Women carrying a germline BRCA1 or BRCA2 mutation are advised to have risk-reducing salpingo-oophorectomy 5 to 15 years before natural menopause. That prevents ovarian and tubal cancer and produces abrupt surgical menopause in a woman in her late thirties or forties, with the vasomotor, bone and cardiovascular consequences that follow.
Menopausal hormone therapy is the most effective way to mitigate that, and this review in Obstetrics and Gynecology argues that uptake stays low precisely in the group with most to gain, driven by misinformation about what MHT does to breast cancer risk in carriers. The authors summarise the existing literature on MHT and breast cancer in high-risk populations and flag their intention to evaluate conjugated oestrogen combined with bazedoxifene — a selective oestrogen receptor modulator — as a formulation that might control symptoms and protect bone while not adding, and possibly reducing, breast cancer risk.
For now the practical content is the counselling conversation. A woman who has just been told to have her ovaries removed at 38 is being asked to accept two decades of oestrogen deficiency, and the default of declining hormone therapy is often made in the same consultation, on the strength of a risk figure that was never derived from her population.
- Separate the decision about oophorectomy from the decision about hormone therapy — they do not have to be made in one visit
- Ask what the woman believes MHT does to her breast cancer risk before correcting it
- Baseline bone density in a woman entering surgical menopause before 45, whatever she decides about MHT
- Involve the genetics or breast team in the MHT conversation rather than deciding alone
- Bazedoxifene-containing regimens are a research direction here, not an option to offer
Why it matters
The women most likely to be harmed by early surgical menopause are the ones least likely to be offered treatment for it.
Don't overread it
This is a narrative review and a statement of research intent, not new outcome data in BRCA carriers.
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