"Can't Take Estrogen?" Dr. Corinne Menn on Who Should, Who Shouldn't & What's Changed

Dr. Menn describes how during her own chemo in 2001, no one addressed the genital and urinary devastation that would follow. She now teaches that GSM isn't just 'dryness'—it includes vulvar and clitoral atrophy, decreased sensation, urinary urgency, recurrent UTIs, and even inability to tolerate a speculum for cervical cancer screening. She sees women whose marriages have collapsed because sex became excruciating, yet they were told to 'use coconut oil.' She advocates proactive treatment: rather than waiting until a woman can't have intercourse or a Pap smear, start local estrogen early, alongside moisturizers and lubrication. The safety of vaginal estrogen in breast cancer survivors is supported by multiple society guidelines (AUA, ASCO growing awareness, Menopause Society). The key point: taking one brick off a survivor’s back—the agony of GSM—can dramatically improve her ability to stay on life-saving endocrine therapy and maintain relationships.

Dr. Menn stresses that many survivors are told they have no options and are left to 'ride out' severe hot flashes and insomnia, which can lead to stopping cancer therapy. She points to the Menopause Society’s list of evidence-based non-hormonal approaches and the FDA-approved drug fezolinetant (a neurokinin 3 receptor antagonist). She also mentions that SSRIs were offered to her only 5 years into her suffering, when they could have helped much earlier. The message is that treating vasomotor symptoms is not a luxury; it’s a necessary step to stabilize mood, energy, and cognition so that women can engage in the lifestyle behaviors that truly matter for survivorship.

Dr. Menn explains that the oophorectomy itself drastically reduces ovarian cancer risk and even considerably reduces breast cancer risk, likely by removing the ovarian contribution to circulating hormones. Studies demonstrate that giving back exogenous hormones to these women up to the age of natural menopause does not erase that protective effect, and might even further lower breast cancer risk—a puzzling but reassuring finding. She emphasizes that this protocol is endorsed by NCCN, ACOG, and The Menopause Society. Yet many women are sent home with no hormones and told to endure surgical menopause, which she considers a failure of counseling. She uses herself as an example: she underwent oophorectomy but had no plan for estrogen, later realizing the unnecessary suffering. She now says, 'You could have your cake and eat it too: you’ve lowered your risk and you get your hormones back.'

Dr. Menn shares the story of her friend Dr. Shannon Clingman, who was on HRT and feeling good, but after a breast cancer diagnosis had to switch to an aromatase inhibitor. Clingman leaned hard into lifestyle and reported feeling even better—stronger, sleeping better, more muscle, cleaner diet, no alcohol. Dr. Menn uses this as evidence that while HRT is a helpful ingredient, the core of health must be built on daily habits. She tells patients not to try to become a superwoman overnight, but to start by removing one brick from their burden—maybe focusing on nutrition for a season, then adding exercise. The goal is to make the body resilient enough to handle the marathon of cancer treatment and estrogen deficiency.

Dr. Menn’s own journey illustrates the gap. When diagnosed at 28, she tested negative for BRCA 1/2 by the limited methods of 2001. Years later, after reading about BART mutations and panel testing, she insisted on an update. The result was a BRCA2 mutation, explaining her young diagnosis and her mother’s ovarian cancer death at 54. She says this was actually good news because it allowed her family members to get tested and take preventive steps (enhanced screening, prophylactic surgeries). She strongly advises anyone with a pre-2014 negative test to revisit testing, citing the dramatic expansion in genes and sequencing completeness.

Dr. Menn notes that women shoulder immense roles (mother, organizer, cook) and when cancer hits, they often can’t maintain them. Partners end up taking on extra without understanding why intimacy has vanished or why she’s irritable. She urges that partners learn about the biology of GSM—vaginal atrophy means sex hurts, and clitoral atrophy reduces sensation, making desire hard to summon. Exhaustion from untreated hot flashes leaves no energy for connection. She recommends resources like 'You Are Not Broken' by Dr. Kelly Casperson to help navigate intimacy conversations, and stresses that it’s okay for women to drop the cheerful mask and be vulnerable because that invites support.

Dr. Menn and colleagues used social media to rapidly recruit participants, gathering both quantitative and rich qualitative data. They presented it at ASCO and published it to force attention on the scale of the problem. She described the results as "shock and awe"—women explicitly detailed how pain with sex, vaginal atrophy, and menopausal symptoms destroyed relationships and mental health, while almost no one received referrals or treatments beyond a dismissive remark.

She acknowledges general red flags—unexplained postmenopausal bleeding, active liver disease, recent thrombosis, major cardiovascular events, and estrogen-dependent breast cancer—but argues that even in these scenarios, there are nuances. For example, transdermal estrogen does not raise clot risk, so a past clot may not preclude use. She wants the conversation to move from 'you can't have it' to 'let’s see what we can safely do for you'.

Dr. Menn points out that conditions like migraines with aura, endometriosis, fibroids, factor V Leiden, and hypertension are often used as guillotines to deny estrogen. Yet many of these can be managed by choosing transdermal over oral HT, adjusting progestogens, or monitoring. She wants every clinician to see each patient as a 'Weird Barbie'—unique and requiring a tailored plan—not a check-box that fails the protocol.

Dr. Menn explains that for BRCA mutation carriers without cancer, removing the ovaries slashes ovarian cancer risk and also reduces breast cancer risk. The studies show that giving back systemic hormones (estrogen, progesterone, testosterone) up to the age of natural menopause does not reverse that protective effect. NCCN, ACOG, and The Menopause Society all support this. The upshot: women can have both cancer risk reduction and quality-of-life-preserving hormones. She calls it “having your cake and eating it too.”

She explains that her mutation was in the BART sequence, a large rearrangement that was not routinely assayed. Only broad panel testing after 2014 picked it up. She urges all women with a significant family history and an old “negative” result to see a genetic counselor for updated multi-gene testing, which can uncover variants in PALB2, CHEK2, ATM, and others, opening the door to tailored screening and prevention.