Told You Can Never Take Estrogen? HRT After Breast Cancer

In this episode of unPAUSED, Dr. Mary Claire Haver sits down with breast oncologist Dr. Eleonora Teplinsky, author of Beyond the Pink, to take on the dogma that women with breast cancer — or a family history of it — can never take estrogen. They cover why estrogen does not cause breast cancer, who is and isn’t a candidate for hormones, the script for a dismissive appointment, vaginal estrogen and DHEA for survivors, and the NCCN’s shift on testosterone from “contraindicated” to “use with caution.” Guest links: Dr. Eleonora Teplinsky (Website) https://interludecancerstories.com/ Dr. Eleonora Teplinsky (Instagram) https://www.instagram.com/drteplinsky/ Dr. Eleonora Teplinsky (Substack) https://drteplinsky.substack.com/ Dr. Eleonora Teplinsky (TikTok) https://www.tiktok.com/@drteplinsky Dr. Eleonora Teplinsky (Facebook) https://www.facebook.com/drteplinsky/ Dr. Eleonora Teplinsky (LinkedIn) https://www.linkedin.com/in/eleonora-teplinsky-md-fasco-220aa02 Dr. Eleonora Teplinsky (YouTube) https://www.youtube.com/@drteplinsky Dr. Eleonora Teplinsky (X) https://x.com/drteplinsky INTERLUDE: Cancer Stories with Dr. Teplinsky (Apple Podcasts) https://podcasts.apple.com/us/podcast/interlude-cancer-stories-with-dr-teplinsky/id1451816690 Living Beyond Breast Cancer https://www.lbbc.org/ Books: “Beyond the Pink,” by Dr. Eleonora Teplinsky https://www.hachettebookgroup.com/titles/dr-eleonora-teplinsky-m-d/beyond-the-pink/9781538777145 “The New Perimenopause,” by Dr. Mary Claire Haver https://thepauselife.com/pages/the-new-perimenopause-book “The New Menopause,” by Dr. Mary Claire Haver https://www.amazon.com/dp/B0CKBZ4K1Z Never miss an episode—sign up for The ‘Pause Life Newsletter: https://thepauselife.com/pages/newsletter Medical Disclaimer: The information, including opinions and recommendations, on this platform is meant for informational and educational purposes only. Mary Claire Media, LLC, the unPAUSED podcast, and The ‘Pause Life are not medical organizations. Medical advice or medical diagnosis cannot be provided to you through the platform, any associated website, or customer portals. Using this platform does not establish a patient-physician relationship.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Speaker 00

  We know that estrogen does not cause breast cancer.

• 0:03Dr. Mary Claire Haver?

  Let's say that again.

• 0:04Speaker 00

  Estrogen does not cause breast cancer. In some cases, the risk of recurrence from drinking alcohol may outweigh the risk of recurrence from taking hormones, depending on the individual situation.

• 0:16Dr. Mary Claire Haver?

  Yeah, yeah, yeah.

• 0:17Speaker 00

  We can't apply 25-year-old data to a completely different, you know, we use different formulations that we think are safer. Women are thrust into estrogen deprivation without even understanding what's happening, what to expect, how we're going to treat it. And I have had women tell me it feels like not.

• 0:33Dr. Mary Claire Haver?

  Let's talk about testosterone.

• 0:35Speaker 00

  The National Comprehensive Cancer Network, their guidelines used to say, prior to 2026, that testosterone was contraindicated.

• 0:43Dr. Mary Claire Haver?

  Really?

• 0:43Speaker 00

  In patients with breast cancer. It just changed. All of these are theoretical. However, on a positive note.

• 0:59Dr. Mary Claire Haver?

  The views and opinions expressed on UnPaused are those of the talent and guests alone, and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. I want to start with something I was taught in my training, something I believed for years, and something I know now is wrong. If you have had breast cancer, or even if you only had a family history of it, you cannot take estrogen. That was the dogma. It is in our textbooks. And it has left millions of women to suffer through menopause with the door to treatment

• 1:42Dr. Mary Claire Haver?

  slammed shut before the conversation even started. Here's what the data actually says. The 2002 study that scared everyone off hormones translated to eight additional cases of breast cancer per 10,000 women per year. And that stat showed up in only one specific hormone combination, not with estrogen alone. And a 2025 study of women who carry the BRCA gene, who are amongst the highest-risk women, found that those who used hormone therapy had a lower rate of breast cancer than those who did not. Yet, right now, up to 60% of breast cancer survivors live with genital urinary symptoms that low-dose vaginal estrogen safely treats.

• 2:27Dr. Mary Claire Haver?

  And nearly 75% say no provider ever discussed this treatment with them. My guest, Dr. Eleonora Teplinsky, is a board-certified medical oncologist specializing in breast and gynecologic cancers, and the author of Beyond the Pink, the book I wish every one of my patients and every Pre-Viver had the day they were diagnosed or tested. She doesn't traffic in fear. She traffics in evidence and choice. Today, we're going to discuss the truth about estrogen after cancer and with a family history, what your options really are, and the line from her book I cannot stop thinking about. I'm Dr. Mary Claire Haver, a board-certified obstetrician-gynecologist and certified menopause

• 3:11Dr. Mary Claire Haver?

  practitioner, and adjunct professor at the University of Texas Medical Branch. Welcome to UnPaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life.

• 3:27Dr. Mary Claire Haver?

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• 4:08Dr. Mary Claire Haver?

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• 4:36Dr. Mary Claire Haver?

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• 5:27Dr. Mary Claire Haver?

  Dr. Eleonora Teplinsky, welcome to UnPaused.

• 5:30Speaker 00

  Thank you so much for having me.

• 5:32Dr. Mary Claire Haver?

  So I like to ask this question of all of our clinicians. How does menopause show up in your clinic?

• 5:38Speaker 00

  As a breast oncologist, menopause shows up in my clinic every single day. All of our patients are experiencing some, you know, form problems, concerns, questions about menopause, whether it is their cancer treatment that put them into an earlier premature menopause, or whether they're in natural menopause and now are on cancer treatment that is exacerbating those side effects. So we are talking, thinking about it every single day.

• 6:05Dr. Mary Claire Haver?

  And you are the author of Beyond the Pink. And tell me, what is this pink ribbon leaving out? You know, why did you title it Beyond the Pink?

• 6:15Speaker 00

  The pink ribbon leaves out so much. I think the, you know, symbol of the pink ribbon is really a brand now. You know, it has very clear brand recognition about breast cancer, so it accomplished that. But that really focuses on awareness and very little about what actually comes after. What comes after diagnosis, the treatment that we kind of think about more mainstream, like chemotherapy and surgery and radiation, and then everything after that we don't talk about. And so when I think you see the pink ribbon everywhere, it does not highlight the after. And honestly, there are so many more challenges with the after, and we're not talking about them, and we're not helping our patients.

• 6:53Dr. Mary Claire Haver?

  Here's a woman I want you to talk to, okay? She's listening right now, more than likely. She finished her breast cancer treatment two years ago. She's 51. She's not sleeping. She has hot flashes all night. Sex hurts. And her oncologist told her, because that's how they were trained, no estrogen ever, and the conversation shut down.

• 7:15Dr. Mary Claire Haver?

  What do you think she was really owed in that appointment? You know, where's the failure here? And what did she need to hear?

• 7:20Speaker 00

  I see this every single day. These are the patients that I'm taking care of day in and day out in clinic. The conversation, first of all, I think when we think about the menopause conversation, I know we're going to do a deep dive into hormones, and that is one part of the conversation. There, you know, the other really important part of the menopause conversation and how we're caring for our patients is really a comprehensive evaluation of their side effects. What are effective non-hormonal options that we can try? Where is the counseling on lifestyle medication, the modifications, and lifestyle choices and habits? And then that conversation about hormones, and we'll separate vaginal hormones, which we're very comfortable with, with systemic hormones, where they may be right for some

• 8:02Speaker 00

  women who've had breast cancer, they may not be right for others, but you have to have a conversation about what exactly is the risk? What symptoms are we trying to, you know, take care of, both in the short and long term? And how does your risk of recurrence, you know, would that, how would that be impacted by systemic hormones? So it can't be a hormones, no, and shut down the conversation. Really need to start diving deeper into those discussions.

• 8:29Dr. Mary Claire Haver?

  So give her a script, okay? What are the first three sentences? She sits down with her oncologist, maybe even she's past treatment, you know, with her primary care doctor, with her OB-GYN. What, what should she say?

• 8:41Speaker 00

  Number one, name the symptoms. I am suffering from vaginal dryness, trouble sleeping, horrible hot flashes, whatever it is, name them, and they are impacting my quality of life. And I would urge people not to kind of downplay them. I see this every day. They're not so bad. I feel bad complaining, right? Name, stop doing that. Name the symptoms, explain how they're truly affecting you without trying to downplay that. The number two, specifically state, I would like to have a conversation about the use of systemic hormone replacement therapy for me. I understand that there might be a risk of recurrence, increased risk of recurrence, but I'd really like to better understand what that looks like for my individual breast

• 9:26Speaker 00

  cancer, balancing the tumor characteristics, my side effects that I'm having, and what I've tried in the past. And so really. Pinpoint, you know, ask for that data, right? Follow that with, based on the available data that we have, what would be the increase in my risk of recurrence if I were to go on hormone therapy? Right, to really start to make sure that those conversations are happening? And I would follow that with if the person that you're, that she's speaking to is not comfortable or is unsure.

• 9:59Dr. Mary Claire Haver?

  Yeah.

• 9:59Speaker 00

  Right, we want to then have that referral to the person that's going to help her. Right, so it's not enough to say, oh, I'm, I don't, I'm not really, I don't know how this would affect you and shut down the conversation. We want to then have the next step of, but here are people who could help you.

• 10:15Dr. Mary Claire Haver?

  Mm-hmm.

• 10:15Speaker 00

  Right, and I want to see this documented in the chart.

• 10:18Dr. Mary Claire Haver?

  We, our clinic has become a little bit of a referral center for patients and usually well past their treatment and they're suffering horribly from symptoms. And so we've gotten really good at pulling data to show them, okay, risk of recurrence with this grade, this stage, you know, with, as far as we can tell, with this particular formulation of hormone therapy would be X, Y, Z. And then we, they're grown women. We let them make a decision for themselves. Are you willing to take this 0.3% increase, you know, whatever it is, to get this quality of life issue managed?

• 10:52Speaker 00

  Exactly.

• 10:52Dr. Mary Claire Haver?

  And the answer is usually yes. And they, we have them sign forms and...

• 10:57Speaker 00

  It's risk tolerance. You know, everyone has a different...

• 11:00Dr. Mary Claire Haver?

  Do you think that's been denied to patients?

• 11:01Speaker 00

  A hundred percent, a one hundred percent. You know, everyone has a different risk tolerance. And if you think about it, alcohol increases breast cancer risk. We don't police how much alcohol people are going home and drinking. Most women aren't even, no one is, no one's even talking to them about that as a risk. And so in some cases, the risk of recurrence from drinking alcohol may outweigh the risk of recurrence from taking hormones, depending on the individual situation.

• 11:30Dr. Mary Claire Haver?

  Yeah, yeah, yeah.

• 11:31Speaker 00

  And so, yes, our patients, our women are educated, they're smart.

• 11:35Dr. Mary Claire Haver?

  Yeah.

• 11:36Speaker 00

  I, it's all about what level of risk you're willing to tolerate. I do have patients who say, I will do anything not to have a recurrence and I will do anything not to have another diagnosis.

• 11:45Dr. Mary Claire Haver?

  That's fair.

• 11:46Speaker 00

  And that's fair. And then other people will say, well, of course I don't want to have my cancer come back, but I am suffering and this is not a quality of life that I am comfortable with. And we should not be denying them those conversations, those discussions, and then helping them make a decision that they feel comfortable with.

• 12:02Dr. Mary Claire Haver?

  Not every woman is a candidate, correct?

• 12:04Speaker 00

  Yes.

• 12:05Dr. Mary Claire Haver?

  Uh, so who, you know, in your practice should genuinely not be on systemic hormone therapy, at least during what time period?

• 12:12Speaker 00

  So when someone is newly diagnosed, especially with a hormone receptor positive breast cancer, estrogen, you know, can fuel the growth of those cancer cells. And so we do, in that new, you know, new diagnosis, kind of a few, you know, within a few years after diagnosis, that may not be the right time. Again, more for a hormone receptor positive breast cancer. For hormone receptor negative, it gets a little bit more nuanced and we can talk about some of that. A lot of it really depends on where we are from diagnosis, what treatment someone is on, what symptoms are they having, what is their risk of recurrence? And then for hormone receptor positive, it, you know, there's, if someone, let's say, is a stage three breast cancer diagnosed two years ago, and I, I, I may want to hold

• 12:57Speaker 00

  off, I may want to see, make sure we don't have a recurrence and can we manage those symptoms non-hormonally, you know, with non-hormonal medications? On the other hand, if you had someone who had a stage one breast cancer, that's, you know, let's say diagnosed at 35 and is now 45 and really struggling, right? That could be something that we are more comfortable with. Metastatic breast cancer, stage four, again, we have a little bit less comfort, but it really depends on the individual situation. These are cancers that can come back five, 10, 15, 20 years down the road. And so I don't think we should be saying, well, for 20 years, that's it, you can't have anything. But we really need to weigh those individual risks. And that really goes into the stage, the treatment they receive, the characteristics.

• 13:41Speaker 00

  And so I, I don't have like a blanket yes or no. I think it's really that discussion, because there's so much that goes into it, but it comes down to you have to be, you have to have that conversation.

• 13:53Dr. Mary Claire Haver?

  Right. And they're not getting it.

• 13:55Speaker 00

  They're not getting it.

• 13:56Dr. Mary Claire Haver?

  By and large. Um, walk me through, so we have a healthy breast cell and a 25-year-old woman, right? And it has estrogen and progesterone receptors on it normally, right? When we go through the malignant transformation, what happens? Like, why are some, some breast cancers estrogen receptor positive, some are negative? I'm asking this because I want us to understand, so many women think estrogen caused my breast cancer, progesterone caused my breast cancer. And I think there's a ton of misinformation and misunderstanding around that conversation.

• 14:29Speaker 00

  Exactly. So we know that estrogen does not cause breast cancer.

• 14:34Dr. Mary Claire Haver?

  Okay, let's say that again.

• 14:35Speaker 00

  That estrogen does not cause breast cancer. However, if you do have a cell that has undergone malignant transformation, about 70% of breast cancer cells will express hormone receptors.

• 14:48Dr. Mary Claire Haver?

  Will retain their hormone receptors.

• 14:50Speaker 00

  Exactly. And remember, these are cells that are now growing out of control. They are proliferating very rapidly and estrogen will now fuel their growth. These are not normal cells anymore. They have completely lost that. And so now they are following these very aberrant, abnormal growth pathways. And so estrogen will fuel their growth, but that's very different than estrogen causing them to form, which did not happen. Where I think there's a lot of misconception, you know, there's, uh, breast cancer is on the rise in younger women and there's a lot of thought about why that's happening and we don't know all the answers. But some factors that could be contributing are that girls are going through, getting, you know, going through menarche and getting their periods at an earlier age.

• 15:35Speaker 00

  Um, people are having children later in life or not having them at all. And so that's kind of been construed. We'll say, wait, you have more estrogen if you get your periods at an earlier age, but, and that's not the case. It's really what is happening in those cells. And as they're dividing, every time a cell divides, there's a chance for mistakes to be made and DNA errors to be made. And that's where you can have those malignant transformations, but it's not the estrogen that's doing that.

• 16:02Dr. Mary Claire Haver?

  If you get breast cancer, somehow people think it will define the rest of your life. And in many ways it will. No one wants to get cancer, right? I'm doing multiple things in my life to avoid cancer. But somehow the breast cancer diagnosis, more than lung, more than brain, more than colon, carries this emotional, I don't know, do you see this in your practice?

• 16:22Speaker 00

  Yeah, I, there's a lot of fear. I mean, I talk to patients, I see patients all the time who've, you know, never had, who don't even have a genetic mutation, you know, never been diagnosed, to talk about hormones and from that breast cancer perspective. And they, there's, there is a lot of fear. And I think it's just so ingrained in us, right? That one in eight women will get breast cancer and, and you see it everywhere. And again, here's the pink ribbon, right? Making its way everywhere. And so there, there is a lot of fear, but I think we really have to think through of, okay, well, for somebody who is not at high risk, you know, we'll, we'll talk about those in a second, we have to think about benefit of hormones and the impact on short and long term health. And yes, of course, we don't want a breast cancer diagnosis, but we, we have to understand

• 17:07Speaker 00

  that women with, who were on hormones and who weren't on hormones are still being diagnosed with breast cancer. So it's not an absolute. Yes, you could be one of those additional eight women, but you also could be one of the thousands who don't get diagnosed.

• 17:25Dr. Mary Claire Haver?

  Don't get it. Welcome back to another Midi Pause. I'm Dr. Mary Claire Haver, the host of UnPaused. Did you know that one of the most powerful tools for navigating perimenopause and menopause is exercise and movement? When hormones start shifting, many women can notice changes that feel frustrating. Maybe your energy levels aren't what they used to be. Maybe you're gaining weight despite not changing your habits. Maybe you're experiencing joint stiffness, trouble sleeping, or feeling more stressed than usual. While there's no magic solution to menopause, exercise remains one of the most powerful prescriptions for healthy aging.

• 18:09Dr. Mary Claire Haver?

  But the right type and intensity matter. Building strong bones and muscle requires progressive overload, the principle of gradually increasing resistance or intensity to stimulate adaptation. Lifting the same three-pound weights for years will not maintain our bone density. Our bodies need challenge to change. Traditional light weights and high rep workouts are excellent for endurance, but not sufficient to prevent frailty. To maintain balance, bone strength, and independence, women must train for power, not just stamina. Strength training in particular becomes incredibly important.

• 18:54Dr. Mary Claire Haver?

  As estrogen levels decline, women naturally begin to lose muscle mass and bone density. Resistance training can help improve both while supporting metabolism, balance, and long-term mobility. Cardiovascular exercise matters too. Whether it's walking, cycling, swimming, dancing, or jogging, regular movement supports heart health, which becomes even more important after menopause when cardiovascular risk begins to increase. And don't underestimate the value of flexibility and recovery. Activities like yoga, stretching, and mobility work can help reduce stiffness, improve balance, and support overall well-being.

• 19:39Dr. Mary Claire Haver?

  But here's something many women need to hear. More is not always better. The workout routine that worked in your twenties or thirties may not be what your body needs today. During perimenopause and menopause, recovery, sleep, stress management, and proper nutrition become just as important as the workouts themselves. That's why personalized guidance can make such a difference. Midi Help helps women understand how hormonal changes impact everything, from energy levels and muscle mass to recovery and overall health. Midi's clinicians take a whole-body approach to menopause care, helping women create strategies

• 20:23Dr. Mary Claire Haver?

  that support their goals and symptoms, not just offering generic advice.

• 20:29Dr. Mary Claire Haver?

  What's especially valuable is that Midi helps women connect the dots. If you're struggling to maintain muscle, feeling exhausted after workouts, or dealing with joint pain, or wondering why your body suddenly responds differently to exercise, their providers can help identify what's actually driving those changes. They can evaluate hormone-related symptoms, discuss treatment options, review lab work when appropriate, and create a plan tailored to your specific needs and goals. So if you're in perimenopause or menopause, remember, movement is one of the best investments you can make in your future self, and it's never too late to start.

• 21:10Dr. Mary Claire Haver?

  Go to joinmidi.com, join M-I-D-I.com, and connect with one of their clinicians today.

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• 22:57Dr. Mary Claire Haver?

  So if, and I always, for the survivors who come to us, and we have the long conversation and we decide, or she decides, "Okay, I would like to do this for my quality of life, for my bones, you know, for my sleep, for whatever," I always warn her, "If you recur, the uneducated and uninformed will blame you for this, that you did this to yourself because you were selfish and you wanted a better quality of life."

• 23:24Speaker 00

  Yeah, 100%. I mean, yes, people are afraid to say, and here's the thing, and I tell this to my patients all the time, you, there could be a recurrence, but there also could be a recurrence not on hormones. So you could recur whether you take them or whether you don't. But we have to get, we have to stop, we see this so, it's in women's health and medicine all the time. We have to stop the blame and the shame.

• 23:48Dr. Mary Claire Haver?

  So back to the Women's Health Initiative. I want our listeners to understand that study was with a very specific type of hormone therapy, which was the most popular form back in the 90s when we were starting this study. And it's not something, I've never, I haven't prescribed it in years, I mean, since I was a resident. And so the conjugated equine estrogen, so it was an oral estrogen which had multiple forms of estrogen in it, and then midroxiprogesterone acetate, which is Provera. And it's probably not okay to assume that all of the formulations work the same.

• 24:29Speaker 00

  Exactly. And synthetic, we, you know, we now know that synthetic progestin is going to carry, we think, a higher breast cancer risk than a non-synthetic. And it's important to note that the Women's Health Initiative study, and we're gonna, you know, was for patients who had not been diagnosed with breast cancer. And so I know we're gonna talk about the breast cancer studies.

• 24:49Dr. Mary Claire Haver?

  Yeah.

• 24:49Speaker 00

  But understanding that these are not the formulations that we use now. And so we can't apply 25-year-old data to a completely different, you know, we use different formulations, we use forms of progesterone that we think are safer. And, you know, observational studies with the, you know, micronized progesterone really don't show that same risk that we see with the synthetic forms.

• 25:13Dr. Mary Claire Haver?

  And then the 20-year follow-up that was published in JAMA in 2020 found that the breast cancer incidence in the estrogen-only arm was lower.

• 25:22Speaker 00

  Yeah, but that didn't get any attention.

• 25:24Dr. Mary Claire Haver?

  No, so it's like headlines, the world stopped, everyone threw their, you know, all hormone therapy away, and the black box warning went on that's, you know, I was prescribing vaginal estrogen, we all were, and then the patients would get it, open up that packaging, and it basically says, "You're gonna have a stroke, you're gonna die, you're gonna, you're going to have a heart attack, you're going to have a stroke, you're going to have all these horrible things." And they'd be like...

• 25:48Speaker 00

  I mean, I still see this today.

• 25:50Dr. Mary Claire Haver?

  Today. Yeah, the new packaging just came out in February. So they, the black box came off in November, but it takes a while for the packaging.

• 26:00Speaker 00

  And people are still being told.

• 26:02Dr. Mary Claire Haver?

  Still.

• 26:03Speaker 00

  Still being told when they pick it up, "But just had this happen last week, are you sure?

• 26:08Speaker 00

  This is not, this is not safe for you."

• 26:10Dr. Mary Claire Haver?

  From the pharmacist. Wow. So let's talk about the black box warning. So the FDA and HHS announced the removal in November, the labels came out in February, but we're still struggling with the patients, too. But I do think this is power of social media. You know, every time I post about reducing the risk of recurrent UTIs, which will therefore probably reduce the risk, well, we know it'll reduce the risk of sepsis death. And the orthopedic surgeons who fix hips say that 60-plus percent of women who come in at the time of hip fracture have a concurrent UTI, and that they, they feel like there was some delirium involved from the infection that led to the fall.

• 26:56Dr. Mary Claire Haver?

  You know, getting out of bed in the dark, going to pee, you know, your irritated bladder, and then boom, fall.

• 27:01Speaker 00

  This is a medical issue. This isn't even about, you know, women's pleasure, which even gets less attention. But this is a medical issue. And I was just speaking at a conference, and a woman came up to me, because I'd been talking about sexual health and vaginal estrogen, and she says, "You know, my mom is 85, and she's been really confused recently because of a urinary tract infection. Do you, she's like, a light bulb just went off that she should be on vaginal estrogen." I said, "Call her doctor today and get her started on that."

• 27:27Dr. Mary Claire Haver?

  So there's a growing group of clinicians, myself included, who feel like all women above a certain age, or, you know, in a certain menopausal stage, should be on vaginal estrogen prophylactically. Do you feel that way?

• 27:40Speaker 00

  I agree. I mean, I think that we are so hesitant to prescribe it for something that is life-saving, life-changing for so many women. And I think that if we can remove some of the barriers, you know, on it, I think it would make it more accessible, more acceptable. You know, the, in the breast cancer literature, we have so many studies showing that it does not increase the risk of death, and our guidelines, multiple guidelines support it, you know, with shared decision-making, because guidelines, and people point to those, but guidelines have to be, you know, they're, they're not gonna be absolute, right?

• 28:17Dr. Mary Claire Haver?

  We're still human.

• 28:18Speaker 00

  Yeah, they have to give a buffer, you have to allow for the conversation. And I think it is important that, you know, we're counseling women, especially in how to effectively use vaginal estrogen. I think that's really important, because I do see some patients on it, but they're not, maybe they're using it once a month, or they're not, you know, they have it, but they're not using it at all, or they're using a really tiny amount. So I do think the counseling and how to effectively use it is valuable.

• 28:40Dr. Mary Claire Haver?

  Is important. In your book, you talk about two separate trials, the HABITS trial and the Stockholm trial. And let's go through those and what you think is important about those two.

• 28:51Speaker 00

  So we've had, you know, a number of different studies really looking at what happens to using hormones after a breast cancer diagnosis. So WHI was for patients who never had breast cancer. So HABITS is the one that's most kind of commonly cited and quoted, it's the most popular one. And it was a study of several hundred women that, you know, had a stage, up to a stage two, and included breast cancer. And they followed them for a few years, and, you know, they gave them hormones, and half the group received, and half the group didn't receive hormones.

• 29:20Dr. Mary Claire Haver?

  And this is systemic hormones.

• 29:22Speaker 00

  Yes, systemic hormones, so not, not vaginal hormones. And the study was terminated prematurely after about two years, when they found that there was a higher risk of recurrence in the group that used systemic hormones. And so that study, again, published now over 20 years ago, really has been kind of the pivotal one that people point to and say, "Wait, we can't do it." Now, there's a lot of caveats to this. Again, it's 20 years old, higher, you know, different forms of estrogen. Again, you know, we're not using the synthetic progestin that we used back then. We also don't know anything about, really about how these women were treated. This was before the day that we were even doing things like checking HER2 on breast cancers, right? So it does not reflect modern-day breast cancer treatment.

• 30:08Dr. Mary Claire Haver?

  For our listeners is one of the oncogenes.

• 30:10Speaker 00

  It's one of the, yes, it's one of the markers that we check and we really tailor our treatment. If you have a HER2 positive breast cancer. And so when you look at, you know, higher risk of recurrence, we don't know, these were not women that were treated the way we treat women now. And the other thing is that they did not have a mammogram prior to enrolling onto the study. They weren't, they weren't required to like rule out active disease, you know, with, before enrolling onto the study. So certainly possible that there may have been a recurrence brewing already. And so that's where, you know, it's really hard to use the data. It's the best, it's the data that we have, but it's hard to use that data now in 2026 because things are so different.

• 30:53Speaker 00

  Now they, you know, they did a lot, a follow up on that study and some of those, you know, kind of risks again persisted. But again, you have to think through, wait a second, we're not using the same hormones. We have completely different and better treatments. Risk of recurrence for breast cancer in general has improved significantly in the last 20 years. With so many drugs that we didn't have back then. So I find it hard to apply, you know, a lot of that, the data. Now Stockholm was a, you know, similar study, but used kind of a lower dose of progesterone. And, and so initially Stockholm did not show the same increase in the risk of recurrence. And, and so you have Stockholm, you have habits.

• 31:38Speaker 00

  And then you have a number of observational studies that have come out that have shown maybe there isn't that same increase in risk. You can see all the data is very nuanced. So how do you now think about it for the woman that's sitting in front of you and saying, well, what do I do? Right? And I go through it. I go through what we know, what we don't know. And then I go through her risk of recurrence. Everyone wants to know, well, what is my risk of recurrence? And I think of it as low, medium or high.

• 32:04Dr. Mary Claire Haver?

  Okay.

• 32:05Speaker 00

  Rather than, you know, you can, I can give you a number of 13%, right? But what is that? How do we contextualize that? Right? I say you're in the low risk, medium risk or high risk. And if you're at high risk of recurrence, right? Maybe hormones are not going to be our first.

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• 33:23Dr. Mary Claire Haver?

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• 35:16Dr. Mary Claire Haver?

  So give me an example of who would be high risk for recurrence.

• 35:19Speaker 00

  So good example is, let's say I have a 37 year old woman who was diagnosed two years ago.

• 35:26Dr. Mary Claire Haver?

  So young?

• 35:26Speaker 00

  Young with a lymph node positive, larger sized tumor that has a high grade, meaning these cells are growing very rapidly. And so we worry about giving them more fuel, right? That's somebody who currently is going to be at a high risk of recurrence.

• 35:41Dr. Mary Claire Haver?

  Is this just based on stage or?

• 35:43Speaker 00

  No, it's based on stage. It's based on really a lot of tumor characteristics that some make it into the stage, some don't.

• 35:50Dr. Mary Claire Haver?

  Cause the survivors are taking notes right now.

• 35:52Speaker 00

  So it's not as simple as saying lymph node positive. It's how many lymph nodes were involved? Do the cells in the lymph node, how do they look? Do they have what's called extranodal extension where the cells look like they're maybe breaking through? Right? All of these factors. And, and so it's also age, grade, you know, we know. And, and what's the treatment recommended? And what's the treatment that's been done? And what was the response to that treatment? And when were you diagnosed? And so you may be at high risk of recurrence right now. You might not always be at high risk of recurrence. Some time could go by and you haven't recurred. And we might think, okay, that risk is going to be lower now. On the other hand, a low risk of recurrence could be my 55 year old woman

• 36:31Speaker 00

  who had, you know, five years ago, an eight millimeter lymph node negative cancer, did not need chemotherapy. That may be someone who is at a lower risk. It doesn't mean you can't recur, but it helps us to think about that risk tolerance and then helps us really think through, how are we approaching hormones? And how are we approaching the conversation? And is it no, or is it not right now?

• 36:58Dr. Mary Claire Haver?

  You authored a study called the Wish Breast Survey Trial, well, Survey. And it was of survivors. It was almost 2,000 survivors.

• 37:11Dr. Mary Claire Haver?

  And you found that 73% said a provider never discussed sexual health with them. And 78% reported vaginal dryness. When you see that number, you know, why do you think we're sidelining? You know, you went through the oncology training, you specifically just treat gynecologic and breast cancers. What's happening?

• 37:33Speaker 00

  So this was a study where I did with current Dr. Kernman and Dr. Leila Agarwal. We surveyed women on, both on social media and through.

• 37:39Dr. Mary Claire Haver?

  I shared that, so.

• 37:41Speaker 00

  Thank you. Through, you know, our patient groups and, you know, over a thousand women responded and they responded immediately. They wanted to share their experiences. And I will say, we were not surprised when we saw the numbers, but it was really important to have that named.

• 37:57Dr. Mary Claire Haver?

  Right.

• 37:58Speaker 00

  Right? To have that published, to share that.

• 38:00Dr. Mary Claire Haver?

  We don't have data, it doesn't exist in science, so.

• 38:04Speaker 00

  Exactly. And so it was really important to have this published in our oncology journals, right? To have our clinicians say, wait a second. And there are a number of reasons for why we're not discussing it. So patients are hesitant to bring it up. They're nervous about bringing it up. They don't know if they should. They think they might be alone. They think they're the only ones maybe experiencing something. And sometimes they're there in their appointment with a spouse, a partner, a family member, and they're not comfortable. It should not be on the patient to bring up sexual health. It should be on their healthcare team to acknowledge that this is a side effect that many women experience. Acknowledge, you know, talk about ways to, what symptoms we might have, and then talk about treatment. And yet, you know, providers are not bringing it up.

• 38:50Speaker 00

  And years ago, I worked with this lovely older male oncologist and he goes to me, you talk about this an awful lot. It's not really happening. And I said, no, no, no. Patients are just not talking to you about it because they're shy and they're not sure. And, you know, and so just because patients aren't bringing it up does not mean it's not an issue. And so I really think, and I'm hoping we can change this by having these conversations in the oncology literature, that we're really hoping that our clinicians are bringing it up and saying, many women experience sexual health changes after a cancer diagnosis and treatment. Here are symptoms to watch for, and it's more than dryness.

• 39:35Speaker 00

  It's the recurrent UTIs, it's pain, it's burning, it's irritation, it's all of these.

• 39:39Dr. Mary Claire Haver?

  What about libido?

• 39:40Speaker 00

  And we'll talk, we'll get there in a sec. And here are ways that we can address it, including vaginal hormones. Libido, it's even lower on the list of things that we talk about. And so many women experience changes in libido. And I will say, we're talking about women, men also get breast cancer. And this is something that happens to men as well. But libido is affected by so many factors. One, if it's painful to have sex.

• 40:06Dr. Mary Claire Haver?

  Right.

• 40:07Speaker 00

  Who wants to have sex? But then the body image changes. The, the change in everything, right? The symptoms, you're not sleeping, you're having hot flashes. There's so many factors. And then relationships change and how people, how you feel about your body, how your partner, partners say to me all the time, I'm afraid to hurt her.

• 40:26Dr. Mary Claire Haver?

  High divorce rate, what is that? Let's talk about it.

• 40:30Speaker 00

  Yeah, relationships change after a diagnosis. I have seen every, I've seen some relationships really grow stronger. I've seen the partner show up to appointments and take notes and be involved and be part of the conversation. And then I see the women that are initially come with someone and then start to come alone. And I had a woman who sat in front of me and said, he just doesn't understand me. You know, I, I, I'm suffering, I'm talking about my brain fog, I'm talking about how things don't feel good in my body. I'm not myself and I'm getting blamed for it. I'm getting blamed for not recovering faster. And it's really hard and I think we have to talk about it. I think we have to name it and explain that this is common.

• 41:15Speaker 00

  And so I, from day one, I'll say, this is a strain on, on relationships, right? Roles change, responsibilities change, everything kind of shifts.

• 41:26Dr. Mary Claire Haver?

  Wow.

• 41:28Dr. Mary Claire Haver?

  So genital urinary syndrome of, I hate to call it of menopause because we see it with nursing. We see it with long-term birth control. You know, anytime we have low estrogen in our body, the genital urinary system is going to take a hit. So, but it's up to 70% in survivors versus roughly half of women in natural menopause. I think those numbers are skewed.

• 41:49Speaker 00

  Oh, yeah.

• 41:49Dr. Mary Claire Haver?

  I think 100% of women in natural menopause at some point untreated have GSM. But, um, but let's talk about aromatase inhibitors here. So I'm a non-oncologist, I know just barely scratched the surface. So when we're trying to reduce the effect of estrogen on breast cancer, okay? We have two basic options. We can block the receptors with something like Tamoxifen, okay? So that's one treatment option, but we can also stop the production of estrogen in the body, which is a more dramatic effect with an aromatase inhibitor, which basically stops the conversion of the prehormone to the estradiol. So she has no estrogen in her body whatsoever.

• 42:34Dr. Mary Claire Haver?

  And Tamoxifen kind of preferentially binds to different alpha and beta receptors. So she, she does a little bit better as far as some of the symptoms of menopause on Tamoxifen versus aromatase inhibitor. But, um, what's happening in the tissue on the aromatase inhibitor?

• 42:49Speaker 00

  So I describe being on an aromatase inhibitor as menopause on steroids.

• 42:53Dr. Mary Claire Haver?

  Okay.

• 42:53Speaker 00

  It's really profound estrogen deprivation, again, more so than what we see in natural menopause. So in that vulvar vaginal tissue, everything is dry, it's thin, it's fragile, it's uncomfortable. Again, more so than what you see in natural menopause. So we see discomfort very quickly, very early on. We see UTIs or we see people with, you know, that feeling like they have a UTI, but there's no actual, you know, bacteria growing on the culture. And then that again impacts libido, it impacts comfort or discomfort with sex. And it has really widespread, you know, effects. And for some people, I mean, I have had women tell me it feels like knives.

• 43:33Speaker 00

  You know, every time I go to the bathroom, every time I try to have sex, it is painful, it is uncomfortable and it's, it's awful.

• 43:40Dr. Mary Claire Haver?

  And it's treatable.

• 43:41Speaker 00

  It's treatable and it's treatable with low dose vaginal hormones, which are local, which have very little, if any systemic absorption, and they're life-changing.

• 43:52Dr. Mary Claire Haver?

  So what would you tell the patient who's been denied twice? You know, my doctor said, nope, nope, nope, nope, nope. What would you, would you have her print out the AUA guidelines, which clearly say we can treat breast cancer patients with this?

• 44:04Speaker 00

  So I would, yes, I would, I would, there are a number of studies that have been published and in the book I list them all out. And then we have guidelines and I would bring the studies with the guidelines, not just from-

• 44:15Dr. Mary Claire Haver?

  We will link these in the show notes for our listeners.

• 44:17Speaker 00

  Not just from the American Urologic Association, but from our oncology society that show that with shared decision-making, 100% we can use vaginal estrogen. So I would bring the guidelines to the oncologist. And I will say, everyone is doing their best. We are limited very often by 15, 20-minute appointments.

• 44:37Dr. Mary Claire Haver?

  Same as us.

• 44:39Speaker 00

  And it's hard to do a lot. And it may not be that everyone's trying to just, you know, it, it may just be that your oncologist does not know. It's not aware of the guidelines or is not aware of the studies. And so if we're going to be partners in our healthcare, right? I think bring the studies and say, or send them on the portal. I'd like to make an appointment to review these studies together. Right? Really be very clear about what you're asking.

• 45:06Dr. Mary Claire Haver?

  So to be clear, and this is, at least, you know, my world is ACOG, American College of OB-GYN, says that low dose vaginal estrogen may be used, including women actively on Tamoxifen or on an aromatase, excuse me, or on an aromatase inhibitor with shared decision-making. So that is clear.

• 45:28Speaker 00

  Yeah.

• 45:28Dr. Mary Claire Haver?

  You know, and women are under the assumption, well, I'm on an anti-estrogen estrogen blocker. I can't use vaginal estrogen. That's not true.

• 45:35Speaker 00

  Not true at all. And I will add that we use vaginal hormones in women who are not just with a history of breast cancer, but who are living with metastatic disease as well. Often they feel excluded that some of these guidelines don't apply and then we use them. And I will say if there is concern of absorption, right? The big concern is that you're going to absorb some of that estrogen and it's going to raise the estrogen levels in the blood. We can monitor the estrogen levels in the blood if there is concern. You want to be mindful of that because initially if it's very dry, when you start using it-

• 46:06Dr. Mary Claire Haver?

  Right, you'll have more absorption in the beginning. It's just really thin, but it's six weeks, you grow the tissue back.

• 46:11Speaker 00

  Follow it, you know, or check it in, for, you know, don't check it immediately. Don't check it in a week, right? Give it a few weeks and you can monitor those levels. And sometimes they will provide some additional comfort, knowing that we're not increasing the systemic absorption.

• 46:24Dr. Mary Claire Haver?

  Let's talk about DHEA and where that would fit for your patient and how it's different than vaginal estrogen.

• 46:30Speaker 00

  So DHEA is a hormone that gets converted to estrogen and testosterone. So we can administer it vaginally. This is prosterone or intrarosa. And it's another option for vaginal hormones. The nice part about DHEA is that there's also some testosterone. So for some patients, they don't get full relief with simply vaginal estrogen. And for them, DHEA might be a better option because testosterone also innervates the vaginal and the vulvar tissues. And so if you're very low testosterone, estrogen alone may not be enough. So that's an option for some of our patients. And we actually do have some data. There was a study of a couple of hundred women using DHEA in patients with breast cancer.

• 47:13Speaker 00

  And what they showed was that although there was a little bit of increase in hormone absorption, it still remained in the lowest kind of quartile of post-menopausal range. So it didn't bring anyone to, you know, a pre-menopausal range, I mean, minimal. And there was improvement in sexual function. So this is an option, but just like with vaginal estrogen, there's a warning on it that you can't take it in breast cancer, but yet we have the data. I think I use it and sometimes the big issue I have is really access and cost. Vaginal estrogen is cheaper and more affordable.

• 47:45Dr. Mary Claire Haver?

  Yeah, there's no generic for the prosterone, for the DHEA, for intrarosa. I mean, the, I wish the sexual medicine docs love it because they get the testosterone, you know, the androgen and the estrogen in the vulvar tissues. And so you bind both receptors and the patients love it. But cost is an issue. So in vaginal estrogen, uh, cost plus pharmacy, you can get it for $13 right now for a tube.

• 48:10Speaker 00

  And it'll last you, the tube will, will last for some time.

• 48:14Dr. Mary Claire Haver?

  Just quick to back to vaginal estrogen, did you love that study where they put it on the finger instead of the applicator? I was, I tell my patients that all the time, but I love that, that now we have a study to say, it works just as well.

• 48:26Speaker 00

  So throw out the applicator, put it on your finger. And I think it actually is easier for people to apply. The applicator gets messy and sticky and-

• 48:33Dr. Mary Claire Haver?

  Yeah, you have to wash it and it never gets clean.

• 48:35Speaker 00

  Throw it out and, you know, I think part of it also is as we're prescribing it in the oncology world, I prescribe it like every, every day. We also have to counsel people on how to use it, right? So we do recommend, you know, think about bottom third of the vagina, but also both internally and externally. That's really important to put on the vulva as well. And so it is important not just to prescribe the vaginal hormones, but to actually counsel our patients on how to use them to get the most benefit from them.

• 49:01Dr. Mary Claire Haver?

  So walk our listeners through it. If you've got your tube of estrogen, how would, just use your words, you know, how would you do it?

• 49:06Speaker 00

  So if you have estrogen cream, um-

• 49:08Dr. Mary Claire Haver?

  How much do you put on your finger?

• 49:09Speaker 00

  I always say, kind of put it just on the like top, you know, kind of top part of your finger. I always kind of apply it to like how you're putting on under eye cream, you know, kind of similar to that. Put it on top of your finger, put it both bottom third of the vagina internally and then on the vulva externally. And you can do a loading dose of, you know, daily for two weeks. You don't have to do a loading dose. Some people are nervous about that, so then skip the loading dose and then about twice a week after. And that really, really helps so many women.

• 49:41Dr. Mary Claire Haver?

  I tell patients to, when we're doing the external, I say, okay, start at your clitoris and then work your way down the labia minora. Most women knows, you know, with that. And then we have a model in clinic and we can show them exactly where to apply. And then of course, and then I say rhodoruterit in the, you know, halfway up your vagina and you'll be fine.

• 50:01Speaker 00

  Yeah. And I think the key is not to go all the way up to vagina. And that's really the big thing because that's where we might see more absorption.

• 50:07Dr. Mary Claire Haver?

  Let's talk about testosterone. So in 2019, there was a global consensus position statement that lists exactly one evidence-based indication, hypoactive sexual desire disorder. There was a paper that just got, um, published in Journal of Sexual Medicine, GSM, I guess, that kind of looked at, and it was observational. Again, the patients were all treated, they were all in a private clinic, you know? So a very special subset of the population, they did not have breast cancer, but they saw global improvements, you know? These women on menopause hormone therapy in the form of estrogen plus or minus progestin, who were still symptomatic outside of hot flashes. Their hot flashes were managed, but they were still having sleep issues and fatigue and da, da, da.

• 50:52Dr. Mary Claire Haver?

  And I guess 23 out of 26, you know, domains got better when they added testosterone, but we don't have an indication for that yet.

• 51:00Speaker 00

  So, and in breast cancer, there was a similar study, very small in a menopause clinic for breast cancer survivors in the UK. Again, showing very similar things. Testosterone, it helped with menopause and menopause-related quality of life. Again, observational, small numbers. But what's interesting is, and what's not really being talked about is that the NCCN, the National Comprehensive Cancer Network, their guidelines used to say prior to 2026, that testosterone was contraindicated-

• 51:26Dr. Mary Claire Haver?

  Really?

• 51:26Speaker 00

  In patients with breast cancer. It just changed.

• 51:30Dr. Mary Claire Haver?

  Like the theoretical conversion of testosterone to estrogen?

• 51:34Speaker 00

  So theoretical concerns that testosterone gets converted to estrogen and that if there are residual cancer cells, they could express the androgen receptor, which testosterone could bind to and could theoretically stimulate growth. All of these are theoretical. However, on a positive note, those guidelines just changed to say testosterone should be used with caution in patients with breast cancer. That's a huge step. For an oncology guideline to go from contraindicated to use with caution, I actually think really opens the door for conversation.

• 52:06Dr. Mary Claire Haver?

  Do you think medical oncologists by and large are comfortable even talking about sexual health and wellness? And then talking about testosterone?

• 52:14Speaker 00

  No, but I, no, I think it's changing a little bit. I do see in our conferences, discussion groups, that people are starting to ask the questions, which is more than they were doing a few years ago. And then also I think a lot of it is, if we're working with a gynecologist or a menopause specialist, right? A lot of it they'll say is, well, I can prescribe it for you, but your oncologist has to say yes.

• 52:36Dr. Mary Claire Haver?

  And I fell into that trap for a long time.

• 52:38Speaker 00

  Yeah.

• 52:38Dr. Mary Claire Haver?

  You know?

• 52:39Speaker 00

  And so if the oncologists are, you know, at least now we have these guidelines that can, that are opening the door.

• 52:45Dr. Mary Claire Haver?

  Thank you so much for sharing all of your wisdom and knowledge with our listeners today. I think you've made a huge impact.

• 52:52Speaker 00

  Thank you for having me.

• 52:55Dr. Mary Claire Haver?

  You can find full episodes of UnPaused on YouTube at Dr. Mary Claire. Also, you can find me on Instagram at Dr. Mary Claire and get honest and accurate information on health, fitness and navigating midlife at thepauselife.com. UnPaused is presented by Odyssey in conjunction with Good Roommate Media and Long Wave Digital.

• 53:21Dr. Mary Claire Haver?

  This episode was sponsored by Midi Health, the first virtual clinic created for women by women for the treatment of menopause. Don't let anyone tell you menopause is something you have to suffer through alone. Midi can help. Visit joinmidi.com to learn more.