Stacy London (00:00) So, Dr. Menn, I have oodles and oodles of questions for you. But one of the things I find so interesting in the menopause landscape today is that it really has become medicalized, in a sense. Now we're talking about hormone replacement as what we should be doing, for any number of reasons, and forgetting that there were reasons people stopped taking hormones in the first place. I know that the WHI study was not accurate in terms of the data, because of the people who were involved, the age of the women involved, and things like that. But it took hold so quickly. We stopped giving hormones to women. We said they cause breast cancer, period. And then there just wasn't a lot of information about menopause.

Now that menopause is coming back into the scene, I feel like the connection between hormones and breast cancer is being lost, or at least rewritten a little, because the study had villainized hormones, and now we're trying to make them heroes. What's the in-between for somebody who has a history of breast cancer in their family, or who has had breast cancer? And is this shift kind of jarring?

Dr. Corinne Menn (01:22) Well, first of all, the devil is always in the details, right? I always want to remind patients that I don't think the WHI was an inaccurate study. I think the way it was messaged to the media and to physicians was inaccurate and poorly managed. But I don't want to throw the baby out with the bathwater. I often ask people who make these outrageous claims — "estrogen is terrible, don't ever go on HRT" — and scare women: did you actually even read the study? So I think it's very important to understand what we know about hormone therapy. And I don't believe that anybody who's practicing evidence-based medicine is actually saying that all women have to be on HRT. That's a total oversimplification of what people who are actually advocating for women are saying.

What we are saying is that every woman deserves to understand what her options are to manage menopause. She deserves to understand what menopause means for her — her body, her symptoms, her quality of life, her long-term health — and that we have all these tools, not just hormone therapy. We shouldn't be afraid of hormone therapy. We should have an intelligent, evidence-based discussion of the benefits, the risks, and the right recommendations for it.

And I tell patients: you can't out-patch a really crappy lifestyle. I can give you an estrogen patch, but if you're on your phone until midnight, you never move your body, you eat lots of processed foods, you don't have enough fruits and veggies, and you don't lift some weights — listen, you don't have to be perfect in every area, but those lifestyle pillars are the most important thing. Whether you take hormone therapy or not, we always have to lean on those things.

I think that's a really important message, especially when we're talking about vulnerable women like breast cancer survivors, who feel really left out of the party. And I'm like, no, no, no — we have so much we can do for you. We can actually speak to you intelligently about hormones, but it has to be nuanced and individualized. I know it can seem like the pendulum swung so far that everyone feels they're doomed unless they take hormones. I always want to say: no, you are not doomed if you don't take hormone therapy. But it is really important that you understand, and are given, the true benefits and the options for you. Let's cut away a lot of the myths that persisted, and remember that the WHI taught us a lot of good information — as long as we know how to discuss it correctly.

Stacy London (04:08) So could we talk about that just briefly? I think this is really important. This is a nuanced conversation. We rediscovered hormones as we finally started talking about menopause again — but, as you said, don't throw the baby out with the bathwater. And it's also not a one-size-fits-all solution. Because women were denied hormones for so long, there's now this big pendulum swing back toward "they do have benefits — let's just rewrite history and pretend they're great for everybody." I'm talking about the way it appears on social media or in the news; I do realize that doctors who specialize in menopause are much more nuanced than that.

So let's talk about what the actual study — the SWAN study — said that was misconstrued in a way that really hurt women. And let's talk about the ways you talk about it now that allow for that nuance, and allow us to reframe the way we look at all kinds of menopause treatment.

Dr. Corinne Menn (05:15) Sure. The SWAN study is also an important one, but you meant the WHI, I'm sure. So, the Women's Health Initiative study. The best way to break this down is to remind patients there were two arms of this study. We had an estrogen-only arm — specifically a conjugated equine estrogen–only arm, for women who didn't have a uterus. And then we had an arm where the women had a uterus, so they had to take a progesterone or progestin, and back during the WHI, they were given medroxyprogesterone acetate. So the Women's Health Initiative is essentially a study with two arms: one with conjugated equine estrogen, and another with conjugated equine estrogen plus medroxyprogesterone acetate.

In the estrogen-only arm — I'll just say "estrogen only" for simplicity — the really great news that never made it to a press conference is that the women who took hormone therapy had a lower risk of ever getting breast cancer, and a significantly lower risk of dying of breast cancer. But that didn't make a splashy headline.

What caused all the hubbub was that in the arm of the study with the synthetic progestin, there was a tiny — and when I say tiny, I mean tiny, barely statistically significant — increase. That data can be argued, but let's take it at face value, because we could spend a whole hour on that. The women who were given conjugated equine estrogen with a synthetic progestin had a very small increase in the diagnosis of a new breast cancer. But at the 20-year follow-up — published by the WHI investigators themselves, not by outside data — there was no increased risk of breast cancer mortality. And in fact, when adjusted for things like family history, breast density, BMI, and other risk factors, there was no increased risk.

Along with that, the women who were taking this oral estrogen with this oral synthetic progestin, who were over 60 or more than 10 years from their period, had a slightly increased risk of blood clots and stroke. Why? Because we know that when we give oral estrogen — any type of oral estrogen, even a birth control pill — it can increase clotting factors.

The average age of a woman in the Women's Health Initiative was around 63. So most women were far beyond having estrogen in their bodies — they were more than 10 years out. It's pretty common sense: if you give oral estrogen to someone who's more than 10 years from her period, and you think it's magically going to prevent atherosclerosis or heart disease in a 63-, 65-, 70-, or 72-year-old — that disease is already there. They've already developed that acceleration of heart disease, because they've gotten older and they've been more than 10 years without estrogen. We know that when we lose our estrogen, through the menopause transition, our heart disease risk accelerates. That doesn't mean everyone has to take estrogen to prevent heart disease, but we have to be honest and say that when you lose your estrogen, that's when we see a decline in the health of the small blood vessels.

So what did we learn from that study? Don't give oral estrogen to prevent heart disease in women who are more than 10 years from their period. Don't expect a 72-year-old to reverse her heart disease or stop dementia when she's already developed these chronic diseases. And oral estrogens are not a good bet for clotting risk. But none of those things actually apply to a woman who is within the first 10 years.

And there's nothing in that data at all suggesting that the estrogen alone — the conjugated equine estrogen — was the culprit in increasing breast cancer risk. In fact, we suspect conjugated equine estrogen actually behaves a little uniquely; it probably has some other properties that might be somewhat protective on the breast. That's why many of us like to speak a little differently — there's also estradiol, and we can talk about that data too. And we know that of all the progestins we use to protect the uterine lining, medroxyprogesterone acetate is the most inflammatory and the most likely to increase breast density. It's not the ideal progestin. It's the least breast-happy progestin out there.

We wish we had a large randomized controlled study in women within 10 years of menopause, using estradiol and progesterone. We don't have that study. So what do we do? We look at the studies that looked at estradiol alone — and there are some, though not as many as with conjugated equine estrogen. And we've had subsequent studies looking at what happens when we swap in progesterone. The majority of those studies suggest that when we use progesterone rather than a synthetic progestin, it appears to be neutral — it doesn't increase the risk of breast cancer, and it doesn't lower it.

Across all of the high-quality studies using estrogen alone — most with conjugated equine estrogen, but also if you include the smaller studies that looked at estradiol — the preponderance of the data, published I think two years ago by the WHI investigators, comes to a bottom-line conclusion: estrogen alone does not increase the risk of breast cancer, and in fact lowers the risk. We are not saying we should give estrogen to women to lower their breast cancer risk. But if they're using it for the appropriate reasons, they shouldn't be afraid of it in terms of breast cancer risk. And these studies apply to what we'd call the average patient. What you and I are talking about right now is not breast cancer survivors — we're talking about a woman who has never had breast cancer.

So the message I like to send my patients is: if you have lots of menopausal symptoms, you're concerned about your risk of osteoporosis, and you want to consider hormone therapy, you should not let the fear of breast cancer deny you a conversation about it, or access to it. You should not be afraid. When you can, you'll choose a progesterone rather than a synthetic progestin. But if you have to take a synthetic progestin, that's okay. We tend not to use medroxyprogesterone; we'll use norethindrone acetate, or a progestin IUD in the uterus. Or there's a medication — not new, it's been around for about a decade — called Duavee, which is an estrogen with bazedoxifene. That's really interesting, and we can talk about it later. So we've got newer formulations, and—

Stacy London (12:46) I was going to ask — sorry to interrupt you — I also didn't realize that we were still using equine urine as the estrogen.

Dr. Corinne Menn (12:57) Well, most patients are now getting estradiol. But when we're explaining the data, I just want to mention that it was conjugated equine estrogen. Most patients are not being prescribed Premarin, or conjugated equine estrogen. But I think it's important for women not to be afraid of it, because the reality is, that's our best data showing a lower risk of breast cancer, or a lower risk of dying of breast cancer. Where does it come from? Conjugated equine estrogen. Let's call a spade a spade. It is what it is. The subsequent data on estradiol also suggests that as well; we just don't have the same huge amounts of data we have from the WHI. So most women are getting estradiol and progesterone, which is good, because we're avoiding the medroxyprogesterone acetate.

Stacy London (13:44) Right, okay. I guess what I want to understand, with you spelling all of that out, is: how did it all get conjugated into "hormones cause breast cancer"? How did that happen?

Dr. Corinne Menn (14:02) Well, we know what happens when a media message goes out. This was a press conference held in 2002. The message was sent out by a few of the primary investigators before all of the principal investigators even had a chance to comment. The press conference happened a few weeks before the study was even published, so nobody could look at what this press conference was about. They had to wait weeks until it arrived in their mailbox, because this was before the internet, right? The New York Times, Time magazine, every news program in the world picked up on "nobody should take HRT — it causes breast cancer, it causes heart disease, it causes blood clots." Actually, that's not what the WHI showed. It just showed that you shouldn't give it to prevent heart disease in someone who is more than 60 years old or more than 10 years from her period, and that you should probably not use medroxyprogesterone acetate. If you actually read even the original studies, they were extremely reassuring. The message was just very, very poor.

There isn't new WHI data, really. It's that people have actually read the study and said, no, the media message was really poor. And that message went all the way down to even local vaginal hormones. They scared women away from even using local vaginal estrogen, out of fear of breast cancer. That's because once that WHI press conference happened, in subsequent years they put a black box label on anything that contained estrogen. And it's really funny when you look back: the estrogen-only arm of the study never showed an increased risk of breast cancer, yet all estrogen products said "increased risk" — well, not anymore. They took the black box label off.

So old habits die hard. Once it's buzzed — that was the clickbait of the 2000s, right? Being on the cover of Time magazine.

Stacy London (16:14) Yeah, it really was.

Dr. Corinne Menn (16:16) Or being on the Today show with Matt Lauer — you can look back and see the clips. That's where women and doctors were hearing that information. So it just took so many years. I think what's changed now is that we have access to the internet. We have social media. And women in positions of power — whether it's people in your world, people in my world, people in the media, in medicine, in law and politics — all of us are of the age of menopause now. We're in positions of power and we have a voice, so we can speak up and say, "Hey, guys."

I think that's why. Even just 10 years ago, there were lots of doctors and researchers from the Menopause Society who knew this data — they knew it, and they were taking care of their own patients. But it was very hard to get the message out, because they weren't on social media, and women didn't have the ability to look this stuff up on their own. So it's a revolutionary change.

Stacy London (17:24) I think part of the problem is that people are not that proactive, right? All they took was the clickbait and the headline.

Dr. Corinne Menn (17:31) And I get it. People are busy.

Stacy London (17:34) People are busy — I get it too. But what I find so interesting is that it took hold so quickly, and nobody was really fighting back or saying, "Hey, this is probably not right, and we're denying..."

Dr. Corinne Menn (17:45) Well, fear sells.

Stacy London (17:49) Fear sells. And that's why it's so hard to have this conversation — especially, I would assume, with somebody who's already been through breast cancer and now has to make this decision, because it must feel that much more—

Dr. Corinne Menn (18:00) Yes — or their family members. We're definitely going to talk today about the breast cancer survivor and how we approach her. But there are millions of women out there who say, "My sister had breast cancer. My mom, my grandma had breast cancer. I have really dense breasts." Or their best friend just got diagnosed. The words "breast cancer" have entered their space, because guess what? Breast cancer is the most common cancer. It's common whether you take hormone therapy or not. So it's in women's worlds. And that association is the biggest barrier to any menopause care at all, because when you feel that fear, you're less likely to even ask your doctor, "Hey, can I have hormones?"

And that doctor — she might be older, he might be younger, whatever it is — may not be up to date. Because the reality is, OB-GYNs are so busy doing obstetrics and surgery and trying to stay current, and we're all pressed for time. We only have about 10 minutes with patients. We didn't get any menopause training. It's really easy for them to say, "No, I don't believe in HRT," or "No, that causes breast cancer," because that's what they were taught. They don't mean harm. They just don't have the time, frankly.

So there are all these layers of barriers. And then, even if women did get the information, Stacy, they'd get their prescription, open up the package, and the black box label scared the bejesus out of them. That was another barrier.

So I'm so glad the barriers are coming down. But to your point, women who have had breast cancer are saying, "Well, it still doesn't help me. I'm doomed now, because everyone's telling me HRT is the best thing since sliced bread, and I can't have it." I think breast cancer survivors feel more alone than ever, because they feel even more left out of the conversation. And not just breast cancer survivors — also gynecologic cancer survivors, other cancer survivors, and women who have complicated menopause from things like endometriosis. There's a whole swath of women who feel like, "I'm not invited to this menopause party." That's how they feel. Which is not okay.

Stacy London (20:12) Right — which I really do understand, and it's part of the reason we wanted to do this episode so badly. I don't think people recognize that there's a huge part of the menopausal population that can't or won't participate in hormone care, and that's their choice. We've popularized hormones in a way that's like, "Do you have the latest handbag?" — "Do you have your patch?" We've turned it into a trend, rather than a medical choice to make with your doctor, based, as you're saying, on nuanced, individualized information.

Dr. Corinne Menn (20:49) And those patients aren't even given that choice. Those women don't even get accurate information. A lot of women think they can't have hormone therapy, and I'm like, no — you can actually have a discussion. You're a big girl. You deserve to know the data and how it applies to you. But there are so many barriers there. I'm totally in agreement.

Stacy London (21:11) And I'm also thinking — we kind of made it a trend. It's like a fashion trend: hormones are in this spring. But they don't work for everybody, and there isn't enough discussion around that—

Dr. Corinne Menn (21:30) Not everybody is going to choose them or take them.

Stacy London (21:32) Right. So how do you make sure that patient is getting that 360-degree view? If you've only got 10 minutes with someone — let's say five, after taking clothes on and off — what do you say to somebody who's like, "I'm not sure what my choices are"? We're not talking about a ton of time. How can people understand some of their choices, if not all of them — what choices besides hormones are out there — if they're only going to have limited time with their doctor? How can they come in best prepared for that discussion?

Dr. Corinne Menn (22:10) Absolutely. This applies to all women — of course it really applies to the complex patient, like a breast cancer survivor, but to all women. First of all, you're not going to get anything solved in one visit, I don't care what kind of patient you are. You have to meet your doctor where they're at. So I think the best thing you can do as a patient is be informed and be prepared for your appointments. Have a list: What are your symptoms? What are your concerns? What is your health history? I say you have to approach this like an important business meeting. Be prepared, and understand that if your appointment is for your annual exam — your Pap smear, your breast exam, et cetera — that's not necessarily the time. But it is the time to say, "Hey, doctor, I'm also having these concerns. I'd like to schedule a follow-up. Here are my concerns." Or you can even send them through the portal.

And it's really, really important — if you can, and it doesn't always happen — to have that forethought even before menopause happens. I'd suggest that women in their late 30s or early 40s, or anyone who's just been diagnosed with, say, breast cancer, say: "Listen, there's a lot for us to talk about, but I want to start thinking about how this is going to impact me. What are some things I should be looking at?" Start to get yourself educated.

From the provider standpoint, what can a doctor do? I think the most important first thing is to acknowledge that women have questions. They're concerned about menopausal symptoms — especially if they're at high risk for breast cancer, in the middle of breast cancer treatment, or have a condition where they've been told they can never take hormones. One: acknowledge it. "I get it. You're dealing with a lot of medical stuff, and all this talk about menopause is scary. You feel like you're going to be doomed if you don't take systemic hormones. I hear you. And let me tell you, we have a whole toolbox for how we can treat you."

There are systemic, non-hormonal things we can do. The pillars of lifestyle medicine are key — again, I can give you a patch, but if you have a crappy lifestyle, I can't help you. There are local, low-dose hormones that all women can take. And there are some high-risk patients, and some patients who've had a breast cancer diagnosis, who can consider systemic hormone therapy on an individual basis — because breast cancer is not one disease. There are many different types of breast cancer, and we need to speak to these patients individually and not lump them all into one category. We don't treat them the same in terms of their treatments — their chemo, their adjuvant endocrine therapy, or none if they're triple-negative. So why would we treat their choices, decisions, or options on hormone therapy the same? We shouldn't. They're different types of breast cancer.

So for a busy clinician: acknowledge, and tell them there are tools. And if you don't know where to go, there are some basic places you can send patients right off the top. My favorite one to mention, which we'll talk about later on, is menopauseandcancer.org. It's a nonprofit for anyone facing any type of cancer — it's not just breast cancer, although there's a ton of information for breast cancer patients on managing menopause. So that's one great example of a resource for complex patients.

Stacy London (25:31) It's fantastic.

Dr. Corinne Menn (25:32) So that's what you'd do first. The other thing I'd say is that you have to divide up the way we talk about the average-risk patient; someone who is at very high risk for breast cancer, like someone with a BRCA1 or BRCA2 gene mutation — I'm a carrier, and I do a lot of work with BRCA previvors, women who carry the mutation and are at very high risk but have never actually had breast cancer, and who have very unique issues we can talk about — and then the breast cancer survivor. We treat each of those buckets a little differently, and that's really, really important.

Stacy London (26:16) You used the word "risk," which made me think a lot about the risk versus the benefit — of hormones versus cancer, to put it that way. Because what I've noticed, and certainly what I experienced during menopause, was: if hormones are going to help me with the pillars of health — sleep, eating regularly, exercising, all of those things — I'll take the risk. My life was so impaired by the symptoms of menopause that, weighing the risks and benefits, even if I were high risk — I'm making this up — I would still want to take hormones.

And it's so interesting to me. I didn't even think about all the different types of breast cancer, or the fact that you'd have to treat them all differently, and look at them all through that particular lens, in order to talk to them about menopause. This is the first time I've heard of that website, and I think that's great information. That's what we strive for: to give our listeners new places to go, and new ways to think about how they can be participants in their own healing and their own medical journey. Because I think we put a lot of onus on doctors to know everything—

Dr. Corinne Menn (27:44) It's a lot.

Stacy London (27:45) —not recognizing that the better we know ourselves, the more helpful that partnership is going to be.

Dr. Corinne Menn (27:51) Right. So, a simple message — because I know you want to get to the more complicated, high-risk patients — for the average woman out there: I always want you to know your risk for breast cancer. But I also want to know: What's your risk for osteoporosis? What's your risk for heart disease? What are your quality-of-life risks — meaning, how bad are you feeling? We don't want to make your HRT or MHT decision, whatever you want to call it, based only on fear of breast cancer, because you are more than your breasts.

To your point, we can tell you that you've got to exercise and sleep and have good communication and relationships and do all this stuff. But if you can't sleep because you're up all night sweating, you've got heart palpitations, and you have new-onset anxiety because of the perimenopause transition — which can be really rough on mental health — I'm sorry, it's really hard to do all those lifestyle things when you're suffering. So sometimes you can do the lifestyle medicine pillars better when you're actually addressing those symptoms.

For the average patient out there, the preponderance of evidence is that menopausal hormone therapy, with modern formulations, does not further increase your risk of breast cancer. Even the Menopause Society — which is a medical society, so by default it has to be broad and a bit more conservative in its recommendations; that's what medical societies' jobs are. Its guidelines aren't rules, just guidelines, and they tend to be a little more conservative. And I point out that its 2022 position statement, which everybody holds up like the Bible, says the preponderance of data suggests that with breast density, family history, and other high-risk reasons, hormone therapy is not contraindicated. The preponderance of data does not indicate that hormone therapy is going to significantly further increase your risk. So that should not be used as a reason to tell a woman no.

We don't tell a woman no because she has a family history of breast cancer. We don't tell her no because she has dense breasts. But we are going to ask: what is your risk? Why do I want to know that? Because I want to know how to screen you. Do you need an MRI? That's not even about whether you take hormones. I care about your breast cancer risk — not to deny you hormones, but so that I'm screening you properly, and so that if you need genetic testing, I refer you to it. One in four adults in this country meet criteria to at least be referred for genetic testing. That doesn't mean one in four carry a mutation, but one in four qualify for genetic testing for hereditary cancers — hereditary breast and ovarian cancers, but there are also hereditary colon cancers, pancreatic cancer, and others. I want to know your risk so I know how to manage your overall health. Based on that, we'll tailor your screening, and then I'll have an intelligent conversation about how we're going to manage your menopause.

So, for the average patient who wants to use hormone therapy: ideally, you'll start within the first 10 years, and you'll use FDA-approved options like the ones we've mentioned.

Then there are high-risk patients — and there are millions of them. I like to start with the highest-risk women and work our way backward. A BRCA carrier has a very high risk — up to an 80% chance at some point in her life of getting breast cancer — and also of getting ovarian cancer, and there's a small increased risk of pancreatic cancer as well.

Now, over 80% of patients who get breast cancer do not carry a mutation. And most patients who get breast cancer don't have a family history, because breast cancer is caused by many factors. Some of it is genetics. Some of it is genetics we haven't identified yet — there's no mutation we've found. A lot of it is environmental: diet, nutrition, alcohol exposure, other environmental exposures — we live in a complicated world. And there are reproductive changes over time. Let's remember, 100 years ago, women were either pregnant or breastfeeding for most of their reproductive lives — pregnant, getting over a pregnancy, or lactating. In all of those situations, hormone levels are very different from someone who's ovulating every single month. Over time, that has changed the breast and rates of breast cancer. It doesn't mean we should all be getting pregnant and breastfeeding forever, but that's part of why, in modern life, our ovarian and breast cancer risks have changed.

But if you carry a BRCA mutation, you are at high risk. So what do we recommend? Women are offered increased screening and surveillance — more frequent imaging, MRIs, imaging at an earlier age. Many women who have a BRCA mutation will choose to have a bilateral mastectomy; we call it a risk-reducing, or prophylactic, mastectomy. Some women will choose risk-reducing medications — they can take tamoxifen for three to five years to lower their risk. The vast majority of BRCA carriers will at least have enhanced surveillance, and many will have bilateral mastectomies.

But here's where menopause enters the picture. Some of these women may never choose to have their ovaries removed, but the guidelines recommend that if you're done with childbearing, the ovaries and tubes are removed by around age 35 to 40 for BRCA1, and between 40 and 45 for BRCA2, to lower your risk of getting ovarian cancer. Really, really important. The problem is that these women are then plunged into premature surgical menopause.

And we have very clear guidelines: if you have premature menopause before age 40, or early menopause before 45, the gold standard is full HRT — and I say HRT because it is full hormone replacement therapy — up to the natural age of menopause. Why? Because we know premature menopause carries very significant health risks: increased risk of cardiovascular disease, stroke, dementia, diabetes, osteoporosis, mental health issues, sexual dysfunction, Parkinson's — you name it. We must treat these young women with early menopause. That's the standard of care. So why does that guideline go out the window just because they're a BRCA carrier? It shouldn't.

And we actually have a lot of data. Back in 2016, the Menopause Society published a really wonderful practice pearl authored by Dr. Susan Domchek — she's an amazing lead researcher and a leading voice in the BRCA world, at the Basser Center at Penn. She pulled together all of the data back then, and we have more data now, saying that women should never delay their life-saving, risk-reducing surgery to remove their ovaries out of fear that they'll be denied HRT. In fact, they should be offered full HRT at least up to the natural age of menopause, because all of the data suggests that hormone therapy does not increase their risk of breast cancer.

In fact, at the San Antonio Breast Cancer Symposium and the American Society of Clinical Oncology meeting this past year, new data was presented showing that women who removed their ovaries early — and these were women who chose not to have a bilateral mastectomy, so they still had their breast tissue — and who took estrogen alone (these women didn't have a uterus), all BRCA carriers, had a lower risk of ever getting breast cancer. The estrogen lowered their risk. And the women who took estrogen with progesterone did not have an increased risk.

So the data we have now supports that these BRCA carriers — again, women who have not had breast cancer — should be offered hormone therapy up to the natural age of menopause. That's where we have the best data: giving it to them for their premature menopause. Then, at around age 50 or 51, they can have an individual discussion and decide whether they want to continue, like other menopausal women would. And they very well may. At the very least, we want to have given them that protection from early, premature menopause. But what happens, Stacy—

Stacy London (36:51) Sure — sorry, go ahead.

Dr. Corinne Menn (36:55) This is the scary thing. Women are reluctant to get their ovaries out because they're scared. A 36-year-old woman is scared: "I'll lose my ovaries. I don't want to go into surgical menopause." So they delay their ovary removal. And I have personally witnessed — not my own patients, but friends of friends, or patients I've heard about — women who are no longer with us because they said, "I'll just put it off. I'll wait till I'm 43." And they waited, and they got ovarian cancer, and they're no longer with us. It's a shame, because the reason they put it off is that their doctors said, "Well, once you lose those ovaries, no HRT for you."

What makes me angry is that the NCCN guidelines — the National Comprehensive Cancer Network guidelines, which we all follow — as well as the Menopause Society and American College of Obstetricians and Gynecologists guidelines, have said for over a decade that these women can and should be offered hormone therapy, and that we should not deny it to them. But there's so much misinformation, and it causes harm. That's a huge problem. To me, it's low-hanging fruit. We've got the data. We know we can give them hormone therapy at least up to natural menopause.

The newer thinking for these women is that if they're done with childbearing, they can also remove the uterus, and that makes hormone therapy even simpler — we can give estrogen alone, which has the best safety data. And for women who aren't quite ready to lose their ovaries, there's more research going on, but we have what we call an opportunistic salpingectomy, where we remove just the tubes, because we now think ovarian cancer starts in the tubes. By removing the tubes, we can preserve the ovaries for a little while, and then when they're ready to remove the ovaries, they can. So it's a stepwise process: take the tubes out, which lowers your ovarian cancer risk significantly, and then when you're ready, do the ovaries. There are a lot of ways these women can—

Stacy London (38:49) I'm sorry, I just wanted to clarify. You said something interesting before: that a lot of women who carry the BRCA gene don't get a bilateral mastectomy.

Dr. Corinne Menn (39:00) Well, many do, but some don't.

Stacy London (39:04) Right. I'm talking about the ones who don't, but do have oophorectomies — have their ovaries removed. That's interesting to me, since breast cancer is the thing I'd associate most with hormones. So there's a way to bypass having a bilateral mastectomy by having your ovaries taken out, and that's considered prophylactic?

Dr. Corinne Menn (39:28) Well, no — the ovaries are being taken out to lower your ovarian cancer risk, period. But—

Stacy London (39:33) For ovarian cancer risk, okay. So it has nothing to do with—

Dr. Corinne Menn (39:35) Well, this is going to blow your mind. This is super interesting.

Stacy London (39:38) God, I get so confused.

Dr. Corinne Menn (39:42) No, but it's so interesting. Just remember: BRCA carriers have a high risk of both breast and ovarian cancer. The thing about breast cancer is that we have screening tests for it. We can do mammograms and ultrasounds and MRIs — very, very good screening tests. There is no good screening test for ovarian cancer. In these high-risk women, we can measure markers like CA-125, and we can do ultrasounds, but neither has ever been shown to lower your risk of dying from ovarian cancer. So we don't have an effective screening test for ovarian cancer. That's why, for a BRCA carrier, we know that eventually having those ovaries removed is very, very important.

As someone who has survived breast cancer, my personal opinion is this: if you're a BRCA carrier and you haven't had breast cancer, yes, you have a choice. You can have increased surveillance. You can do increased surveillance with tamoxifen, because tamoxifen can be used for prevention in high-risk women, not just for treatment. A lot of women are reluctant to do that because they're concerned about the side effects, but there are ways we can manage that. Or you can have surgery. I'm going to be honest: my professional and personal opinion is, when you're ready, choose the prophylactic mastectomy, because even early-stage breast cancer treatment stinks. That's just me. But you have all of these options, because we can screen you.

Here's what's super interesting, and I don't think we really understand why. We know that in these BRCA carriers, when we remove their ovaries, we actually lower their breast cancer risk as well. But here's what's crazy: if we give them back hormone therapy, we don't further increase their breast cancer risk.

Stacy London (41:31) Talk about nuance. This is blowing my mind.

Dr. Corinne Menn (41:36) But this is well established. We've known this for a while, and we don't know exactly why, but we know there's a benefit in these BRCA carriers: when we take their ovaries out, their breast cancer risk also goes down. It does. And the preponderance of data says that when we give back hormone therapy to alleviate their menopausal symptoms, we do not negate the risk reduction they got.

Now, ovary removal isn't enough for full risk reduction — it's a small risk reduction in terms of breast cancer. The real risk reduction is in the prophylactic mastectomy. So these patients are really, really important, because I like to say I want them to have their cake and eat it too — although I know none of this is like having a slice of cake. I want them to lower their risk of getting cancer, to be empowered, to be proactive. But also: no, you don't have to suffer with premature surgical menopause. We can give you back safe hormones. And you need to have that counseling before you have your ovaries out.

Because what I see in my practice is women finding me at 37, 38, 41. Their ovaries were removed prophylactically, and most of them have had prophylactic mastectomies. And they say, "Dr. Menn, it's been three or four years. I'm suffering. I've had terrible menopause symptoms, and no one will give me anything." And I'm like, that's not even the guidelines. It's silly. They should have a pre-op plan. They should wake up in the recovery room with their estrogen patch on. There's no reason these women should be denied their hormones. We wouldn't chop off a 35-year-old man's testicles and then, if he didn't have a contraindication, not give him his testosterone back. These women do not have a contraindication. But instead they're told, "Well, we'll just see how it goes." See how it goes? That's not a plan.

Stacy London (43:38) And first of all, just coming up with a plan, I think, is kind of wonderful. There's so much information here to digest that it's really important that, at the end of it, there's a conclusion that's a plan: what's best for you, what's best for your health. Do you find that there's more conversation now between gynecologists and oncologists? Or should there be more communication, if there isn't? Because everything you're saying seems to require the input of both doctors in order to make the best decisions for a patient.

Dr. Corinne Menn (44:15) Yes. Of course there should be. There's tremendous pressure on physicians and surgeons out there — time, insurance constraints. Lack of communication is often part of the problem, and so is lack of knowledge. What the oncologist or the surgeon is saying isn't always what the menopause specialist is saying, and everyone's living in their silos. But there is more communication, and I'm really heartened by it. At the big breast cancer meetings this year, ASCO and the San Antonio Breast Cancer Symposium, there were sessions on all of this. The Menopause Society invites medical oncologists. At ISSWSH, the sexual medicine society, I just moderated a wonderful discussion with two medical oncologists where we talked about all these issues. And the bottom line was: nothing's off the table. Everyone deserves shared decision-making — even, and we haven't talked about this yet, patients who actually have breast cancer.

So we've already said the average woman should not be afraid. She can choose to use menopausal hormone therapy, and it doesn't further increase her risk of breast cancer. The very, very high-risk woman — yes, she can use hormone therapy. Then there are the women I call the gray-zone people: those with things like extremely dense breasts, or an abnormal biopsy that wasn't breast cancer, like atypical hyperplasia. They're at higher risk for breast cancer. So again, we make informed decisions, we weigh risks and benefits, and if we're going to use hormone therapy, we choose the options best suited to them. Hormone therapy is still an option for them. Some of them will want no theoretical risk at all, and will use non-hormonal options — which is okay. You're not doomed. You'll be okay. And you can always use vaginal estrogen.

And then there's what I call the biggest pink elephant in the room: the woman who already has a pink X on her back — she's had breast cancer. When she goes in for menopause care, people's eyes glaze over. "I don't know — use some lube, go exercise more." She's literally given very little guidance. We could spend hours talking about that, but the way I like to keep it nice and simple is: these women must be offered help with their menopause. Many of them are being put into abrupt menopause, prolonged estrogen deprivation — because their ovaries are being removed, or they're on ovarian suppression, or medications like tamoxifen and aromatase inhibitors if they're younger. Women who were already menopausal are often put on an aromatase inhibitor. Or, if they were on HRT, they're told to come off cold turkey, and given no guidance. Chemotherapy induces menopause. So there are a lot of individual issues happening across the board.

And those menopause symptoms are not like regular menopause. This is turbo menopause — extreme menopause — because it's coupled with really difficult cancer treatments, and it's often more extreme estrogen deprivation. It's not menopause; it's estrogen deprivation. With aromatase inhibitors, you take a natural menopausal estrogen level — I don't know, less than 20 — and make it almost zero. That's not menopause. That's removing all estrogen, and that can be very, very hard on a woman.

Now, it's not all bad for everybody — some women manage it well. Many women don't. And many could manage it better if they were at least given non-hormonal options; real lifestyle support — actual prescriptions and concrete advice; and local vaginal hormones. That basic framework, we all agree on. There's no controversy with those options. Yet women aren't even given those. They're not given help, because the breast cancer treatment overtakes the whole conversation.

Stacy London (48:31) That also becomes the priority in the conversation, right? It's the fallout.

Dr. Corinne Menn (48:34) Which I understand. I was in that position.

Stacy London (48:38) Well, that's what I was going to ask you, and this is probably a great place for us to land, because you have survived breast cancer. What was the personal experience like for you, and how has it informed your decision-making? I'm assuming that having gone through it is very different from just talking about it, or making recommendations around it.

Dr. Corinne Menn (49:05) It is. My experience was absolutely terrible, because no one helped me, and I wasn't well informed myself. My doctors were wonderful — I thank my medical oncologist and my surgeons for truly saving my life and treating me as best they knew how. But when I look back, I suffered for a long, long time, because I went through menopause twice temporarily.

Once from the chemotherapy — temporary menopause. I was shell-shocked. I thought all my symptoms were side effects of chemo. Looking back, I actually tolerated the chemo pretty well. It was the abrupt menopause that was really frigging rough, at 28. Then my periods recovered, and I was put on tamoxifen with ovarian suppression — an injection to suppress my ovarian function. That was really, really hard for me.

Then I was given a choice, with shared decision-making based on observational data, that women could pause their tamoxifen to get pregnant. That's what I did. I stopped my tamoxifen, got pregnant on my own — well, with my husband's help — had a healthy baby girl, and then went back on tamoxifen. Back then, in 2003, that was kind of an emerging thing we were supporting: fertility preservation for breast cancer patients. There was data suggesting that pregnancy after breast cancer didn't make your outlook worse — it didn't worsen mortality or recurrence. It wasn't perfect data; it was mostly observational. But they said: you have shared decision-making, you have patient autonomy. "Corinne, if this is something you value, we think it's reasonable." Okay, doctor. That's what I did. Then I listened to them, went back on my treatments, and completed them.

At some point along the way, after I had my first child, I decided I was never going to take a pause again to have another baby. We adopted our second baby, and I had my ovaries removed — that's a whole other long story — because my mom died of ovarian cancer. I was told I was BRCA negative. Then, over a decade later, I was retested, and I actually do carry the BRCA mutation. That's because in the early 2000s we didn't look at the entire rearrangement of the gene; the updated testing looked at the gene in a larger way. But at the time, I was just like: my mom was only 54, I'm not going to have another baby, so I'll just take out the ovaries. And they said, "You don't have to — you're not BRCA." I said, "No, I think I do."

So then I had surgical menopause at 34.

Stacy London (51:41) Wow.

Dr. Corinne Menn (51:43) So yes, it informed me, because I experienced it three times, in three different scenarios.

Stacy London (51:49) And each time adding a child. So you experienced menopause three times, with two children.

Dr. Corinne Menn (51:55) Yeah. We got back from the adoption — it was an international adoption of my younger daughter — and a couple of months later I'm like, okay, time for the ovaries. So I got my ovaries out, and then I joined an OB-GYN group practice. Talk about being thrown to the wolves. It was really, really hard. I didn't do any of the things I talk about now. I didn't do the lifestyle medicine pillars. No one ever gave me anything non-hormonal to help with my hot flashes until years later, when a lovely nurse practitioner in my oncologist's office said, "Corinne, I can give you an SSRI, and that might help a little bit." I was like, thank you. I had literally gotten no help. No one had been following my bone density. None of the things I talk about now did I get done for myself.

Obviously, I learned all of that by becoming informed — going to the Menopause Society, getting certified, educating myself. None of that suffering needed to happen. And that was before I ever even considered HRT for myself or for any of my breast cancer patients. When I look back, there was so much that could have been done that would have made my quality of life and my chronic disease risk much better.

So the first thing I learned was all the preventive health we've talked about. Then I learned that vaginal estrogen is safe for breast cancer patients — yes, even if you're on chemotherapy or tamoxifen, and yes, even if you're using aromatase inhibitors. There are particular formulations we especially like, which are very low-dose and very safe, along with moisturizers, lubricants, and pelvic floor therapy. There's so much we can do, and we have the data on it.

Stacy London (53:32) Right, and that's what I was going to ask you. Are there different menopausal issues that come up depending on the kind of cancer treatment you're doing? You've been talking a lot about non-systemic hormones, like vaginal estrogen. But let's say it's hot flashes — you're getting hot flashes from tamoxifen, and sex isn't the issue. Do you treat that differently? I can understand that if your vagina is dry, of course vaginal estrogen is going to help. But if you're dealing with hot flashes and night sweats that just won't let you sleep, what's recommended now?

Dr. Corinne Menn (54:25) We have good stuff. There is good stuff — we have more than just SSRIs. Back in 2023, the Menopause Society published a really nice resource that anybody can download — a great resource for your listeners — the 2023 Nonhormone Therapy Position Statement. It outlines all the evidence-based approaches. Yes, there's lifestyle, and there's cognitive behavioral therapy — those are things you can do. But in terms of evidence-based medications to treat hot flashes and night sweats — and the reason I tell women this is important: I get it, you don't want to take a medication. Women don't want to keep taking medications. But if you're up all night with hot flashes or night sweats and your sleep is disrupted, I'm sorry, it's really worth considering doing something medically for that.

So we've got a bunch of categories. We've got the SSRIs — antidepressants like venlafaxine, brand name Effexor, and paroxetine. You can't take paroxetine if you're on tamoxifen, but you can take Effexor instead. There's a bladder medication called oxybutynin that can be helpful. For women who mostly have night sweats or sleep disturbances, gabapentin, brand name Neurontin, can be helpful — it makes you sleepy.

And we've got two new non-hormonal ones. The brand names are Veozah and Lynkuet — fezolinetant and elinzanetant. These are non-hormonal, and they act specifically in the hypothalamus of your brain, which is where hot flashes and night sweats start — the thermoregulatory center of your brain. Veozah was not studied in breast cancer survivors, but they're collecting data on breast cancer survivors. For Lynkuet, they did look at patients who were on tamoxifen or aromatase inhibitors and found it to be effective.

Now, the caveat I give is that these medications are new. We do not have long-term data on them. Just because a medication is non-hormonal and new and flashy — and their ads are everywhere; at every Menopause Society or ACOG meeting you go to, there are huge ads for them — I'm sorry, they're new medications. So I tell my breast cancer survivors: I think these are helpful. They can be very effective. We don't have very, very long-term data on them, but the short-term data suggests they're safe and effective. Talk to your medical oncologist, and don't delay and just try to suck it up if you're having these symptoms.

So that's our general approach for someone who's in the middle of estrogen receptor–positive breast cancer treatment, because those women have to take some type of hormonal manipulation to lower or block estrogen for five to 10 years. That's how we lean in to help her.

That doesn't mean that when she completes that treatment, or comes off that medication, she can't say, "Okay, I get it. What about me? I've done this, it's behind me. I'm at very low risk of recurrence." Now, some of these women are high risk for recurrence — they had lots of disease, lots of lymph nodes. With those patients, we're probably never going to talk about systemic estrogen. If you have advanced, late stage two, stage three, or metastatic estrogen receptor–positive disease, we're generally not doing systemic hormone therapy. But there's a large swath of these women who are very early stage, with a tiny risk of recurrence. That doesn't mean zero risk. As estrogen receptor–positive breast cancer patients, we live with the fact that there's always a chance of a late recurrence. It's a hard thing to hear, and ER-positive patients know it — we've been told. Our five-year survival rate is awesome, but after five years, there continues to be a risk of recurrence. And your risk of recurrence is based on your individual cancer.

So, as an intelligent woman with autonomy, shared decision-making, and nuance — if you're really suffering from symptoms, you might want to have a conversation: "I might want to try a low dose of hormone therapy. I understand there's a theoretical risk that if I add estrogen back, I could have a recurrence. I'm willing to sign an informed consent. I want shared decision-making. I've tried these other things, and my life is bad" — or, "I'm at really high risk for osteoporosis, and I don't want those other medications." I feel like that should be a choice.

The other thing that's really important, Stacy, is that about 20% of women with breast cancer have what's called estrogen receptor–negative breast cancer — we often call it triple-negative, though it's not always triple-negative. Triple-negative means ER-negative, PR-negative, and HER2-negative. Some of these patients are HER2-positive; HER2 isn't a hormone receptor — it can be overexpressed, positive, or negative. But to simplify it, just think of it as estrogen receptor–negative or estrogen receptor–positive.

For women with estrogen receptor–negative breast cancer, we don't lower their estrogen to treat their breast cancer. We don't remove their ovaries to treat their breast cancer. We don't give them estrogen blockers. Many of these women will have chemo that might put them temporarily into menopause if they're young, and their periods return. Some of these women are older and never get their periods back, because they were already menopausal, or they had chemo and their periods never returned. But a significant number of young women are diagnosed with triple-negative breast cancer. If you're under 40 and have triple-negative breast cancer, about 30% of the time you may also have a BRCA mutation. Those women then lose their ovaries — but to lower their ovarian cancer risk, not to treat their triple-negative breast cancer.

So there are all these young women with triple-negative breast cancer who actually regain their ovarian function — their periods return — and they get past four or five years. For a triple-negative patient, unlike an ER-positive patient, the highest risk of recurrence is early on. If they make it through those four to five years, their risk of a recurrence is really low. At some point, they'll either go through natural menopause, or early menopause just because of the chemo, or because they carry a BRCA mutation and have their ovaries taken out. But at that point, after many years of having periods and high estrogen levels, why can't we have a discussion with them about low-dose MHT? These women are often denied even vaginal estrogen, because all breast cancer patients are denied vaginal estrogen. It doesn't even make sense. These are women whose estrogen receptors we were never manipulating. They're ER-negative. To me, again, that's a different population, and we can't lump these people all together. Do you understand what I mean?

Stacy London (1:01:20) Yes, yes.

Dr. Corinne Menn (1:01:21) I think most oncologists love to say, "Let's do lifestyle and non-hormonal options first." Fine — no one's saying there's anything wrong with that. But we also have to find the buckets of patients who might actually be reasonable candidates, with shared decision-making, knowing we don't have perfect data on any of this — using reasoning, common sense, and available data from other clinical scenarios to say, "Okay, in your case, yes, we can do this."

Stacy London (1:01:54) Yeah. And what I really appreciate about that is — look, the whole conversation around menopause, heretofore, has really been about: let's inform ourselves, let's figure out all the things we need to talk about, what the symptoms are when you're going through it, what it means, what it means for longevity, all of this stuff. But there are these more specific pockets of the population dealing with menopause who aren't going to be able to follow these one-size-fits-all general rules. And it's very helpful to hear a doctor — and not only a doctor, but somebody who's been through breast cancer herself — talk about the fact that there are options. That kind of optimism is really lacking, from where I sit. I don't hear enough of this to feel like we can bring breast cancer patients, or BRCA carriers, into this conversation in a way where they feel included.

So I really appreciate the time and effort it took to sit with me today and go through it with me. Even knowing the options, and where to look for those options, gives me so much more hope for people who are in such a high-need state. We need more of this. We need more conferences. More, more, more.

Dr. Corinne Menn (1:03:12) Totally. Well, thank you for giving us a space to talk about it, because rates in young women are rising, but women are surviving. We've got better and better treatments. Women are being cured. They're living for years and decades with a breast cancer diagnosis behind them. So we have to address it. We can't hide from it anymore.

Stacy London (1:03:39) No — especially because there was such confusion after 2002 about breast cancer and pharma. Even your unraveling of it, just to explain it to me like I'm four, is complicated. I can't imagine, especially when you're also dealing with all of the psychological devastation of being diagnosed with cancer, period. I think this is such a helpful conversation — so many things I didn't understand.

Just to reiterate: one, medically and technologically, we have modern hormones compared to what people were taking before the WHI study, and we've reinterpreted that study to at least understand the data that was given to us through a different lens than the original one. And two, there are people who are BRCA gene carriers, breast cancer survivors, or even people with breast cancer, who can mitigate the symptoms of menopause, either with low-dose hormones or without — they just need to have shared decision-making with their medical team.

Dr. Corinne Menn (1:04:53) Yeah. And you're never doomed. The bottom line is, if you choose at some point — it doesn't matter who you are — not to take systemic hormone therapy, you're not doomed. But please don't put your head in the sand and ignore what menopause is. Just be empowered, and you can make choices to live a long, healthy life, whether you use hormones or not. You deserve information on how you're going to manage it. So recognize what menopause is: it's an opportunity. Evaluate your risks and how you can live a healthier long-term life, and then choose the best path for you. But it should be based on facts, not on outdated fears.

Stacy London (1:05:36) Exactly — which is still so pervasive. I really appreciate all the facts today. Thank you so much.

Dr. Corinne Menn (1:05:40) It's so pervasive. Well, this was just so much fun. I could talk forever about this, obviously.

Stacy London (1:05:49) Well, you're amazing at it. And it really is something to talk about this when we're not talking about it through the lens of fear, because I feel like that's all we've had for so long. This idea of agency, and shared decision-making, and really getting the facts feels so exciting when we've been put in a position for so long not to have them. There's something really optimistic for me in that — that women can make these decisions for a much healthier, happier, and longer life.

Dr. Corinne Menn (1:06:20) Absolutely.

Stacy London (1:06:22) Thank you so much.

[End of episode]

‍