Podcast Summary:

Better! with Dr. Stephanie
Episode: HRT, Breast Cancer Risk & Vaginal Estrogen: Risks & Myths Explained with Dr. Corinne Menn
Date: April 14, 2025
Host: Dr. Stephanie Estima
Guest: Dr. Corinne Menn, Board-Certified OBGYN, Menopause Society Certified, Breast Cancer Survivor

Episode Overview

This episode offers an in-depth examination of hormone replacement therapy (HRT), breast cancer risk, and the role of vaginal estrogen in women’s health—especially as related to perimenopause, menopause, and survivorship after cancer. Dr. Stephanie Estima welcomes Dr. Corinne Menn, an OBGYN and breast cancer survivor, to clarify science, dismantle prevalent myths, address persistent physician and patient fears, and provide nuanced advice for navigating hormone therapy, breast cancer, and vaginal health.

Key Discussion Points & Insights

1. The Women's Health Initiative (WHI) Study: Setting the Record Straight

• Legacy of Fear & Misinformation

  • Dr. Menn highlights the profound legacy of fear set in motion by the WHI study, which led to widespread abandonment and hesitancy around HRT for both women and physicians.
    • “The vast majority of women and doctors are making their hormone therapy decisions based on fear and...misconceptions. And the fear of breast cancer is largely driving women's access and decision making.” (00:00)

• WHI Study’s Purpose and Flaws (05:36)

  • The WHI aimed to assess whether HRT could be used to prevent heart disease, not test its safety for treating menopausal symptoms (already established).
  • WHI enrolled older, less healthy women—an unrepresentative group compared to typical HRT seekers.
  • The sound bite “estrogen causes breast cancer” is not supported by the WHI data.
    • Estrogen-only arm: Showed no increased risk of breast cancer, possibly a protective effect.
    • Estrogen + progestin arm: Showed at most a tiny, statistically questionable increase in risk, analogous to lifestyle risks.

  Quote:
  “In the estrogen only arm...no increase, actually a lower risk of dying of breast cancer...the progestin arm showed a slight increase, statistically not significant.”
  — Dr. Corinne Menn (07:37)

  • Formulations in WHI (conjugated equine estrogens and old synthetic progestins) differ from today’s preferred bioidentical estradiol and progesterone.

2. Understanding Bioidentical vs. Synthetic Hormones

• Definition and Practical Guidance (16:09–19:41)

  • "Bioidentical" = molecularly identical to a woman’s own hormones.
  • Can be obtained from standard pharmacies, not just through compounding.
  • Bioidentical estradiol and progesterone appear preferred for efficacy and tolerability, but synthetic versions are not inherently dangerous when used appropriately.

  Quote:
  “It just means … it’s literally the same hormone as what your body's producing.”
  — Dr. Corinne Menn (16:09)

3. Systemic Challenges: Medicine’s Neglect of Menopause

• Societal & Medical Gaps (22:23)

  • Menopause education is historically neglected in medical training.
  • Women's sexual health and well-being after reproductive age are undervalued.
  • Current change is grassroots—empowered women are demanding better care and information.

  Quote:
  “Zero, zero education in menopause in my residency…That narrative is shifting—thank goodness to powerful leaders.”
  — Dr. Corinne Menn (23:10–24:20)

4. Breast Cancer, HRT & The Language of Risk

• Clarifying ‘Estrogen-Positive’ (27:07)

  • All cells, including breast cells, have estrogen receptors.
  • “Estrogen-positive” breast cancer means the cancer cells have retained the receptor—not that estrogen caused the cancer.
  • Breast cancer is not a single disease; different subtypes require individualized management.

  Quote:
  “All cells in your body have estrogen receptors on them…That is a very different idea than...estrogen caused your breast cancer.”
  — Dr. Corinne Menn (27:07–30:16)

• Advocating for Nuanced, Individual Care (34:43–38:06)

  • Survivors and “previvors” (those with high genetic risk) deserve nuanced, personalized menopause management—including the option to consider HRT.

5. Navigating Conversations with Oncologists and Primary Care Providers

• Empowering Patient Advocacy (38:06–48:45)

  • Oncologists often lack menopause management training; patients should request dedicated appointments to discuss menopause symptoms and options.
  • There’s a growing consensus that individualized, shared decision-making is essential.
  • Patient autonomy should extend to HRT after thorough risk/benefit discussion.

  Quote:
  “Everybody after breast cancer deserves a conversation on how we’re going to manage our menopause and that you do have options.”
  — Dr. Corinne Menn (45:47)

6. Determining HRT Candidacy After Breast Cancer

• Best & Worst Case Scenarios (49:30–56:35)
  • Low-risk survivors (e.g., DCIS, bilateral mastectomy, no systemic therapy) are generally suitable candidates.
  • Caution and deeper risk/benefit analysis are required for those with higher-risk, ER+ disease, or those still in active treatment.
  • Individualization and reassessment (even drug holidays or switching from aromatase inhibitors to tamoxifen) are vital.

7. Myths and Facts: Vaginal Estrogen and Genitourinary Syndrome of Menopause (GSM)

• Vaginal Estrogen: More Than Lube (67:37–74:12)

  • GSM affects all women after menopause; it is progressive and impacts urinary and sexual health, not just lubrication.
  • Vaginal estrogen is safe for nearly all women (including cancer and clot survivors) and critical for preventative care—think of it as “vaginal skincare.”
  • Using lubricants is not enough; atrophy, UTI risk, and sensation loss continue without local estrogen.

  Quote:
  “I think personally all women should be 100 and you know, vaginal estrogen...it's really safe to start it...it’s preventative skincare for the vaginal skin.”
  — Dr. Corinne Menn (68:01–70:09)

8. Cultural and Relationship Implications of Neglecting Women’s Sexual Health

• Gender Inequities and Societal Impact (74:12–80:55)

  • Men receive ED treatments with little stigma; women’s sexual health is shrouded in shame/disinterest.
  • Untreated GSM can erode relationships and quality of life.

  Quote:
  “If vaginal estrogen was routinely handed out and discussed with perimenopausal women, I think half of the divorces would have been saved…”
  — Dr. Corinne Menn (74:12)

9. Dr. Menn’s Personal Breast Cancer & Menopause Journey

• Firsthand Experience - Challenges & Lessons Learned (82:50–92:16)

  • Diagnosed with breast cancer at 28, furthered her OBGYN career amidst treatment, eventually paused and restarted tamoxifen to have a child, and experienced severe menopause with little guidance.
  • Only much later, and with support, began low-dose HRT and testosterone, which she described as “game changers” for quality of life and function.

  Quote:
  “It took me a really long time to get to a place where I treated myself.”
  — Dr. Corinne Menn (86:17)

Notable Quotes & Memorable Moments

• On WHI Study’s Impact:
  “That has left a legacy of fear and misinformation that has left a generation of women and doctors feeling really uncomfortable and nervous...” (00:00, Dr. Menn)

• About Patient Advocacy:
  “You have to act like the CEO of your health...You really do have to do the work yourself and bring it to your physician.” (43:34, Dr. Menn)

• On the Power of Vaginal Estrogen:
  “Vaginal estrogen improves tissue quality, keeps it thicker, more blood flow to the clitoris, less atrophy. So then the sensation is good. So now maybe that woman not only tolerates that sex, but actually wants it.” (75:38, Dr. Menn)

• On Gender Discrepancy:
  “Men aren't embarrassed. I mean, for God's sake, they all get ED medications like it's going out of style. It's easy for them to get testosterone, as well...” (80:55, Dr. Menn)

Timestamps for Important Segments

• 00:00–05:36: Intro, legacy of WHI, setting the landscape
• 05:36–15:39: Detailed explanation of WHI, actual risks
• 16:09–19:41: Bioidentical vs synthetic hormones
• 22:23–26:15: Societal neglect & lack of menopause education
• 27:07–34:41: Language, estrogen receptors, breast cancer isn’t monolithic
• 38:06–47:08: How to have the conversation with your oncologist, patient advocacy
• 49:30–56:38: Best/worst case scenarios for HRT post-breast cancer
• 67:37–80:55: Vaginal estrogen, why GSM matters, wider impact (relationships, aging, UTI risk)
• 82:50–92:16: Dr. Menn’s personal narrative and transformation
• 95:09–end: Takeaways, resources, episode wrap-up

Resources Mentioned

• Books:
  • Estrogen Matters by Carol Tavris & Avrum Bluming (for detailed WHI analysis and estrogen’s case)
• Studies & Tools:
  • The Wisdom Study (breast cancer risk stratification)
  • Menopause and Cancer resources (menopauseandcancer.org)
• Organizations for Further Care:
  • The Menopause Society
  • Alloy (telehealth for menopause)

Actionable Takeaways

• Don’t be afraid to ask for nuanced, individualized care regarding HRT, regardless of a personal or family history of breast cancer.
• Vaginal estrogen is preventative, not just therapeutic, and should be destigmatized and normalized as women age.
• Menopause symptoms are multidimensional and deserve more than dismissal or antidepressants—there are effective and safe options, both hormonal and non-hormonal.
• Empower yourself with accurate information, seek specialists when necessary, and demand a seat at the table in your own health decisions.

Dr. Menn’s Final Message:

“Don’t let yourself be limited. If your in-person GYN isn’t up to par on menopause, it’s okay to seek a second opinion—you’re worth it. Speak up. Be a squeaky wheel.” (94:11)

For further information, see the resource list in the show notes, and check Dr. Menn’s recommended links and guides for survivor-specific guidance.