October 29, 2025 • 37 mins
Breast cancer survivors are sometimes told to endure the fallout of estrogen deprivation. Speaking of Women's Health Podcast Host sits down with Dr. Corinne Menn, a long‑term breast cancer survivor, to unpack what real, evidence‑based menopause care looks like for breast cancer survivors, high‑risk women, and BRCA previvors—without fear and without shame.
For more information on Dr. Corinne Menn, visit drmenn.com.
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Episode Transcript
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Dr. Holly Thacker (00:10):
Welcome to the Speaking of Women's Health
Podcast.
I'm your host, Dr.
Holly Packer, and I am back inthe Sunflower House for a new
and very special edition with afabulous woman and gynecologist
and breast cancer survivor.
Dr.
Men.
(00:31):
Welcome, Dr.
Corine Men, to our um podcasttalking about breast cancer
survivors, menopause.
It's October, breast cancerawareness.
This is really important everymonth of the year for so many
women.
And we're going to talk aboutum strategies for a young woman
(00:52):
who's a breast cancer survivor.
And um, if we have some time,we'll talk about the recent FDA
panel discussion on hormonetherapy, which was very exciting
to finally have.
And I had so many friends andand uh colleagues that were
there.
So welcome, Dr.
Men.
Do you want to tell us a littlebit about yourself?
Dr. Corinne Menn (01:14):
So, Dr.
Corinne Men, I'm an OBGYN um umand have practiced for over 23
years.
And in even though you onlylook 23.
Oh, well, um thank you.
I'm gonna be 53.
I have not afraid to share myage and and I've been through a
lot.
So hopefully I've got somelines to show it.
(01:35):
Um my battle wounds, so tospeak.
So, yeah, so for the last 15years or so, I've really focused
on um menopause management,perimenopause management, and
really speaking up and helpingthe most vulnerable women in
menopause.
Um, and that is the breastcancer survivor or the BRCA
(01:55):
previvors or other women who arehigh risk for breast cancer.
Um, and also other cancers,because that's, you know, like
we talk a lot about breastcancer, but there's a lot of
women out there with othercancers, which we know are
increasing in younger women.
And then they're kind of leftwith all this menopause stuff,
and you know, no one's reallytackling it.
Dr. Holly Thacker (02:14):
So excellent.
Well, thank you so much forjoining us and sharing uh your
expertise and your personalexperience.
Uh, and you're quite the hit onuh social media, which I think
is really important because somany women are getting their
information on social media, butyou made that comment about,
(02:35):
well, how can you explainsomething so important in just a
few few minutes?
Dr. Corinne Menn (02:39):
Yeah, it's not easy, but I think, you know,
part of the issue with menopauseafter breast cancer, say, is
just to kind of open the door sothat we can recognize that
there is collateral damage ofestrogen deprivation, um, the
loss of hormones, the earlyabrupt surgical or premature
menopause.
And so just kind of likeplanting the seeds that, hey,
(03:01):
this is okay to talk about, andthere are things for you to do.
So, you know, I think becausethere is a big um menopause
movement, which is great, allwomen are being empowered to
learn about their bodies anddiscuss the safety and options
of menopausal hormone therapyfor their symptoms, et cetera.
But often breast cancersurvivors feel left out and
(03:22):
often scared that wow, there'sall these benefits to hormone
therapy that maybe I can't have.
So I'm doomed for a life ofosteoporosis and cardiovascular
disease and dementia and badquality of life.
And I want them to know, evenif you can't use systemic
hormones, and we can talk aboutwhen you can consider that.
Um, there's so many things thatwe can do, including local
hormones, non-hormones, otherthings.
(03:45):
Um, so I want them to feelincluded because it's millions
of women.
Dr. Holly Thacker (03:49):
Well, I was so excited to start to talk to
you that I didn't really giveyour formal presentation and
information about you, ourguest.
So, Dr.
Corinne Men is aboard-certified OBGYN physician,
and she's also a menopausesociety certified practitioner.
She has dedicated her medicalpractice to menopause management
(04:11):
and the unique health careneeds of female cancer
survivors.
She also talked aboutpre-vivors, which is meaning you
don't have cancer yet, butyou're at increased risk,
potentially because of genetics,and just women in general at
high risk for breast cancer.
She's now practicingexclusively through telehealth.
So that means lots of peoplecan see her.
(04:33):
And she does women's healthconsultations and a lot of
patient education.
And she's also a medicaladvisor and a prescribing
physician on alloy, which is amenopause or telehealth
platform.
And she's a like she said, eventhough she looks 23, she is a
23-year-old survivor of breastcancer, and she is a proud
(04:56):
53-year-old uh woman.
And because of her breastcancer, she herself had
premature menopause, uh, BRCAcarrier.
And she uses her personalexperience to help navigate
women uh through their ownhealth challenges.
So thank you so much.
We've wanted you on ourspeaking of women's health
(05:16):
podcast for so long.
And I've had other podcastinterviews on breast cancer
awareness, on genetic testing,on the gene law, on um breast
cancer survivors.
But I just think that um youreally kind of typify all the
different perspectives.
And so we're so lucky to haveyou.
(05:37):
And start off by talking abouthow women can advocate for
themselves.
Dr. Corinne Menn (05:43):
Yeah, I think, you know, I learned that when I
was told I was too young forbreast cancer.
So when I was diagnosed at 28,I was a second-year OBGY in
residence.
So we should just like, youknow, just have it said, young
women can and do get breastcancer, as do older women.
And so if you feel somethingnot right, something different
in your body, in your breast,speak up, be a squeaky wheel.
(06:05):
I wrote myself off for almostfour months and thought it was
just a cyst or probably afibroadenoma, my GYN and my
fellow OBGYN, like friends,residents who I let them, you
know, let them check it out.
They're like, I'll just watchit for a few menstrual cycles,
right?
Um, because I had never heardof a young woman with breast
cancer, right?
But unfortunately, youngerwomen under the age of 40, it's
(06:26):
increasingly um a common thing,sadly, for a variety of reasons,
right?
So I think the first start, thefirst part to being your best
advocate is to don't be afraidto speak up.
And if one doctor says no orwrites you off, and whether it's
your breast cancer symptoms oryou know, something that you
feel, or whether you're a breastcancer patient and you're
(06:48):
having a hard time withtreatment or the side effects of
menopause, you have to be thesqueaky wheel.
Because in this medical system,the doctors mean well by and
large, but many of them arenever educated on some of these
nuances of breast cancer care,especially menopause.
And they're also working in areally tough system where they
have time constraints and lotsof pressure.
(07:10):
So you have to really, you kindof have to be noisy.
Dr. Holly Thacker (07:14):
Right.
And be very prepared.
Um schedule those appointments.
I always say it's easier tocancel them than schedule them
and come with a couple of thingsthat you want to address
because it is uh so complicated.
Yes.
Um now uh why why uh do youthink that it's important um for
(07:36):
this communication of thisdifficult information?
And what do women do who justget rushed off?
Because I see women all thetime.
Sometimes I'm their tenthphysician that they finally seen
and they're just they've workedso hard at it.
Dr. Corinne Menn (07:48):
Yeah.
So particularly when we'retalking about breast cancer
patients, basic breast cancersurvivors in menopause, um, we
know that the average woman inmenopause sees multiple
physicians, may it may take upto two years for her to finally
find someone who's offering herevidence-based options for her
menopause symptoms and we'llhave a discussion on hormone
therapy or other options.
(08:08):
And so when I say when yousprinkle in the pink very dust
of a breast cancer diagnosis, itmakes it even harder because
you know, OBGYN's primary caredoctors have not really been
well educated in menopause ingeneral.
And so if you think that theoncologist or the breast surgeon
has much, you know, you know,medical training in managing
(08:30):
menopause or sexual side effectsafter cancer, it's it's even
less, right?
And so, you know, the women arereally bounced around.
And so you have to be educated.
It's part of why I do go out onsocial media and speak a lot
because I think we're only goingto solve this problem and I'm
already seeing it actually outthere.
The information is tricklingdown, and women are rising up,
(08:50):
they're going into theironcologists, they're going into
their GYNs, being like, hey,like I I've heard I don't have
to suffer with horrificallypainful sex and recurrent
urinary tract infections, like,or or whatever, or I've heard
that there are things for my hotflashes, and I've heard
something called shared decisionmaking.
And so there, there's, I reallythink change will come from the
(09:10):
bottom up.
So, you know, you you have toreally be educated and you have
to know about your diagnosis,all the ins and outs of it.
You have to, I tell people tokeep a, you know, a really a
paper binder, ask for a copy ofall your reports and keep a list
of your symptoms.
Because in this digital world,sometimes things are all over
and you don't really know.
(09:31):
Um like put everythingtogether, track your symptoms,
and we can go through all of themenopause stuff today um so
that people can feel reallyprepared to kind of work with
their doctor.
And if your doctor doesn'tknow, it's okay.
But they should if if they'rein this business, they must have
a referral for you.
Dr. Holly Thacker (09:50):
Absolutely, absolutely.
And I think trusting yourso-called gut instinct.
Um, I have a friend who was ayoung woman, had a breast lump,
and everybody just blew her offbecause she was so young and she
didn't actually even getdiagnosed with her breast cancer
like until a year later whenshe was pregnant and had to go
through pregnancy, had to gettreatment for breast cancer,
(10:12):
interrupted her treatment umafter she delivered because she
wanted to breastfeed, and thenafter breastfeeding, underwent
treatment and is um really, youknow, quite quite an ordeal.
But it was the pregnancy thatfinally pushed her over to say,
This the I think there'ssomething wrong.
Dr. Corinne Menn (10:30):
Sadly, it's it's still a fairly common
story.
So when I was diagnosed in um2001, the Young Survival
Coalition was quite young then.
They were only about five yearsold, and I was lucky enough to
know someone who was um one ofthe founders.
So I got that support.
Um, and back then we were, youknow, advocating for you know
the medical profession torecognize that young women can
(10:52):
do get breast cancer and thatthey have unique and different
needs than the older woman.
But it's kind of shocking forme to see 24 years later, and
now on social media, I'm I seethese young women posting the
exact same story that you said,you know, they're put off, or
particularly if they'rebreastfeeding, you know, it's
written off that it's just aclogged milk duct or you know,
(11:15):
etc.
And so um, you know, that's themost basic, just believing
women when they say something'schanged in their breast, right?
Dr. Holly Thacker (11:24):
That is is very important.
And I've been gratified thatyounger women who are breast
cancer survivors, if if they'reable to and want to have a
family, they can becomepregnant.
And as someone who hasn'tpracticed in obstetrics or
focused my practice on that, Ialways say I delivered my 23rd
baby on my 23rd birthday onJanuary 23rd.
(11:45):
That was enough obstetrics fromme.
Um, and I focused on midlifewomen that are generally past
that stage.
It just seems so ageous to meto say it's fine to get pregnant
after we're done treating yourbreast cancer, which is very
high estrogen levels, but thenyou live long enough to be
naturally menopausal, and thenyou don't have any estrogen, you
(12:06):
have less estrogen than a man,and oh sorry, uh we're we're not
going to even consider it.
Dr. Corinne Menn (12:13):
And you are screening myself.
So thank you, fruit, for that.
And I think it's so let's talkabout that, you know.
So to kind of set the tone,when I was, you know, 28, one of
my biggest fears beingdiagnosed with breast cancer,
because I knew enough, I wasonly a second-year resident, but
I knew enough of what breastcancer treatment meant.
(12:35):
It meant that I was likelygoing to be on some type of
estrogen, I ear positive breastcancer, some type of estrogen
blocker.
Um, I was I had to havechemotherapy, which could damage
the ovaries, and it didtemporarily put me into
menopause.
And then some of mymedications, like my lupron and
my tamoxifen, also thentemporarily put me into
menopause.
But my doctors back then, um,there was observational data at
(12:58):
the time showing that it didn'tseem that a pregnancy after
breast cancer, it didn't seemthat it impacted prognosis or
increased the risk ofrecurrence.
But we didn't have such robustdata.
But even then, with the lack ofrobust data, all of the
professionals in the New YorkCity area where I got consults,
they all encouraged me topreserve fertility prior to
(13:19):
chemo.
I saved some embryos.
Yep.
And and they said, okay, youcan pause tamoxifen and
lutebrone for a little bit.
I got pregnant on my own.
I didn't, my ovaries worked.
They they recovered from chemoand I had a healthy pregnancy,
and then I went back on mytamoxifen.
So they encouraged that andsupported that shared decision,
(13:40):
saying, like, listen, Kurtin, wedon't know for sure, but we
think it's okay.
And so if you're gonna do this,let's do this now and get you
back on your tamoxifen.
And I did it, and all is well,thank goodness.
And my daughter's 21.
Um, and Dr.
Holly Peterson, our colleague,you know, recently wrote this
very point in a new practicepearl that was published by the
Menopause Society talking abouthow do we have this shared
(14:02):
decision making about menopausalhormone therapy after diagnosis
of breast cancer?
And we'll talk about who wouldbe ideal candidates in a minute.
But her point was this, it'svery paternalistic and um really
antithetical to this notionthat we would allow someone
shared decision making to stoptreatment for up to two years,
(14:22):
get pregnant, but yet yearslater, when she wants a very
small amount, right, of estrogenum just to relieve symptoms,
maybe help with her bone loss,etc.
It's not even a considered to,you can't even have a
conversation.
You're literally consideredcrazy.
I've had women tell me when Ibring it up, my doctor's like,
(14:43):
are you nuts?
But I really feel it's becausesociety values women's capacity
to have babies.
They don't value us when ourreproductive capacity ends.
It's absolutely you know, andwhat's so interesting is they
value us getting pregnant somuch that in the New England
Journal of Medicine waspublished, and I'm so glad Dr.
(15:05):
Ann Partridge did this study,it was called the positive
trial, which your listenersshould know about.
It was a really important trialwhich looked at, you know, um a
control group of women who did,you know, who did not pause
versus a woman, women who pausedtheir adjuvant endocrine
therapy to get pregnant.
And it showed in the short termit didn't appear any increased
(15:25):
risk of um recurrence, and it'ssupported by lots of other data.
And um, so it's just veryinteresting that we will allow
that, but we will not allow adiscussion about, you know, help
with menopause.
And we'll allow them to getpregnant, but we won't even give
women vaginal estrogen so thatit doesn't hurt when they have
(15:45):
sex when they're trying to getpregnant.
Like I just, it really is veryupsetting.
Dr. Holly Thacker (15:52):
Well, I was really happy to be part of the
campaign to really push breastoncologists.
Uh, why don't you examine yourfemale patients' genitalia?
Because the therapies,especially the aromatase
inhibitors, much more so thantamoxifen, which has some
estrogenic effects on the uterusand the vagina, really cause
devastating problems.
And um, it's just it's notacceptable.
(16:16):
And I know that some physicianswho've either personally had
that experience or their spousehas had the experience, once
they see it from that personalstandpoint, they kind of change
their perspective and take alook at the literature.
And I've been prescribinghormone therapy to breast cancer
survivors from the beginning ofmy practice with shared
(16:37):
decision making, informedconsent, going over all the
alternatives.
But I think that women feelvery afraid because when they
have a physician tell them, no,you can't do this, it doesn't
always matter what options Ishow them and the evidence I
show them, they have that in theback of their mind that it's
not a good thing.
And I think that's justterrorizing for so many women.
Dr. Corinne Menn (16:57):
It yes.
And so, and I think it'simportant for anybody listening
to make sure that youunderstand, like we are talking
about, you know, we can talk,we're gonna talk today about
systemic hormone therapy.
But if we reference um vaginalhormones, that's low-dose local
vaginal hormones, that we have atremendous amount of published
literature.
And it's actually written inthe guidelines, even from the
(17:19):
American Society of ClinicalOncology, um, ACOG, the MENAPUS
Society, et cetera, that locallow-dose vaginal estrogen is
safe for patients with breastcancer.
Yes, even while you're ontamoxifen, and yes, even when
you're on an aromataseinhibitor.
There may be a formulation thatwe might prefer for someone on
an aromatase inhibitor, but thedevastation of 10 years of
(17:42):
estrogen deprivation, it's a lotmore than vaginal dryness.
And I think that's part of theproblem, Dr.
Thacker, is that the medicaloncologist might just think of
it as like, well, it's justvaginal dryness, because that's
typically what their studiesbasically when they look at
adverse effects, vaginaldryness.
But no one asks patients aboutclitoral atrophy, severe vaginal
(18:03):
stenosis where they're unableto have a pap smear, you know,
um, you know, labia that is justshrunk and gone away.
So like any sort of touching ispainful and, you know, not
pleasurable, recurrent urinarytract infections, right?
Because it's the genitalurinary syndrome.
So we have to like move, Ithink when we name it what it is
(18:23):
and don't call it vaginaldryness, it kind of opens up the
eyes, you know, of our of ourmedical colleagues.
Dr. Holly Thacker (18:30):
And you know, just an aside, because I was uh
um helping some of my juniorstaff who just joined me who
finished our two-year fellowshipin specialized women's health,
it's it's not just breast cancersurvivors that get this.
Um, you know, we have a lot ofhigh-risk cardiac patients,
people with heart failure andorgan transplants and histories
of blood clots and dissectionsand whatever.
(18:52):
And, you know, we had acardiologist uh tr try to tell
our menopause specialists, shedoesn't need estrogen, you know,
for her hot fleshes.
Why don't you just give herprogesterone?
And it just amazes me thatpeople that don't have any
expertise or knowledge in thisare making recommendations to
patients that they can just dosomething or not do something.
Dr. Corinne Menn (19:14):
Well, it would imagine if I took a patient off
a cardiologist, the medicationthat the cardiologist put them
on, or you know, or I gave theorthopedic surgeon a different
plan that I told the patient adifferent plan of the approach
to their knee surgery orwhatever.
But I actually routinely seepatients who are being
prescribed even something verysafe like local lotus vaginal
estrogen go to another colleagueand they're told you should
(19:38):
stop that.
It's it's it's just really um,I think we just really need to,
I think the menopause space isgrowing a lot, but there's a lot
of echo chamber.
There's a lot of menopausespecialists and people who get
it talking to each other, whichis great.
So I'm really excited to try topush in and try to like reach
into, you know, speak to themedical oncologist, get in with
(19:59):
the cardiologist, like start tobuild bridges there so that we
can all understand, like if youcare for women, I don't care
what your specialty is.
You must know the basics ofmenopause.
And you can't give theminformation that is fear-based
if you don't really know it.
You could just simply say, I'mnot sure if that's safe.
Let me speak to your doctor,you know, or you know, you know,
(20:20):
let me let me consult.
But don't, don't, don't, don'tfill your patient with fear.
So if you're a woman and you'rehearing this and you're like,
oh, this resonates for me, whatdo I do?
Go back and call the doctor whoprescribed you your medicine
before you freak out and getscared, right?
Um, and let let let the medicalprofessionals we'll support
(20:40):
you.
Don't feel like you're beingput in the middle.
Dr. Holly Thacker (20:43):
Well, you have been listening to the
Speaking of Women's Healthpodcast.
I'm your host, Dr.
Holly Thacker, the executivedirector of Speaking of Women's
Health, and I run ourspecialized women's health
center at the Cleveland Clinicand our specialty fellowship.
And we are speaking to Dr.
Corinne Men, who is an OBGYNspecialist in uh menopause and
(21:04):
cancer survivors, and is along-term uh breast cancer
survivor herself.
And uh we've been talking aboutadvocating for yourself, that
there are options, that we don'tjust have to only focus on
young women and reproduction,even though that's wonderful.
It's a wonderful time of lifeand it's so important.
Uh, but the postmenopausalyears are important too.
(21:26):
And my son, who's a PhD inmolecular medicine and cancer
genetics, he he would talk aboutthe anthropologic data and how
grandmothers are very importantand their involvement in
childbearing of the youngergeneration.
So, you know, we need ourcolleagues to think about the
grandmother's role in, you know,furthering grandmothers
(21:48):
healthy.
Dr. Corinne Menn (21:48):
Yes, so that they're breaking their hips so
that they can help with thegrandchildren.
Dr. Holly Thacker (21:53):
Exactly, exactly.
And function.
I mean, just the workproductivity, you know, people
that have untreated vasomotorsymptoms.
And we have some great newoptions um of non-hormonal
options for hot flashes and bonehealth and non-estrogen vaginal
DHEA.
And we've covered a lot ofthese details on um uh several
of our prior podcasts that youcan find on speaking of women's
(22:15):
health.
But I want to get into um moreof your pearls, your experience,
um, takeaways, because we havenot just lay women listening or
you know, in a hundredcountries, but we also have a
lot of physicians and nursepractitioners who listen to our
podcast.
Dr. Corinne Menn (22:30):
Absolutely.
Dr. Holly Thacker (22:34):
So you want to talk about um we we have gone
over genetic testing.
Um do you want to talk aboutbreast cancer treatment in women
uh or dealing with survivorswho've had genetic mutations
versus those that don't?
Does that factor in?
Dr. Corinne Menn (22:48):
Let's start with the BROCA previous.
A couple things that I reallywant women to know.
Um, if you are a BRCA previvor,you've not had cancer yet, or
maybe you have anotherhereditary mutation where you
are going to get your ovariesout early, right?
So I had my ovaries removedearly as well to lower my risk
of ovarian cancer because Ifound out, you know, I do carry
(23:10):
the BRCA2 gene.
I found that out later and wecan talk about that.
But we want you to know, wedon't want you to fear removing
your ovaries out of the fear ofpremature abrupt surgical
menopause.
Particularly BRCA cares, weactually have literature on
this.
The NCCN guidelines, themenopause society guidelines,
(23:30):
ACOG, etc., make it quite clearthat all of the data says that
you can remove the woman'sovaries to lower her risk of
ovarian cancer when you're donewith your childbearing and if
you don't need fertilityanymore.
And we must, we really shouldgive back hormone replacement
therapy.
And I say HRT because if you'reunder the age of 40 or the
(23:51):
underage of 45, you really needa little bit higher doses.
Um, so these these Brocacarriers should have that
hormones um given back to themup to at least the age of
natural menopause, and then theycan make that decision.
Now, many of these women havealready had their prophylactic
mastectomies, some have not.
Um, and whether you've had thatprophylactic mastectomy or not
(24:13):
should not change the decisionand the option to go on, go on
hormone therapy if you've hadpremature surgical menopause
because of the risk reducingBSO.
And the literature shows thatyes, the risk-reducing DSO
lowers your ovarian cancer risk,and it actually does lower your
breast cancer risk.
But giving back menopausalhormone therapy in that
(24:34):
premature early menopause timedoes not appear to take away the
benefit of a lower breastcancer risk.
It's really interesting.
And I think it's reallyimportant for these pre-vivors
to know we want you to have yourcake and eat it too.
Lower your risk, but still havea good quality of life because
if we remove those ovariesearly, and I just presented this
(24:55):
weekend about this, that isfemale castration.
I know it sounds shocking topeople, but it's it's it's
you're being castratedprematurely, and you um have
then dramatic increases in heartdisease, dementia,
osteoporosis, sexualdysfunction, mood disorders,
etc., that hormone therapy canreally mitigate.
(25:15):
And so please know that yes,the guidelines support this.
Now, this is not the sameconversation for someone with
invasive breast cancer.
So I'm just making thingsclear.
This is for our Brock upprevivors.
And just as a personal story, Ihave seen women delay their BSO
till 41, 42.
(25:37):
They're pushing it.
They're like, oh, because mydoctors at like a big cancer
center said, well, once you dothat, you know, no hormones for
you.
And um, they're not hereanymore.
Okay.
I'm I'm you know, I'm nottrying to be shocking, but they
they they died of ovarian cancerbecause they kept on pushing it
off because their physicianstold them once they have it,
(25:58):
there is no HRT for them.
And you know what?
It's it's it's really a failureof the system when we have such
fear-based information forthese women.
Um, and so if you're listeningto this, that's a big thing.
And then the other one thing Iwant to say is if you have a
family history of breast cancerand have been told that your
genetics are negative becausemom had the test or the your
(26:18):
aunt had the test, or maybe youpersonally had genetic testing
prior to 2013-2014.
I'm a living proof I had breastcancer.
I was BRCA negative.
I demanded retesting in 2014because I learned, oh, they have
update panels.
They looked at a larger portionof the BRCA gene and we now do
(26:41):
panel testing because it's notjust BRCA, there are other
genes.
And so lo and behold, eventhough it is rare to have a
mutation in the largerearrangement of the BRCA gene,
that's where my BRCA2 mutationis.
And if I didn't demand and Iwasn't a squeaky wheel and I
wasn't knowledgeable, I wouldhave gone on thinking that I was
not a carrier and my familywould not have been tested.
(27:03):
And some of them are positiveand are taking action.
So just if you're listening tothis out here, I constantly hear
women and even breast cancersurvivors tell me, yeah, yeah,
my test was negative.
I'm like, what am I saying?
They're like, oh, 2011.
I was like, you're AshkenaziJewish, you've had breast
cancer, but you know, under, youknow, you're younger, you have
multiple families, and no one'sretested you, no one's told you
(27:26):
to have update testing.
And I'm telling you, this ishappening at major NCCN cancer
centers, famous world-classsurvivorship clinics.
Nobody is telling patients theyneed update testing.
So I always have to get thatlittle squeaky warning in.
Dr. Holly Thacker (27:42):
You know, one of my uh pet peeves, and I
wonder what your clinicalperspective is um if someone
knows that they're not gonna dochildbearing.
Now, some women might choose tohave the complete uh tubes
taken out while they still wantto keep the ovaries if they're
very young and and they don't,you know, want childbearing and
then go in and take the ovaries.
(28:03):
But what really irritates me isif there's not a reason to keep
the uterus because someone'sgonna do IVF afterwards, which
I've had brach-positive patientswithout tubes and ovaries, you
know, do assisted reproductivetechniques in their 50s and have
a baby.
I mean, that's a whole otherdiscussion about whether you
want to have a newborn in your50s.
But I I've seen it, andobviously you want to empower
(28:24):
women to pick their choices, butleaving that uterus when there
is some increased risk ofuterine cancer with BRAC-1, even
potentially BRAC-2, and thenestrogen alone reduces breast
cancer, and we can't useestrogen alone if you have that
uterus.
And it just seems like the GYNoncologists um want to just, oh,
(28:45):
we'll just take out the ovariesand tubes, and that's all you
need.
Dr. Corinne Menn (28:48):
Yeah, you know, I I I agree.
Actually, I wound up not takingout my uterus because this was
a long time ago, right?
And at the time they were, theywere really not encouraging
that.
Um, when I have patients umlike you're referring to, I do
encourage them to say, listen,you know, if you're you're not
gonna use your uterus, have anexcellent CYN oncology surgeon,
(29:09):
they're experts, they can taketake these uteruses out in their
sleep.
It's an easy procedure.
Um, you can preserve yourcervix even if you want to,
because some women are concernedabout the loss of the cervix in
terms of sexual function andorgasm.
Um, so because there is a someliterature that suggests a
slightly increased risk ofuterine cancer, and it does
simplify hormone therapy.
(29:30):
It doesn't mean that if youdon't have a uterus, that we
can't consider giving youprogesterone because many women
benefit from progesterone, butwe never have to worry about the
bleeding side effect, which canhappen with hormone therapy.
And to your point, the bestdata that we have, which is from
the WHI, which I don't want tovilify the women's health
initiative.
It's very important for womento understand the WHI was an
(29:52):
incredibly important study.
It was actually an incrediblesafety study.
We actually know how safehormone therapy is, just they
need a new PR.
Campaign.
But basically, the estrogenalone arm of the study,
conjugated equine estrogen,women had a significantly lower
risk of ever getting breastcancer or dying of it.
And it may have to do for anumber of reasons, but
(30:12):
particularly conjugated equineestrogen, given alone, seems to
have a protective effect on thebreast.
So, and then when we don't haveto worry about the progestin,
which that's what was used inthe women's health initiative.
So kind of getting a little bitof that in, right?
It was the progestin, which,you know, showed a very tiny
(30:33):
increase incidence of perhapsbeing diagnosed with breast
cancer, but not dying of breastcancer.
And that tiny incremental riskwas so low that it must be
looked at in proportion to thebenefits of bone health, quality
of life, and a whole lot ofother things.
Dr. Holly Thacker (30:50):
Oh, absolutely.
I I would certainly endorse allof that.
And I do think that post-WHI umoral hormone therapy, including
conjugated uh estrogens, havebeen vilified.
And in women at high risk forbreast cancer who don't have a
uterus, who don't have bloodclotting issues or high
triglycerides, I favor it, quitefrankly, because of the bulk of
(31:13):
the information.
And it also seems like sincethere's 10 different estrogens
in that formulation, in somewomen, it seems to give them an
extra kick.
Like they feel a differencecompared to a patch or plain
estradiol.
Dr. Corinne Menn (31:25):
100%.
I, you know what I really thinkit's so important to say this
because oral estrogen, whetherit's conjugated equine estrogen
or oral estradiol, can be agreat option.
Sometimes it's a moreaffordable option for women.
And particularly with theconjugative equine estrogen, you
know, it's not estradiol,right?
It's conjugative equineestrogen.
And we suspect there's like areal mix of things in it, and
(31:48):
probably some CERM-like, someselective estrogen receptor
module like properties, sotamoxidin-like properties in
conjugative quinestrogen or thebrand name premarin, um, that it
may be blocking receptors inthe breast tissue.
And perhaps that's why we saw alower risk.
So we shouldn't vilify um thatoption.
And um, and then it's lead, weshould mention duo V with the
(32:11):
brand name duo of V, which is acombination of conjugative
quinestrogen with not aprogestin, um, but um something
that's actually similar.
I tell patients it's like afancy cousin to tamoxifen.
Yeah, fancy cousin.
Yeah.
And I say, listen, tamoxifene,basodoxifene, right?
These are in the same family ofselective estrogen receptor
(32:32):
modulators.
And people are confused.
Why are you giving me estrogenand a blocker?
I'm like, well, think of itlike this.
We're giving you an estrogenand then the basodoxifene um
selectively and very powerful,powerfully um blocks and
actually somewhat degrades theestrogen receptor in the breast
tissue as well as in the uterinelining, uterus.
(32:53):
So, but it's very specific.
It's not doing that all overthe body.
It's it really likes the breastin the uterine lining, and we
have very good safety data onit.
And so when paired with uhconjugative equine estrogen when
someone has a uterus, it'sgreat.
There's no bleeding.
Women do wonderful on it.
But also we've got great datathat shows it doesn't increase
proliferation of breast cells,doesn't increase breast density,
(33:15):
and that at ASCO there was justa great paper that we can talk
about showing that women whowith it was a window of
opportunity studying newlydiagnosed DCIS, ER-positive
patients, yes, were given dubavyfor a short period of time
before they had their largerexcisional biopsy, and they
looked at some markers like aKI67, it just showed like the
cells did not proliferate, theDCIS basically didn't appear to
(33:38):
kind of grow, um, and they hadmenopausal symptoms treated,
right?
And so it's a reallyinteresting option.
So if you have a uterus, I dolove Duavy.
If you don't have a uterus andyou're high risk for breast
cancer, I agree with Dr.
Thacker.
Primarin can be lovely, um, butI'm also not afraid to give you
estradiol in a patch or sprayor gel or pill if that's what
(34:00):
works best for you.
Dr. Holly Thacker (34:01):
Yeah, no, it's great to have um all these
options.
Dr. Corinne Menn (34:04):
Yeah, lots of FD-approved, right, Dr.
Thacker.
People don't have to run outand get a compounded concoction.
Yes.
Dr. Holly Thacker (34:24):
That is excellent advice.
And these pellets with womencoming in with testosterone
levels higher than a man are arejust ridiculous.
Dr. Corinne Menn (34:30):
No, and we like testosterone.
We can talk about it, butpellets basically just think of
it, it's just you're putting apellet in, you can't control the
amount.
It can like really surge, andthen when it surges, you could
have lots of side effects, andit can even get converted into
extra estrogen.
So we really want to know whatyou're getting when we're giving
a hormone.
And pellets are not the mostelegant way, I would say, to
(34:51):
deliver the hormone.
Dr. Holly Thacker (34:53):
Absolutely, absolutely.
I I would say that um sinceduave is such a low dose, young
women, especially who don't havetheir ovaries, a lot of times
it's not enough estrogen.
I have added extra primer tothat, but um there's been some
recent uh uh data, uh comparisonshowing perhaps slightly
elevated um risk of uterinecancer.
(35:17):
So any woman, whether you're onhormones or not, if you have
abnormal bleeding and you'reover 40, we do need to rule out
uterine cancer.
And tamoxifen, which is anexcellent drug to treat breast
cancer and prevent breastcancer, also is associated with
an increased 1% chance ofuterine cancer.
Dr. Corinne Menn (35:33):
Yes.
Dr. Holly Thacker (35:34):
So where can people um find you, see you,
follow you?
It's been so great having youon.
We'll have to have you again totalk about that FDA panel.
Dr. Corinne Menn (35:43):
Absolutely.
Um, so you can follow me, Dr.
Men OBG Byan, on Instagram, um,also TikTok, but mainly
Instagram and also on Substack.
And so I write a lot onSubstack about these more um, I
get into more in-depth on someof these topics.
Um, I'm also if you need helpwith hormone therapy and you're
(36:04):
not getting it, um, you needaccess to vaginal hormones, um,
me and my colleagues, epatientsat myalloy.com.
And um if you're a medicalprofessional, I do teach a
course, a CME course, you canfind it on my website or online
on managing menopause afterbreast cancer.
Um, and I kind of go throughhow to make those more difficult
(36:25):
shared decision-makingdecisions.
Um, because I know we didn'tget into it, but I'll just kind
of just say like we have toremember that we can't compare
someone who had DCIS and abilateral mastectomy to someone
who is five years out from anearly stage triple negative
breast cancer to maybe anER-positive patient who maybe
has a high risk for recurrenceor maybe has a very low risk for
recurrence.
(36:45):
We have to look at each one ofthose people in it in their own
light.
So just please keep that inmind when you're like talking to
patients, if you're listeningto this out there.
So, and we can, you and I cantalk for hours, I'm sure.
Dr. Holly Thacker (36:59):
Well, thank you so much for joining us on
this episode of Speaking ofWomen's Health.
If you enjoyed this podcast,give us a five-star rating.
Uh, make sure that you followor subscribe so you don't miss
any of our podcasts, and and youcan forward it and share it uh
to friends and family.
So I look forward to seeing youagain in the Sunflower House.
(37:19):
We'll definitely have Dr.
Ben back.
Remember, be strong, behealthy, and be in charge.
Welcome to the Speaking of Women's Health
Podcast.
I'm your host, Dr.
Holly Packer, and I am back inthe Sunflower House for a new
and very special edition with afabulous woman and gynecologist
and breast cancer survivor.
Dr.
Men.
(00:31):
Welcome, Dr.
Corine Men, to our um podcasttalking about breast cancer
survivors, menopause.
It's October, breast cancerawareness.
This is really important everymonth of the year for so many
women.
And we're going to talk aboutum strategies for a young woman
(00:52):
who's a breast cancer survivor.
And um, if we have some time,we'll talk about the recent FDA
panel discussion on hormonetherapy, which was very exciting
to finally have.
And I had so many friends andand uh colleagues that were
there.
So welcome, Dr.
Men.
Do you want to tell us a littlebit about yourself?
Dr. Corinne Menn (01:14):
So, Dr.
Corinne Men, I'm an OBGYN um umand have practiced for over 23
years.
And in even though you onlylook 23.
Oh, well, um thank you.
I'm gonna be 53.
I have not afraid to share myage and and I've been through a
lot.
So hopefully I've got somelines to show it.
(01:35):
Um my battle wounds, so tospeak.
So, yeah, so for the last 15years or so, I've really focused
on um menopause management,perimenopause management, and
really speaking up and helpingthe most vulnerable women in
menopause.
Um, and that is the breastcancer survivor or the BRCA
(01:55):
previvors or other women who arehigh risk for breast cancer.
Um, and also other cancers,because that's, you know, like
we talk a lot about breastcancer, but there's a lot of
women out there with othercancers, which we know are
increasing in younger women.
And then they're kind of leftwith all this menopause stuff,
and you know, no one's reallytackling it.
Dr. Holly Thacker (02:14):
So excellent.
Well, thank you so much forjoining us and sharing uh your
expertise and your personalexperience.
Uh, and you're quite the hit onuh social media, which I think
is really important because somany women are getting their
information on social media, butyou made that comment about,
(02:35):
well, how can you explainsomething so important in just a
few few minutes?
Dr. Corinne Menn (02:39):
Yeah, it's not easy, but I think, you know,
part of the issue with menopauseafter breast cancer, say, is
just to kind of open the door sothat we can recognize that
there is collateral damage ofestrogen deprivation, um, the
loss of hormones, the earlyabrupt surgical or premature
menopause.
And so just kind of likeplanting the seeds that, hey,
(03:01):
this is okay to talk about, andthere are things for you to do.
So, you know, I think becausethere is a big um menopause
movement, which is great, allwomen are being empowered to
learn about their bodies anddiscuss the safety and options
of menopausal hormone therapyfor their symptoms, et cetera.
But often breast cancersurvivors feel left out and
(03:22):
often scared that wow, there'sall these benefits to hormone
therapy that maybe I can't have.
So I'm doomed for a life ofosteoporosis and cardiovascular
disease and dementia and badquality of life.
And I want them to know, evenif you can't use systemic
hormones, and we can talk aboutwhen you can consider that.
Um, there's so many things thatwe can do, including local
hormones, non-hormones, otherthings.
(03:45):
Um, so I want them to feelincluded because it's millions
of women.
Dr. Holly Thacker (03:49):
Well, I was so excited to start to talk to
you that I didn't really giveyour formal presentation and
information about you, ourguest.
So, Dr.
Corinne Men is aboard-certified OBGYN physician,
and she's also a menopausesociety certified practitioner.
She has dedicated her medicalpractice to menopause management
(04:11):
and the unique health careneeds of female cancer
survivors.
She also talked aboutpre-vivors, which is meaning you
don't have cancer yet, butyou're at increased risk,
potentially because of genetics,and just women in general at
high risk for breast cancer.
She's now practicingexclusively through telehealth.
So that means lots of peoplecan see her.
(04:33):
And she does women's healthconsultations and a lot of
patient education.
And she's also a medicaladvisor and a prescribing
physician on alloy, which is amenopause or telehealth
platform.
And she's a like she said, eventhough she looks 23, she is a
23-year-old survivor of breastcancer, and she is a proud
(04:56):
53-year-old uh woman.
And because of her breastcancer, she herself had
premature menopause, uh, BRCAcarrier.
And she uses her personalexperience to help navigate
women uh through their ownhealth challenges.
So thank you so much.
We've wanted you on ourspeaking of women's health
(05:16):
podcast for so long.
And I've had other podcastinterviews on breast cancer
awareness, on genetic testing,on the gene law, on um breast
cancer survivors.
But I just think that um youreally kind of typify all the
different perspectives.
And so we're so lucky to haveyou.
(05:37):
And start off by talking abouthow women can advocate for
themselves.
Dr. Corinne Menn (05:43):
Yeah, I think, you know, I learned that when I
was told I was too young forbreast cancer.
So when I was diagnosed at 28,I was a second-year OBGY in
residence.
So we should just like, youknow, just have it said, young
women can and do get breastcancer, as do older women.
And so if you feel somethingnot right, something different
in your body, in your breast,speak up, be a squeaky wheel.
(06:05):
I wrote myself off for almostfour months and thought it was
just a cyst or probably afibroadenoma, my GYN and my
fellow OBGYN, like friends,residents who I let them, you
know, let them check it out.
They're like, I'll just watchit for a few menstrual cycles,
right?
Um, because I had never heardof a young woman with breast
cancer, right?
But unfortunately, youngerwomen under the age of 40, it's
(06:26):
increasingly um a common thing,sadly, for a variety of reasons,
right?
So I think the first start, thefirst part to being your best
advocate is to don't be afraidto speak up.
And if one doctor says no orwrites you off, and whether it's
your breast cancer symptoms oryou know, something that you
feel, or whether you're a breastcancer patient and you're
(06:48):
having a hard time withtreatment or the side effects of
menopause, you have to be thesqueaky wheel.
Because in this medical system,the doctors mean well by and
large, but many of them arenever educated on some of these
nuances of breast cancer care,especially menopause.
And they're also working in areally tough system where they
have time constraints and lotsof pressure.
(07:10):
So you have to really, you kindof have to be noisy.
Dr. Holly Thacker (07:14):
Right.
And be very prepared.
Um schedule those appointments.
I always say it's easier tocancel them than schedule them
and come with a couple of thingsthat you want to address
because it is uh so complicated.
Yes.
Um now uh why why uh do youthink that it's important um for
(07:36):
this communication of thisdifficult information?
And what do women do who justget rushed off?
Because I see women all thetime.
Sometimes I'm their tenthphysician that they finally seen
and they're just they've workedso hard at it.
Dr. Corinne Menn (07:48):
Yeah.
So particularly when we'retalking about breast cancer
patients, basic breast cancersurvivors in menopause, um, we
know that the average woman inmenopause sees multiple
physicians, may it may take upto two years for her to finally
find someone who's offering herevidence-based options for her
menopause symptoms and we'llhave a discussion on hormone
therapy or other options.
(08:08):
And so when I say when yousprinkle in the pink very dust
of a breast cancer diagnosis, itmakes it even harder because
you know, OBGYN's primary caredoctors have not really been
well educated in menopause ingeneral.
And so if you think that theoncologist or the breast surgeon
has much, you know, you know,medical training in managing
(08:30):
menopause or sexual side effectsafter cancer, it's it's even
less, right?
And so, you know, the women arereally bounced around.
And so you have to be educated.
It's part of why I do go out onsocial media and speak a lot
because I think we're only goingto solve this problem and I'm
already seeing it actually outthere.
The information is tricklingdown, and women are rising up,
(08:50):
they're going into theironcologists, they're going into
their GYNs, being like, hey,like I I've heard I don't have
to suffer with horrificallypainful sex and recurrent
urinary tract infections, like,or or whatever, or I've heard
that there are things for my hotflashes, and I've heard
something called shared decisionmaking.
And so there, there's, I reallythink change will come from the
(09:10):
bottom up.
So, you know, you you have toreally be educated and you have
to know about your diagnosis,all the ins and outs of it.
You have to, I tell people tokeep a, you know, a really a
paper binder, ask for a copy ofall your reports and keep a list
of your symptoms.
Because in this digital world,sometimes things are all over
and you don't really know.
(09:31):
Um like put everythingtogether, track your symptoms,
and we can go through all of themenopause stuff today um so
that people can feel reallyprepared to kind of work with
their doctor.
And if your doctor doesn'tknow, it's okay.
But they should if if they'rein this business, they must have
a referral for you.
Dr. Holly Thacker (09:50):
Absolutely, absolutely.
And I think trusting yourso-called gut instinct.
Um, I have a friend who was ayoung woman, had a breast lump,
and everybody just blew her offbecause she was so young and she
didn't actually even getdiagnosed with her breast cancer
like until a year later whenshe was pregnant and had to go
through pregnancy, had to gettreatment for breast cancer,
(10:12):
interrupted her treatment umafter she delivered because she
wanted to breastfeed, and thenafter breastfeeding, underwent
treatment and is um really, youknow, quite quite an ordeal.
But it was the pregnancy thatfinally pushed her over to say,
This the I think there'ssomething wrong.
Dr. Corinne Menn (10:30):
Sadly, it's it's still a fairly common
story.
So when I was diagnosed in um2001, the Young Survival
Coalition was quite young then.
They were only about five yearsold, and I was lucky enough to
know someone who was um one ofthe founders.
So I got that support.
Um, and back then we were, youknow, advocating for you know
the medical profession torecognize that young women can
(10:52):
do get breast cancer and thatthey have unique and different
needs than the older woman.
But it's kind of shocking forme to see 24 years later, and
now on social media, I'm I seethese young women posting the
exact same story that you said,you know, they're put off, or
particularly if they'rebreastfeeding, you know, it's
written off that it's just aclogged milk duct or you know,
(11:15):
etc.
And so um, you know, that's themost basic, just believing
women when they say something'schanged in their breast, right?
Dr. Holly Thacker (11:24):
That is is very important.
And I've been gratified thatyounger women who are breast
cancer survivors, if if they'reable to and want to have a
family, they can becomepregnant.
And as someone who hasn'tpracticed in obstetrics or
focused my practice on that, Ialways say I delivered my 23rd
baby on my 23rd birthday onJanuary 23rd.
(11:45):
That was enough obstetrics fromme.
Um, and I focused on midlifewomen that are generally past
that stage.
It just seems so ageous to meto say it's fine to get pregnant
after we're done treating yourbreast cancer, which is very
high estrogen levels, but thenyou live long enough to be
naturally menopausal, and thenyou don't have any estrogen, you
(12:06):
have less estrogen than a man,and oh sorry, uh we're we're not
going to even consider it.
Dr. Corinne Menn (12:13):
And you are screening myself.
So thank you, fruit, for that.
And I think it's so let's talkabout that, you know.
So to kind of set the tone,when I was, you know, 28, one of
my biggest fears beingdiagnosed with breast cancer,
because I knew enough, I wasonly a second-year resident, but
I knew enough of what breastcancer treatment meant.
(12:35):
It meant that I was likelygoing to be on some type of
estrogen, I ear positive breastcancer, some type of estrogen
blocker.
Um, I was I had to havechemotherapy, which could damage
the ovaries, and it didtemporarily put me into
menopause.
And then some of mymedications, like my lupron and
my tamoxifen, also thentemporarily put me into
menopause.
But my doctors back then, um,there was observational data at
(12:58):
the time showing that it didn'tseem that a pregnancy after
breast cancer, it didn't seemthat it impacted prognosis or
increased the risk ofrecurrence.
But we didn't have such robustdata.
But even then, with the lack ofrobust data, all of the
professionals in the New YorkCity area where I got consults,
they all encouraged me topreserve fertility prior to
(13:19):
chemo.
I saved some embryos.
Yep.
And and they said, okay, youcan pause tamoxifen and
lutebrone for a little bit.
I got pregnant on my own.
I didn't, my ovaries worked.
They they recovered from chemoand I had a healthy pregnancy,
and then I went back on mytamoxifen.
So they encouraged that andsupported that shared decision,
(13:40):
saying, like, listen, Kurtin, wedon't know for sure, but we
think it's okay.
And so if you're gonna do this,let's do this now and get you
back on your tamoxifen.
And I did it, and all is well,thank goodness.
And my daughter's 21.
Um, and Dr.
Holly Peterson, our colleague,you know, recently wrote this
very point in a new practicepearl that was published by the
Menopause Society talking abouthow do we have this shared
(14:02):
decision making about menopausalhormone therapy after diagnosis
of breast cancer?
And we'll talk about who wouldbe ideal candidates in a minute.
But her point was this, it'svery paternalistic and um really
antithetical to this notionthat we would allow someone
shared decision making to stoptreatment for up to two years,
(14:22):
get pregnant, but yet yearslater, when she wants a very
small amount, right, of estrogenum just to relieve symptoms,
maybe help with her bone loss,etc.
It's not even a considered to,you can't even have a
conversation.
You're literally consideredcrazy.
I've had women tell me when Ibring it up, my doctor's like,
(14:43):
are you nuts?
But I really feel it's becausesociety values women's capacity
to have babies.
They don't value us when ourreproductive capacity ends.
It's absolutely you know, andwhat's so interesting is they
value us getting pregnant somuch that in the New England
Journal of Medicine waspublished, and I'm so glad Dr.
(15:05):
Ann Partridge did this study,it was called the positive
trial, which your listenersshould know about.
It was a really important trialwhich looked at, you know, um a
control group of women who did,you know, who did not pause
versus a woman, women who pausedtheir adjuvant endocrine
therapy to get pregnant.
And it showed in the short termit didn't appear any increased
(15:25):
risk of um recurrence, and it'ssupported by lots of other data.
And um, so it's just veryinteresting that we will allow
that, but we will not allow adiscussion about, you know, help
with menopause.
And we'll allow them to getpregnant, but we won't even give
women vaginal estrogen so thatit doesn't hurt when they have
(15:45):
sex when they're trying to getpregnant.
Like I just, it really is veryupsetting.
Dr. Holly Thacker (15:52):
Well, I was really happy to be part of the
campaign to really push breastoncologists.
Uh, why don't you examine yourfemale patients' genitalia?
Because the therapies,especially the aromatase
inhibitors, much more so thantamoxifen, which has some
estrogenic effects on the uterusand the vagina, really cause
devastating problems.
And um, it's just it's notacceptable.
(16:16):
And I know that some physicianswho've either personally had
that experience or their spousehas had the experience, once
they see it from that personalstandpoint, they kind of change
their perspective and take alook at the literature.
And I've been prescribinghormone therapy to breast cancer
survivors from the beginning ofmy practice with shared
(16:37):
decision making, informedconsent, going over all the
alternatives.
But I think that women feelvery afraid because when they
have a physician tell them, no,you can't do this, it doesn't
always matter what options Ishow them and the evidence I
show them, they have that in theback of their mind that it's
not a good thing.
And I think that's justterrorizing for so many women.
Dr. Corinne Menn (16:57):
It yes.
And so, and I think it'simportant for anybody listening
to make sure that youunderstand, like we are talking
about, you know, we can talk,we're gonna talk today about
systemic hormone therapy.
But if we reference um vaginalhormones, that's low-dose local
vaginal hormones, that we have atremendous amount of published
literature.
And it's actually written inthe guidelines, even from the
(17:19):
American Society of ClinicalOncology, um, ACOG, the MENAPUS
Society, et cetera, that locallow-dose vaginal estrogen is
safe for patients with breastcancer.
Yes, even while you're ontamoxifen, and yes, even when
you're on an aromataseinhibitor.
There may be a formulation thatwe might prefer for someone on
an aromatase inhibitor, but thedevastation of 10 years of
(17:42):
estrogen deprivation, it's a lotmore than vaginal dryness.
And I think that's part of theproblem, Dr.
Thacker, is that the medicaloncologist might just think of
it as like, well, it's justvaginal dryness, because that's
typically what their studiesbasically when they look at
adverse effects, vaginaldryness.
But no one asks patients aboutclitoral atrophy, severe vaginal
(18:03):
stenosis where they're unableto have a pap smear, you know,
um, you know, labia that is justshrunk and gone away.
So like any sort of touching ispainful and, you know, not
pleasurable, recurrent urinarytract infections, right?
Because it's the genitalurinary syndrome.
So we have to like move, Ithink when we name it what it is
(18:23):
and don't call it vaginaldryness, it kind of opens up the
eyes, you know, of our of ourmedical colleagues.
Dr. Holly Thacker (18:30):
And you know, just an aside, because I was uh
um helping some of my juniorstaff who just joined me who
finished our two-year fellowshipin specialized women's health,
it's it's not just breast cancersurvivors that get this.
Um, you know, we have a lot ofhigh-risk cardiac patients,
people with heart failure andorgan transplants and histories
of blood clots and dissectionsand whatever.
(18:52):
And, you know, we had acardiologist uh tr try to tell
our menopause specialists, shedoesn't need estrogen, you know,
for her hot fleshes.
Why don't you just give herprogesterone?
And it just amazes me thatpeople that don't have any
expertise or knowledge in thisare making recommendations to
patients that they can just dosomething or not do something.
Dr. Corinne Menn (19:14):
Well, it would imagine if I took a patient off
a cardiologist, the medicationthat the cardiologist put them
on, or you know, or I gave theorthopedic surgeon a different
plan that I told the patient adifferent plan of the approach
to their knee surgery orwhatever.
But I actually routinely seepatients who are being
prescribed even something verysafe like local lotus vaginal
estrogen go to another colleagueand they're told you should
(19:38):
stop that.
It's it's it's just really um,I think we just really need to,
I think the menopause space isgrowing a lot, but there's a lot
of echo chamber.
There's a lot of menopausespecialists and people who get
it talking to each other, whichis great.
So I'm really excited to try topush in and try to like reach
into, you know, speak to themedical oncologist, get in with
(19:59):
the cardiologist, like start tobuild bridges there so that we
can all understand, like if youcare for women, I don't care
what your specialty is.
You must know the basics ofmenopause.
And you can't give theminformation that is fear-based
if you don't really know it.
You could just simply say, I'mnot sure if that's safe.
Let me speak to your doctor,you know, or you know, you know,
(20:20):
let me let me consult.
But don't, don't, don't, don'tfill your patient with fear.
So if you're a woman and you'rehearing this and you're like,
oh, this resonates for me, whatdo I do?
Go back and call the doctor whoprescribed you your medicine
before you freak out and getscared, right?
Um, and let let let the medicalprofessionals we'll support
(20:40):
you.
Don't feel like you're beingput in the middle.
Dr. Holly Thacker (20:43):
Well, you have been listening to the
Speaking of Women's Healthpodcast.
I'm your host, Dr.
Holly Thacker, the executivedirector of Speaking of Women's
Health, and I run ourspecialized women's health
center at the Cleveland Clinicand our specialty fellowship.
And we are speaking to Dr.
Corinne Men, who is an OBGYNspecialist in uh menopause and
(21:04):
cancer survivors, and is along-term uh breast cancer
survivor herself.
And uh we've been talking aboutadvocating for yourself, that
there are options, that we don'tjust have to only focus on
young women and reproduction,even though that's wonderful.
It's a wonderful time of lifeand it's so important.
Uh, but the postmenopausalyears are important too.
(21:26):
And my son, who's a PhD inmolecular medicine and cancer
genetics, he he would talk aboutthe anthropologic data and how
grandmothers are very importantand their involvement in
childbearing of the youngergeneration.
So, you know, we need ourcolleagues to think about the
grandmother's role in, you know,furthering grandmothers
(21:48):
healthy.
Dr. Corinne Menn (21:48):
Yes, so that they're breaking their hips so
that they can help with thegrandchildren.
Dr. Holly Thacker (21:53):
Exactly, exactly.
And function.
I mean, just the workproductivity, you know, people
that have untreated vasomotorsymptoms.
And we have some great newoptions um of non-hormonal
options for hot flashes and bonehealth and non-estrogen vaginal
DHEA.
And we've covered a lot ofthese details on um uh several
of our prior podcasts that youcan find on speaking of women's
(22:15):
health.
But I want to get into um moreof your pearls, your experience,
um, takeaways, because we havenot just lay women listening or
you know, in a hundredcountries, but we also have a
lot of physicians and nursepractitioners who listen to our
podcast.
Dr. Corinne Menn (22:30):
Absolutely.
Dr. Holly Thacker (22:34):
So you want to talk about um we we have gone
over genetic testing.
Um do you want to talk aboutbreast cancer treatment in women
uh or dealing with survivorswho've had genetic mutations
versus those that don't?
Does that factor in?
Dr. Corinne Menn (22:48):
Let's start with the BROCA previous.
A couple things that I reallywant women to know.
Um, if you are a BRCA previvor,you've not had cancer yet, or
maybe you have anotherhereditary mutation where you
are going to get your ovariesout early, right?
So I had my ovaries removedearly as well to lower my risk
of ovarian cancer because Ifound out, you know, I do carry
(23:10):
the BRCA2 gene.
I found that out later and wecan talk about that.
But we want you to know, wedon't want you to fear removing
your ovaries out of the fear ofpremature abrupt surgical
menopause.
Particularly BRCA cares, weactually have literature on
this.
The NCCN guidelines, themenopause society guidelines,
(23:30):
ACOG, etc., make it quite clearthat all of the data says that
you can remove the woman'sovaries to lower her risk of
ovarian cancer when you're donewith your childbearing and if
you don't need fertilityanymore.
And we must, we really shouldgive back hormone replacement
therapy.
And I say HRT because if you'reunder the age of 40 or the
(23:51):
underage of 45, you really needa little bit higher doses.
Um, so these these Brocacarriers should have that
hormones um given back to themup to at least the age of
natural menopause, and then theycan make that decision.
Now, many of these women havealready had their prophylactic
mastectomies, some have not.
Um, and whether you've had thatprophylactic mastectomy or not
(24:13):
should not change the decisionand the option to go on, go on
hormone therapy if you've hadpremature surgical menopause
because of the risk reducingBSO.
And the literature shows thatyes, the risk-reducing DSO
lowers your ovarian cancer risk,and it actually does lower your
breast cancer risk.
But giving back menopausalhormone therapy in that
(24:34):
premature early menopause timedoes not appear to take away the
benefit of a lower breastcancer risk.
It's really interesting.
And I think it's reallyimportant for these pre-vivors
to know we want you to have yourcake and eat it too.
Lower your risk, but still havea good quality of life because
if we remove those ovariesearly, and I just presented this
(24:55):
weekend about this, that isfemale castration.
I know it sounds shocking topeople, but it's it's it's
you're being castratedprematurely, and you um have
then dramatic increases in heartdisease, dementia,
osteoporosis, sexualdysfunction, mood disorders,
etc., that hormone therapy canreally mitigate.
(25:15):
And so please know that yes,the guidelines support this.
Now, this is not the sameconversation for someone with
invasive breast cancer.
So I'm just making thingsclear.
This is for our Brock upprevivors.
And just as a personal story, Ihave seen women delay their BSO
till 41, 42.
(25:37):
They're pushing it.
They're like, oh, because mydoctors at like a big cancer
center said, well, once you dothat, you know, no hormones for
you.
And um, they're not hereanymore.
Okay.
I'm I'm you know, I'm nottrying to be shocking, but they
they they died of ovarian cancerbecause they kept on pushing it
off because their physicianstold them once they have it,
(25:58):
there is no HRT for them.
And you know what?
It's it's it's really a failureof the system when we have such
fear-based information forthese women.
Um, and so if you're listeningto this, that's a big thing.
And then the other one thing Iwant to say is if you have a
family history of breast cancerand have been told that your
genetics are negative becausemom had the test or the your
(26:18):
aunt had the test, or maybe youpersonally had genetic testing
prior to 2013-2014.
I'm a living proof I had breastcancer.
I was BRCA negative.
I demanded retesting in 2014because I learned, oh, they have
update panels.
They looked at a larger portionof the BRCA gene and we now do
(26:41):
panel testing because it's notjust BRCA, there are other
genes.
And so lo and behold, eventhough it is rare to have a
mutation in the largerearrangement of the BRCA gene,
that's where my BRCA2 mutationis.
And if I didn't demand and Iwasn't a squeaky wheel and I
wasn't knowledgeable, I wouldhave gone on thinking that I was
not a carrier and my familywould not have been tested.
(27:03):
And some of them are positiveand are taking action.
So just if you're listening tothis out here, I constantly hear
women and even breast cancersurvivors tell me, yeah, yeah,
my test was negative.
I'm like, what am I saying?
They're like, oh, 2011.
I was like, you're AshkenaziJewish, you've had breast
cancer, but you know, under, youknow, you're younger, you have
multiple families, and no one'sretested you, no one's told you
(27:26):
to have update testing.
And I'm telling you, this ishappening at major NCCN cancer
centers, famous world-classsurvivorship clinics.
Nobody is telling patients theyneed update testing.
So I always have to get thatlittle squeaky warning in.
Dr. Holly Thacker (27:42):
You know, one of my uh pet peeves, and I
wonder what your clinicalperspective is um if someone
knows that they're not gonna dochildbearing.
Now, some women might choose tohave the complete uh tubes
taken out while they still wantto keep the ovaries if they're
very young and and they don't,you know, want childbearing and
then go in and take the ovaries.
(28:03):
But what really irritates me isif there's not a reason to keep
the uterus because someone'sgonna do IVF afterwards, which
I've had brach-positive patientswithout tubes and ovaries, you
know, do assisted reproductivetechniques in their 50s and have
a baby.
I mean, that's a whole otherdiscussion about whether you
want to have a newborn in your50s.
But I I've seen it, andobviously you want to empower
(28:24):
women to pick their choices, butleaving that uterus when there
is some increased risk ofuterine cancer with BRAC-1, even
potentially BRAC-2, and thenestrogen alone reduces breast
cancer, and we can't useestrogen alone if you have that
uterus.
And it just seems like the GYNoncologists um want to just, oh,
(28:45):
we'll just take out the ovariesand tubes, and that's all you
need.
Dr. Corinne Menn (28:48):
Yeah, you know, I I I agree.
Actually, I wound up not takingout my uterus because this was
a long time ago, right?
And at the time they were, theywere really not encouraging
that.
Um, when I have patients umlike you're referring to, I do
encourage them to say, listen,you know, if you're you're not
gonna use your uterus, have anexcellent CYN oncology surgeon,
(29:09):
they're experts, they can taketake these uteruses out in their
sleep.
It's an easy procedure.
Um, you can preserve yourcervix even if you want to,
because some women are concernedabout the loss of the cervix in
terms of sexual function andorgasm.
Um, so because there is a someliterature that suggests a
slightly increased risk ofuterine cancer, and it does
simplify hormone therapy.
(29:30):
It doesn't mean that if youdon't have a uterus, that we
can't consider giving youprogesterone because many women
benefit from progesterone, butwe never have to worry about the
bleeding side effect, which canhappen with hormone therapy.
And to your point, the bestdata that we have, which is from
the WHI, which I don't want tovilify the women's health
initiative.
It's very important for womento understand the WHI was an
(29:52):
incredibly important study.
It was actually an incrediblesafety study.
We actually know how safehormone therapy is, just they
need a new PR.
Campaign.
But basically, the estrogenalone arm of the study,
conjugated equine estrogen,women had a significantly lower
risk of ever getting breastcancer or dying of it.
And it may have to do for anumber of reasons, but
(30:12):
particularly conjugated equineestrogen, given alone, seems to
have a protective effect on thebreast.
So, and then when we don't haveto worry about the progestin,
which that's what was used inthe women's health initiative.
So kind of getting a little bitof that in, right?
It was the progestin, which,you know, showed a very tiny
(30:33):
increase incidence of perhapsbeing diagnosed with breast
cancer, but not dying of breastcancer.
And that tiny incremental riskwas so low that it must be
looked at in proportion to thebenefits of bone health, quality
of life, and a whole lot ofother things.
Dr. Holly Thacker (30:50):
Oh, absolutely.
I I would certainly endorse allof that.
And I do think that post-WHI umoral hormone therapy, including
conjugated uh estrogens, havebeen vilified.
And in women at high risk forbreast cancer who don't have a
uterus, who don't have bloodclotting issues or high
triglycerides, I favor it, quitefrankly, because of the bulk of
(31:13):
the information.
And it also seems like sincethere's 10 different estrogens
in that formulation, in somewomen, it seems to give them an
extra kick.
Like they feel a differencecompared to a patch or plain
estradiol.
Dr. Corinne Menn (31:25):
100%.
I, you know what I really thinkit's so important to say this
because oral estrogen, whetherit's conjugated equine estrogen
or oral estradiol, can be agreat option.
Sometimes it's a moreaffordable option for women.
And particularly with theconjugative equine estrogen, you
know, it's not estradiol,right?
It's conjugative equineestrogen.
And we suspect there's like areal mix of things in it, and
(31:48):
probably some CERM-like, someselective estrogen receptor
module like properties, sotamoxidin-like properties in
conjugative quinestrogen or thebrand name premarin, um, that it
may be blocking receptors inthe breast tissue.
And perhaps that's why we saw alower risk.
So we shouldn't vilify um thatoption.
And um, and then it's lead, weshould mention duo V with the
(32:11):
brand name duo of V, which is acombination of conjugative
quinestrogen with not aprogestin, um, but um something
that's actually similar.
I tell patients it's like afancy cousin to tamoxifen.
Yeah, fancy cousin.
Yeah.
And I say, listen, tamoxifene,basodoxifene, right?
These are in the same family ofselective estrogen receptor
(32:32):
modulators.
And people are confused.
Why are you giving me estrogenand a blocker?
I'm like, well, think of itlike this.
We're giving you an estrogenand then the basodoxifene um
selectively and very powerful,powerfully um blocks and
actually somewhat degrades theestrogen receptor in the breast
tissue as well as in the uterinelining, uterus.
(32:53):
So, but it's very specific.
It's not doing that all overthe body.
It's it really likes the breastin the uterine lining, and we
have very good safety data onit.
And so when paired with uhconjugative equine estrogen when
someone has a uterus, it'sgreat.
There's no bleeding.
Women do wonderful on it.
But also we've got great datathat shows it doesn't increase
proliferation of breast cells,doesn't increase breast density,
(33:15):
and that at ASCO there was justa great paper that we can talk
about showing that women whowith it was a window of
opportunity studying newlydiagnosed DCIS, ER-positive
patients, yes, were given dubavyfor a short period of time
before they had their largerexcisional biopsy, and they
looked at some markers like aKI67, it just showed like the
cells did not proliferate, theDCIS basically didn't appear to
(33:38):
kind of grow, um, and they hadmenopausal symptoms treated,
right?
And so it's a reallyinteresting option.
So if you have a uterus, I dolove Duavy.
If you don't have a uterus andyou're high risk for breast
cancer, I agree with Dr.
Thacker.
Primarin can be lovely, um, butI'm also not afraid to give you
estradiol in a patch or sprayor gel or pill if that's what
(34:00):
works best for you.
Dr. Holly Thacker (34:01):
Yeah, no, it's great to have um all these
options.
Dr. Corinne Menn (34:04):
Yeah, lots of FD-approved, right, Dr.
Thacker.
People don't have to run outand get a compounded concoction.
Yes.
Dr. Holly Thacker (34:24):
That is excellent advice.
And these pellets with womencoming in with testosterone
levels higher than a man are arejust ridiculous.
Dr. Corinne Menn (34:30):
No, and we like testosterone.
We can talk about it, butpellets basically just think of
it, it's just you're putting apellet in, you can't control the
amount.
It can like really surge, andthen when it surges, you could
have lots of side effects, andit can even get converted into
extra estrogen.
So we really want to know whatyou're getting when we're giving
a hormone.
And pellets are not the mostelegant way, I would say, to
(34:51):
deliver the hormone.
Dr. Holly Thacker (34:53):
Absolutely, absolutely.
I I would say that um sinceduave is such a low dose, young
women, especially who don't havetheir ovaries, a lot of times
it's not enough estrogen.
I have added extra primer tothat, but um there's been some
recent uh uh data, uh comparisonshowing perhaps slightly
elevated um risk of uterinecancer.
(35:17):
So any woman, whether you're onhormones or not, if you have
abnormal bleeding and you'reover 40, we do need to rule out
uterine cancer.
And tamoxifen, which is anexcellent drug to treat breast
cancer and prevent breastcancer, also is associated with
an increased 1% chance ofuterine cancer.
Dr. Corinne Menn (35:33):
Yes.
Dr. Holly Thacker (35:34):
So where can people um find you, see you,
follow you?
It's been so great having youon.
We'll have to have you again totalk about that FDA panel.
Dr. Corinne Menn (35:43):
Absolutely.
Um, so you can follow me, Dr.
Men OBG Byan, on Instagram, um,also TikTok, but mainly
Instagram and also on Substack.
And so I write a lot onSubstack about these more um, I
get into more in-depth on someof these topics.
Um, I'm also if you need helpwith hormone therapy and you're
(36:04):
not getting it, um, you needaccess to vaginal hormones, um,
me and my colleagues, epatientsat myalloy.com.
And um if you're a medicalprofessional, I do teach a
course, a CME course, you canfind it on my website or online
on managing menopause afterbreast cancer.
Um, and I kind of go throughhow to make those more difficult
(36:25):
shared decision-makingdecisions.
Um, because I know we didn'tget into it, but I'll just kind
of just say like we have toremember that we can't compare
someone who had DCIS and abilateral mastectomy to someone
who is five years out from anearly stage triple negative
breast cancer to maybe anER-positive patient who maybe
has a high risk for recurrenceor maybe has a very low risk for
recurrence.
(36:45):
We have to look at each one ofthose people in it in their own
light.
So just please keep that inmind when you're like talking to
patients, if you're listeningto this out there.
So, and we can, you and I cantalk for hours, I'm sure.
Dr. Holly Thacker (36:59):
Well, thank you so much for joining us on
this episode of Speaking ofWomen's Health.
If you enjoyed this podcast,give us a five-star rating.
Uh, make sure that you followor subscribe so you don't miss
any of our podcasts, and and youcan forward it and share it uh
to friends and family.
So I look forward to seeing youagain in the Sunflower House.
(37:19):
We'll definitely have Dr.
Ben back.
Remember, be strong, behealthy, and be in charge.
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