83: Dr Corinne Menn: Breast Cancer and Menopause Management

Welcome to the Dear Menopause podcast, where we discuss the menopause transition to help make everyday life a little easier for women. Hey there, this is Sonia, and I am the host of Dear Menopause, the podcast. Today, I am bringing you an episode that I have planned for a very long time. I connected with Dr Corinne Menn. Corinne is an US-based OBGYN. She is also a breast cancer survivor, and we have a conversation that goes deep and wide. I truly hope that you enjoy this conversation. Hey, Corinne, welcome to Dear Menopause.

Thank you for having me. I'm so excited for this conversation.

Yeah, I am too. I think for our audience, particularly given my audience is very Australian, New Zealand based, perhaps not familiar with who you are and why I have you here today, would you like to give yourself a little bit of an intro.

Sure thanks. My name is Dr Corinne Menn and I'm a board certified OBGYN and a menopause society certified practitioner. I've been practicing for oh goodness, almost 23, 24 years now. In recent years I've really tailored my practice to the treatment of the menopausal woman as well as breast cancer survivorship issues. The important thing to know about me is that I have the professional expertise, but I also have the personal experience of being a long-term breast cancer survivor. Really, that's how I found my passion of taking care of women in menopause and with breast cancer, because when I was 28 years old I was a second year OBGYN resident. I was diagnosed with stage 2A ERP HER2 negative breast cancer six weeks after my mom suddenly died of ovarian cancer. Many years later found out I do carry the BRCA to genutation Because no one helped me with my menopause symptoms and the collateral damage beyond menopause symptoms of breast cancer treatment. As well. As just seeing that in the US at least and I know it's certainly throughout the world that OBGYNs are not trained in menopause care in general, much less in a breast cancer survivor, and they're not really trained at all in sexual health and addressing those issues, I need to really up my game, just to take care of the average woman and then go one step further and really take care of the menopausal woman who's also either a breast cancer survivor or who is at high risk. That's really what I'm all about these days, and I only practice by telehealth now, via alloy, which is a menopause platform in the US, but also in a small private practice. Really, I've just gotten excited about doing a lot of social media education because I'm just really passionate about education.

Yeah, and I'm so grateful because I discovered you through your social media platform and presence, obviously, and through different connections that we have in common. I really want to talk to you today and I think it will be really beneficial for my listeners to hear a little bit about your own experience with your breast cancer journey and your menopause journey in particular, as a result of. I know a little bit about your story and you went in and out of menopause a couple of times for various reasons. I think it'd be great for people to hear that side of the story, because you were so young when you were diagnosed as well. Then I'm really keen to dive into talking about the gap in care for women that are surgically or medically induced menopause, and then going into the treatment for, or if it's available for, women to manage their symptoms, how that is managed, how it's changing and what we can do to kind of perhaps create a little bit more change more quickly. So let's start with your story around what you're happy to share around your menopause kind of experience.

Sure, I'm super open about my breast cancer story in the menopause. Basically I was 28 and I again stage two a breast cancer elected to have a bilateral mastectomy with reconstruction and then I did. Prior to starting chemotherapy, which had six months of chemo, I did save some eggs to protect for fertility preservation, never wound up needing those. We'll get to that because I was able to get pregnant on my own. But I bring that because the first kind of interesting point is they used tamoxifen to stimulate my ovaries because tamoxifen is a cousin of clomid, so I got lots of multiple eggs, ovulation and tamoxifen makes your estrogen levels go up. So I just wanted to put that out.

And that's only if you're premenopausal. Is that right You're?

premenopausal. Yeah, you're premenopausal, so save some eggs, delve in did six months of chemo and within a couple of months my ovaries temporarily shut down. So from the chemotoxic effects on my ovarian function. But because I was very young I did. Eventually, when chemo ended, I was able to regain ovarian function. So that was menopause hit number one. So it was a temporary chemical menopause from chemotherapy and looking back, I think that yes, there was lots of hard things about having chemo. But looking back, I think a lot of my symptoms that I struggled with during chemo like insomnia, increase in anxiety, a lot of symptoms I think it was really just this kind of profound new, sudden menopause at 28. So that was pretty rough. Finish chemo came out of that and went on tamoxifen. A few months later my periods did come back and so I did handle tamoxifen okay at first and they added they're like let's add some lukewarm. So they shut down my ovaries and I was like, okay, great, I didn't know. Well, that was, you know, menopause number two from having, you know, ovarian suppression with the tamoxifen. So I did that for a little bit of time. Then I stopped that and, in conjunction with my oncologist, decided to pursue a pregnancy. So pause my adjuvant endocrine therapy so I could get pregnant, which is something that is now like pretty widely supported in the oncology community. At the time Remember this was, you know, about 23 years ago Lucky I was in New York City and I had some really like cutting edge doctors who were like really looking at this and we had data all the way back then that women could probably pause therapy you know, endocrine therapy to get pregnant. So luckily I had access to that information, so had came off metamoxifen, had got pregnant very easily on my own I didn't need those little eggs that they saved and had a successful baby pregnancy and I have a 19 year old daughter now and as soon as I delivered her I went right back on my tamoxifen. They put me back on Lupron again and I like only lasted a few months. I was like, yeah, this is, I'm not doing this anymore, I can't do the Lupron. It was really rough, so I just kind of did you might have.

I interrupt you there for one second. Lupron isn't a drug that I'm familiar with. So what does Lupron do?

Lupron is like Zoolodex. It's basically it's just. It's just an injection for ovarian suppression. So when women are remanopausal and we want to make them temporarily menopausal and quiet their ovaries down and we often do it in younger patients with a more aggressive breast cancer when we want to give them an aromates inhibitor. Aromates inhibitors only work if you're menopausal, so you can remove the ovaries surgically or we give you a shot. So that's what Lupron did for me and it was pretty, you know, and I it was really hard having that kind of chemical menopause hit me again, you know, trying to be a new mom with a new baby and a new young doctor. So I kind of knew. My oncologist said, okay, I just stand tamoxifen. And so I had regular menstrual periods and, you know, plenty high levels of estrogen. I just had, you know, nine months of high levels of estrogen, you know, during my pregnancy and for me and I know some not everybody tolerates tamoxifen, but for me I really didn't have a problem, you know, with tamoxifen and I did that for, you know, a number of years. And then I decided so I alluded to that right before my diagnosis my mom had died suddenly of ovarian cancer. It's a tragic story, it's for another podcast. But we had no family history, we did not know we carried any mutation and so it never sat right with me. I'm like, wow, I'm 28 with breast cancer and my mom is 54 when she died and my initial genetic testing was all normal negative. I was like, really, did you do the right test? They didn't. I'll tell you about that. But at that point I was like, ok, my baby was a year old. I was like you know what? I think I want to stay in my tumoxidon. We chose to grow our family through adoption and so we adopted a baby girl from Guatemala and she is now 17. And she just texted me. She got a college acceptance. So we're so excited, so exciting, so wow. I never would have thought that I'd ever be here. I thought that, honestly, breast cancer would have got me a long time ago. I really just wanted to get through. I don't know, just maybe getting my kids to age 10, and now the fact that they're almost eating up in their late teens, early 20s, so blessed, but anyway. So we decided we're not going to have any more babies ourselves, so we're going to adopt. So I'm like I want those ovaries out. And this is a really interesting point because at the time I think it was 33 or 34. And no oncologist, no one was saying, corrine, we need to shut your ovaries down. They weren't saying that I was early stage breast cancer. I was doing very well on tamoxifen, I had lots of estrogen, having normal menstrual cycles. They're like you don't have to do this, you don't have to remove your ovaries. It wasn't a treatment for my breast cancer. It was a treatment because I thought that something was just not right. I was like I want those ovaries out. I'm not trusting this genetic testing and I'm glad I didn't trust it because, lowell and Pold, a number of years later, I realized in 2013 that the standard panel that they did, looking at the BRCA gene, did not include the large rearrangement of the gene called the BART sequence, and that's where my mutation was. So in 2013, I demanded to get retested not even panel testing, which we do now, where we're looking at more than the BRCA gene. It was just a repeat of the BRCA test and, lowell and Pold, yes, I carry the broccoli gene mutation. So I listened to my gut. There was something wrong with my gene. So that's where I had my ovaries removed. But what that did was overnight, put me into surgical menopause, which was something that couldn't even compare to what I dealt with with the temporary kind of chemotoxic menopause or the temporary menopause from Lebron. Having that surgical removal of my ovaries was like a whole new level of really suffering. So I had no ovaries and surgically menopausal and I stayed at Tamaxivim, and that's when the Tamaxivim was harder to manage now because it was now being given in a different environment. And I think that was probably my lowest point in my symptoms. And that's when I decided to go to the North American Menopause Society now called the Menopause Society and get certified and really understand, because I was like god, my patients are dealing with this, I've got to learn to help them. But I still didn't know really how to help myself. As a breast cancer surgeon I was like I can help other people, but I'm just going to have to suffer from it. I'm just lucky I'm alive, right, and so that's where I was there. And then it took many years for me to really learn the nuances of the breast cancer survivor and how to manage them.

Yeah, there's a couple of things I'd like to pick up from that you mentioned. The first one is going back to when you were in your initial chemically induced menopause. You mentioned that you had some menopausal type symptoms, or you now recognize them as menopausal type symptoms. One of the things that I have noticed and I'd love to get your thoughts on this is there seems to be a quickness from an oncologist perspective to dismiss a lot of the symptoms that women are experiencing and just bobbing them off as chemo symptoms. And I even had this happen to me about two months ago when I was speaking on a panel Actually, it was World Menopause Day and I was speaking on a panel, speaking from a lived experience perspective, and there was an esteemed doctor on the panel and she had to throw the comment in right at the end well, sonya, you had gone through chemo. They were potentially distal chemo symptoms and I wonder how often or how easy is it to actually distinguish between what is chemo symptoms? And, let's be honest, chemo is awful and does come with its own symptoms. But when you're also experiencing that induced menopause state, how do we ask our oncologists to see the difference between those two states?

Yeah, well, listen, if you think OBGYNs don't know anything about menopause and most of them don't, because I'm telling you we're not trained with, there's not much curriculum in the OBGYN residency in menopause Oncologists have no education in menopause. They think of it, like the general public thinks of it, as only hot flashes and only night sweats. So if you're not having those things, then they don't think of it as menopause. But you know, I know, that there's over 30 symptoms probably with menopause, including joint pain, dry skin, mood changes, anxiety, insomnia, heart palpitations, sexual side effects, bladder problems. I mean, the list goes on, right. And so do we have a good way to say what's chemo and what's menopause? No, but I think it wouldn't really be that hard to educate oncologists and OBGYNs to just kind of recognize that two things can exist at the same time and they both worsen each other, right? So some of the side effects of chemo are going to make it really harder for you to cope with hot flashes or insomnia, and the insomnia and the hot flashes and the mood changes are going to make it harder for you to cope with chemo. So we should take them both seriously and not just write them off as, oh, it's just chemo brain right and I think that a lot of women who then stay in menopause because obviously, depending on your age and depending on your treatment plan, it may not be temporary right. And so I see a lot of women who then, all right, the chemo's done, it's six months a year, it's two years and now they're in permanent menopause, for whatever reason, and they are convinced that it's chemo brain is why they have some cognitive changes and brain fog. And I am not discounting chemo brain. I know that there's data and science showing it's a real thing, I believe it. But please, please, do not ignore the elephant in the room that we know there's huge cognitive changes and memory and brain fog and all this stuff and the insomnia and what that does, and we need to recognize that and treat it and understand it. And I think oncologists are living in a silo and they're not looking at the bigger picture of the collateral damage that's happening out there. And I do don't fault them. They're working so hard and they're so busy and medical practices don't really give them the time to really look holistically at patients and neither in the OBGYN rule does it, and I know that their perspective is they just want to cure us and keep us cancer free, and I love that and I love my oncologist. But I think we just have to think more holistically.

Yeah, I agree, and I think I feel quite strongly that there needs to be more of an ethical responsibility from the surgeons or the oncologists that, at the end of the day, are responsible in some ways for putting women into these forced menopause states.

Oh, if you break it, you fix it, like that's. Like there's a thing like first do no harm, yeah. And so you know, and I'll give a perfect example of you know, I see these patients all the time who are either new to their adjuvant endocrine therapy or they've been on it for a few years. So they're on an aromatics inhibitor or they're on to maximum and they may be really struggling. And again, not everybody struggles. There's all you know. We understand there's lots of different ways that people respond to this. But I ask them did anybody actually give you informed consent on this adjuvant endocrine therapy and explain to you the risks, the benefits for you individually? And and I think that if women would understand the benefit, the true benefit as well as the true risk, they could better make an informed decision. But what's told to them is you have a 50 percent decrease risk of breast cancer occurrence if you use this adjuvant in drug therapy. And you probably see this more and more. There's more and more women who are being told 10 years, a roma test inhibitor and a variant suppression. So what I like to say is extreme adjuvant endocrine therapy and for some women, yes, that risk reduction is worth it because they have a higher disease burden and they have a higher risk of recurrence. But they should be fully informed of what that risk reduction is. So what I'm seeing is, say, a stage Ia low grade, moderate grade, no negative patients being kind of basically re-eroded into very extreme adjuvant endocrine therapy, being told it's a 50 percent reduction. So then I said, well, did they tell you what your baseline risk is? Well, no, they said I don't know that. And so when we look it up, we look at their oncotype score or whatever information their oncologist said, and it's actually a 6 percent risk of recurrence. And if I do this, it cuts it in half to 3 percent. And then I say to them OK, so it's a three. So fine, all right, so there is a risk reduction there. But then I say to them did they explain to you that when they give you those numbers, they're talking about adjuvant endocrine therapy in general and the nuance is then between ovarian suppression and an oremotase inhibitor versus tamoxifin. You're talking about single digit differences. So when you put it in that perspective and I says you've already done it for two or three years or four years, like there is this law of diminishing returns over time, and yes, maybe you would get the maximal benefit at, say, 10 years with the most extreme adjuvant endocrine therapy, but at what cost? And did anybody explain to you that maybe you're getting a couple percentage benefits? And they say, no, they're not. And so to me I don't even think. Not only are they not being talked about how to deal with their menopausal symptoms, I don't think they're actually being informed of the benefits, as well as the risks and what the true reduction is. And it also works on the others, the end of women who have very high risk for recurrence disease or a high disease burden. Those women, sometimes they want to abandon their therapy because they don't understand the risk reduction. And so I said listen, let's go through it for you. Wow, you have a 30% risk and it's lowering it to 15%. So let's work together to find ways for you to stay on it. So I think on IC, patients on both spectrums, people who are probably can maybe come off it or change it up and make it more manageable, and they're not being informed of what they can do there, and, on the other hand, women just being so measurable that they give up on it because no one's addressing their symptoms. And so I feel like we're failing both groups of those women. I don't think we do this to men. If you cut a man's testicles off and you didn't address their testosterone and you didn't address their sexual function and what they feel like, it would be considered just cruel and usual. And guess what? It doesn't happen. It doesn't happen in the male world, but it's happening to women because there's an acceptable level of women suffering in the name of curing their breast cancer and there's an acceptable level of suffering at menopause. It's like, just deal with it and so the people who are most vulnerable, which would be the cancer survivors, the women with premature menopause, the women with surgical menopause the acceptable level of suffering is really really high and it's cruel.

It is cruel. Yeah, where do you think that acceptance of suffering comes from?

Oh, I mean the devaluing of women. This is misogyny at its finest, I think, and I think that I don't think individual physicians are misogynists I'm certainly not saying that but I think there's a cultural norm that there's a rite of passage to menopause for the average woman that they should just suck it up and deal with it. I think that when you're talking about cancer and I always tell patients whenever you're getting advice from doctors think about the lens that that doctor is looking at you from. So the oncologist wants to cure your cancer from a medical. Thank you a lot. Yeah, the breast surgeon wants to cut it out and ship you off. The plastic surgeon wants to make you look pretty at all costs, even if it's like too many surgeries for you personally, or even if it's like you don't want even reconstruction. You just want to go flat. And some plastic surgeons be like why would you do that? I can make you beautiful. So everyone has their lens, the OBGYN has their lens and, frankly, all of these lenses are clouded by fear and misinformation. So the OBGYN, the minute they hear you had breast cancer, it's like they glaze over. They're like oh OK, well, I don't really know what to do with you, you're high risk, I can't touch you, I can't give you anything, I can't talk about hormones with you. The oncologist is like their lens is like I don't know anything about sex and hot flashes Like please be lucky, you're alive, why would you care about that? And so I always tell women don't blame the doctor. They're kind of a victim of the medical training in the system and understand that their lens is kind of shaping the advice they give you and they're only hearing the literature from their little world. We're not all getting together Like the menopause doctor getting together with the oncologist and the breast surgeon. We're all going to our own conferences and our little silos and the woman is left in the middle.

Yeah, yeah, I think that's it Really concise example description of exactly what is going on.

And I think that it takes a lot of work on a patient's part and it's a lot of onus on you as a survivor and it sucks because it's like God. How much do we have to ask of these women to be medical experts, in addition to being survivors and just living our lives and taking care of their families and going to a job? But you know what your life is worth it and you have to educate yourself and you have to be pushy, you have to be. You know, and I think most doctors are actually caring people and they're smart people and if you advocate for yourself and it may take a couple of doctors, you may have to jump around a little bit you will find help eventually, but it's hard.

Yeah, yeah, absolutely is. One of the other things I'd like to start diving into with you we mentioned right up the front is what, for these women that are really struggling and having a poor quality of life, often as a result of being in this menopausal state, what treatment options are available? And let's also I really want to talk about hormone therapy here as well.

Absolutely so. I think when I talk to patients about what we're going to do, I think we always have to put it first in, like where are you in your treatment course? And explain to them that the way we help you is going to evolve as your survivorship evolves. And so I think, on the very front end, when they're going through therapy and they've made their decision on their treatment plan, which is unique for each individual number one they should be fully informed, as I alluded to, because I think sometimes their treatment can be tweaked to help make it more tolerable and really more humane and holistic. But if you're in the middle of treatment with something that is going to be with some type of adjuvant endocrine therapy and there's absolutely no discussion of systemic hormones, we have non-hormonal ways that we can help your menopause symptoms. They're underutilized and they're often not offered until patients come in crying and begging for help, and even then there's often not a lot of nuances. And so I would direct people when you're looking for non-hormonal ways to help with systemic menopausal symptoms that would be half-bushes, night sweats, insomnia I think you can look to the menopause society non-hormonal position statement that they published in 2023. And it's beautiful because it really is an evidence-based look with everything laid out very clearly. Of all the different medications that are off-label, so SSRIs, snris the new medication Vioza, oxybutanin and GABA pentad those are the big medication ones that we can do, and then also CBT and lifestyle things, and so I think it's really important for women to be aggressively offered those things and at all stages women should be aggressively offered vaginal hormones, because we have so much safety data. There is no reason for a breast cancer survivor at any point in her treatment. Even if she's on an aromatics inhibitor, she should be able to use vaginal hormones, and we've got lots of different ways that we can give that to them and we've got consensus statements on that and we have a lot of data there. So that's kind of the easier thing to address, and even that is not well addressed in patients. Then the next stage would be OK, you've finished your treatment. Whether you're estrogen receptor positive, estrogen receptor negative, whatever it is, you've moved on and now you're looking at well, what's next? Ok, and if you're then at that point dealing with a lot of menopausal symptoms, or because I think women need to have true autonomy, even if your menopausal symptoms at this point aren't severe, but you want to have a smart, intelligent conversation about the risks and benefits of hormone therapy and hey, can I get some of these benefits that I've heard about? I think you are owed the conversation and it should not be a blanket no. And I think that we always can talk to patients about non-hormonal ways to manage their symptoms. As I alluded to, we should always talk about use of vaginal hormones for local, non-systemic treatment of their genitourinary syndrome and menopausal symptoms and lifestyle. These things are so important, but it is unreasonable to categorically deny women access to what the scientific literature shows about the use of low dose FDA approved in the US or approved standard hormone therapy. And what does it mean for a breast cancer survivor? Because actually we have data. We do not have perfect data, we do not have data that is consistent across the board, but we actually have data. And so to say, oh no, it's totally unsafe and there's no data is actually not. It's not true, and women deserve more than that. And also women breast cancer survivors know this. Each of our cancers are different, so yours is different than mine, you're positive is different than you're negative, and then even within those categories, there's lots of nuances and different. So to kind of say that all women who have had any type of breast cancer, any stage, any receptor status, categorically are not allowed to even have a discussion about the use of very low dose hormone therapy is absurd. It's absurd.

And we were talking before we started recording. One of the things I wanted to talk to you about was I'm speaking from an Australian perspective and I personally was estrogen progesterone positive, h her negative, and I was 47 when I had my chemo and was diagnosed. So I did go immediately into menopause surgically, medically induced, obviously, but my menopause was permanent because, given my age and proximity to my natural menopause stage, I have been categorically denied Point blank won't even enter the conversation for six years any access to hormone therapy until recently, and that came off the back of me doing my own research, being privileged enough to be in the position to sit down and have conversations with the likes of yourself and many other experts in this area, weighing up my own risk versus benefit and then finding researching, until I found a GP that was comfortable enough to prescribe me some hormone therapy, and that has only been in the last four weeks that I have been able to start doing that. Now, when I look at the most recent practitioner toolkit that was published here in Australia about a month ago, we're recording this in mid-December. It was literally published maybe one month, two months ago, and if you look at that, they've got these beautiful flowcharts on it of how to help GPs decide so our general practitioners decide how to treat a woman Under contraindications just point blank contraindications. It says estrogen dependent cancer. So there's a couple of things I want to talk about there. One is the use of that language estrogen dependent cancer because one thing I have come to learn and I think it's my biggest learning for this year is that my estrogen positive cancer does not mean that estrogen caused my cancer.

That's pretty much yeah, and I think that, listen, I am not, I will listen. Estrogen positive breast cancer. We have now decades of data showing that, yes, blocking that estrogen receptor or temporarily suppressing estrogen levels does help treat that breast cancer. And that's because the estrogen receptor, when stimulated by estrogen, can help send signals to the cell telling it to grow right. Because let's just kind of talk about a normal breast cell and I think this really helps patients, I think, understand what we're talking about here Estrogen as a hormone. In a normal menstrual cycle, the first half of your menstrual cycle your estrogen levels rise and the job of that in your breast is to start to stimulate breast glands and breast ducts to hate, get prepared, because she's gonna have sex maybe and she may get pregnant and you're gonna have to be prepping for a baby, right? So in a very simplistic form, yeah, the estrogen is rising, your little breast cells are gonna grow and kind of get ready, and then progesterone comes along and says let's get these breast glands and ducts a little bit organized. We can't have unchecked growth and progesterone is part of this beautiful growth and organization and then, if you're not pregnant, all the hormone levels drop and boom, the whole cycle starts over again and that's because there's receptors on your breast cells and in normal, healthy breast cells estrogen receptors and progesterone receptors. Okay, so what's happened in the world is that when people are diagnosed with estrogen receptor positive breast cancer because women don't really talk normal women don't talk about estrogen receptors, right, that's not common lingo. So then they're like oh my God, I have estrogen receptor positive breast cancer. So that must mean that estrogen caused me to get breast cancer and caused this type of breast cancer. No, it didn't cause it. Okay, it just means that your breast cancer and again, why people get cancer is a much more complex, above my pay grade conversation but your breast cells, your breast cancer cells, have retained an estrogen receptor. So, yes, they are estrogen receptor positive. They haven't lost those receptors. And one of the benefits of having estrogen receptor breast cancer is that we have all these tools and we can manipulate that receptor and do things so that we can stop any circulating levels of estrogen in your body from binding to the receptor on those breast cancer cells and telling it to grow. Okay, so, from a very simplistic standpoint, I think it's just important for women to know all breast cells healthy breast cells have an estrogen receptor, some of those. Sometimes if you have a breast cancer that develops, it is a breast cancer that has kept those receptors. And women who have estrogen receptor negative breast cancer, those cells have changed so much they look very different than a normal breast cell and in fact, so different that they don't even have estrogen receptors on it, so we can't manipulate that cell in any way, okay. And women who are premenopausal, who have lots of estrogen in their bodies, they get estrogen receptor negative breast cancer and they get estrogen receptor positive breast cancer. Same thing with postmenopausal women. So these cancers develop in both a high estrogen state and a low estrogen state, right. And we don't know exactly who gets what and why. Some of its genetics, lots of things, right. But it doesn't mean that estrogen caused your breast cancer. And I think it's really important because I think what's happened is women now fear something that their own bodies for years have made. And where I find the conversation get really, really interesting, in whether women can consider even a discussion of HRT after cancer, is that it's much celebrated these days and at the last last year's San Antonio Breast Cancer conference, which is the big you know US breast cancer research symposium it's happening right now, actually in San Antonio, they released the positive trial. So the positive trial was looking at could women who have ER positive breast cancer take a break from their tamoxifen and rheumatism inhibitors? Take a break, get pregnant, take two years up to two years off of all therapy, get pregnant and even use assistive reproductive technology. So use whatever they needed to help get them pregnant high hormones, nine months of super high hormones, and then go back on whatever tamoxifen and rheumatism inhibitor and carry on. And it was looking at all right. Well, did they have a higher risk of recurrence and higher risk of death? And the answer is no, right. And so you know, obviously it's still an individual decision and they're still gonna look at long-term risks and stuff. But I can tell you that data was there even when I got pregnant, because 23 years ago. So there was data in the literature. But this positive trial was, you know, a formal trial that looked at this, and so it gives us a more solid answer, right, and so it seems like it's not that controversial anymore to tell a woman like sure, you can take a break, even from your in the middle of treatment, take a break, let your estrogen levels be sky high. I mean I'm talking crazy high, right, but God forbid we let someone who has early stage, well-treated breast cancer it's behind them, they're really suffering and they wanna have a conversation about using, like I'd say, a teardrop of transdermal estradiol and a touch of low dose progesterone if they have a uterus still. And it is like no, absolutely not. And I'm like what it makes me so angry. Are we worth it? Are we only here to have babies? But you know, once we're menopausal, we it doesn't matter like that suffering and what we're dealing with doesn't matter. It seems like very strange to me that that's somehow okay but we can't talk about this. You know how emotional about it.

But and that's why I wanted to have this conversation with you because you sit in this really unique position of having the lived experience and also, you know, treating women that come through your clinic and through your telehealth. But you also have such an in-depth understanding of the research and the studies that have been done behind it, and I feel very strongly, and I believe that like you, that the tides are turning, that it's time to start having these conversations. I mean, it's well overdue time to start having these conversations and having more public awareness around the nuances that do mean that it cannot be, and or it should not be, a blanket no.

No, and some other examples For our triple negative survivor sisters out there. Okay, I have a dear friend and a patient of mine who had triple negative breast cancer. She, you know, had her surgery, her chemotherapy. She went on to have a successful pregnancy, delivered twin girls. They're doing beautifully. And you know, she wasn't on any adjuvant endocrine therapy because she's triple negative right and she had normal menstrual cycle in very high levels of estrogen, obviously for many number of years and around her, you know, I don't know, maybe early 40s. At this point now she was probably 40. She carries the BRCA1 gene and she decided to remove her ovaries to lower her risk of low-gaming cancer. At no point in time was a variant suppression or lowering her estrogen levels ever a you know a part of her treatment plan. But the minute she got her ovaries out, everybody was afraid to give her HRT because she had breast cancer right. But she had one triple negative breast cancer who she's now prematurely surgically in menopause, which you and I both know has tremendous health risks of increased cardiovascular dementia, hip fractures, depression, the list goes on. I mean it's actually really significant what happens with premature surgical menopause and it took a lot of pushing and working for her to get some damn HRT, and it's absurd. She is now on it and it's a huge game changer, right, and so that's an example. The other example I have is I have patients who have DCIS, who had mastectomies. For God's sakes, and no, absolutely not. We can't talk about age or training. I'm like, really, you know, the first scientists were doctors. Really, you can't logically think this through. You don't manage patients with blanking statements. It's absurd.

Yeah, one of the last areas I wanted to touch on with you and thank you for going into so much depth on that and giving us those examples, because I think when we can that's why I love doing this podcast so much is when we can really hear living examples and lived experience of you know, and then you can really see the almost ridiculousness of those blanket contraindications. But I wanted to ask you around. So HRT has changed in its formulation a lot Like if we go back to the when the Women's Health Initiative was done, you know that the studies were done on an old formulation of HRT to which we use today. There's an infographic that gets shared a lot and particularly here in Australia, I would imagine also in the UK. It's produced by the Women's Health Concern, which is an arm of the British Menopausal Society, the BMS, and it's a comparison of lifestyle risk factors versus HRT. Now it was produced in November 2015. So help me out here, because I'm a little vague on or I just don't have the knowledge around dates and when. Hormone therapy kind of changed from being that old formulation to what we now use with the micronized progesterone and the. You know the gel HRT or the versus. You know you're internally taking HRT. Do we have comprehensive data on risk cancer risk for women that are using the newer body identical HRT?

Unfortunately we don't and I think it's because we have some data and I'll tell you what we have. You know, unfortunately the Women's Health Initiative in the United States caused so many long lasting problems with research and menopause because once they released their report, which caused havoc around well, certainly in the US and around the world and women went off their HRT overnight. There was a lot of they're basically, you know, people were not interested in studying more. Okay about it. But even the Women's Health Initiative which is often much maligned but I tell patients no, no, no, don't throw the baby out with the bathwater we learned a whole lot and there's a lot of good points in the Women's Health Initiative that unfortunately, the primary investigators to this day refuse to, you know, celebrate. So let's just remember and I don't want to malign the old hormone therapy, but I also want to talk about what has changed. So in the Health Initiative, whi, they used conjugated equine estrogen in primary right. So in the conjugated equine estrogen are in women who did not have a uterus. They had a 30% decreased risk of breast cancer. 30% decrease, okay, they had a almost 40% decreased chance of dying of breast cancer and a 30% decreased risk of ever getting breast cancer. And that holds true even, you know, decades later, at the 20 year follow-up right and then in the other arm, they used conjugated equine estrogen again, but in oral with a synthetic progestin, and the reason why the study was halted was because they saw a slight increased risk in the diagnosis, but not immortality of breast cancer. But unfortunately, even that doesn't hold water and that message is what caused everybody to panic, right? But even if you believe their numbers which I'll explain why you really shouldn't but even if you believe those numbers, it was an additional, one additional case for every thousand women taking it and it was just an additional case of being diagnosed, never an additional case of a woman dying of. And it was on that basis alone that the rates of HRT dropped by 75% and I think that had a huge impact then on what happened in the breast cancer survivor world where, you know, then it became even more taboo to consider HRT after, after the receptor positive breast cancer. So it was like a real perfect storm. But we shouldn't completely malign that conjugated equine estrogen, because that conjugated equine estrogen given orally has never shown, given alone has never shown an increased risk of breast cancer. In fact it just will do a decreased risk. What has evolved since then is, you know, a trend which is a good trend, I think to bioidentical but FDA approved or you know kind of government approved and regulated and well studied. You know bioidentical options and we have many of them, so we have real estradiol. So I mean, it's very. It's exactly chemically what looks like you know your own estradiol in your body is, and we have it in gel, so transdermal forms, gels, sprays and patches. We also have it in oral form. And so at the menopause society last year in the US they did present an article that looked at formulation and breast cancer risk and they showed that estrogen alone, conjugated white estrogen no increased risk. Estradiol alone no increased risk. Estradiol was a progestin. They used the data from the WHO showing this tiny increased risk and they said and then some other and then data if it was progesterone, so bioidentical progesterone, no increased risk, so either neutral or maybe slightly beneficial. Now it's not the same level of data comparing those bioidenticals that we had, like the numbers in the WHO, so smaller numbers, but the trend is that it's at least as safe, if not better. But I should never miss, you know, knock conjugated equinestrogens Because, let's face it, all of the good data in terms of showing osteoporosis prevention, lower risk of dementia when women started within 10 years, lower cardiovascular risk when women started in the first 10 years, that data all comes from oral conjugated equinestrogen. Let's not forget that right. So it's not totally misaligned. And the reason why I bring it up is because, for the breast cancer survivor, I want you all to know and I don't know if you guys have this available in Australia, but in the US we have something called Duovie, which is a combination of conjugated equine estrogen paired with basodoxaphen. Okay, so it's a very unique HRT option. It's an oral option, but why I want your listeners to know about it and do you guys have this in?

Australia. I haven't heard of it Doesn't mean we don't have it, but it's not something I'm familiar with, though it's very important.

So out of the WHI, there's all these fears that the progestin was maybe the culprit in causing this increase. So drug companies were like, well, what could we do here? What could we pair conjugated equinestrogen with? And so researchers and these amazing doctors who helped develop this actually spoke at the menopause conference this past fall discussing this medication called basodoxaphen. So basodoxaphen sounds similar to tamoxaphen, doesn't it? It's because it's kind of causing. And it's basically what they were trying to find is what could we give with estrogen that would protect the uterine lining, right? Because that's why we give progesterones that you don't have thickened uterine lining and uterine cancer and bleeding. So what could we give that could protect the uterine lining and also protect the breasts from any extra stimulation, right? So they looked and they said well, you know, we know tamoxaphen has these selective estrogen receptor properties in different tissues, so let's see if we could find something similar to that, right? So they found this medication is called basodoxaphen. It has very strong, powerful anti-receptor effect in the breast. It actually degrades the estrogen receptor in the breast so that it's not even functional. And it does the same thing in the uterus. So you don't bleed, you have no uterine lining stimulation, you have no increased risk of uterine cancer. It's positive on brain, on the bone, on skin. It's not causing any anti-estrogen effects there. But it's blocking, or I should say degrading the estrogen receptors in the breast and I have to say it was actually very profound to see the slide of showing what breast you know with the slide show what it looks like in the breast tissue and how powerful and anti-proliferative basodoxaphen is when given with conjugated equine estrogen. So Duoville is an oral one-size-fits-all medication. So it's basically 0.0625 of CE, so similar to about one milligram of bio-genital estradiol, and paired with basodoxaphen. So it's not being paired with a progestin. There is no progestin or progestin. It's this unique thing. So this is a super interesting option for people who have intact breasts, who are ER positive, breast cancer patients. Because basodoxypene on its own I think in Europe they've looked to approve it as a cancer treatment. So basodoxypene everyone has to think of it as almost like a superpower to moxethane, right so. But in the US market Bayer decided like we're not going to pursue that FDA label right, Even though we know it's a powerful cancer drug. So it's a very interesting thing for people to understand that you might be able to have your cake and eat it too, Treat your menopause symptoms, protect your bones, protect your brain, travel and also maybe have this powerful effect on breasts. So that's one interesting option that I think could be very promising, and yesterday at the San Antonio Breast Cancer Conference, there was data presented and a lot of discussion about this and my oncology Dr Friend and I are going to, we're going to be doing an Instagram live, we're going to talk through the slides and the presentation so people can stay tuned for that and then I will say the other option is what you kind of alluded to is generally in my practice, bioidentical, but regulated, not especially compounded or policy or anything like that, but properly bioidentical in a transdermal patch comes in lots of doses, low to high. You can treat patients based on what their symptoms are by minimizing side effects, and we pair it with a bioidentical progesterone. His bioidentical progesterone has not had to show any negative impact on breast tissue and does not also have any negative impact on cardiovascular markers, clotting factors, anything like that. So for my average menopausal patient, I love that. I think Duavit that I mentioned is also another great option, and so I think both of those options are the options that, when I am talking about it with someone who's had breast cancer. Those are two options that I talk to them about. And when I talk to them about using HRETA after breast cancer, we have to we talk about it in a holistic way. What are your symptoms, what is your pathology, what is your oncology team tell you? Let's talk about. You know your medical situation, and then we talk about what the data shows. Okay, and then what I? You know my. These appointments take a long time, and so this is why it's hard for the average oncologist or anyone to do it, but I think it's really, really important that women, then, are able to know that there is published literature, and you know this article is the beauty of it all. It's called hormone replacement therapy after breast cancer. It is time. It was published in the cancer journal in May of 2022 by Avron Blooming, and he did a beautiful literature review with these lovely tables. This one is a summary of 21 studies that have been published between the years of 1980 and 2013. Looking at and again, not all perfect data. Some of it is observational studies, Some of it is retrospective cohorts, Some of them are protect perspective, randomized but the point is, of this chart of 25 studies, only one of them shows an increased risk of local or contralateral tumor, but no increased risk of metastasis or death. Every other 24 out of the 25 studies shows either reduced recurrence, reduced mortality. Both were no difference. So to categorically deny women access when we've got actual published peer review literature is just an unreasonable and unfair thing. And then you go one step further. There's been 20 published meta-analysis in reviews of those studies and none of those, none of those reviews show any difference. And it's on the basis of the one study, the habits trial, that was published in the oncology literature that scared everybody and, of note, it came out around the same time as the WHI, so it was a poison pill from the beginning. And that own habits trial has a lot of problems with it as well as do all studies right, but in life we've got to take the preponderance of evidence and all the data and individualize it for a patient, and so I review this data with them and then we make a decision together and I have an informed consent so they can sign a consent form. So in terms of any medical liability, because in the US it's like it's no joke. The medical malpractice is no joke here and I think that's a very reasonable approach. And as part of the discussion, we also talk about non-hermonal options and we talk about the vaginal health and the sexual health options which are not systemic hormones. So that's kind of how I tackle it.

Yeah, wow, I wish that I had had an OBGYN like you years ago, years ago, and I hope, I really do hope that we can come to a point in Australia where we are seeing more informed consent discussions between clinicians and patients, particularly in this breast cancer survivor space, because it is so important and it is so needed.

And the only way you'll ever get that is it's going to be grassroots and it has to come from the breast cancer community. So if you care about this, you need to go and tell your oncologist or OBGYNs, you have to document, you have to tell them, you have to speak up and say it's more than just half flashes. This is what I'm worried about. This is what I'm reading and it's going to take a lot of noise, but I think this is the positive side of social media is that we can all talk and connect over this and certainly for your listeners, I will provide some links and some documents and some access to things so that they can read and help start to get themselves educated.

That'd be amazing. Thank you so much, and I'll make sure that all of that gets leaked through to in the show notes of today's podcast as well. Anybody can reach out to me personally to get those if they're more interested in deep diving into all of that. Corinne, I have gained so much from our conversation. I've learned a lot. I'm pretty sure our listeners definitely would have learned a lot. Is there anything else that you'd like to leave anyone with before we kind of wrap things up?

I would just say please take seriously menopause. It's not a joke. When it's premature, whether it's at the natural age, there are repercussions not only to whether you're taking hormones or not, but for other things bone density, heart health, mental health, sexual health. You're worth it, you deserve it. Pushing at the answers and I promise you there is help for you, and the very last thing I will say is please use vaginal estrogen for life. It's safer for all you breast cancer survivors. That's really low hanging fruit. It is.

Corinne, thank you so much for your time today. I hope that perhaps someday in the future we might see you down here in Australia to speak on this. I think that would be an amazing opportunity for people to learn from you, oh I would love to.

That sounds like fun.

We will talk. Awesome Thanks, corinne. Thank you for listening today. I am so grateful to have these conversations with incredible women and experts and I'm grateful that you chose to hit play on this episode of Dare Menopause. If you have a minute of time today, please leave a rating or a review. I would love to hear from you because you are my biggest driver for doing this work. If this chat went way too fast for you and you want more, head over to StellaWomencomau slash podcast for the show notes and, while you're there, take my midlife quiz to see why it feels like midlife is messing with your head.