Hormonal management after risk-reducing surgery in BRCA-mutated triple-negative breast cancer survivors

Premenopausal women carrying a BRCA1 or BRCA2 mutation are frequently advised to undergo risk-reducing bilateral salpingo-oophorectomy (BSO) to lower their significantly increased lifetime risk of ovarian cancer. However, this procedure induces abrupt estrogen deprivation, resulting in premature menopause with well-documented consequences including vasomotor symptoms (e.g., hot flashes, night sweats), urogenital atrophy, and long-term risks such as osteoporosis, cardiovascular disease, and cognitive decline (Nelson in Lancet 371(9614):760-770, 2008; Shuster et al. in Maturitas 65(2):161-166, 2010). To alleviate symptoms and prevent sequelae, hormone replacement therapy (HRT) remains the most effective intervention. However, the issue becomes complex when the patient has a personal history of triple-negative breast cancer (TNBC). Although TNBC lacks hormone receptor expression, systemic HRT has traditionally been contraindicated in breast cancer survivors, as early studies indicated an increased risk of recurrence with hormone therapy, even in receptor-negative subtypes (Kenemans et al. Lancet Oncol 10(2):135-146, 2009a). This leads to a critical question: Is HRT appropriate in BRCA mutation carriers with a history of TNBC following BSO, and if so, under what clinical conditions? What do current international guidelines, evidence, and expert recommendations suggest?