Erin Keyser, MD, on navigating hormone therapy in high-risk menopause cases

In a recent interview with Contemporary OB/GYN, Erin Keyser, MD, FACOG, with Brooke Army Medical Center, discusses the nuanced and often complex decisions involved in managing menopausal symptoms, particularly in high-risk patients.

To begin, Keyser provided an overview of hormone therapy (HT) for vasomotor symptoms, including hot flashes, night sweats, outlining the different available regimens. A key case discussed involved a woman using a Mirena intrauterine device (IUD) during perimenopause or menopause. While the Mirena is FDA-approved for up to 8 years for contraception and around 6 years for abnormal uterine bleeding, its role in protecting the endometrium during systemic estrogen use is less clear. Based on hormone release data, Keyser suggests a duration of 5 to 6 years may be reasonable.

Another critical case involved patients with ductal carcinoma in situ (DCIS) or a history of breast cancer who inquire about HT. DCIS, a non-invasive form of breast cancer, is frequently treated aggressively in the United States, sometimes with mastectomies, radiation, and tamoxifen. Keyser emphasizes that the data is inconclusive about whether HT is contraindicated in these cases. Therefore, decisions should hinge on shared decision-making—balancing risks and benefits while considering the patient’s values, medical history, and quality of life goals.

Keyser also noted that the fear surrounding HT largely stems from the Women’s Health Initiative (WHI) study, which suggested an increased risk of breast cancer. However, she highlighted that the WHI studied older, synthetic hormone formulations not commonly used today. Modern practice favors bioidentical hormones such as FDA-approved estradiol and micronized progesterone, which may not carry the same risks. Additionally, estrogen-only therapy in the WHI actually showed no increased risk of breast cancer.

Keyser also pointed out the often overlooked benefits of HT, including reduced risks of osteoporosis, colon cancer, cardiovascular disease, and improved overall survival. For some women, especially those with severe symptoms, the benefits may outweigh the potential risks.

Importantly, non-hormonal options such as fezolinetant, an NK3 receptor antagonist, are now available and can be effective for vasomotor symptoms. However, Keyser cautioned that these do not always address the full spectrum of menopausal symptoms, such as brain fog, anxiety, and muscle pain.

In conclusion, Keyser stressed the importance of personalized care and comprehensive counseling, urging patients to seek providers who present a range of options. She advocated for empowering women through information, emphasizing that quality of life considerations are central to choosing the best treatment path.

Reference:

Keyser E. Optimizing Treatment of Vasomotor Symptoms: It’s Not One-Size-Fits-All. Presentation. Presented at: 2025 ACOG Clinical and Scientific Meeting. May 16-18, 2025. Minneapolis, Minnesota.

Disclosure:

Astellas Pharma US Inc