Starting Menopausal Hormone Therapy in a Patient with Fibroadenoma
You can start estrogen therapy now without waiting for the follow-up ultrasound, as fibroadenomas are benign lesions that do not contraindicate hormone therapy and do not increase breast cancer risk with estrogen use. 1, 2
Why Fibroadenomas Are Not a Contraindication to MHT
Fibroadenomas are benign breast lesions composed of both epithelial and stromal tissue, most commonly seen in women under 40 but can occur in perimenopausal women. 3, 4
Estrogen replacement therapy does not significantly elevate the risk of invasive breast cancer in women with benign breast disease, including fibroadenomas. A large retrospective cohort study of 9,494 women with benign breast biopsies found no significant increase in breast cancer risk with ERT use. 2
The absolute contraindications to MHT are: active or history of breast cancer, unexplained vaginal bleeding, active or history of venous thromboembolism, active or history of arterial thrombotic disease, active liver disease, or known estrogen-dependent malignancy. 1, 5 A fibroadenoma under surveillance does not fall into any of these categories.
Clinical Context for This Patient
At age 46 and perimenopausal, this patient is in the optimal window for initiating MHT (under 60 years or within 10 years of menopause onset), where the benefit-risk profile is most favorable. 5, 6
The follow-up ultrasound for the fibroadenoma is for surveillance purposes only, to ensure stability of a known benign lesion. Fibroadenomas typically present as smooth, mobile masses with well-circumscribed borders on imaging. 7, 3
Important Caveats About Fibroadenomas in Perimenopausal Women
While fibroadenomas are uncommon in perimenopausal women, maintain a high index of suspicion if imaging characteristics change or the lesion grows rapidly. In rare cases, breast cancer can mimic fibroadenoma on imaging in postmenopausal women. 8
Ensure the fibroadenoma diagnosis was confirmed by triple assessment (clinical examination, imaging, and tissue sampling via FNA or core biopsy). If tissue diagnosis was not obtained, this should be done before starting MHT. 8
Surgical intervention for fibroadenomas is indicated only if: the lesion is symptomatic, diameter exceeds 2 cm, rapid growth occurs, complex features are present, or the patient has significant anxiety. 3 Close follow-up alone is appropriate for stable, simple fibroadenomas.
Recommended MHT Regimen
For a 46-year-old perimenopausal woman with an intact uterus, use combined estrogen-progestin therapy to prevent endometrial hyperplasia. 1, 5
First-line formulation: Transdermal estradiol 50 μg/day patch (changed twice weekly) plus micronized progesterone 200 mg at bedtime. 5, 6
Transdermal estradiol is preferred over oral formulations due to lower rates of venous thromboembolism and stroke. 5, 6
Monitoring Plan
Proceed with the scheduled follow-up ultrasound for the fibroadenoma as planned, independent of MHT initiation. 7
Reassess MHT at 3-6 month intervals to ensure the lowest effective dose is being used for symptom management. 5
If the fibroadenoma shows growth (>20% increase in volume or diameter over 6 months), tissue sampling should be repeated regardless of MHT use. 7