitigated, uncontrolled vasomotor symptoms are serious and far-reaching. And I do not feel, in my experience, that patients are getting effective management of this one set of menopause symptoms.

(00:22:56):

This is a slide from the Menopause Society nonhormonal position statement. It’s a really great, handy resource for any clinician, and it outlines the doses, the starting dose of all the different evidence-based approaches for managing hot flashes.

(00:23:13):

I was recently at the Young Survival Coalition — this is a beautiful fan that they were handing out — and I was talking about this topic. And there were all these young women sitting in the front and they were fanning themselves. And I said, “Guys, a fan. Yes, it’s comfort measure, but you should not be told to just wear cotton pajamas and have a fan or something or have cold water.” That’s not evidence-based for vasomotor symptom management, but that’s often what patients are told to start with.

(00:23:41):

In the nonhormonal position statement, they actually reviewed what evidence actually supports these various things. And table 1 shows these are the medications that actually are effective. You can tell people to do yoga and lose some weight and exercise, but these are not recommended, evidence-based approaches. Those things are important. Women need actual treatment.

(00:24:08):

Traditionally, we’ve leaned on the SSRIs, so the antidepressants, SNRIs, as well as other medications like gabapentin. But now we’ve got FDA-approved specific medications, fezolinetant and elinzanetant. And these medications I personally believe have become a game changer for patients.

(00:24:32):

I urge you to talk to your patients that there are a lot of good medication options. I’ve personally moved away from … we often used to start, say, Effexor, or venlafaxine, or one of the antidepressants as a first line. And while those can still be effective — and you don’t have to jump through hoops with pre-authorizations to get them approved by insurance — they’re really less effective, and they have more concerning side effects, in my opinion. I’ve leaned into Lynkuet being one of my first-line options because it seems to be particularly helpful for the insomnia, and they actually studied Lynkuet, or elinzanetant, in women taking tamoxifen and aromatase inhibitors.

(00:25:16):

But the other options can be helpful. I say if you have only nighttime symptoms and you want to do something besides Veozah or Lynkuet, gabapentin is an option. But we have to recognize gabapentin can have dependency issues, and long-term impacts of gabapentin are not necessarily well studied or even desired some of the side effects.

(00:25:37):

Oxybutynin is a bladder medication. So if your patient’s got urinary urgency and frequency, you could use it, but they probably need vaginal estrogen, and we’ll get to that. And I think we have to be really cognizant that there’s a lot of women that are knee-jerk put on antidepressants, but antidepressants we know have significant sexual side effects and they are another risk factor for bone loss because your bones have receptors for serotonin on them. So I think we have to really think about what is actually going to be the most beneficial for any one patient.

(00:26:10):

And many patients don’t want another medication. They’re already taking breast cancer medications, but I try to remind them that when we stop the collateral damages of these unmitigated vasomotor symptoms, we can really improve a lot of other health outcomes.

(00:26:26):

I think it’s also important — and I think patients are overwhelmed with information when they’re first diagnosed — but it’s important to recognize that cardiovascular disease is the number one non-cancer cause of death in women with early-stage breast cancer who survive beyond 5 to 10 years, and then it eventually surpasses it. We’re diagnosing more and more women, but they’re living longer and longer. We have to really think about what are we doing to the long-term for these women.

(00:26:55):

Busy slide here, but I just want to point out that the age of menopause, so the earlier it is—the type, so if it’s surgical, if the vasomotor symptoms and hot flashes are worse and more bothersome. If they also have sleep disturbance and depression. All of these things independently accelerate your cardiovascular disease risk. That early loss of estrogen prior to age 40, I’m including. And when we take these all together, we’re really accelerating these women’s heart risk. And what I find, patients come to me and say, “I want HRT, Dr. Menn, because I am petrified of dying of heart disease down the road.” And I think it’s really important to just recognize that and not say, “Oh, well, you don’t need HRT for that.” And just say, “I recognize that fear, and I’m going to be proactive. We’ve got this, whether we can use hormone therapy or not.” And we’ll come to the hormone therapy question. But I really think it’s important for patients to feel heard and that their heart risks are elevated when they have premature estrogen loss due to cancer treatments.

(00:27:59):

These are the cardiac risk intake questions that I ask all of my patients. I calculate their ASCVD score, or there’s a new PREVENT score tool that the American Heart Association recently did where you can plug in their blood pressure, et cetera.

(00:28:15):

But I also check off what are their breast cancer-specific risk factors for heart disease. Did they have anthracycline-based chemotherapy? Herceptin? Radiation? Are they on aromatase inhibitors? Did they have premature bilateral salpingo-oophorectomy? Are they on ovarian function suppression? Each one of these check marks increases their cardiac risk.

(00:28:35):

Are their premature menopause symptoms unmitigated and significant? And are they dealing with depression and anxiety? And the more risk factors they have, I add that as an asterisk to their ASCVD or PREVENT risk score.

(00:28:50):

The next thing I think, again, women want honesty. We need to be honest with women about what these medications, like tamoxifen, aromatase inhibitors, ovarian function suppression, and early menopause, do to weight and metabolic health.

(00:29:05):

This directly relates to, not only cardiovascular disease, but also to the very frustrating thing of weight gain due to cancer treatments. Yes, it’s decreased activity. Yes, it’s food choices. But we have to be honest with women that the loss of estrogen increases visceral fat around the organs, which inhibits insulin sensitivity, encourages insulin resistance. Fatigue, hot flashes, joint pain from aromatase inhibitors, these things get in the way with patients being as active. And so we have to really care about these things because again, a very negative snowball effect.

(00:29:47):

The loss of estrogen also leads to earlier loss of skeletal muscle. The less muscle you have, the lower your basal metabolic rate is. This is happening in normal menopause. And remember, what these women are facing is not normal menopause. So not to scare women, but to be honest that their medications, tamoxifen, aromatase inhibitor, are directly antagonizing metabolic health. We know this, that along with the menopause itself. And I just think it’s important to then recognize the problem and give them skills on how they can live in a more healthy way.

(00:30:30):

Sleep disturbance. I think it’s one of the most common thing that women in menopause due to cancer treatment report. And so what I remind patients is they have to treat their vasomotor symptoms. That’s the very first thing we can do. Sleeping pills are not first line. Treat their hot flashes and night sweats. Cognitive behavioral therapy for insomnia. There are many very low cost, inexpensive apps that you can share with a patient. The VA has a great one. Or there are in-person resources that you can send patients to. But I think that’s really important. It’s not just sleep hygiene, it’s actual skills.

(00:31:13):

They need to get a sleep study. Up to 60% of breast cancer survivors, patients, have sleep apnea, and it’s due to a number of reasons. It could be from weight gain, but also the hormonal changes that happen in the anatomy of literally the neck and your throat and the muscles, et cetera, literally increase their risks of sleep apnea. Very, very important.

(00:31:35):

Encourage lifestyle medicine pillars. But sleeping pills are not that first-line option. I see far too many women just given a script for Trazodone, and they call it a day. And treating their genitourinary symptoms. When someone has to get up to pee three times a night, urinary frequency and urgency, vaginal estrogen can also help with sleep disturbance.

(00:31:58):

I also think it’s about time we stop telling patients that it’s chemo brain. I think when we call it chemo brain, we are. … When we call it chemo brain, we are not explaining to patients that the loss of estrogen, progesterone, testosterone have profound impacts on how your brain functions. Not only is it causing disturbances with sleep, which then the next day you might feel more distracted, you could have mood changes, you don’t feel like yourself, your attention span is worse, but it’s not just that sleep loss, it’s that loss of estrogen. Estrogen is really a neuromodulator and a master regulator of your neurotransmitters.

(00:32:47):

What do I tell patients who right now can’t take systemic estrogen hormone therapy? We have to be, again, we look at the big picture. Treat their underlying sleep issues. Treat their hot flashes. Avoid alcohol. Heart health is brain health. The second reason, probably maybe the number one reason, people after breast cancer want HRT is they’re afraid of dementia. They’re like, “Dr. Menn, I don’t want to beat breast cancer and have dementia.” And I remind them that their heart health is their brain health. So cardiovascular health will lower their risk of dementia and Alzheimer’s even if they can’t take systemic estrogen.

(00:33:29):

And screen these women for anxiety and depression because brain fog or chemo brain can actually be untreated anxiety and depression.

(00:33:38):

Bone health. All right, I’m in the New York City area. I cannot believe how many cancer centers just in this metropolitan area still tell patients who are premenopausal on tamoxifen that it’s protective on their bones. It is not. There is about 1% to 2% annual loss of bone in your lumbar spine on tamoxifen. And at 3 years, a woman who is still getting her period on tamoxifen can lose close to 5% of her bone mineral density. And with more emphasis on ovarian function suppression in these young women, we are really, I think, losing the plot when we’re not being proactive. So I urge you to encourage your patients to get a baseline before treatment because many women actually enter their mid-30s already behind on their bone health for a variety of reasons. So be a bit more aggressive. Bone densities are not expensive and cash pay is like $100 for a bone density. There’s no reason that these women should be missing them. And on aromatase inhibitors, we need to be proactive.

(00:34:45):

To me, when you signal to the patient, “I care about your bone health, I’m not going to just write it off and say, ‘Oh, don’t worry.’” It’s replacing fear with empowerment. I’m going to follow your bone health. We’re going to come up with a proactive plan together.

(00:35:03):

And the other important thing is if you have someone who’s already starting low and they’re on an aromatase inhibitor, we can be proactive with bisphosphonates. We can be proactive with strength training before we get to the point where we have significant loss. And if we’re seeing a very, very rapid loss, the reason why I check it a little bit more frequently every year when they’re first starting these medications is I’ve caught a few patients who had incredibly high accelerated loss, and we’ve actually worked with their medical oncologist to switch their endocrine therapy sometimes to tamoxifen or to be more proactive. So that’s important.

(00:35:40):

Moving beyond what we want to think about with bones is the musculoskeletal syndrome, which I know many of us deal with with our patients, this aromatase inhibitor musculoskeletal syndrome. It is specific not just to the aromatase inhibitor, but we have to understand it’s the profound loss of estrogen at the receptor of the joint. Estrogen is responsible for the production of collagen, blood flow. The muscle support around the joint is lost with the loss of estrogen unless we really proactively strength train to support our joints. This can be one of the most debilitating effects, and I think it prevents a lot of patients from even continuing their endocrine therapy.

(00:36:34):

Genitourinary syndrome of menopause. This is the one area that I think you could be the most powerful in helping your patients. When we tell patients it might be some vaginal dryness, again, we’re missing out on an opportunity to educate them on what the GSM actually is. Very, very important to inform patients it’s external genital symptoms, it’s sexual symptoms, and it’s urinary symptoms. Vaginal estrogen, full stop, is safe in all breast cancer patients. Yes, even patients on aromatase inhibitors. At the end of this talk, I have a QR code with a list of all of the studies, all of the position statements, and even the specific data points on women with aromatase inhibitors.

(00:37:16):

There’s one study I want to point out, the Danish observational cohort study, which is highly, highly problematic. And the results on that do not apply to modern practice when we’re talking about the use of local, low-dose vaginal hormones to treat the genitourinary syndrome of menopause.

(00:37:35):

Most of the patients in that study were higher. Well, I should go back.

(00:37:43):

The study was a population of 1992 to 2004. So these patients in the study, they didn’t know what the HER2 status was. They didn’t receive Herceptin. Oncotype wasn’t available, et cetera. And what we saw in the study was that there was a very higher risk group who got aromatase inhibitors, and up to 40% didn’t receive any endocrine therapy at all, meaning that it was a skewed population. Only the very highest risk patients who were given endocrine therapy with aromatase inhibitors. At baseline, they were already at higher risk for recurrence. So we can’t draw a cause-and-effect that in this one study, they saw a small tiny increased risk of recurrence, but not mortality. And they were using outdated formulations like larger amounts of vaginal estrogen cream. And interestingly, the study that everybody cites to withhold vaginal hormones from these patients, this same study showed no recurrence risk in those using systemic HRT after breast cancer. So there’s a lot of problems with this study, and it really should not be used. We can safely use local low-dose vaginal hormones.

(00:38:58):

My biggest takeaway from this whole thing is if you walk away, please, I really feel like the current guidelines are inadequate. We are waiting for the inevitable when we signal to patients that they must wait till their symptoms of GSM be severe before we consider something hormonal, and that we insist that they first fail nonhormonal medications. They premedicated me so that I would be successful with my chemotherapy. I wouldn’t have nausea, et cetera. Why are we not premedicating or being proactive with women on 10 years of severe estrogen deprivation? Because what we will have is a patient who has worse pain, worse GSM with many, many other associated problems — relationship breakdown, chronic UTIs, et cetera.

(00:39:47):

I encourage you to do something called the HEAL Protocol. We start the low-dose hormones upfront. They get the AI prescription, they should be getting the Vagifem or a low-dose vaginal estrogen cream or whatever FDA-approved option you’d like to use. We educate them on being proactive. We talk about the biopsychosocial model of communication and sexual function. You can moisturize, you can use lubricant. These are very, very important, but those things don’t heal estrogen-deprived tissue. So these are powerful ways to give some agency and control back to patients.

(00:40:23):

Now, I know we’re running short, but I want to really tackle this systemic hormone therapy after breast cancer. I was recently asked to speak at Harvard Medical School at their Women’s Health and Menopause Conference with three esteemed medical oncologists. And right after I spoke, this wonderful commentary in the Journal of Clinical Oncology was published. Again, I really encourage you all to read it. And the title was “Menopause Hormone Therapy After Breast Cancer: Personalization, Not Prohibition.”

(00:40:52):

The conversation is changing in that we can’t treat all breast cancer survivors with one approach. We have to individualize it. The problem is we don’t study this. We have not had a new randomized controlled trial of the use of menopausal hormone therapy or what we used to call HRT, hormone replacement therapy, since 2004, right around the time of the Women’s Health Initiative, which in itself caused a lot of fear and misinformation. And it really impacted how we viewed the HABITS and the STOCKHOLM trial, which were two randomized trials that were trying to answer the question, Could in some patients we give them hormone therapy?

(00:41:39):

We could spend a long time going through all these studies, but the majority of the observational data suggests no, it didn’t increase the risk. The STOCKHOLM trial showed no difference between those who took hormone therapy and not after breast cancer treatment. The HABITS trial did show an increased risk of local recurrence. The problem with these studies, they were stopped short. They never accrued the full amount of patients to come up with statistical significance and really make it a study that we can get good data from. But the bottom line is patients are asking about it, and we can’t ignore this with younger women and more women living longer.

(00:42:20):

So why in the world would any breast cancer survivor want hormone therapy? Well, I just presented to you that premature and early menopause and chronic health risks are a big deal. Symptom management is a big deal.

(00:42:32):

Quality of life for some women is a big deal, and women have family history concerns. They’re already at higher risk for other chronic diseases. We have four FDA-approved indications: hot flashes, preventing osteoporosis, GSM, and premature early estrogen loss. We’ve got relative contraindications for hormone therapy: unexplained bleeding, a history of a DVT or a PE, a history of serious heart disease. I don’t mean cholesterol being elevated, I mean a serious cardiovascular, like a previous heart attack, et cetera. and a current treatment for an estrogen-sensitive tumor. Notice this does not say triple-negative breast cancer. And I will say that for the FDA-approved indications: Hot flashes? Yes, we’ve got nonhormonals. Prevention of osteoporosis? There’s a lot we can do to prevent osteoporosis. GSM? We could be super proactive with vaginal estrogen. And I think that we need to, though, also think about what a patient values.

(00:43:35):

I’m going to point out, just because we are not going to come up with every answer here, but we value fertility preservation in pregnancy as an option for young breast cancer survivors. And we encourage shared decision-making. Many of you know women can pause their tamoxifen for up to 2 years to have a baby. Or when they’ve completed their treatment, we encourage them if they’d like to have pregnancy, we’ve got data to support it. But suddenly when her reproductive capacity is not part of the equation, we won’t even have a conversation with her about could she use low dose of hormone therapy. I encourage everybody to check out the Menopause Society Practice Pearl that was published last year on it. And I quote here, “An absolute ban on hormone therapy seems antithetical to the current oncological approach of interrupting endocrine therapy in patients with early-stage breast cancer to enable childbearing.” And basically the point of this article is in this Practice Pearl is that we need to personalize our approach.

(00:44:39):

I just want to point out that the NCCN guidelines supports hormone replacement therapy in BRCA carriers who have risk-reducing salpingo-oophorectomies. Yep, those are people we can take that data, and we can think about a patient like Dani who had triple-negative breast cancer. Hormone deprivation was not part of her treatment plan. Lowering her estrogen levels did not improve her triple-negative breast cancer. So when she was disease-free for many years and then she removes ovaries to lower ovarian cancer risk, why aren’t we talking to her about estrogen? We need to, and this is an example of personalizing things.

(00:45:18):

This is another article which would take me far too long to go through today, but I want to point it out to you. Menopausal hormone therapy for breast cancer patients. What is the current evidence? It’s probably one of the best published articles you can read, open access, that really categorizes patients into lower, intermediate, and higher risk.

(00:45:36):

Our lower risk patient with DCIS who has had a bilateral mastectomy, she doesn’t even get estrogen blockers. So why when she goes through her menopause, suddenly we can’t give her a low dose of estrogen? That’s a reasonable patient. As is someone who has completed her treatment with a lumpectomy and endocrine therapy.

(00:45:53):

We’ve got our intermediate-risk patients, someone who’s had a triple-negative or an ER-negative breast cancer who is more than 3 or 4 years out, meaning that’s the highest interval when recurrence can happen. And we look at the stage, the lymph nodes, et cetera, their genetic mutations, mastectomies, et cetera.

(00:46:11):

And then our higher risk patients, and we’re more cautious with ER-positive patients. But it’s not a no to every single one of these patients. We have to individualize it.

(00:46:20):

So how do I do my framework when I’m talking to my patients? We talk about what’s her local and her distant recurrence risk at this time and what can we predict for the future. What’s her risk for a new breast cancer? Did she have a mastectomy? Does she have a mutation? Did she complete her endocrine therapy? If she’s struggling on endocrine therapy and wanting HRT, did we first try to deescalate or individualize her endocrine therapy? If she’s triple-negative and she’s more than 4 to 5 years out disease-free, her risk of a recurrence at that point is very small, and there is no data point on earth that suggests giving her estrogen is going to harm that. And have we optimized our nonhormonal, our GSM, and our lifestyle medications.

(00:47:06):

We know we need more data, so I encourage all of you to go to londonbreastcancer.com/meno-abc-trial. You can scan this and get a link. Your patients will get a survey on their experience on menopause after cancer. And then once the trial gets started, they will be invited to participate. There’s going to be a randomized arm, but there’s going to also be just a cohort arm where you could just put your patient’s data in and we can collect our data on patients who choose nonhormonal versus hormonal versus local, et cetera. Because we desperately need to study this. This problem’s not going away.

(00:47:47):

If you want more, because I know this was very fast, do this QR code. I’ve got a bunch of my favorite papers, resources pulled from my Substack, and I believe we can tell our patients we can recognize that we can do hard things, and this can be their best era yet. But they must feel more supported. Thank you.

Michelle Bronzo, MA, LPC, LCPC, LMHC, CT, FT (00:48:05):

Thank you so much, Dr. Menn. You’re such a wealth of information, and I know that there’s a lot to get through in this presentation. I encourage everyone that’s listening to use the resources that Dr. Menn linked so that you can learn more about the studies that she mentioned.

(00:48:24):

So we’ll just jump into the Q&A because we have a lot of questions to get through. We’ll do as many as we can, and I’ll just kick it off.

(00:48:32):

For cancer patients, taking HRT is really just a symptom management decision. I think it’s really emotionally complex and can really feel like an impossible choice between living longer and living well. Even when there’s a medically recommended course of action, the psychological experience is rarely straightforward. And I think that patients continue to feel intense anxiety about their future, around the decision-making around their future, because no option feels completely safe.

(00:49:02):

So what are some suggestions for how clinicians can help patients navigate uncertainty and anxiety about future in their HRT decision-making?

Corinne Menn, DO, FACOG, MSCP (00:49:13):

This is such a great question. And so how I deal with it in my practice is, first of all, my first visit with the patient, most of the time we’re just finding out, identifying their needs, what are their goals, and trying to take the temperature down a bit.

(00:49:30):

Dani and I recently talked about this, that a lot of people who want hormone therapy after breast cancer often are choosing it because they’re very, very afraid of dying of heart disease and dementia. And so sometimes by just taking some of the fear out of that and saying, “Listen, HRT doesn’t necessarily stop you from getting heart disease or dementia.” Now, yes, if you have premature menopause or early menopause, we know it’s beneficial in that. But when I can empower them and show them that there’s so many ways that we can do that, that helps a lot.

(00:50:05):

And then finding out why do you want to take hormone therapy. What is your reasoning? And also just being really honest about risks and benefits. Many patients have never been told the actual benefit of their cancer treatment in absolute numbers. They get told things in relative risk numbers, which is very confusing. For instance, I’ll have a patient who is struggling with endocrine therapy and wants to quit. And I might show her that she actually has a really meaningful benefit and that we’re going to work together to get her to stay on it. But the opposite is also true. I have patients who are struggling and guilt-ridden that they can’t complete their endocrine therapy. And I show them it’s a very small benefit you’re getting from it. And so we need to sometimes level the playing field, so to speak, on where our risks are and where our benefits actually are.

(00:51:02):

And I tell patients, Rome wasn’t built in a night and we don’t have to make our HRT or hormone decision. But I also like to take the fear out of the things that we can do. We have to take the fear out of vaginal hormones. We have to take the fear out of telling your medical oncologist that you’re having a hard time, because they can’t help you or adjust if you just say, “I’m doing OK.“

Michelle Bronzo, MA, LPC, LCPC, LMHC, CT, FT (00:51:28):

Thank you. Dani, was there anything you wanted to add to that?

Dani Binnington (00:51:31):

I think in general, it’s addressing the void. I think many people think hormone replacement therapy is the only option because no one’s given them any other options. And so if we start to talk about our experiences as patients, our doctors will start to really understand, “Gosh, these patients are struggling. What can I do for them?” And the medical community will want to do a better job.

(00:51:55):

I sat on all of my fingers when I was going through chemotherapy because my nails were coming off. But I didn’t want my breast care nurse to know because I was so scared they might lower my dose of chemotherapy, and I wanted to do everything to be a good patient. No one could help me.

(00:52:09):

So it’s a real lesson for patients as well because we want to be the good patient. But like Dr. Menn says, the only way someone to be really able to help us is by talking about our experiences, even if they’re really difficult.

Michelle Bronzo, MA, LPC, LCPC, LMHC, CT, FT (00:52:25):

Thank you. Our next question is, what is the evidence and your thoughts on testosterone replacement therapy?

Corinne Menn, DO, FACOG, MSCP (00:52:33):

So this is an evolving area, and this is how I approach it with my patients. It was really interesting when we were at Harvard with the medical oncologists, it was great. We all agreed on this.

(00:52:44):

A couple of things. Number one, if you’re interested in testosterone therapy, regardless of where you are in your cancer journey, the best available evidence about the use of testosterone is for low libido or hypoactive sexual desire disorder. That’s where we have the most data. There is mixed data on is it beneficial in other areas, mood, et cetera. My clinical experience says, yeah, I see some patients find a benefit there. The published data is mixed. So we number one, have to be honest with patients about that, number one.

(00:53:18):

Number two, we lose the plot when we apply how testosterone is used in women who have natural menopause versus someone who at 37 had their ovaries removed. We have to be honest with women that taking out your ovaries removes a source, a major source, at least one-third to a half of your androgen production comes from your ovaries. So these are two different populations when we’re talking about testosterone. And we’ve got published data that shows sexual dysfunction is worse when women have their ovaries removed and their testosterone is lowered by half.

(00:53:57):

So the way I approach it with a patient is, is testosterone suppression part of your cancer treatment. If it’s not, and we’ve made sure that your GSM is treated, meaning you’re not having terrible, painful sex, because that’s not going to want to make you. Your desire’s going to be low if it hurts. So we’ve got to treat the pain. We’ve got to make sure the partner is good because you’re not going to want to have sex if your partner’s a jerk. That’s just true. But when we have those things in order, it’s reasonable to tell women that we have data that shows women with premature menopause, surgical menopause, or just low libido and menopause do improve on testosterone.

(00:54:39):

And we can, with shared decision-making, acknowledge we don’t have large studies in breast cancer patients, but the data that we do have when it’s used appropriately and guideline supported, meaning we don’t recommend high doses of injections or pellets. But when we use guideline-dosed, small amounts of testosterone gel, we can also check to make sure it’s not being converted to estrogen. Because there is a fear that it’s going to change to estrogen. But when we use it appropriately, it generally does not do that.

(00:55:11):

So I find it particularly low-hanging fruit that we need to consider more often. It’s not a “Hell yes!” for every patient, but it shouldn’t be an absolute no.

(00:55:23):

Sarah Glynne and team recently published a review of this in the Menopause journal. And in the menopause consensus that I referenced, there’s a whole section explaining this part, which I think is probably the best source for a clinician who’s interested. And I do offer testosterone therapy with shared decision-making and coordination with the medical oncologist in women on aromatase inhibitors and on tamoxifen.

Michelle Bronzo, MA, LPC, LCPC, LMHC, CT, FT (00:55:47):

Great. We have time for one final question. I’m going to start with Dani on this question before we go back to Dr. Menn. Earlier on in the presentation, Dr. Menn, you noted that cancer centers in general are not sufficiently addressing breast cancer patients’ menopausal symptoms. So can both of you talk about what you think cancer centers should do to move this forward? And how can a provider help identify a menopause champion at their own cancer center?

Dani Binnington (00:56:16):

I think traditionally oncology was there to save people’s lives and treat people’s cancer and help people stay on cancer treatment for as long as possible. And then people are being discharged and they might live with cancer or live with the aftermath and they go to the general practitioner. And that general practitioner might think, “Oh my gosh, this patient had cancer. I don’t know what to do with her.” So there is this massive void.

(00:56:38):

The only way to do better is bring this conversation into oncology services. And we’re campaigning for this here really for the change in the UK. And I think there is lots happening across the world as well, and it’s bringing clinicians together globally. Survivorship clinics are brilliant within cancer centers because they start to address all of these late effects. They talk about exercise, they talk about diet, they talk about all these things that worry us.

(00:57:04):

When I really needed to talk about my own low libido or non-existent libido, it took me several goes to find a doctor and talk about it. I was ashamed. I thought it wasn’t important enough. I thought, wow, this isn’t life-threatening. I don’t want to bother my oncologist with my sex life. So where do I go with these questions? Survivorship clinics with a real focus on menopause care within oncology settings I think will really be the future and the answer because we can’t just treat patients and then just drop them.

Michelle Bronzo, MA, LPC, LCPC, LMHC, CT, FT (00:57:35):

Dr. Menn, anything else to add to that?

Corinne Menn, DO, FACOG, MSCP (00:57:38):

Yeah. I mean, listen, we have to admit that we know general menopause care does not pay well. It’s a huge problem. General OB-GYNs are not offering menopause care because our healthcare system is based on procedural care, hence why I think large centers don’t find it profitable. And that’s just the truth.

(00:57:58):

Yes, the medical oncologist has a responsibility to manage the side effects, but we have to be honest that they are so burdened already with caring for the complexities of cancer. And they have very short appointment times, and they are overbooked.

(00:58:12):

So piling it on the medical oncologist is never going to solve the problem. These cancer centers, I believe we need to have a grassroots effort where patients and advocates like you here on here stand up and say, “You know what? This is actually unethical and you cannot be an NCI-Designated Cancer Center of Excellence unless you actually are treating the patient’s symptoms.” We wouldn’t remove someone’s leg at an orthopedic hospital and say, “Well, just good luck with that.” But we remove ovaries and do severe deprivation of hormones without any support.

(00:58:50):

So if you want to be a hero at your cancer center, you could do a couple simple things. Make a flyer with some basic information: Menopause and Cancer, this webinar, some of the resources. Make a flyer and share it with your colleagues because they’re desperate. They want help too. Try to advocate for your administrative team to send one point person to a menopause training CME, and then they can come back and share it with their colleagues.

(00:59:22):

Low-hanging fruit. Someone at your cancer center needs to be knowledgeable of vaginal hormones. It is unconscionable that patients go years jumping around famous cancer centers and nobody will give them vaginal estrogen. Talk to them upfront and provide some education, even just basic information to make patients feel that you take it seriously and that you’re going to work together. But I think we need to start putting pressure on, it goes beyond the oncologist. It has to be the administrators at these hospitals to actually value it.

(00:59:58):

And from a marketing standpoint, I was a cancer patient. I chose my place for chemo because I thought they were more patient-centered. I think if you’re in New York City or LA or any of these places, and you are a cancer center, “We have a menopause and cancer clinic.” I would choose that clinic over another one. So from a purely marketing standpoint, tell your hospital administrators, “This is good business.”

(01:00:22):

I’m being dead serious because I think it’s the only way that it’ll change things.