In menopausal women, which is a contraindication to hormone therapy: family history of breast cancer, personal history of breast cancer, prior vaginal birth, or controlled hypertension?

Personal History of Breast Cancer is an Absolute Contraindication to Hormone Therapy

Personal history of breast cancer is an absolute contraindication to hormone therapy (HT) in menopausal women, regardless of hormone-receptor status, time since diagnosis, or severity of menopausal symptoms. 1, 2

Why Personal History of Breast Cancer is the Correct Answer

• Women with a prior breast cancer diagnosis face a 10–20% risk of recurrence or contralateral disease over 5–10 years, and systemic hormone therapy may stimulate residual microscopic disease or promote new hormone-sensitive tumors 1, 3
• The American College of Obstetricians and Gynecologists, American Society of Clinical Oncology, and all major guideline societies classify personal history of breast cancer as an absolute contraindication to systemic HT 1, 2
• This prohibition applies to all forms of systemic estrogen therapy—oral, transdermal, combined estrogen-progestin, and estrogen-alone regimens 1, 3

Why the Other Options Are NOT Contraindications

Family History of Breast Cancer

• Family history without a confirmed BRCA mutation or personal diagnosis is not an absolute contraindication to HT 1, 4, 2
• Women with BRCA1/2 mutations who undergo risk-reducing bilateral salpingo-oophorectomy may use short-term HT until approximately age 51 (average natural menopause) without negating the surgery's protective benefit 1, 4
• The critical distinction is between personal history (absolute contraindication) versus family history (requires individualized risk assessment but not prohibited) 1, 2

History of Vaginal Birth

• Vaginal birth has no relationship to HT contraindications and does not appear in any guideline as a safety concern 1, 2
• Mode of delivery (vaginal versus cesarean) does not influence estrogen metabolism, thrombotic risk, or cancer susceptibility 1

Controlled Hypertension

• Controlled hypertension is not a contraindication to HT; it is a relative consideration that influences route selection 1, 2
• Transdermal estradiol is the preferred formulation in hypertensive women because it avoids first-pass hepatic metabolism and does not raise blood pressure as oral estrogen may 1
• Blood pressure should be monitored at baseline and annually during HT, but well-controlled hypertension does not preclude therapy 1, 2

Management of Menopausal Symptoms in Breast Cancer Survivors

• Non-hormonal alternatives are first-line for women with prior breast cancer: selective serotonin reuptake inhibitors (venlafaxine, paroxetine), gabapentin, clonidine, or cognitive-behavioral therapy reduce hot-flash frequency by 50–60% 1, 3, 5
• Low-dose vaginal estrogen (rings, suppositories, creams) can be considered for severe genitourinary symptoms after thorough risk-benefit discussion, as systemic absorption is minimal 1, 3
• Paroxetine and fluoxetine should not be used in women taking tamoxifen due to CYP2D6 inhibition that reduces tamoxifen efficacy 1

Common Clinical Pitfall

• Do not confuse family history with personal history—family history of breast cancer (even with multiple affected relatives) does not automatically prohibit HT unless the patient herself has had breast cancer or carries a known pathogenic mutation requiring special consideration 1, 4, 2