HRT after gynecologic cancer: Why are we still saying no?

New research reveals a troubling gap between evidence and practice – and what we can do about it

When Joanne finished her treatment for early-stage endometrial cancer, she felt relieved. At 45, she'd caught it early, had excellent surgery, and her prognosis was good. But within months, surgical menopause hit her like a freight train. Hot flashes so severe she couldn't sleep. Joint pain that made her feel decades older. Brain fog that threatened her career.

When she asked her oncologist about hormone therapy, the answer was immediate: "Absolutely not. It's contraindicated after cancer."

Sarah is not alone. And according to new research published in Menopause journal, her experience reflects a widespread problem: most doctors are refusing hormone therapy to gynecologic cancer survivors – even when the evidence suggests it's safe [1].

The grim findings

A 2024 national survey of gynecologists and oncologists across the United States revealed some shocking statistics [1]:

• Only 64% of doctors will prescribe estrogen therapy to endometrial cancer survivors

• Only 65% will prescribe to ovarian cancer survivors

• Meanwhile, 97% felt comfortable prescribing for cervical cancer (which isn't hormone-driven)

But here's what makes this particularly troubling: the doctors most likely to refuse? General obstetricians and gynecologists – the very practitioners most cancer survivors will see for ongoing care.

The reasons doctors gave for refusing were telling:

• "Hormones are contraindicated"

• "Better options exist"

• "Risks outweigh benefits"

Yet none of these align with current evidence for appropriately selected patients with endometrial or ovarian cancer.

What the evidence actually shows

Let's be clear about what we know – and what we don't.

Endometrial cancer

For early-stage, low-grade endometrial cancer, multiple studies show reassuring safety data:

• The GOG Study 137 – the only randomized controlled trial – found zero increased recurrence risk with hormone therapy [2]

• Multiple large cohort studies have shown no difference in mortality or recurrence rates between women using hormone therapy and those not using it [3]

• A 2017 meta-analysis confirmed these findings, particularly for early-stage disease [4]

Ovarian cancer

The evidence here is even more reassuring:

• Most epithelial ovarian cancers are not hormone-dependent, unlike endometrial cancer

• Meta-analyses consistently show no increased recurrence risk with hormone therapy [4]

• Some studies actually suggest improved survival in hormone therapy users, though this may reflect healthier patients being more likely to receive treatment

• The main exception: low-grade serous tumors, which may be more hormone-sensitive

What about breast cancer?

This is where the story differs significantly. For estrogen receptor-positive breast cancer (70-80% of cases), studies do show increased local recurrence risk with systemic hormone therapy [5]. The 2021 meta-analysis found an 80% increased recurrence risk (though importantly, no increased mortality) [5].

However, even here, a 2025 expert consensus statement called for moving away from automatic refusals toward individualized decision-making, acknowledging that some women may choose to accept increased risk for significant quality of life improvements [6].

And crucially: vaginal estrogen appears safe across all breast cancer types, with a 2024 meta-analysis showing no increased recurrence risk [7].

The cost of fear-based medicine

While doctors refuse hormone therapy, what are cancer survivors actually facing? Proven, documented harms:

• Accelerated bone loss leading to osteoporosis and fractures

• Increased cardiovascular disease risk (especially with early menopause)

• Genitourinary syndrome causing painful intercourse and recurrent urinary infections

• Cognitive decline risk

• Devastating impact on quality of life – severe hot flashes, sleep disturbances, joint pain, mood changes

These aren't theoretical risks. They're happening to real women, right now, while we withhold the most effective treatment for menopausal symptoms based on outdated fears.

Why the disconnect?

The gap between evidence and practice stems from several factors:

Outdated medical training: Many doctors learned "hormone-dependent cancer = never give hormones" without nuance for cancer type, receptor status, or time since diagnosis.

Medicolegal fear: Concerns about liability outweigh evidence. Doctors worry more about a potential recurrence (even if not caused by hormone therapy) than about the proven harms of untreated menopause.

Conflation with breast cancer: The biology of endometrial and ovarian cancer is fundamentally different from breast cancer, but doctors often apply breast cancer data across all gynecologic cancers.

Lack of updated knowledge: The GOG 137 study was published in 2006. The Stockholm trial's 10-year follow-up came out in 2013. Yet many practitioners aren't aware of this evidence.

Practical steps for change

So how do we close this gap? Here are evidence-based recommendations for practitioners:

1. Know the actual evidence by cancer type

Endometrial cancer (early-stage, low-grade):

• GOG 137: No increased recurrence with hormone therapy

• Multiple cohort studies confirm safety

• Vaginal estrogen particularly safe due to minimal systemic absorption

Ovarian cancer (most epithelial types):

• Meta-analyses show no increased recurrence

• Exception: Consider caution with low-grade serous tumors

• Vaginal estrogen safe

Breast cancer:

• ER+ disease: Evidence shows increased local recurrence risk with systemic hormone therapy

• ER- disease: No proven increased risk, but limited data

• All types: Vaginal estrogen appears safe

2. Stop blanket refusals

Replace automatic "no" with individualized assessment considering:

• Cancer type, grade, stage, receptor status

• Time since diagnosis

• Type of surgery performed

• Severity of menopausal symptoms

• Impact on quality of life

• Patient values and preferences

3. Always offer vaginal estrogen

Low-dose vaginal estrogen preparations have minimal systemic absorption and strong safety data across cancer types. This should be standard of care for genitourinary symptoms, not an exception.

The American College of Obstetricians and Gynecologists states that vaginal estrogen "may be used in individuals with a history of breast cancer, including those taking tamoxifen or aromatase inhibitors" after shared decision-making [8].

4. Understand the data limitations

Be honest with patients about what we don't know:

• Most hormone therapy studies enrolled women ~2 years post-diagnosis

• Follow-up periods were relatively short (2-10 years)

• Studies didn't stratify by specific surgical approaches

• No data exists for women who had mastectomy with no lymph node involvement

• Modern aromatase inhibitor combinations haven't been studied

5. Reframe the risk-benefit discussion

Instead of focusing solely on theoretical recurrence risk, help patients weigh:

• Known harms of untreated menopause (bone loss, cardiovascular disease, quality of life impact)

• Potential risks based on their specific cancer characteristics

• Individual circumstances (age, time since diagnosis, severity of symptoms)

• Personal values (how they prioritize quality of life versus small increases in recurrence risk)

6. Refer when appropriate

If you're uncomfortable prescribing hormone therapy after cancer, refer to specialists experienced in this area rather than simply refusing. Oncologists who specialize in survivorship, menopause specialists, or gynecologists with expertise in hormone therapy

can provide individualized guidance.

7. Keep learning

Medical knowledge evolves. The 2025 expert consensus statement on hormone therapy after breast cancer represents a significant shift toward nuanced, patient-centered care [6]. Stay current with guidelines from:

• The Menopause Society (formerly NAMS)

• American College of Obstetricians and Gynecologists

• National Comprehensive Cancer Network

• International Menopause Society

A call to action

Here's the uncomfortable truth: we're leaving cancer survivors to suffer from proven harms to avoid unproven or minimal risks.

This isn't evidence-based medicine. It's fear-based medicine.

And it needs to change.

Every gynecologic cancer survivor deserves accurate, individualized counseling about hormone therapy based on their specific cancer, their risk factors, and their values – not blanket prohibitions based on outdated assumptions.

The evidence exists. The guidelines are evolving. Now it's time for practice to catch up.

What can you do?

• Review the references below

• Audit your own practice patterns

• Have honest conversations with patients about risks and benefits

• Offer vaginal estrogen as standard care

• Refer when needed rather than simply refusing

• Advocate for better survivorship care

Our cancer survivors deserve better. Let's give it to them.

References

[1] McDowell JL, et al. Estrogen therapy in patients with gynecologic cancer: a survey of gynecologists and oncologists in the United States. Menopause. 2026;33(2):161-166.

[2] Barakat RR, et al. Randomized double-blind trial of estrogen replacement therapy versus placebo in stage I or II endometrial cancer survivors (GOG 137). Obstet Gynecol. 2006;107(6):1315-1321.

[3] Shim SH, et al. Hormone replacement therapy and the risk of endometrial cancer recurrence in endometrial cancer survivors. Maturitas. 2014;79(4):426-430.

[4] Li D, et al. Hormone replacement therapy and risk of breast and ovarian cancer recurrence: a systematic review and meta-analysis. Climacteric. 2017;20(2):107-115.

[5] Poggio F, et al. Safety of systemic hormone replacement therapy in breast cancer survivors: a systematic review and meta-analysis. Breast Cancer Res Treat. 2022;191(2):269-275.

[6] Glynne S, et al. Menopausal hormone therapy for breast cancer patients: what is the current evidence? Menopause. 2025;33(1):88-117.

[7] Beste ME, et al. Vaginal estrogen use in breast cancer survivors: a systematic review and meta-analysis of recurrence and mortality risks. Am J Obstet Gynecol. 2024. (Epub ahead of print)

[8] ACOG Committee Opinion No. 838. Urogenital symptoms in individuals with a history of estrogen-dependent breast cancer. Obstet Gynecol. 2021;138:950-960.