Is Menopausal Hormone Therapy (MHT) contraindicated in women with a family history of breast cancer?

Menopausal Hormone Therapy in Women with Family History of Breast Cancer

Menopausal Hormone Therapy (MHT) should be used with caution in women with a family history of breast cancer, as it may increase their already elevated baseline risk, but it is not absolutely contraindicated unless there is a personal history of breast cancer or other specific contraindications. 1

Risk Assessment and Considerations

• Family history of breast cancer increases a woman's baseline risk of developing breast cancer, and MHT may further elevate this risk, particularly with combined estrogen-progestogen formulations 2
• The degree of risk depends on the strength of the family history - women with "strong" family histories have approximately double the baseline risk compared to those with "average" family histories 2
• MHT use should be approached with particular caution in women with increased genetic cancer risk, including those with BRCA1/2 mutations or strong family histories suggestive of genetic predisposition 1

Decision-Making Algorithm

Step 1: Assess Contraindications

• Absolute contraindications to MHT include:
  • Personal history of hormonally mediated cancers (including breast cancer) 1
  • Abnormal vaginal bleeding 1
  • Active or recent history of thromboembolic events 1
  • Pregnancy 1
  • Active liver disease 1

Step 2: Evaluate Family History Strength

• Determine if the patient has:
  • Early-age-onset breast cancer in family members 1
  • Multiple breast primaries or breast and ovarian cancer in a single individual 1
  • Two or more breast primaries in close relatives from same side of family 1
  • Known BRCA1/2 or other gene mutations associated with breast cancer risk 1

Step 3: Consider Alternative Therapies First

• Non-hormonal options for managing menopausal symptoms should be tried before MHT in women with family history of breast cancer 1:
  • Cognitive behavioral therapy (CBT) for vasomotor symptoms 1
  • Vaginal moisturizers and lubricants for vaginal dryness 1
  • Other medications like selective serotonin reuptake inhibitors for hot flashes 3

Step 4: If MHT is Necessary

• Use the lowest effective dose for the shortest duration possible 1
• Consider formulation carefully:
  • Estrogen-only MHT carries lower breast cancer risk than combined formulations 4
  • Transdermal estrogen may be preferred over oral formulations due to lower VTE risk 1
  • Micronized progestin may be preferred over medroxyprogesterone acetate due to potentially lower breast cancer risk 1

Special Considerations

• Women with BRCA mutations who undergo risk-reducing salpingo-oophorectomy (RRSO) may safely use short-term MHT to manage menopausal symptoms, as studies indicate this is safe among healthy BRCA1/2 mutation carriers 1
• Custom compounded bioidentical hormones are not recommended as they lack data supporting claims of improved safety or efficacy 1
• The risk-benefit calculation must be individualized based on:
  • Severity of menopausal symptoms 1
  • Impact on quality of life 1
  • Strength of family history 2
  • Presence of other risk factors (e.g., hypertension, smoking) 1

Monitoring and Follow-up

• Women with family history of breast cancer using MHT should:
  • Undergo appropriate breast cancer screening according to guidelines 1
  • Have regular follow-up to reassess the need for continued MHT 1
  • Consider discontinuation or dose reduction if risk factors change 1

While MHT is not absolutely contraindicated in women with family history of breast cancer, the decision to use it requires careful consideration of risks and benefits, with preference given to non-hormonal alternatives when possible 1.