Clinical Practice
Hormone Replacement after Breast Cancer: What's New?
Dr. Francisco Tostes
Scientific Director, SottoPelle Brasil
Hormone replacement therapy (HRT) during menopause in women with a history of breast cancer continues to be one of the most complex and discussed topics in gynecological endocrinology. New evidence and guidelines now allow for a more personalized and balanced assessment.
Hormone replacement therapy (HRT) during menopause in women with a history of breast cancer continues to be one of the most complex and discussed topics in gynecological endocrinology. For a long time, an extremely conservative approach prevailed, centered on the fear of recurrence. However, new evidence and guidelines now allow for a more personalized and balanced assessment.
Understanding the Complexity: The Role of Tumor Biology
Not all breast cancers respond to hormones in the same way. Therefore, it is essential to understand the histology and molecular profile of the tumor:
| Tumor Subtype | Hormone Receptors | Implication for HRT |
|---|---|---|
| Infiltrating ductal carcinoma HR+ | ER+/PR+ | Contraindicated systemic HRT |
| Pure HER2+ carcinoma | No hormonal expression | Case-by-case evaluation |
| Triple-negative (ER-, PR-, HER2-) | Absence of receptors | Greater openness to discuss HRT |
| Carcinoma in situ (DCIS/LCIS) cured | Depends on subtype | May be considered |
What Do the Main Evidence Say?
- The CGHFBC meta-analysis published in The Lancet (2019) pointed to an increased risk of recurrence with continuous use of combined HRT in women with HR+ cancer.
- Isolated estrogen demonstrated much lower risk, mainly in hysterectomized women.
- An integrative review published in 2025 (Acervo Saúde) showed that the duration and type of hormone used directly influence this risk.
New Guidelines: More Individualization
The NICE (2024) and BMS (2024) guidelines propose a more flexible approach:
- Systemic HRT remains contraindicated in active or recent HR+ breast cancers.
- It may be discussed in cases of triple-negative or HER2+ cancer, cured for many years, provided there is approval from the oncologist and specialized team.
Vaginal Estrogen: A Safe Option?
- According to NICE and BMS, low-dose vaginal estrogen does not increase the risk of recurrence in women with HR+ breast cancer.
- A study presented at ASCO 2025 showed that women over 65 who used vaginal cream had reduced mortality.
- It can be indicated for urogenital symptoms such as vaginal dryness, dyspareunia, and recurrent urinary infections, always with multidisciplinary monitoring.
Practical Tips for Clinical Management
- Active or recent HR+ breast cancer: formal contraindication to systemic HRT.
- Triple-negative, pure HER2+, or cured DCIS: may allow individualized evaluation.
- Local vaginal estrogen (low dose): safe even in HR+, with oncological approval.
- The therapeutic decision should be shared and multidisciplinary, considering risks, benefits, and patient quality of life.
References
- NICE. Menopause: identification and management (NG23). 2024.
- British Menopause Society (BMS). Consensus Statement, 2024.
- The Lancet. Type and timing of menopausal hormone therapy and breast cancer risk. 2019.
- Acervo Saúde. Terapia hormonal na menopausa e câncer de mama: revisão integrativa. 2025.
- Reuters Health. Older breast cancer patients using estrogen cream live longer. 2025.
- The Times. Menopausal cancer survivors offered HRT under new guidance. 2025.
Article written by the Scientific Director of SottoPelle Brasil, Dr. Francisco Tostes.