Navigating menopause with BRCA: Testosterone’s potential in menopause care

For women who have been diagnosed with breast cancer or carry the BRCA gene mutation, menopause may arrive earlier because of surgery and more abruptly than expected. An estimated one in 400 women in the United States. carries a BRCA1 or BRCA2 mutation, and roughly 1 in 8 will develop breast cancer in their lifetime.^1,2 These genes also carry the risk of ovarian cancer, which is much more likely to kill them. Many of these women will undergo elective risk-reducing surgeries like a prophylactic removal of the breasts and ovaries, the latter of which triggers the immediate onset of menopause.³ If the gene is found after the diagnosis of breast cancer, these patients could experience medically induced menopause as a result of their cancer treatment, such as chemotherapy or radiation, which causes a sudden drop in estrogen and initiates this transition.

Menopause affects approximately 1.3 million new women in the United States each year,⁴ with symptoms that vary drastically. Recognizable symptoms such as hot flashes, night sweats, and joint pain are often accompanied by a host of lesser-known symptoms ranging from heart palpitations to gum disease to memory lapses. Women with severe symptoms may find their work productivity, personal relationships, and mental well-being heavily impacted.

Hormone replacement therapy (HRT) is recognized by the Menopause Society as the most effective treatment of vasomotor symptoms, addressing the root cause of hormonal imbalance.⁵ However, for women with BRCA mutations or a history of hormone-sensitive breast cancer, traditional HRT may increase the risk of developing cancer or experiencing a recurrence. This creates a complex clinical challenge of how to manage symptoms when fewer therapeutic options, including first-line treatment, are available.

Understanding the BRCA challenge

BRCA gene mutations affect how the body processes and responds to hormones, especially estrogen and progesterone. In healthy women, cells can experience DNA damage during normal processes such as cell division, but this damage is usually identified and repaired. However, women who have BRCA gene mutations have a defective cellular repair system and can't effectively repair this damage, which then builds up over time.¹ As the damage accumulates, the risk of these cells becoming cancerous increases.

About 70 to 80% of breast cancers are estrogen receptor-positive and more than 50% are both estrogen- and progesterone-receptor positive,⁶ meaning that when the cells are exposed to these hormones, the cancer will grow. The hormones don't cause cancer, but they can make it grow once it is there. For those cancers, most providers will not consider traditional HRT because it is estrogen-based and can increase the already-elevated cancer risk. While providers will frequently recommend diet, lifestyle modifications, and naturopathic remedies, these approaches alone often fail to provide relief for patients experiencing severe menopause symptoms. This leaves women with BRCA mutations or a history of cancer in a very difficult position: endure potentially debilitating menopause symptoms without relief in the present or consider taking HRT and increasing their cancer risk in the future.

Testosterone replacement therapy (TRT) for menopause symptoms

For women with BRCA mutations who undergo risk-reducing surgery or have contraindications to estrogen-based HRT, testosterone replacement therapy has emerged as an alternative therapeutic option. It is not as rigorously studied as estrogen, but observational studies suggest that many women experience relief of some of the most problematic menopause symptoms, including vasomotor symptoms, vaginal dryness, libido loss, mood concerns, and cognitive difficulties.⁷

As the Senior Medical Advisor for one of the largest hormone optimization education companies in the country, I'm increasingly seeing a widening gap between what patients are asking for and what guidelines currently endorse. While testosterone therapy is not FDA-approved specifically for menopausal symptoms in women, low-dose testosterone therapy is emerging as a potential means of managing persistent symptoms, including low libido, energy loss, and brain fog. This is especially true for BRCA mutation carriers who may not be candidates for traditional estrogen replacement therapy. Those of us specializing in menopause care see an increase in the exploration of testosterone as an alternative option.

For many years, breast cancer survivors suffering from menopause symptoms have been safely and effectively treated with testosterone therapy. A ten-year prospective study of more than 1,260 women receiving testosterone therapy found that long-term subcutaneous testosterone treatment did not increase the incidence of invasive breast cancer, offering reassurance about its safety.⁷ Beyond menopausal treatment, there have been studies that indicate more far-reaching benefits to testosterone in women, including positive changes to sexual function, bone density, mood, and cognitive function.^{8, 9, 10}

Certainly, local/vaginal estrogen therapy has been established to be safe, even though the FDA refuses to remove the black box warning on the product despite no evidence that it causes harm.¹¹

The medical community is seeing increasing evidence that testosterone therapy can be an effective treatment for managing menopause symptoms in BRCA carriers despite the lack of FDA approval. This emergence of data, however, is accompanied by a critical need for more consistent education and training around hormone optimization. In the absence of standardized protocols or clear clinical guidance, treatment decisions vary widely across providers. It is essential that the care we provide reflects both a patient's symptom burden and clinical data and is not completely reliant upon lab results. There is also a need for more robust, long-term research to better understand the safety and efficacy of testosterone in women, especially in cancer survivors and BRCA-positive patients. Until this research occurs, clinicians will have to rely upon shared decision-making and individualized care planning to navigate this area of menopause management responsibly.

Nonhormonal treatment options: Helpful, but not comprehensive

For a woman navigating their menopause journey, maintaining a healthy diet and lifestyle is a foundational pillar of symptom management. While not a substitute for medical therapy, regular physical activity has been shown to improve mood, support cardiovascular health, and reduce the intensity of symptoms like hot flashes or sleep disturbances. Diets rich in whole foods, plant-based proteins, and healthy fats may help control hormonal fluctuations and support overall wellbeing. Vitamins and supplements, like vitamin D, calcium, and omega-3 fatty acids, are frequently recommended to support bone health, mood stability, and cognitive function. There are even naturopathic remedies that I've used with patients before, including a Swedish Flower Pollen Extract (Relizen), which is a plant-based and non-hormonal supplement that has been shown in small clinical studies to reduce the frequency and severity of hot flashes.¹²

A non-hormonal medication that has also proven effective in the treatment of hot flashes and night sweats is Neurokinin-3 (NK3), a receptor antagonist. This medicine works by targeting and blocking the activity of NK3 receptors in the hypothalamus of the brain, which plays a role in regulating body temperature. By blocking the NK3 receptors, this treatment can reduce the frequency and severity of vasomotor symptoms, although it does not help with the multitude of other symptoms common to menopause.^13,14

Moving forward with personalized care for every woman

Millions of women begin facing menopause each year, yet many struggle to find providers equipped to address the root causes of their symptoms. For high-risk patients, this challenge is even greater. The path forward requires a fundamental shift in how we approach menopause care. Providers should engage in meaningful conversations with patients about their options before declining treatment outright. This means weighing individual risk factors, discussing emerging alternatives, establishing appropriate monitoring protocols, and above all, understanding what the patient needs to achieve their highest quality of life.

Recent legislation has been introduced across 15 states aiming to improve clinician training and education surrounding menopause, expand insurance coverage, and incorporate workplace considerations. This marks an encouraging step in the right direction. Until there is complete industry and policy reform, real change is driven at the individual level, where providers take symptoms seriously and work together with their patients to develop personalized treatment plans.

For BRCA carriers and cancer survivors, effective symptom management is about reclaiming quality of life during a vulnerable transition. Whether through carefully monitored HRT, non-hormonal alternatives, or TRT, the most effective treatment plan is the one that provides the most relief.

Disclosure: Dorr is a senior medical advisor for Biote.

References

1. National Cancer Institute. BRCA gene changes: cancer risk and genetic testing. December 19, 2023. Accessed October 16, 2025. https://www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet
2. American Cancer Society. Breast Cancer Facts & Figures 2024-2025. Atlanta, GA: American Cancer Society; 2024. Accessed January 15, 2025. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/breast-cancer-facts-and-figures/2024/breast-cancer-facts-and-figures-2024.pdf
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6. Breastcancer.org. Breast cancer hormone receptor status. Updated November 2024. Accessed January 15, 2025. https://www.breastcancer.org/pathology-report/hormone-receptor-status
7. Glaser RL, York AE, Dimitrakakis C. Incidence of invasive breast cancer in women treated with testosterone implants: a prospective 10-year cohort study. BMC Cancer. 2019;19(1):1271. doi:10.1186/s12885-019-6457-8
8. Glaser RL, York AE, Dimitrakakis C. Beneficial effects of testosterone therapy in women measured by the validated Menopause Rating Scale (MRS). Maturitas. 2011;68(4):355-361.doi:10.1016/j.maturitas.2010.12.001
9. Glaser R, Dimitrakakis C. Testosterone therapy in women: myths and misconceptions. Maturitas. 2013;74(3):230-234. doi:10.1016/j.maturitas.2013.01.003
10. Davis SR, Wahlin-Jacobsen S. Testosterone in women - the clinical significance. Lancet Diabetes Endocrinol. 2015;3(12):980-992. doi:10.1016/S2213-8587(15)00284-3
11. The 2022 Hormone Therapy Position Statement of The North American Menopause Society Advisory Panel. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794. doi:10.1097/GME.0000000000002028
12. Winther K, Rein E, Hedman C. Femal, a herbal remedy made from pollen extracts, reduces hot flushes and improves quality of life in menopausal women: a randomized, placebo-controlled, parallel study. Climacteric. 2005;8(2):162-170. doi:10.1080/13697130500117987
13. Prague JK, Roberts RE, Comninos AN, et al. Neurokinin 3 receptor antagonism as a novel treatment for menopausal hot flushes: a phase 2, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10081):1809-1820. doi:10.1016/S0140-6736(17)30823-1
14. Fraser GL, Leddy JJ, Attardi BJ, et al. Safety and efficacy of fezolinetant in moderate to severe vasomotor symptoms associated with menopause: a phase 3 RCT. J Clin Endocrinol Metab. 2023;108(8):2037-2045. doi:10.1210/clinem/dgad058