The Doctor Who Survived Cancer Reveals The Truth About Cancer Treatment! | Dr. Corinne Menn

Summary

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The Neuro Experience

Host: Louisa Nicola (with Pursuit Network)
Guest: Dr. Corinne Menn
Episode: The Doctor Who Survived Cancer Reveals The Truth About Cancer Treatment!
Date: May 18, 2026

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Episode Overview

This episode dives deeply into the personal and professional journey of Dr. Corinne Menn, OB/GYN physician, breast cancer survivor, and advocate for better menopausal care after cancer. Through Dr. Menn’s story, Louisa and Corinne explore the rising rates of breast cancer in young women, the genetic and lifestyle complexities behind cancer risk, the impact of cancer treatment on hormonal health, and the critical care gaps survivors face—especially regarding menopause and hormone replacement therapy. With clarity, empathy, and up-to-date science, this episode provides both a primer and a call to action for women, clinicians, and the medical system at large.

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Key Discussion Points & Insights

1. Dr. Corinne Menn’s Story: From Doctor to Survivor

• Personal diagnosis:
  • Diagnosed with stage 2A ERPR positive breast cancer at age 28, while in OB/GYN residency ([01:19]).
  • Experienced both being dismissed as a patient ("too young for breast cancer") and losing her own mother to late-diagnosed ovarian cancer ([01:19]).
  • "My doctors also dismissed me... they said, oh, you're too young for breast cancer. Let's just watch and wait." – Dr. Corinne Menn ([01:19])
• Silver lining: Her experience led to her life’s mission in patient advocacy and informed menopause/cancer care.

2. The Breast Cancer Landscape: Incidence, Risk, and Misconceptions

• Rising rates:
  • Fastest increase among women under 30 ([00:00], [03:24]).
• 80% of breast cancers occur in women without a strong family history ([00:00], [06:23], [09:49]).
• Risk assessment:
  • Urges earlier and more nuanced risk assessments, beginning at age 25, including family history, benign biopsies, and periodic reassessments.
  • "We lump all breast cancer patients into one bucket when we're talking about how we're managing menopause and premature menopause." – Dr. Corinne Menn ([06:23])

3. Genetics, Mutations, and Misunderstandings

• BRCA1 and BRCA2:
  • Most recognized mutations but not the only ones—many other actionable genes are linked to cancer risk ([13:13], [14:54]).
  • Personal anecdote: Dr. Menn’s initial testing was falsely negative due to early limitations in testing; updated panel years later showed BRCA2 positivity ([13:13]).
  • "There are other genes that we've identified that also raise the risk of breast, ovarian, and then other cancers as well..." ([06:23])
• Screening gaps: Only about 10% of eligible people are referred for genetic counseling/testing ([06:23])
• Importance of proper testing: Fun consumer DNA tests (e.g., 23andMe) are insufficient ([13:13]).

4. Premenopausal and Medically Induced Menopause: The Unaddressed Crisis

• Treatment realities: Most breast cancers are treated by lowering/blocking estrogen, inducing early or premature menopause in increasing numbers of young survivors ([03:23], [04:53], [17:42]).
• Premature menopause:
  • 3-4% of U.S. women experience it, often linked to cancer treatment, genetic risk, or surgical intervention ([41:39]).
  • Special vulnerabilities for Black women, who are more likely to be pushed toward surgical menopause ([41:39]).

5. Estrogen, Cancer Biology, and Public Fear

• Physiology:
  • Estrogen receptors are everywhere—not only in breast tissue.
  • "If you develop estrogen receptor positive breast cancer, it means those tumor cells have... kept that estrogen receptor... It doesn't mean estrogen caused the cancer." – Dr. Corinne Menn ([18:02])
• Debunking myths:
  • Being on birth control, not breastfeeding, or never having children are incorporated into oversimplified risk models.
  • "We have to step back and get away from this idea of estrogen good, estrogen bad..." ([23:48])
  • Soy/phytoestrogens are not dangerous, and alcohol’s risk is more about inflammation than hormone levels ([27:20]).

6. Endocrine Therapies: Tamoxifen and Aromatase Inhibitors

• Tamoxifen:
  • Selective estrogen receptor modulator (SERM): blocks estrogen in some tissues, acts as agonist in others ([28:03]).
  • Does not lower estrogen, but blocks receptor—causing menopausal symptoms, especially in premenopausal women ([28:03], [30:34]).
  • "It's not forcing you into menopause. Estrogen does not lower your estrogen level, but it causes menopause symptoms." ([28:03])
• Aromatase inhibitors:
  • Used in postmenopausal women or those with ovarian suppression.
  • Nearly eliminate estrogen everywhere, leading to severe symptoms and long-term health risks ([34:42]).
  • Used for 5–10 years, or lifelong with metastatic disease ([34:42], [60:16]).

7. Survivorship and the Glaring Care Gap

• After treatment:
  • No medical specialty “owns” the survivor; oncologists and gynecologists both deflect responsibility for menopause management ([51:21], [51:53]).
  • Most top cancer centers in the U.S. lack programs addressing menopause and survivorship side effects ([53:53]).
  • "They're told you might have some hot flashes and some vaginal dryness, and then they're sent on their way and maybe given an SSRI, you know, antidepressant, and told to use some coconut oil..." ([48:05])
• Local vs systemic HRT:
  • Local (vaginal) estrogen therapy is safe even for many survivors, but is often denied due to persistent myths ([53:53]).
  • Systemic HRT is controversial, but recent guidelines urge individualized approaches based on cancer type, risk, and personal values ([50:50], [60:32]).

8. The Case for Patient Empowerment and Individualized Care

• Self-advocacy:
  • Patients must take charge; being “a squeaky wheel” is necessary ([68:32]).
  • "You have to be your own CEO and you have to manage this because no one's coming to save you when it comes to this topic, unfortunately." ([53:53])
• Building teams:
  • Survivors are encouraged to build their own “board of directors,” including oncologists, OB/GYNs, neurologists, and more ([69:11]).
• High-performing survivors:
  • Many survivors become highly engaged in lifestyle medicine and wellness, sometimes fitter and more purposeful than the average ([66:30]).
  • "You can't out patch a crappy lifestyle and kind of just a sedentary life." – Dr. Corinne Menn ([66:30])

9. Memorable Quotes and Moments

• On the state of care: "No one's coming to save you when it comes to this topic, unfortunately." ([53:53], [00:00])
• On systemic undervaluing of ovarian function:
  • "We're not valued beyond our reproductive capacity. And if we were, it would be a good thing." ([69:55])
• On navigating ambiguous evidence:
  • "We don't have perfect data. We have some data. We can also put our thinking caps on and say, what's the best way to approach it for you?" ([64:53])
• On patient wishes:
  • "I want to be able to have sex with my husband again... Think about what that does to a brain in terms of depression and mood and anxiety." ([48:14])

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Timestamps for Major Segments

• Background & Dr. Menn’s story – [00:00] to [03:23], [01:19]
• Breast cancer rising in young women & risk assessment – [03:23] to [06:23]
• Genetic mutations, BRCA1/2, and hereditary risk – [13:07] to [17:42]
• Basics of estrogen receptor positive cancer & misconceptions – [17:42] to [20:11]
• Environmental/lifestyle risk, alcohol, and soy – [25:40] to [27:45]
• Mechanisms & side effects of tamoxifen and aromatase inhibitors – [27:45] to [37:09], [34:42] (aromatase)
• Menopause care gaps post-cancer – [37:09] to [54:18]
• Hormone therapy, local and systemic, after cancer – [50:31] to [64:53]
• Empowering patients, positive stories, actionable steps – [66:18] to [70:45]

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Notable Quotes (with Speaker & Timestamp)

• On being dismissed as a young patient:
  • "My doctors also dismissed me... they said, oh, you're too young for breast cancer. Let's just watch and wait."
    — Dr. Corinne Menn ([01:19])
• On unique care needs:
  • "Your breast cancer and its treatment is as unique as your fingerprint."
    — Dr. Corinne Menn ([06:23])
• On estrogen's misunderstood role:
  • "It doesn't mean estrogen caused the cancer... we have estrogen receptors everywhere."
    — Dr. Corinne Menn ([18:02])
• On survivorship gaps:
  • "No one is helping them with the surgical menopause that happens once they have their ovaries taken out... it's a tremendous crisis."
    — Dr. Corinne Menn ([16:12])
• On local vaginal hormone therapy:
  • "Vaginal estrogen is extremely safe for these women who are dealing with an ER positive breast cancer."
    — Dr. Corinne Menn ([48:14])
• On the need to value ovaries for more than fertility:
  • "I just would wish that we would value ovarian function beyond our reproductive capacity."
    — Dr. Corinne Menn ([69:55])
• On empowering survivors:
  • "I need to empower them so that they can work with their own physicians in their community. Because there's only one of me."
    — Dr. Corinne Menn ([68:40])

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Summary & Takeaways

• Breast cancer rates are rising, especially in young women, largely disconnected from family history.
• Menopausal symptoms and long-term health risks from cancer treatments are poorly managed, leaving young survivors unsupported by the medical system.
• Genetic screening is underutilized, and many actionable mutations go undetected due to lack of clinician and patient education.
• Estrogen’s role in cancer is complex—misconceptions drive fear and compromise appropriate care.
• Endocrine therapies like tamoxifen and aromatase inhibitors, while lifesaving, create profound side effects that require specialized and individualized management.
• Gaps in survivorship care demand self-advocacy; there’s a critical need for knowledgeable, multidisciplinary teams.
• Emerging consensus and patient demand may shift the standard of care towards evidence-based, holistic management of survivorship and menopause, but progress remains slow.
• Empowering stories remind listeners that vibrant life after cancer is possible—with the right information, support, and determination.
• Dr. Menn’s call to action: Women must be the CEO of their own health, and medicine must do better at supporting women beyond reproductive years.

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For Further Information / Consults

Dr. Corinne Menn provides both direct patient care and educational consults to help empower patients and their local providers ([68:40]).

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This episode provides essential knowledge for women facing cancer treatment, survivors seeking answers, and any listener who wants to champion better, evidence-driven women’s health care.

Transcript

[Dr. Corrine Man]

Breast cancer rates rising, but they're rising in premenopausal women. They're rising the fastest in women under the 30. 80% of women who are diagnosed with breast cancer actually don't have a strong family history. Women are petrified of this. Where do women go right now in the current state of our medical system in the United States and really in the world, they don't have anybody to go to because no one's coming to save you when it comes to this topic. Unfortunately.

[Louise Nicola]

Your story inspired me, so I actually want to start there with your story.

[Dr. Corrine Man]

When I was 28 years old in 2001, I felt alarmed. They said, oh, you're too young for breast cancer. Let's just watch and wait. At the same time, my mom is being dismissed for cancer. She dies of ovarian cancer. At her funeral, I said to myself, well, maybe I should get that lump checked out. And then right before Christmas, I was diagnosed with breast cancer. I'll give you a story about a young woman. She was diagnosed at 28 and she struggled bad for two years because nobody would help her. We got her some testosterone and guess what? Now she's doing fantastic. She's living her best life.

[Louise Nicola]

I'm Louise Nicola and this is the neuro experience. Dr. Corrine, I'm so excited to have you on the podcast. I think it's really important to have context. Now. You. Your story inspired me, so I actually want to start there with your story and what happened during medical school.

[Dr. Corrine Man]

Yeah, so my, my personal medical story really informs how I care for patients and really my entire mission now in life. So that's my silver lining that you'll hear about. So When I was 28 years old in 2001, I was a second year OB GYN resident and I felt a lump and I dismissed myself. My doctors also dismissed me. Some of my fellow colleagues dismissed me and they said, oh, you're too young for breast cancer. Let's just watch and wait. At the same time, my mom is being dismissed for stage 4 ovarian cancer with a delayed diagnosis. So she dies of ovarian cancer. At her funeral, I said to myself, well, maybe I should get that lump checked out. And, you know, a few weeks later, I did. And then right before Christmas 2001, I was diagnosed with a stage 2A ERPR positive breast cancer. And that's the beginning of my story. And at the time, I knew enough that breast cancer treatment was likely going to impact my fertility. And that was the very first thing that came into my mind. I mean it for being a mother, because I knew enough about the impact of cancer treatment on the ovaries, but what never occurred to me, because remember this is 2002 or 2001. Less than a year later, the Women's Health Initiative results would come out. And we didn't really have any menopause training, specifically in my residency. So I was really not prepared for what was about to hit me, which was premature menopause at the age of 28.

[Louise Nicola]

You're so inspiring because now you've been through it and, and you're actually showing that once you know what your diagnosis is and once you get the correct help with the correct information, you can do anything, really. There's so many different pathways and that's what we're going to speak about. So thank you for opening up with that. I actually want to talk about breast cancer survival rates because apparently they're better than ever. 85% cure rate for early diagnosis, but the treatments that achieve that curse systemically destroy estrogen.

[Podcast Sponsor/Guest Contributor]

Is that correct?

[Dr. Corrine Man]

For the majority of breast cancer, about 80% are estrogen receptor positive. And we can speak more about what that actually means. But because of that, either lowering or blocking estrogen production or estrogen receptors are a mainstay of treatment. And the issue is that not only are breast cancer rates rising, but they're rising in premenopausal women. Actually they're rising the fastest in women under the age of 30. So, you know, that leaves the question, we know what we're doing to treat these women, so we've got a larger army of them who are living longer, surviving, but living so many years with significant estrogen deprivation. And then there's another 20% that are not estrogen receptor positive. But many of these women are also plunged into early menopause due to their chemotherapy. Neither group is getting adequate evidence based medical care to manage the collateral damages of those treatments. And it is a growing crisis of care. The last thing I will add is that it's not just breast cancer patients. And that's what I speak about a lot. But we have to remember that cancer rates are growing in all different types of cancers. Colon cancer, those women have chemotherapy and radiation to their pelvis. Gyn cancer rates are rising and then lots of cancers that have nothing to do like colon cancer with hormones. And yet their premature menopause from treatments are not addressed.

[Louise Nicola]

And do you look, I've seen this because a lot of women now in their 30s are actually speaking up saying, you know, just diagnosed with any form of cancer and they're speaking about it. So it begs the question, are they rising or do we just now have access to early diagnosis?

[Dr. Corrine Man]

Well, both, but they're definitely rising. You know, we, we know across the board, rates for all cancers, particularly in young, are rising, and there's a whole host of reasons why. And so it really behooves us to kind of recognize, well, yes, we need better treatments for them, but we also need to better support them with the collateral damages of these treatments. And so I always say, if you think the average menopausal woman doesn't get access to, you know, information about menopause and hormone therapy, well, let me introduce you to the cancer survivor, and particularly the breast cancer survivor, because they basically feel like they have a big pink X on their backs and no one wants to really talk or deal with, you know, that issue.

[Louise Nicola]

Well, it is very frightening.

[Dr. Corrine Man]

Yes.

[Louise Nicola]

You know, to get that, to get that diagnosis. So I think actually, before we move on, it might be, might be great to lay the land of what breast cancer is, because you mentioned one can be hormone related. And then, and then also, is there a predisposition if your, if your mother had it and your grandmother had it? But then there's a, there's a whole host of women getting this disease and, or getting cancer, and nobody in their family has cancer. So let's lay it all out.

[Dr. Corrine Man]

Yeah. So really important first off is that breast cancer is heterogeneous. So fancy word, that just means there's lots of different types of breast cancer. And I always see to patients, your breast cancer and its treatment is as unique as your fingerprint. There's so many different factors that, you know, make your breast cancer unique, and so should be your management of your menopause and your survivorship. We have to look at, like, what are the factors that are relevant to your cancer, number one. And so that's a big problem. We lump all breast cancer patients into one bucket when we're talking about how we're managing menopause and premature menopause. The other thing is 80% of women who are diagnosed with breast cancer actually don't have a strong family history. So we can't just pretend that if, oh, I don't have a family history, I'm not at risk. We need to be doing risk assessments sometime, really by the age 25. And that may just be a really thorough family history and also some education about what modifiable things you can do with your lifestyle to lower your risk of breast cancer. But then you're gonna repeat this Risk assessment over time. So maybe you're a few years older and you've had, I don't know, a benign breast biopsy. And that breast biopsy showed something that elevated your risk, or maybe you found new things in your family history cause your family history changes. And so we should periodically be trying to find which women are more high risk and not just based on family history. So which women can we screen for, not only refer for genetic testing, but which women do need earlier imaging and which women don't. Right. And so that's something that we're all working on, but I think most patients are not really getting that part adequately. And so that leaves a lot of vulnerable women who could be identified as high risk who are not being identified as high risk. Right. And then that kind of gets into what you answered or asked about. Are there some specific things that we can identify like a BRCA mutation or other mutations? So we talk a lot about the BRCA genes, and I think the public is pretty familiar with that. But it's really important that women know that there are other genes that we've identified that also raise the risk of breast, ovarian, and then other cancers as well, depending on the gene. But the interesting thing is, I think about 1 in 4 adults or people in the US qualify for at least a referral for a genetic counselor and to be screened for hereditary cancers. But I think only like 10% actually get that referral. So that's a huge problem because there's probably hundreds of thousands of people walking around out there with a hereditary cancer mutation that's clinically actionable that we can do something about. I like to say you could have your cake and eat it too. You can. You could find out your risks and we could really be empowered to take care of that. And it doesn't necessarily mean you're going to be put into menopause and we won't give you hormones. We're going to talk about that.

[Louise Nicola]

Do you think a lot of this just comes down to education? Because, you know, you and I are in. We run in the same circles and

[Podcast Sponsor/Guest Contributor]

we speak to the same people. And to me, it's like the APOE4 gene, I think.

[Dr. Corrine Man]

Oh.

[Louise Nicola]

And, you know, I see women every day and they don't know. They've never heard about this. So a lot of women just don't know how to ask their physician. Hey, should I be getting this tested?

[Dr. Corrine Man]

Yeah. It's lack of patient education. There's a lack of clinician education, Doctors, medical oncologists, OB GYNs internists, they have so much to learn and cover and unfortunately, not only is menopause not covered very well, but these genetic and hereditary cancer genes or these other things that they should be screening patients for is also not really valued. Right? And then I think when we add into that the health care system is really not set up for doctors and patients to actually have time to like really talk about these things. There's so many wonderful physicians, the medical oncologist out there who helped me, saved my life and I really am grateful. And I also really feel bad for them because they are burdened with the same pressures we all are as physicians. They have a very short period of time with their patients and so they don't have time to address a lot of these concerns that we're going to talk about today.

[Louise Nicola]

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[Podcast Sponsor/Guest Contributor]

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[Louise Nicola]

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[Podcast Sponsor/Guest Contributor]

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[Louise Nicola]

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[Podcast Sponsor/Guest Contributor]

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[Louise Nicola]

Yeah, I actually want to get into some of the genetic mutations. So we mentioned BRCA1. Is there BRCA2?

[Dr. Corrine Man]

Yep. BRCA1 and BRCA2 and those are the most common. And I think it's really important for us to make sure anybody listening to this that knows that, you know, these genes are identified on proper genetic tests. So like a fun 23andMe is not sufficient enough. And then it's a little interesting story about me. I was initially tested negative for the genes. And I remember thinking to myself, well, that doesn't make sense. Like, but this was 2001, it was the early days of this testing and I didn't really, you know, it never sat well with me. I was like, my mom was 54 when she died. I was 28 when I was diagnosed. So many years later when I was doing some continuing medical education for myself and my practice, it was around 2014 or so. And I said to my oncologist, hey, I think you need to do update testing. He's like, oh, I don't think you really need it. It would be very unlikely. I was like, no, test me. And of course he called me about a month later. He's like, I've got bad news. I'm like, it's really not bad news. I want to know why I got breast cancer. He's like, you're a BRCA2 carrier. So my initial testing was negative and update panel testing showed that I did carry it because before 2013, the full rearrangement of the gene was not standard of care. And I see countless women who tell me, oh, my mom assessed it a long time ago or, or they themselves were tested and they're long term survivors of breast cancer, but they have a lot of high risk features. And I said, you need update testing because we may need to know about your risk of ovarian cancer or your risks to your family or your children.

[Louise Nicola]

So you tested positive for BRCA2.

[Dr. Corrine Man]

Yeah.

[Louise Nicola]

What's the difference between BRCA1 and BRCA2?

[Dr. Corrine Man]

So there's differences between the rates and the age of onse of breast and ovarian cancer. So you know, Kind of big picture wise when we think about, like ovaries, because that's really important when we talk about these BRCA carriers. BRCA1 carriers tend to be diagnosed with ovarian cancer earlier than BRCA2. So the BRCA1, and there's a little bit more data and research on BRCA1 patients. BRCA1 carriers are recommended to consider having their ovaries removed really by the age of 35 to 40, when they're done with their childbearing, and then BRCA 2 between 40 and 45. And frankly, with the rates of ovarian and breast cancer just getting younger and younger, I personally recommend these patients to not wait. And the problem is they wait because no one is helping them with the surgical menopause that happens once they have their ovaries taken out. So, yeah, so the age of onset is one big thing. And then the rates of breast cancer cancer as well. But, you know, more importantly is that we shouldn't just be thinking about the BRCA1 and 2 gene because many patients were only tested for that. And now we know other genes. The ATM mutation, PolB2. I mean, the list is growing.

[Louise Nicola]

Is it 1, CA51, is that A.

[Dr. Corrine Man]

There's a. There's a whole bunch of them. You may be thinking of a CA125.125, yes. So CA125 is a blood test that we can do. It's not a screening test for ovarian cancer, but it's something that can be elevated if something's going on with the ovary. But it could be elevated for lots of reasons. But I'm glad you brought that up because, you know, the thing about the BRCA 1 and 2 gene, we know that they have an increased risk of ovarian cancer, but we don't have a screening test for ovarian cancer. There is no screening test. So if you carry one of these genes, we would put you in a high risk surveillance program and, you know, have you get a pelvic exam. And, you know, some programs will, you know, offer a pelvic ultrasound or a CA125 to kind of follow these patients, but those have not been shown to be effective at screening, meaning they don't lower the chance of dying of ovarian cancer. Right. So it's not the same type of screening as mammography. And that's why in these carriers, having their ovaries removed when they don't need them anymore, quote, unquote, for fertility is really, really important. And the biggest message is for these carriers, we call them previvers, they've not had cancer yet. These patients can remove their ovaries and they can, and they should have full hormone replacement therapy up to at least the age of natural menopause. But I'd say easily less than 50%, probably much less actually get offered that. And if they do, they often have to fight for it and it's a tremendous crisis.

[Louise Nicola]

Well, that's what we're dealing with now.

[Podcast Sponsor/Guest Contributor]

Well, at least you are. Yeah.

[Dr. Corrine Man]

Yes, it's a huge problem.

[Louise Nicola]

Okay, so we're going to move in and talk actually now a bit about the biology of estrogen because I think

[Podcast Sponsor/Guest Contributor]

this is really, really important.

[Louise Nicola]

So 70 to 80% of breast cancer of breast cancers are estrogen receptor positive, as you mentioned. So let's just talk about what that means now.

[Dr. Corrine Man]

Yeah, so I think this is really, really important because patients often think, and even doctors, I think are at fault for sometimes sending this message that estrogen caused their breast cancer because their breast cancer tumors have estrogen receptors on it. So I think it's important for all women to know, really, just so that they understand the physiology of their bodies, that we have estrogen receptors everywhere. As you talk about, we're always trying to inform patients, estrogen receptors in your brain, on your skin, on your breast. Males have estrogen receptors on their breast, children have estrogen receptors on their breast. So if you develop estrogen receptor positive breast cancer, it means those tumor cells have developed, they've retained, they've kept that estrogen receptor and they may even over express it. Right? Because that estrogen receptor can be used to help the cell grow. Right. It doesn't mean estrogen caused the cancer. Right. And so I think that's really, really important because when you tell women, or women think that, then it teaches them to fear their own cancer, fear their own bodies and fear their own hormones. And sometimes it makes them even feel guilty, like, oh, did I do something to cause my breast cancer? Was it my birth control pill or was it that I never got pregnant or was it some other reason, or I didn't breastfeed long enough or whatever the reason is. And so I think we have to separate that out. But the other important thing is we have to recognize that the mainstay of treatment for er, positive breast cancer is to block the estrogen receptors or lower the amount of circulating estrogen. And, you know, that's a real fact and it's the mainstay of treatment. And so if that's what we're doing to women, then we better have solutions to help them manage that. And we also better need to better decide which patients need that for a longer period of time. So the estrogen deprivation for longer and which patients can have it for less amount of time or to a less severe degree. And so really individualizing that and then helping the patients in the long term.

[Podcast Sponsor/Guest Contributor]

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[Louise Nicola]

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[Louise Nicola]

You said something really interesting that I just wanted to ask you because you said, you know, sometimes people think maybe they didn't have kids or they didn't breastfeed for long enough. Why does. Or being on the oral contraceptive pill, how do they correlate to breast cancer if they do?

[Dr. Corrine Man]

So, you know, I don't think we know exactly what actually causes cancer. I know, period. Or what causes breast cancer. And I think we have to step back and get away from this idea of estrogen good, estrogen bad, a lot of these. More, I'd say more simple risk assessment models for breast cancer, like the Gail model will take into account, like how old were you when you got your period? How late were you, when you perhaps went through menopause, did you breastfeed? How many children did you have? And they're relating it all to the exposure of estrogen. But if we take a step back and understand that your breast tissue is in cells, there's ducts, there's lobules, they're ever changing tissue and they change throughout the month with your menstrual cycle. They make profound changes during pregnancy, then profound changes during lactation, and then changes post menopause. And so it's not that estrogen bad, estrogen good, but it may be things that are happening at a microcellular level with all of these different changes. Because it's very interesting because pregnancy with very, very, very, very high levels of estrogen is protective. Okay. Breastfeeding then changes the breast tissue and makes it into a more the lobules mature and the whole structure changes so that it can obviously produce milk. And it's going to be in a kind of a different state, a very stable state for maybe perhaps many months. Some women might breastfeed for longer than that, over a year or more. Right. And so that's going to make changes to the breast which have been shown to be protective. Right. So that's a lot different than saying estrogen causes breast cancer.

[Podcast Sponsor/Guest Contributor]

Very different.

[Dr. Corrine Man]

Yeah. And also remember, there's other things that are happening every month with your menstrual cycle. There's progesterone being produced, there's. Yes. Testosterone being produced, all kinds of things. And so I think that that's important because the more sophisticated risk models understand the tyrakusic and now we're going to have much better risk models driven by a. And more advanced technology that are looking at a lot of other things. Right. Including breast density and other changes. And then also environmental lifestyle factors, nutrition, exercise. There's so many things. And I think that's what accounts for why we see growing rates of cancer and not just breast cancer, because we know it's not just estrogen, it's inflammation, obesity, environmental toxins, chronic stress, alcohol, a huge host of things.

[Louise Nicola]

Well, actually alcohol, when you relate it to any type of cancer, it is strongly correlated out of all the cancers to breast cancer.

[Dr. Corrine Man]

Yeah. And what makes me a little. I get a little annoyed when I see people say, well, it's because alcohol raises estrogen levels. And I'm like, how about that? Alcohol causes chronic inflammation, immune dysfunction. I mean, we can go on and on a whole list of really literally

[Louise Nicola]

a toxin to the cell.

[Dr. Corrine Man]

And so to just be like, well, it's because it raises estrogen levels. I'm like, well, I think it's a little bit more than that.

[Louise Nicola]

If that was true, then the same would be true for. I remember. Do you remember going through that phase? I was very young, but they said that don't eat. Was it tofu? Because chickpeas.

[Dr. Corrine Man]

Sorry, soybeans. Yeah, edamame, It's a soy. Because, you know, plant based phytoestrogens are weak agonists on estrogen receptors and in fact they've been shown to be protective. So I think again, we have to stop with this black and white. You know, if estrogen was a bad toxin, then I don't think, you know, us as females would be doing very well. Right. You know, I think it's a lot more complicated than that.

[Louise Nicola]

So let's keep moving on to estrogen blockers. And I actually want to highlight tamoxifen. Tamoxifen. So walk me through what tamoxifen actually does. And you know, it, in terms of the brain, it's blocking estrogen receptors. But those receptors aren't just in the breast tissue, it's also in the brain. So what is it actually doing?

[Dr. Corrine Man]

Yeah, so I think it's really important. Listen, we're going to talk hard things today. I took tamoxifen for over 10 years. I'm not doomed, right? So we're going to say some hard things about what these medications do to your body, and we have to recognize them so that we can empower women to manage these medications. So, like I said, manipulating the receptor or lowering the estrogen levels are a mainstay for, er, positive breast cancer. So tamoxifen was really the really groundbreaking medication decades ago that changed the course of treatment for breast cancer because it's a selective estrogen receptor modulator. And that just means that in certain tissues it binds to the receptor and it's an agonist, or it promotes the effects of estrogen. And other tissues, it, it's an antagonist, it blocks. So in breast tissue or breast cancer cells, it's a blocker. So it's blocking estrogen receptors. There in the uterus, it actually promotes the estrogen receptors. So that's why women who take tamoxifen can have irregular bleeding, they can have ovarian cysts, they can have worsening of their endometriosis. In the brain, of course, it's not so well studied. Just like a lot of things in women's health, it does cross the blood brain barrier and it is an antagonistic on parts of the brain. And there may be parts of the brain where it's an agonist on and the same in the bone, it is a weak agonist, but when it's competing for estrogen, it actually causes osteoporosis and bone loss in a premenopausal woman. But in a postmenopausal woman, when there's no estrogen on board, it's a weak agonist. So it's, it helps with bone loss. So again, tamoxifen, really the most important thing to know is it is blocking estrogen receptors in the breast, but it's not forcing you into menopause. Estrogen does not lower your estrogen level, but it causes menopause symptoms. And when we're talking about the brain, those symptoms could be worsening. Hot flashes, cognitive changes, mood changes, obviously, night sweats, sleep issues, and really there's an impact on every body system. But a lot of women, I think, think or wrongly are told that tamoxifen itself is gonna put them into menopause. And then when I tell them, actually, tamoxifen raises your estrogen levels because it actually stimulates your ovaries to produce more estrogen. Right. But what it's doing is blocking the receptors to those estrogen.

[Louise Nicola]

That actually makes a lot of sense. Obviously, we've got a lot of the estrogen receptors over the hypothalamus, which is the thermoregulatory pathway in the brain. So if we block that and we don't have access to understanding, our internal body temperature is going to cause hot flashes. However, when the estrogen is getting released from the ovaries and you've just got a whole bunch of circulating estrogen.

[Dr. Corrine Man]

Yes. But the estrogen that is released when women are on tamoxifen is less bioavailable. Because when you're on tamoxifen, your sex hormone binding globulin goes way, way up, because tamoxifen acts like an oral estrogen in your liver. So basically, the estrogen levels technically are higher, they're less bioavailable. And you've got this selective blocking in different tissue. But when you stop tamoxifen, those effects do go away and it doesn't leave you in permanent menopause. And tamoxifen is really interesting because it could be used for women who are premenopausal and still have their ovaries working and making estrogen. And in general, not everybody, but in general, women tolerate tamoxifen better when they're premenopausal, although some women have a lot of side effects. But then tamoxifen is also used with ovarian function suppression in younger premenopausal women who are higher risk for recurrence. So these are the different layers of adjuvant endocrine therapy. And then for years in postmenopausal women, tamoxifen was the standard of care. Now it's kind of been replaced by aromatase inhibitors for postmenopausal women, although we can still use to tamoxifen and postmenopausal

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[Louise Nicola]

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That means that you don't have to think about it.

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[Louise Nicola]

Well, let's take it a step further and actually talk about aromatase inhibitors, because they don't just block the receptor, they eliminate the residual estrogen production entirely.

[Dr. Corrine Man]

Yeah, yeah. So aromatase inhibitors kind of emerged after tamoxifen as a treatment. And so in Order for aromatase inhibitors to work, you have to be menopausal. So if you're either naturally menopausal or if you're higher risk for recurrence, you'll either be given medications to shut down your ovarian function, or you would have your ovaries removed surgically. And then aromatase inhibitors, what they do is they prevent androgens, testosterone from being aromatized to estrogens. Right? And so you know that aromatization happens, you know, in the breast tissue. Right. And also happens in fat cells and throughout the body and in the brain. And so it's. So what it's doing is taking a menopausal level of estrogen because women have to know that even in menopause there's still low levels of estrogens being produced, you know, from this conversion in fat and, you know, other places of the body. So it's basically, I tell patients, it's taking it and putting your estrogen like down into the basement, like almost zero. Right? So that's where its impact is on all of these symptoms. It's not that it's blocking receptors, aromatase inhibitors, it's just making your estrogen almost zero and a very profound state of deprivation. It's not lowering your testosterone levels, it's lowering your estrogen estrogen levels. And it has a really profound effect on your symptoms and frankly, your long term chronic disease risk that we need to talk about, it's very, very effective and helpful for treating the breast cancer. So we've got to do two hard things at the same time. We have to treat these women's breast cancer, but we have to recognize this collateral damage and we have to find a balance. And so I kind of alluded that some women will need or will only need kind of, you know, not as severe, you know, endocrine therapy. Other women who are younger or who have more high risk features, like a larger tumor size, you know, more lymph nodes, you know, a higher stage disease, you know, they'll be recommended to be an aromatase inhibitor with a variant function suppression. And then the timing also differs. Some women are recommended it for 5 years, some women are recommended for up to 10 years. And then if a woman has a stage 4 or a metastatic disease, she'll be on that type of, you know, treatment for the rest of her life.

[Louise Nicola]

I've known you for quite some time and I the more I'm talking to you now in a podcast setting, I realize how specialized you are, and it's really beautiful because you you often don't see that. We know how many, you know, there's so many different medical specialties right now. And, and you go into obgyn and, you know, you can just stand there, right, and just do the normal thing or you can go and investigate. And yours obviously came from a personal battle that you had yourself, which makes you so brilliant. I mean, where do women go if they're not coming to you? How many?

[Dr. Corrine Man]

Like, it's really hard. Yes, yes. And listen, it was a specialization by, by necessity. I was struggling. I felt terrible. I was not well cared for by my doctors when it came to that. This, they did a great job in other ways and I'm grateful for that. But I was on my own with this. And I really, it wasn't until I, you know, I had to kind of get myself educated in basic menopause, you know, management. And now it's just become this like passion and labor of love. And the good news is, is that the trickle down effect is happening, but it's happening way too slowly, I think. So there are menopause specialists who are now like, okay, I'm comfortable with general menopause. Now I want to learn a little bit more. And there is a movement in the medical oncology community, thank God, to start to like, recognize this because, you know, medical oncology, you know, residency or you know, fellowship training programs, they don't have any menopause training. General OBGYN residents barely have it. Why would we think that the medical oncologists are going to have it and they have to keep up with so much new information. And so I think, and also the army of survivors are standing up, I think because of social media. This is a positive of social media and saying, like, wait, this is not okay, like to have severe genitourinary syndrome and menopause due to breast cancer treatments or horrific hot flashes, nights with insomnia for literally years or decades without much help besides, have some coconut oil, take a little magnesium and be grateful you're alive. It's just no longer, it's starting to be. It actually is no longer acceptable. And I think finally the medical community, the medical societies, just the past year or two were starting to step up and say, like, maybe we should have some lectures on this. Maybe we should ask somebody to speak on this. Maybe we should educate ourselves.

[Louise Nicola]

So when a woman comes to you, are they coming for a specific purpose?

[Dr. Corrine Man]

Yeah. So I think for me, my practice at this point has gotten like, so specialized, mainly because of my, you know, you know, just my public Education, et cetera. So people, people seek me out and they're really seeking me out. They've already, they've already seen the general menopause specialist, they've already tried the basic stuff. And they're seeking me out for two reasons, either to help them manage their endocrine therapy or their current breast cancer treatment. Right? So like, you know, they're here, they're here saying like, okay, I understand at this point in time I can't take systemic estrogen, but how can I get through this? How can I manage that? And then there's another group, a large group of women who they were many times very early stage. This is, you know, for the most part behind them in terms of active treatment. Many of them were very young at diagnosis, but some of them were already, you know, postmenopausal and maybe were on hormone therapy, had to come off of it for their treatment, whatever. And they're like, could I ever consider some form of hormones? Right. Understanding that there's local vaginal hormones, systemic estrogen, and also the testosterone question. And so those are kind of the two buckets of patients that I'm getting. And then mixed into that are the genetic mutation carriers, the BRCA carriers, who are previvers, who have this fear of breast cancer, or they're being managed for their breast cancer risk. Nobody's helping them with what that means.

[Louise Nicola]

Well, I think across all the specialties, you, it's important to recognize that you can go and get a blood test, right? You can see your biomarkers. It's about who is interpreting the data and who's actually putting you on the protocols necessary after that. Just like getting an APOE for a positive genetic test. You know, your PCP can say, yep, you're positive, but what do you do? Exactly. So let's keep. I, I love that, by the way. I, I think you're phenomenal. Let's keep going and talk about oophorectomies. So the Mayo Clinic cohort data from Walter Rockers group groups show that bilateral

[Podcast Sponsor/Guest Contributor]

oophorectomy before the age of 46 is

[Louise Nicola]

associated with increased risk of cognitive impairment and dementia. But before we even talk about that, can I just understand why would someone get an oophorectomy?

[Dr. Corrine Man]

Yeah, so there's lots of reasons why we remove ovaries, both benign reasons and cancerous reasons. Right. And so, you know, this term iatrogenic menopause just means a medically induced or a surgically induced menopause, either from giving medications that shut down those ovaries. Or by surgically removing them. And so, you know, what's really important to recognize is that there's a whole lot of women out there who go through menopause early. So early menopause is prior to the age of 45, and premature menopause is prior to the age of 40. So the numbers are about 3 to 4% of the US population will have. Have premature menopause. And I believe that rate is growing because of what we're talking about. More breast cancers being diagnosed at younger ages and more genetic mutation carriers having prophylactic, you know, oophorectomies, having their ovaries removed, you know, prophylactically as risk. We call it risk reducing surgery. Right. And then also a whole group of patients who go through menopause early just because of chemotherapy for maybe other cancers. But there's other reasons why women go through early menopause endometriosis treatments. There's something called premature ovarian insufficiency idiopathic, where it just. We don't know exactly why there might be an autoimmune component. And really interesting talking about the BRCA carriers, there's data to suggest that BRCA1 in particular, but also two just that mutation alone causes premature ovarian insufficiency. So even not, these women are at risk because they're often told we tell them all to take their ovaries out eventually, but just having that mutation increases their risk of earlier menopause. So that's a lot of women. So when you say, okay, 3 to 4%, I mean, do the numbers. It's millions of women. And then if you count in the women from age 40 to 45, the numbers vary, but it's anywhere between 6 and 12% of the population will, you know, go through menopause earlier. And, you know, that's like, could be 6 million women. Right. And that's just the U.S. alone. Right. And some of those things that could be just like a little earlier menopause. Think about how many women get their uterus removed, but they keep their ovaries. When that happens, you have an earlier menopause, likely because of collateral blood flow from the o. From the uterus to the ovaries gets cut during that hysterectomy, but they're not informed of that risk, and they don't know to, like, look out for it. And then the women who are the really, you know, also very high risk for that are. Are black women because they are more likely to be pushed to surgical treatments for their bleeding. And other pelvic pain problems rather than, you know, be offered other conservative measures. And they're also the women who are the least likely to get help with menopause in general. So as you can see, it's not just the cancer patients that I'm fighting for. I mean, obviously that's the most personal thing to me. But I see that this is something that is reaching a very broad segment of the female population.

[Louise Nicola]

Even me, for example, who's literally, these are my circles. I still haven't been tested for BRCA1 or BRCA2. Don't have a family history, but I mean, I would still like to get tested and I don't even know where I would get tested for that. So why don't you tell us?

[Dr. Corrine Man]

Yeah, so the good thing is that, you know, genetic testing is becoming, you know, much more available. The biggest problem is people not getting referred insurance will generally not cover genetic testing if you don't meet like the nccn, you know, guideline criteria for testing. But a lot of people actually meet the guidelines and they don't realize it. And you know, there are, you know, commercial or I should say direct to consumer tests that are medically grade that you can, you can get done for, for probably about $250 cash price if your insurance won't cover that genetic testing. But I always encourage women to meet with a genetic counselor because it's not always just BRCA 1 and 2. So patients might say, well, I don't have a breast cancer family history, but you know, I've got a bunch of family members with colon cancer or some gastric cancer or uterine cancer or a lot of male relatives with more aggressive prostate cancer, melanoma. So, so pancreatic cancer. So we really want to do a really thorough job. And there are some out there who advocate for more population based testing. But you know, that's a cost risk benefit analysis out there.

[Louise Nicola]

Yeah, I think it's also, it's interesting when you can now tie in. You know, I'm not sure if you've had an APOE 4 carrier who's also had an oophorectomy and how you counted that, that, how did that go?

[Dr. Corrine Man]

So that happens. Actually it's happening more frequently where I see patients who are either BRCA carriers who are just contemplating the timing of their ovaries out or these women who have breast cancer who are in premature menopause or you know, severe long term estrogen deprivation from their treatments and they're like, Dr. Man, I'm really worried My mom had dementia, we've got early onset Alzheimer's, or I find out that I, you know, I carry the APOE gene and they're terrified, right? I don't want them to be terrified. I want them to be empowered. But the fact does remain that all three factors can make it all worse, right? So when we take the APOE gene, we add it to the BRCA1 or 2 mutation, which again, we just said they're at a higher risk of cognitive changes dimension just because they have the gene and they're at risk of losing their ovaries early. And so that combination of those things altogether, it's a snowball effect, of course. And then the other thing is these patients are not having their hot flashes, their night sweats and their insomnia managed, which we know if you're not managing that, that's also adding to your dementia risk. So, like, unmet side effects are causing the risks to go up. And these things could all be helped. But no one is putting these pieces together and no one's informing these patients. They're told you might have some hot flashes and some vaginal dryness, and then they're sent on their way and maybe given an ssri, you know, antidepressant, and told to use some coconut oil when we could do so much more.

[Louise Nicola]

I keep saying, coconut oil. Who's prescribing coconut oil?

[Dr. Corrine Man]

So they're like, I'm like, cooking oil is not evidence based medicine.

[Louise Nicola]

For what?

[Dr. Corrine Man]

Well, because this is what I can't even. I mean, because this is the problem. So you're gonna make me laugh here, but it's not funny. All right. Major cancer centers here in New York City are telling patients that first line for their genitourinary syndrome of menopause. Severe atrophy, pain with sex aromatase inhibitors in particular cause really severe atrophy and changes, and also urinary tract infections, et cetera. And they're told again, because of misinformations and fears about local, safe vaginal hormones that are guideline supported, that let's just start with moisturizers and lubricants. And for some reason, this idea of coconut oil. And so everyone's like, well, they just told me coconut oil. And so listen, I'm not against coconut oil. A single ingredient, organic coconut oil can be a lovely moisturizer. Lovely. Okay. A moisturizer is not going to fix atrophy, it's not going to improve blood flow, it doesn't prevent urinary tract infections, and it doesn't prevent, you from having urgency and frequency, maybe waking you up at night. So this is why it's related to brain health. Because if you were woken up every night to urinate, you're having disrupted sleep. That disrupted sleep, it's not good for your brain. If you have a total breakdown in your sexual function, your relationship with your partner, what does that do to your brain? I see a lot of women present to me where they're. I always ask them, what's your number one, you know, thing that you want to get out of today's visit? You know, if you could pick one thing. And some say, I want to be able to have sex with my husband again. I want to have intimacy. I want to have pain. Sex without severe pain. Think about what that does to a brain in terms of depression and mood and anxiety. So these things are all related, right? They're all related. And so I get mad when I hear that. Crisco, Crisco, we don't even use Crisco to bake with anymore. Like, we don't do that. Like, that's old school. Right. Why would we put it in our vaginas? Like, it's not okay. We have good, high quality vaginal moisturizers you can use. Vaginal estrogen is extremely safe for these women who are dealing with an ER positive breast cancer.

[Louise Nicola]

So, yeah, yeah, I think this is a really good segue now into the denial of hormone replacement therapy. Now, we've covered HRT in the Women's Health Initiative, but I can only imagine

[Podcast Sponsor/Guest Contributor]

that you're probably still getting a plethora

[Louise Nicola]

of women who say to you, but hang on, I'm not going to take estrogen because doesn't that raise my risk of getting breast cancer? Yeah.

[Dr. Corrine Man]

So, you know, I also see women who want to consider hormone therapy, but, oh, I have a family history of breast cancer or my grandma had breast cancer, or I have dense breasts. So I'm afraid my doctor says, you got to stay away from that stuff. It's poison. So, yes, I spent a lot of time breaking down the myths there and then helping women who either are very high risk for breast cancer or who have already had it, who want to consider. Could I ever consider hormone therapy?

[Louise Nicola]

Yeah, I think there's also something that's not being met. It's the one who's actually been through cancer.

[Dr. Corrine Man]

Yes.

[Louise Nicola]

And I want to actually know who owns this patient. The oncologist says, my job is done. You're cancer free. The gynecologist says, I can't give you hormones because you're of your cancer history.

[Podcast Sponsor/Guest Contributor]

The neurologist isn't even in the conversation.

[Louise Nicola]

So what happens to the women who have had breast cancer?

[Podcast Sponsor/Guest Contributor]

They've been through their therapies.

[Louise Nicola]

They're now cancer free and they've lost. They don't have their ovaries anymore. They need hormone replacement therapy to preserve

[Podcast Sponsor/Guest Contributor]

longevity and brain function.

[Louise Nicola]

Where do they go to?

[Dr. Corrine Man]

Well, right now, in the current state of our medical system in the United States and really in the world, they don't have anybody to go to. I mean, they have me and people like me. And there are more doctors who are trying to help. And it's not always HRT is the answer. I would love to give them all hrt, but there are some patients that can't have that right. If you have, you know, a reason why we have to keep you on your hormone blockers or your risk of recurrence is really high. But we still have to help these women. There's so many things we could do to help them, whether it's lifestyle medicine pillars, non hormonal medications for their hot flashes and night sweats, and then for a subset of those patients, they might be able to consider menopausal hormone therapy. And we can talk about where, you know, things are headed with that in terms of like the, the thinking and, you know, the conversation. But the problem is exactly what you named. Nobody is owning this space. The top cancer centers in the United States, none of them have survivorship, like really robust survivorship programs that include menopause care or management of estrogen deprivation and the collateral damages. Meanwhile, 80% of the cancers, the breast cancers that they're treating, the mainstay of treating them is severe estrogen deprivation. So how do you not have a survivorship clinic that actually has informed up to date physicians and other clinicians that know what this means? I mean, I am actually at my wit's end at this point where I see really top prestigious cancer centers that are doing incredible work saving people's lives and then not having the infrastructure to even answer the question on can she use vaginal estrogen? I mean, that is how low the bar is. These women can't even get guideline approved like NCCN guidelines. You know, this is not a controversial topic, vaginal hormones, but these centers can't even get patients prescriptions for that. So do you think they're getting help with this other stuff that we've talked about, about the increased risks of dementia and bone loss and sexual function and, you know, cardiovascular risks? I mean, all of these things are increased in these women and they're really kind of left to be. I'm trying to tell them you have to be your own CEO and you have to manage this because no one's coming to save you when it comes to this topic, unfortunately.

[Louise Nicola]

Why do you think it is then? Because we're in New York right now. I think what the premier is Sloan Kettering. Okay, so people will go there. Do you think it's because they're just trying to be we want to get

[Podcast Sponsor/Guest Contributor]

rid of the tumor?

[Dr. Corrine Man]

No, I think it's because the way the medical, you know, system is set up in terms of reimbursements, like, I'm sorry, like this type of care doesn't pay, it doesn't generate a lot of money. Resources are, are, are kind of, you know, finite and they're not being kind of. There's no resources put to the side to help this dimension of care. I think the demand and the interest for it and the realization in the oncology community is growing that like, hey, we do need to put resources there, but it's not really happening. I mean, you know, and in fact, in some of these centers, I've even seen the survivorship programs get cut or closed or, you know, maybe they're only have people there, you know, a few times a week. But even if they have a survivorship program, it's not generally addressing these things. It just isn't. And so what is it addressing? It's addressing things like, okay, you know, did you have your, you know, is your, you know, if they're still getting mammograms? Is your mammogram up to date? Are you up to dating your pap smear? How's your blood? Like some basic things, you know, some of them have sexual medicine help, but a lot there I find extremely overly cautious and really not evidence based. And that's where they're like told, start with non hormonal moisturizers and coconut oil. The famous coconut oil again. And when you tell a patient that, what message does that send? It sends, well, you have to suffer and come back with severe symptoms in order for you to qualify for the safe, evidence based treatment that we know works. Where else in medicine do we tell patients just do something that we know isn't really that effective for actually what's happening. Suffer. And then maybe four years later, or whenever it is when you really, you could barely hide, have even a pelvic exam, then maybe you could come back and maybe we'll consider some vaginal estrogen. In fact, the problem is that those changes have kind of progressed so much that it can take a lot longer to get function back. We can do it, but it's hard. And that's a good example of what's happening everything else in the body. So the same thing with brain health, with mood, depression, anxiety, with cardiac health, muscle. If we wait until the patients are just, just really suffering, we've got to do it on the front end. What I would like to see at these centers would be the minute that patient is told, like, okay, the next step in your treatment is now we're going to move into.

[Louise Nicola]

Yes, lead them.

[Dr. Corrine Man]

Yes. And I get it. It can't happen all at once. You get the diagnosis. You got to see the, you know, the breast surgeon, the plastic surgeon, plan your surgery, what chemotherapy or other treatments you're getting. And that's a lot to manage. But if they could just get the message up front that, listen, listen, sometime in this treatment, you know, we are gonna move into this phase where you might have premature menopause or, you know, medication induced menopause. But don't worry, when we get there, we have a whole team of how we're gonna help you manage that. And we're gonna go through the risks and benefits and we're gonna support you. Don't be afraid. But women are petrified of this. And sadly, some women even refuse these treatments, which I get it, because they're either suffering and so they stop early, their endocrine therapy. The rates of endocrine therapy compliance are only about 40%. Some studies quote even higher because women have a very hard time with the side effects. Not all women do. Some women do okay. Some women are well managed. But there's a percentage of people who just. And I feel like half the time when patients come to me for this help and maybe even like, oh, could I ever consider hormone therapy? Sometimes half of my job is just helping them stay on their tamoxifen, helping them stay on their aromatase inhibitors, because they have a real value and a benefit. And then other times I'm like, wait, has anyone explained to you that for you in particular, the percentage value that you're getting from that is not that much, and this is causing you a lot of damage. So there's a spectrum there. Right? But what all of these women would just want is some recognition that it's more than just a little hot flash and dryness and that their concerns about their long term risk of dementia, heart disease, bone health, et cetera, you know, are valid. They're valid. And I get that, like, the metastatic breast cancer can kill you. And for some women, that risk is so significant that that's where we're focused our attention. But with earlier diagnosis and people doing better, living longer, we can't ignore this whole other side. And that's really what I faced and the decisions I had to make for myself when I had to balance all those things. And so I wish these centers would just have those resources. It's actually not that hard.

[Louise Nicola]

I mean, you say it's not hard, and I get that, and I'm completely with you. But now just hearing everything and all this stuff going through my head, it's like, it's so individualized. You know, we've got, you know, 51 of the population are female. We are.

[Podcast Sponsor/Guest Contributor]

And we're all different.

[Dr. Corrine Man]

Yeah.

[Louise Nicola]

Okay, imagine that. And you're saying 3 to 4% of the female population will be diagnosed.

[Dr. Corrine Man]

Was it with, you know, with earlier menopause, with premature menopause, and 6 to 12% with early. So premature and early. And so again, I use the breast cancer patients as an example because I think they're the ones who are. Have it kind of the worst. Right. But again, you know, there's a whole, you know, segment of the population that has. Has similar concerns. Right.

[Louise Nicola]

Yeah. And the reason why I brought you here is because whenever I do a podcast focused on hormone replacement therapy, a lot of the women in the comments are saying, hey, I'm positive for this, and I'm positive for that, and I can't take this. And so if a woman is on tamoxifen. Right. For the. And would that be for the rest of her life? Maybe.

[Dr. Corrine Man]

No. Tamoxifen is either given for five to ten years. Yeah, yeah. It's not permanently, but. But. But remember, when the tamoxifen ends, many of these women are then either already in menopause due to chemo or they've had their ovaries taken out.

[Louise Nicola]

But can you do hormone replacement therapy

[Podcast Sponsor/Guest Contributor]

and be on these drugs at the same time?

[Dr. Corrine Man]

No, we don't give systemic estrogen and progesterone. Typically with women on tamoxifen. Aromatase inhibitors, certainly aromatase inhibitors, they don't work. It requires an already low estrogen state. I'll go out on a limb here and tell you that for women who were on tamoxifen, the standard of care is certainly not to give them systemic estrogen and progesterone. Could it be done? Yeah, it could be. And in fact, in the early studies of hormone therapy, hormone replacement therapy, after diagnosis of breast cancer, the Habits trial, the Stockholm and the Liberate trial. In all of these trials, easily at least 30 to 50% of the women in the trial were on tamoxifen. And I just kind of throw that out there because we have to think a little bit, Big picture in common sense, pre menopausal women who were taking tamoxifen, and I was one of them for many years, I was still premenopausal and I was on tamoxifen. Not many years, but a few years. So I had. My ovaries were producing tons of estrogens. I was ovulating every month. You know, I had progesterone being produced and tamoxifen was being given to me and it was blocking estrogen receptors. So, all right, we could put our thinking caps on. Why is. Why is that different than someone who is maybe on tamoxifen and maybe they lost their ovaries or they're in the late part of perimenopause and they're really suddenly now having a lot of, why couldn't we give her a little bit of progesterone orally at bedtime? Why couldn't we give her a little bit of transdermal estrogen now? Now, it may not help as much for her because the tamoxifen is blocking receptors, but theoretically, it shouldn't be completely off the table. And in fact, they addressed this in a really important piece that was published in the Menopause Journal this January by Sarah Glynn and her team. It was a kind of a consensus review of how to approach these very hard questions about menopausal hormone therapy after breast cancer. Right? The hormone therapy, local hormone therapy, vaginal hormones, we already know. Tamoxifen, aromatase inhibitors, anything in between, you can use local, safe vaginal hormones. The bigger question is the systemic hormones. And so just like breast cancer is treated individually, we're going to look at that patient individually. Right? Are you a triple negative patient? And you don't. Your, you know, estrogen deprivation was never part of your cancer treatment. Right. You may have had years of normal periods and now you've gone through natural menopause, or maybe you're a B or CA1 carrier, because triple negative breast cancer is more common in BRCA carriers. So those patients suddenly face an abrupt surgical menopause from their brca, but it had nothing to do with treating their breast cancer. But because they have a history of breast cancer, no one will talk to them about hormones. Like, it doesn't make any sense. Sense These women went years with normal periods. So this is my one example of how we have to look at these women individually. Right.

[Louise Nicola]

I was just at a lunch, and this woman next to me says, oh, you know, I follow your podcast. Can I ask you some questions? So her mother had had dementia. She had Alzheimer's disease. This woman, I think, you know, I didn't ask her age, but she would have been, you know, in her. Let's just say, late 50s.

[Podcast Sponsor/Guest Contributor]

She went to.

[Louise Nicola]

To three neurologists here in New York, and she said, I have learned about the P Tau 217 and the amyloid beta ratio test. I want to get this done. She got turned away by three neurologists, all because I kept.

[Podcast Sponsor/Guest Contributor]

I was really.

[Dr. Corrine Man]

What are the reasons?

[Louise Nicola]

The reasons for all three of them were simply, it doesn't matter, because if you've got it, if you do have an elevated ratio and you've got towel in your brain, there's nothing we can do. So there's no point. I don't want you to go and get, you know, you're. You're older now. I don't want you to go on and, you know, far and stress over nothing because there's nothing we can do about it.

[Dr. Corrine Man]

That's not true.

[Louise Nicola]

I went.

[Podcast Sponsor/Guest Contributor]

I was livid.

[Louise Nicola]

And so I'm actually going to do a reel on this. You know, I wish she could be part of it.

[Dr. Corrine Man]

Right.

[Louise Nicola]

But, you know, it just.

[Podcast Sponsor/Guest Contributor]

I couldn't believe it.

[Louise Nicola]

I was so shocked. And so she went out by herself and she found that you can do it, you had to pay for it. But she went and did it herself, and she's like, but I've got the results. Now what do I do? I was like, okay, that's a whole different ball game. But it must. That's what women are dealing with now.

[Dr. Corrine Man]

Yeah.

[Podcast Sponsor/Guest Contributor]

Yes.

[Dr. Corrine Man]

And the thing is that even all the things we talked about is scary. And your work and what you do with the dementia and mine with breast cancer. These women deserve to know what risks they have and that there are actionable things we can do and maybe not everybody can do. I always tell patients there's a buffet of choices of how we're gonna deal with this. Right. Some people can choose these things, some people can choose these things, some people can choose them all. And some people have different comfort levels with these different choices or motivations. But you all deserve to be told what your risks are that you're facing, not just for your breast cancer, but for everything else and what choices you have. And if we tell Patients that there's just not enough study. We don't have enough data on this. We have to wait. I don't know enough. You know what? We're big girls. We can handle that. Like, okay, there's limited data on this for you. This applies to you in this way, and you can make an intelligent, informed decision about what's the best way forward. Right. And so it's kind of how I try to explain it to women about things like testosterone after breast cancer or making a decision about menopausal hormone therapy after breast cancer. We don't have perfect data. We have some data. We can also put our thinking caps on and say, what's the best way to approach it for you? Right. But really don't get that. They get like. Because nobody one size fits, nobody owns them. That's why.

[Louise Nicola]

That's. Yeah, no, I completely get that. I. We're coming to the end, but I want you to share some positive stories of if you. If you can, of a patient that has, you know, probably been through hell, but now she's on the other side.

[Dr. Corrine Man]

Okay, well, I'll give you a. I'll give you a story about a young woman who. She's my. My friend. And she was diagnosed also at 28. Her sister was the founder of the Young Survival Coalition, one of the founders. And she was a BRCA1 carrier. And she was going in for a prophylactic mastectomy. And at that time, she found out that she actually already had breast cancer. And so she had an early stage breast cancer. She went through chemotherapy, and she, you know, had a temporary premature menopause. That was hard. She preserved some embryos prior to her treatment, and she went on to have two beautiful baby girls, lots of normal ovarian function. And then a number of years later, she had her ovaries removed. And she struggled bad for two years because nobody would help her. And guess what? Now, after empowering herself and learning, she learned what she needed to do from a lifestyle medicine, you know, way to vaginal hormones to we got her some testosterone. And she's actually with the support of her medical oncologist on menopausal hormone therapy. And she's doing fantastic. And so she's living her best life. And I'll just kind of contrast that with. Also I have a lot of breast cancer survivor friends and patients who are in menopause and will be in menopause forever. And they. They can't take systemic hormone therapy because of their particular case, but that has motivated them to take charge of their health in every other way. And they're frankly fitter, healthier, more vibrant, more purposeful and more driven than a lot of the average menopausal women I see. Because you can't out patch a crappy lifestyle and kind of just a sedentary life. So I know these things sound scary, but you have the power and you need to be a squeaky wheel to demand the care that you deserve.

[Louise Nicola]

Oh my gosh, you're brilliant. I've said that probably like how many times today. Thank you so much. Do you accepting your patients?

[Dr. Corrine Man]

Yes, I do. And I do a lot of consults for patients, even with their doctors. So direct care, but also a lot of just educational consults where I'll get them sited up and then I'll send them on their way. I do them in other countries and other, other states because I need to empower them so that they can work with their own physicians in their community. Because there's only one of me.

[Louise Nicola]

I think, yeah, I think that the future of medicine can be like a board of directors. Imagine if you have a neurologist with you as well.

[Dr. Corrine Man]

Yeah, yeah, totally.

[Louise Nicola]

Everyone.

[Dr. Corrine Man]

Absolutely. And I, I tell patients this all the time. Listen. These breast cancer patients in particular, curate your team wisely. And what you start with is sometimes not who you stay with. I switched my care about through the years. This is my. I'm 25 years from diagnosis this year. Yeah. And so I've seen it all. I've seen a lot of changes and a lot of great positive movement. But I've learned along the way that in the end, you gotta rely on yourself.

[Louise Nicola]

If there was one thing that you

[Podcast Sponsor/Guest Contributor]

could, if you got granted a wish

[Louise Nicola]

for changing the state of the, of the current medical industry in your specialty, what would that wish be?

[Dr. Corrine Man]

I think I just would wish that we would value ovarian function beyond our reproductive capacity. Because what I see is that everything that I experienced as a cancer patient when it came to my ovaries was about how could we protect her ovaries from failing so that she could have a baby. But once that reproductive fertility concern was done, my other concerns about what that ovarian function loss was for me was just no one really thought about it being important. And so I just think that we're not valued beyond our reproductive capacity. And if we were valued beyond that in medicine, it would be a good thing.

[Louise Nicola]

Well, here's to you, my friend. Thank you so much for coming on the podcast.

[Dr. Corrine Man]

Thank you for having me.