Breast Cancer and Menopausal Hormone Therapy: Risks and Benefits

Welcome to The Breastcancer.org Podcast, the podcast that brings you the latest information on breast cancer research, treatments, side effects, and survivorship issues through expert interviews, as well as personal stories from people affected by breast cancer. Here's your host, Breastcancer.org Senior Editor, Jamie DePolo.

Jamie DePolo: Hello, as always, thank you for listening.

Menopause and hacks aimed at eliminating its symptoms seem to be everywhere. Social media is full of people promoting products to ease hot flashes, restore sexual desire, improve sleep, and smooth out wrinkles.

Tops among these solutions is what used to be called hormone replacement therapy, or HRT, now called menopausal hormone therapy. But what if you've been diagnosed with breast cancer or are at high risk for the disease? For many years, people with a history of breast cancer were told menopausal hormone therapy wasn't an option.

Today, things are changing. To help us sort out the facts from the hype, I'm honored to be joined by Dr. Kristin Rojas, a fellowship-trained breast cancer surgeon and board-certified gynecologist at the University of Texas MD Anderson Cancer Center, where she directs the OASIS program. OASIS stands for Onco-Menopause and Intimacy Specialists. Dr. Rojas, welcome to the podcast. It's so wonderful to talk to you again.

Dr. Kristin Rojas: Thank you, so much, for having me, Jamie. I just love our conversations. They're great.

Jamie DePolo: Oh, well, thank you.

This is such a hot topic. Earlier this year, the FDA removed the black box warnings from hormonal therapy products, and overnight, it seems like everyone on social media was promoting estrogen as the cure-all for anything related to getting older. Like I said, wrinkles, dry skin, lackluster hair, belly fat, not to mention all the menopausal symptoms — hot flashes, low libido. 

So I want to start by asking what can and what can't hormonal therapy products do? Does every woman need them, and can you talk a little bit about the history of the black box warning, and the WHI study, and how we kind of went from that to today, where it's, first it was bad, now it's like the magic elixir?

Dr. Kristin Rojas: Yes, this is a great question, and I can definitely speak to… even as a doctor who trained in gynecology, originally, although I'm a breast surgeon now. I remember coming up through residency, and I was a little perplexed because the landmark trial that we use to determine what is the risk profile for this type of medication seems like it was widely misinterpreted back then, and I remember reading it and thinking, huh, this isn't really what I learned.

And then now it's kind of like society is kind of caught up. So, I'm happy to talk about this.

I think, first, most importantly, we should distinguish between local hormone treatments and systemic hormones. And first, I think what we're going to talk about is systemic hormones, and that means like estrogen, plus or minus progesterone, depending on whether you have a uterus, and usually, that means your whole body sees it.

That's what I mean by systemic. So, that's either a pill by mouth, a cream on the skin, that's not the vulva or the vagina, or a patch. And so, in the '80s and the '90s, we had some research studies that were what we call observational. They seem to show a cardiovascular benefit when looking at women who took systemic menopausal hormone therapy.

And what I mean by that is that maybe it was a lower risk of heart attack when women around the natural age of menopause, which is age 51, 52, start to take menopausal hormone therapy.

The reason that that was being prescribed is, for those of our audience that don't know, menopause is usually a pretty gradual process. The ovaries release estrogen, and they typically slowly start to release less and less estrogen over time, and that's manifested as hot flashes, which is usually kind of the barometer for menopause is here. 

Every patient is different, and their experience is nuanced, but patients, once they started to feel hot flashes, would take these hormones. So back then, there were these studies showing that women who took these hormones around the time of menopause had a lower risk of heart attacks. And women, in general, have a lower risk of cardiovascular morbidity or heart attacks. But the rate starts to increase to a rate similar to a man's, once the estrogen goes down. So it does make sense biologically that estrogen can be protective.

So these studies back then shaped enthusiasm for systemic MHT. A lot of people started taking it. We learned that women with a uterus needed to take progesterone, as well, to not increase the risk of uterine cancer. If you think about it, estrogen is like the gas pedal on the uterus. So it can cause atypical or abnormal pre-cancerous cells to grow, whereas progesterone is kind of the brakes. If you still have your uterus, you need progesterone in some form.

So then came the WHI. So the Women's Health Initiative was the first randomized controlled trial looking at this question, and so, it was huge. They took 160,000 women, and there was actually two trials baked into one. So women with a uterus and women without a uterus. The women with a uterus were either randomized, meaning they didn't choose, but they were selected to go on either taking the menopausal hormone therapy, or they got a placebo. And then, the women without a uterus only needed estrogen, whereas the women with a uterus had estrogen plus progesterone.

And this study actually wasn't allowed to finish. So they didn't actually get the final results because it was stopped prematurely. It was designed to look at what's called a global health index. So coming off the heels of these other studies, looking at whether taking menopausal hormone therapy, when studied this way, actually improved the global health index, which included heart health as well as lower cancer rates. 

And it was stopped prematurely because they thought that they saw an increase in the risk of breast cancer for patients who were taking estrogen and progesterone. But as I was coming to residency, looking back at this trial, the media picked this up, and it exploded. Everyone interpreted it as menopausal hormone therapy causes breast cancer. Everyone stopped taking the hormones. Women were suffering all over the place.

And then, when I looked back, I remember seeing, wow, I don't think that's actually what this trial found, when you read the details. Furthermore, the patients who got estrogen alone, their long-term follow-up, after 20 years, they actually had a lower risk of breast cancer. So, when you look at the details, when these results are actually adjusted, meaning they account for different statistical changes, their result was not statistically significant, meaning that the results were similar, but it's kind of complicated.

The absolute risk increase actually was only eight to nine additional breast cancers in women taking this per 10,000 patient-years. So that's actually less than the risk of breast cancer associated with drinking two glasses of wine a day, with obesity, divorce, you know, normal life things that come up. So even in patients where it might increase the risk, it wasn't quite as big.

So menopause entered the chat a few years ago. A lot of big celebrities and other people started talking about it, and everyone started looking at this trial more critically, and thank goodness the FDA removed that black box warning, because we needed it off those vaginal hormone products, for sure. But it's definitely the pendulum has swung in the other direction. And now, I'm trying to help patients understand, okay, when are hormones right for you, and when are they not?

Jamie DePolo: So, does every woman need a hormonal product? I see things online, and people say, oh, well, if you don't take it, you're going to get Alzheimer's, your hair is going to fall out, and you're going to get really fat. So I'm looking at you to help me understand this.

Dr. Kristin Rojas: Yeah, great question. Great question. So systemic menopausal hormone therapy is actually FDA-approved only for a few things, and that's to treat vasomotor symptoms associated with menopause. So that's hot flashes. And for the treatment of what we call premature ovarian insufficiency, which is when women's ovaries stop working before the age of 40.

And so we know that those patients do need some of those systemic hormones back to help decrease the risk of things like osteoporosis and other chronic long-term medical conditions. It is FDA-approved for the prevention, but not the treatment, of osteoporosis, as well. 

But you're right. When people look at social media, they see that, oh my gosh, if I don't take it, like I'm going to turn into some other version of myself. And it can make you pretty scared, but there are many women who go through the gradual process of menopause, and they are healthy, and they feel okay, and they don't have these hot flashes that disrupt their sleep and alter their lives, and not everybody needs hormones.

Thinking back about the Women's Health Initiative, one result that I didn't talk about was that those patients who got hormones actually did have a higher risk of what's called like a blood clot in the lung or the legs, a stroke, and those patients actually that were recruited to that study, there was a large proportion of them that were obese, many smokers in that, and so, those things also increase that risk.

So when I'm thinking about who's right for systemic hormones, outside of the context of cancers, I think about, okay, what's their cardiovascular risk profile? And we know that when we start systemic hormones more than 10 years past the natural age of menopause, it actually increases their risk of some of those catastrophic health events, like a blood clot in the lung or a stroke. 

And so, specifically, patients who are on social media who went through menopause more than 10 years ago should not be just running to the first provider that's going to prescribe this for them, because that could potentially increase their risk of stroke. It's a nuanced discussion and why it's important to seek a well-trained provider for those discussions, as well. But not everybody needs it. It is very helpful for several medical conditions.

It probably helps with a few other things. Like, the data isn't great, but it might decrease your risk of dementia if started around the time of menopause, but we don't see that improvement when we look at patients who start it much later, which is some of…so, there really is something to how many years have passed since you've gone through menopause when we're starting this treatment.

Jamie DePolo: Okay. So, that's talking about women in general. Now I'd like to shift to women specifically with a history of breast cancer who are at high risk. That's primarily our audience. So based on the WHI and other things, it wasn't even an option. 

It was like, okay, especially — and I'm thinking especially of women who were thrown into early menopause because of breast cancer treatment. I know that's tough. I can't even imagine how tough it is. And now, the answer seems to be much more nuanced and individualized. So could you help us understand sort of the latest thinking about hormonal products and breast cancer?

Dr. Kristin Rojas: Sure. Well first of all, I'm a huge proponent of hormones in general. So I'm going to come at this from my like scientific lens and give you the pros and the cons. I also want to say that for women with a history of breast cancer, I'm a huge proponent of local vaginal hormone therapies for treatment of vaginal dryness and painful sex, which is a common side effect from a lot of our treatments. 

So that data is a little controversial, but I'm a huge proponent of that, and I think people that need that should find a good provider who feels comfortable to collaborate with your oncologist.

Now with regards to women with a history of breast cancer, historically, it's been a blanket no, regardless of what type of breast cancer you have. 

And we now know, we've gotten really good at treating breast cancer, women have, I mean, it becomes, you know, part of their chronic medical history, a blip in their medical history for some, and then they've got this diagnosis attached to them, and then they're not eligible for so many things.

And we know that it is a spectrum of disease, and for some patients, it really should be potentially a question, or at least an informed discussion, and not a blanket no, whereas there are other patients where it's like right now is not the right time for this. And I'll explain kind of how I think about that.

We do actually have some data looking at this. There are a lot of proponents for systemic menopausal hormone therapy for breast cancer survivors out there who have kind of pulled together a lot of the observational data and advocate that it's safe, but the two prospective randomized trials that we have, the big ones we always talk about, are the HABITS study and the Stockholm study.

And both of these trials were also stopped prematurely in the wake of the media explosion from the Women's Health Initiative, and it's interesting because they kind of found two different results. One study found that there is an increased risk of recurrence in patients who get hormones, who have a history of breast cancer, and the other study didn't.

So it further muddies the waters. What I advocate for now is a really specialized, nuanced discussion with the rest of the oncology team, and I think about it. So a patient who has, say, 5 mm of DCIS, ductal carcinoma in situ, who had a mastectomy, is five, seven years out, not on any endocrine therapy, like she's going through her natural menopause. Like, maybe she might be an appropriate person to do this in the safest way possible. You know, triple-negative patients, people who don't have estrogen receptor-positive disease, that's a real question, as well. And there is some observational data showing that it probably doesn't increase the risk of recurrence, but we just don't know. It's just a question mark, you know? We don't have the same kind of high-quality data that we like to have as oncologists.

So it's a really nuanced discussion. I would recommend anyone who wants to have a discussion about this to find a local menopause-certified provider in their area who's willing to collaborate with their oncology team. I can tell you that many oncologists are probably going to say no, because that's what our guidelines say.

But I hope that with improving clarity on this issue, the removal of the black box warning, and in an effort to take patients away from what I call fringe therapies, which I think we're going to talk about, I hope that we could start to think about this in a more nuanced way. But DCIS patients who've been completely treated, triple negative patients who are many years out, going through natural menopause, to me, those are very nuanced discussions. 

The patients who are on endocrine therapy still, because they had estrogen receptor-positive breast cancer, that's kind of a no-go, because there's not a lot of safety data on combining endocrine therapy, something like tamoxifen, with systemic estrogen. I worry about those patients having like an increased risk of a blood clot or a stroke.

Jamie DePolo: Okay, and you mentioned at the beginning, and I just want to make sure that we talk about this. In the past, it was a no-go for any hormonal products, but as you just mentioned, local hormone therapy can be very helpful for somebody with a history of breast cancer, and my understanding, and of course, I'm going to defer to you as the expert, is that there is much less risk with local hormone therapy that, say, is applied in the vagina or to the vulva. Am I right in understanding that?

Dr. Kristin Rojas: Yes, with caveats, yes.

Jamie DePolo: Okay.

Dr. Kristin Rojas: So back in the day, when we first started using vaginal hormones, like specifically vaginal estradiol, we used much larger doses than what we use today. So when we measured patients' blood after giving this to them, so they would have very thin vaginal mucosa because they'd had, you know, estrogen deprivation for a while, so they're very symptomatic.

The tissues of the vulva and the vagina are paper-thin. And then you give them the 25-microgram dose of estradiol on that paper-thin mucosa every night for two weeks, you're going to see that the estrogen levels in their blood increase. Today, we have very, very low doses of this vaginal estradiol, including 4 micrograms, 10 micrograms, and we also give it to patients differently. 

So in the OASIS program, we've initiated a protocol to help decrease the risk of systemic absorption to help alleviate not only oncology providers' concerns, but also patients'. So, what we do is we pre-treat those delicate tissues with a non-hormonal moisturizer, improve the quality, get them a little bit thicker, more moisturized, and then we'll add an ultra low-dose vaginal hormone, either estradiol or another hormone called DHEA.

And we'll start with once a week, and then we'll increase to twice a week, and most of the time, we can get patients better with much more infrequent dosing. Sometimes with the estradiol, patients really just have symptoms on the outside, and that comes in a cream.

So we'll oftentimes recommend patients just apply it to the outside, and we know systemic absorption is also lower with that as well. So we're really tailoring how we give vaginal hormones, as well. But I don't tell patients that it's completely off the table, but I do have to have a lot of conversations with oncologists. So I think when I explain all these things that we do to decrease absorption, usually they're more on board.

Jamie DePolo: Okay, and is that also more of a concern for somebody who had hormone receptor-positive breast cancer versus, say, triple-negative or hormone receptor-negative?

Dr. Kristin Rojas: Definitely. Like, these patients, like we've made them estrogen averse. You know, we treat them, and every message that they're getting is no estrogen, no soy, no this, and then, all of a sudden, I come in and say, well, maybe vaginal estrogen. It can be very confusing. But yeah, so, we really apply the same principles to our estrogen receptor-positive and our estrogen receptor-negative breast cancer patients, minimizing systemic absorption, only using what we need to treat.

And I think that's the best way to make everyone happy, both providers and patients. And so, we don't deny patients these medications based on their disease type, whether it's estrogen receptor-positive or -negative. Really, the only true contraindication to vaginal estrogen is patients who have, like. locally advanced hormone-sensitive uterine cancer.

Because it's, like, close by to the vagina and theoretically could potentially increase the risk of recurrence, although the data is kind of iffy on that. So those are the patients that I have a longer conversation with about that, but when we apply these methods for the breast cancer patients, regardless of estrogen receptor-positive or -negative, when we do it this way, I feel pretty comfortable with that.

Jamie DePolo: Okay. Okay. Thank you for that. Now I read a recent JAMA article that said that tens of millions of compounded bioidentical hormone prescriptions are filled each year in the United States. So I have a couple of questions for you about that.

First, can you explain to us what compounded bioidentical hormone products are? I have an idea, but I'm hoping you will tell us, and are they safe? Are they effective? What exactly is going on here?

Dr. Kristin Rojas: Yes. So bioidentical is a marketing term. So estradiol you get that's approved by the FDA is the same estradiol you might get from a compounding pharmacy. So people pitch it as being bioidentical, meaning somehow safer or more effective. That is false. We don't have evidence suggesting that.

Compounded formulations, so when you go to a specialty compounding pharmacy, sometimes, very rarely, we do utilize those pharmacies for patients who might have certain allergies to different additional ingredients in FDA-approved products. Like, sometimes, we collaborate with compounding pharmacies about designing specialized formulations for them, but we have an array of products that are FDA-approved.

And we know how your body is going to absorb them and what the levels are going to be and they're tested. So we know exactly what's inside of them. So the reason that's an issue is they've done studies looking at this. They ordered a bunch of, like, compounded hormone formulations from different compounding pharmacies, and they actually measured in a lab. Do they have what they say they have, at the strength or the quantity that they do? And majority of the times, or oftentimes, they don't, which is pretty disturbing.

And so I think the fact that they're also unregulated by the FDA, especially for patients in the cancer space, makes me very nervous, especially when we have FDA-approved alternatives.

One more issue that I think that's really important for compounded pharmacies is if you have a provider who's, like, sending you to a specific compounding pharmacy for this one thing, you don't always know if they're getting a financial kickback from that. 

There's a huge push to make sure that all these financial disclosures are more clear, especially in the world of Instagram influencers, etcetera. You don't always know when you're seeing an ad, when you're talking to this "expert." I think people should be really, really wary of that.

Jamie DePolo: Okay, and I know, a while back, maybe this isn't true anymore, but the term “bioidentical” was used, a lot of times, talking about things made from plants, and they were saying like, oh, this is the same thing that your body makes, but it's natural. So it's so much safer. Is that still true? Are those types of formulations still out there, and do they work?

Dr. Kristin Rojas: What I've always said is, like, if you make estradiol from a soybean, that's not an any more natural process than what happens with making estradiol in the lab. It still has to undergo…like, that doesn't happen in nature, you know? So for me, it's never really made sense. I'd invite any experts on this to, you know, tell me more about that specific aspect. 

But the North American Menopause Society, now called the Menopause Society, has a really good statement about this, and we really don't endorse these, like, "bioidentical compounded therapies" when we have FDA-approved formulations. Where I think it gets a little tricky, and what we're probably going to talk about, is like testosterone, because we don't have an FDA-approved formulation for testosterone for women, and that's where things get really muddy and confusing.

Jamie DePolo: That is the perfect segue to my next question, because there is a huge buzz right now about testosterone therapy. So I've read a little bit, but what is it used for, is it effective, and are there any risks?

Dr. Kristin Rojas: So, testosterone is not FDA-approved for the use in women. What is happening is that providers typically will prescribe a tenth of the dose that they would prescribe a man for low testosterone and apply that to women. Usually it's given transdermally, through the skin.

The data on testosterone and low desire is not super strong, but many patients will pursue systemic testosterone because of low desire or low libido, but it's also being pitched as, like, helping with muscles and energy and fatigue, and that's a little bit trickier because those symptoms can have, like, multiple factors.

But for these patients, you know, I think also, oftentimes, are told, oh, this is testosterone. You have, you know, an estrogen-sensitive cancer, then this is safe, and we really don't have that data, and I would actually suggest the opposite. I see a lot of patients who are diagnosed with breast cancer, and we're getting them off testosterone pellets. 

We've done studies looking at this, at the blood levels of testosterone in patients who get those pelleted therapies. It can be really, really high. Those pellets can dissolve all at once and lead to these really high levels of testosterone, and we don't know what that means for a patient's cardiovascular issues. There's not great data on that.

And we know that a lot of the testosterone does get converted to estrogen in the fat cells, and so we know that that also means increased estrogen. So we don't know what that means from a cancer perspective.

And then, lastly, this is anecdotal evidence. But I have talked to patients who've had, like, really serious psychiatric manifestations after getting a testosterone pellet that dissolved all at once, like having to go to the hospital for a manic episode. You know, this is outside of the known effects of too much testosterone for women.

And that's the irreversible side effect of voice deepening and potentially reversible side effects of things like acne, hair loss, or what we call temporal balding. So you might get, like, a male pattern baldness and what we call clitoromegaly, which is where the clitoris starts to enlarge.

Jamie DePolo: Oh, okay. Okay. And people are mainly taking this for low desire? That's what people are doing?

Dr. Kristin Rojas: Yeah, I think that because not all providers have the language to talk to patients about low desire, and patients might be embarrassed, it's not always what they say it's going to be prescribed for, but it ends up oftentimes being a motivation. In my anecdotal experience, it's kind of prescribed as this like catch-all for everything that's wrong in your life, and I've seen it cause real big problems.

So oftentimes, when I'm meeting patients, when I'm wearing my breast surgeon hat, is we're trying to get patients off these pelleted therapies, and I feel really bad for them because what I tell them is let's try to taper off what you're on to get you to surgery, not on systemic hormones, but stopping everything abruptly, especially if they've been on pellets, and we're letting it wear out, like they feel awful because their hormone levels have been so high. 

They feel much worse stopping it, like a withdrawal of drugs almost, than if they would have been, you know, stopping a lower-dose systemic hormone. I think there's just a lot out there that's very concerning for me. And one of the reasons that I'm such a vocal proponent of these nuanced discussions about FDA-approved systemic hormones is to try to keep patients away from these potentially unsafe therapies, especially in the cancer space.

Jamie DePolo: Okay, and just, I'm sorry, I don't want to dwell on it, but just one last question. Is most of the people that you're seeing, these are people who've been diagnosed with breast cancer and then went on testosterone, or were they on it before?

Dr. Kristin Rojas: So speaking generally, breast surgeons may encounter a patient who's newly diagnosed, who's coming off systemic hormones, specifically pelleted therapies. I've also seen patients — because I run a different type of program — I know that patients are also being recommended these therapies in the survivor phase of their treatment, when they're in survivorship, because they're being pitched as more safer alternatives.

Jamie DePolo: I see. Okay.

Now, there are so many people on social media touting menopause products, menopause tips. And I know it's hard, but do you have some tips on how people can figure out what's accurate and what's evidence-based? Because I just feel like, it's like sensory overload when you go on social media sometimes. 

Dr. Kristin Rojas: Jamie, you should see my Instagram feed. Because I go in and look at this critically, and you know, I've paused on the video, and I'm like, wait, is this person actually a doctor? You know, and it's like, that is all I'm getting. So it can be very overwhelming. I imagine it's similar for patients.

But I'd say, first thing is, you know, women today are educated health consumers. You know, take that person's name and put it in Google. Are they actually a doctor? That's the first question. Are they licensed in this particular field? 

You know, people can call themselves doctor from a variety of methods, these days, on social media, and they're not really being checked for that. So I'd look and say, okay, is this person employed by, like, a reputable medical establishment, or is this some fringe person who's probably getting kickbacks for pitching this topical estrogen face cream promising like youth forever? I think that that's the first thing, is put it into Google, figure out who they are.

I recommend patients, if they want to speak to someone, looking for Menopause Society-certified practitioners in their area. You can search online. I think that's a great place to start because those providers know the data, and they're going to give you the safest options. Online, you should always think about, are they trying to sell me something? And what are their credentials? Because it can be very convincing. You know, I see it too.

Jamie DePolo: Yeah, and one thing I've seen, too, is people will talk about a study, and then I'll try and go and find the study, and I can't. I'm like, wait, where did this come from? What are they talking about? And to me, that's always a big problem.

Dr. Kristin Rojas: Yes, that's a great point. Because our patients are so informed, they're now on PubMed, actually looking up the trials, and they'll print it out and bring it to me, and I explain it to them. So actually, a really good thing to think about is if you're looking up studies that someone's pointing to, like, look and see what journal published it, okay?

You go to that journal's website, and you can see their impact factor. If they don't have an impact factor, like, you can publish almost anything, where you have 20 patients, and you show that you gave them these pellets, and they didn't develop breast cancer, and they can publish it in some crackerjack journal if you pay like $3,000. But that doesn't necessarily mean that's like our usual rigorous peer-reviewed science.

So something coming from JAMA, like we mentioned earlier, some of those big journals, definitely, they have to have a certain, like, scientific rigor to get published, and we believe that data much better. So not all research studies are created equally. If you go to that person's website, as well, like whoever's pitching you this thing, and there's immediately something that you need to buy, that would also be like a potential red flag, I think.

Jamie DePolo: Okay. Okay. And then, finally, to sum up, what are the most important things about menopausal hormone therapy that somebody with a history of breast cancer should know?

Dr. Kristin Rojas: I'd say the most important things someone with a history of breast cancer should know is that this is a very nuanced discussion. It's not yes or no to hormones or no hormones. There's many different ways that we can give hormones.

Specifically, I talk to patients a lot about local hormones because we can generally agree that when done correctly, it's safe. Just hang in there until I work on these guidelines a little bit more. We have a lot of movement in this area where we're starting to think more critically about, does every patient need a blanket no and at what point might it be safe?

There's some research initiatives in this area. In the meantime, for our systemic symptoms, so like hot flashes, etcetera, we have great non-hormonal options, specifically FDA-approved therapies. So don't just think it's only hormones or nothing. We actually have a lot of ways that we can come at a lot of these issues.

We do a lot of referring to, like, sleep experts. You know, there's a lot of work being done in brain fog now. Historically, a lot of these issues that were hard to treat, we're working on it. So just get an opinion, get a second opinion, and be an educated healthcare consumer. Don't buy the first thing that gets thrown at you through Instagram.

And just know that it's very nuanced depending on what your risks are, the type of cancer that you've had, even your family history, potentially, and where you are in this phase of life. And so, it really does take an expert provider to have that discussion with you. It's never a five-minute conversation. So find a licensed or certified provider who can help you with this, and that's why the Menopause Society is such a great resource.

Jamie DePolo: I'm sorry, one last question. In your experience, do most of the people who are certified by the Menopause Society, do they have experience with cancer, as well, or is that something else that you need to ask about?

Dr. Kristin Rojas: In my experience, the Menopause Society providers I've come across are very experienced in talking to patients with a history of cancer, and know the evidence and how to find the appropriate evidence. So I think that while there might be certain providers who might be more vocal, I definitely think that one of the skills that they have is knowing the best available evidence and safe prescribing practices. So I think it's definitely a good place to start.

Jamie DePolo: Okay, perfect. Dr. Rojas, thank you so much. This has been so helpful, so informative. I can't thank you enough for all this.

Dr. Kristin Rojas: Thank you, so much, for having me. Thank you, Breastcancer.org. I love working with you guys. This is so important.

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