HRT for Gynecologic Cancer Survivors – Part 2: Ovarian Cancer

For many women, menopause symptoms after cancer treatment can be severe, especially when menopause is induced by surgery. Women who have been treated for gynecologic cancers may wonder if hormone replacement therapy (HRT) is safe for them. While every case is unique, emerging research suggests that HRT may be both safe and beneficial for certain ovarian cancer survivors.

Understanding Ovarian Cancer and Menopause

Ovarian cancer includes cancers that originate in the ovaries, fallopian tubes, and primary peritoneal lining (which often begins in the fallopian tubes). Unfortunately, these cancers are typically diagnosed in later stages because early symptoms are vague. The most common type is high-grade serous epithelial ovarian cancer, which is often diagnosed around age 63 but can occur in premenopausal women as well.

For women who who are premenopausal and undergo surgery, chemotherapy, or both, treatment can result in sudden menopause. The loss of estrogen can lead to severe symptoms such as hot flashes, vaginal dryness, brain fog, mood changes, joint pain, and increased risk of osteoporosis, heart disease, and dementia. For women who are post-menopausal, they also may suffer with menopausal symptoms and may wonder if menopause hormone therapy is an option for them.

Does HRT Increase the Risk of Ovarian Cancer Recurrence?

Unlike the concerns surrounding HRT in breast and endometrial cancer survivors, there is no strong evidence that HRT increases the risk of ovarian cancer recurrence. In fact, some studies suggest that HRT may improve overall survival. That said, the data is quite limited although there is enough that we are able to draw some conclusions and have an informed discussion with women interested in HRT after ovarian cancer.

What the Research Shows

Largest RCT (2015 Study): The largest randomized controlled trial (RCT) on this topic found that women who did not take HRT were more likely to experience cancer recurrence or die from any cause. On average, women who took HRT lived 2.9 years longer than those who did not.
Another RCT on Estrogen Therapy: A separate study looking at estrogen replacement therapy (ERT) in ovarian cancer survivors found that even in advanced or severe cases, HRT improved disease-free survival and overall survival. While the results were not statistically significant, there was no evidence that HRT harmed these patients.
Additional Studies: Two other observational studies found improved survival and reduced ovarian cancer deaths in women who used HRT after their cancer treatment.

What About Vaginal Estrogen?

One of the most frustrating symptoms of menopause—especially for cancer survivors—is vaginal dryness, pain with intercourse, and urinary symptoms. Vaginal estrogen, which delivers a very low dose of estrogen directly to the vaginal tissue with minimal absorption into the bloodstream, can be an important treatment option.

The one and only available study on vaginal estrogen in ovarian cancer patients found that it appears to be safe in all ovarian cancer survivors.
The British gynecologic cancer guidelines, based on expert opinion, state that vaginal estrogen is safe in all ovarian cancer survivors who are also considered safe to take systemic HRT.
These guidelines also recommend caution in estrogen-sensitive cancers, though vaginal estrogen may still be considered for symptom relief.
This cautious but supportive approach is also how UCLA’s gynecologic oncology department practices.

Who Might Benefit from HRT?

Based on the available data, systemic HRT may be an option for women with the following types of ovarian cancer:

✅ High-grade serous ovarian cancer (common among BRCA mutation carriers)

✅ Mucinous ovarian cancer

✅ Borderline ovarian tumors (without invasive implants)

Special Consideration: Borderline Tumors

Borderline ovarian tumors are slow-growing and have low malignant potential. These often affect younger women (ages 20-40), who may undergo surgery that removes their ovaries, causing sudden menopause. For these women, HRT is likely safe and possibly beneficial—not only for symptom relief but also for long-term bone, heart, and brain health.

When is HRT Less Clear or Not Recommended?

⚠️ Caution with Clear Cell Ovarian Cancer

Clear cell tumors, which may develop from endometriosis, have unclear data regarding HRT safety. If a patient had extensive endometriosis, there is a potential concern for recurrence. Also, these women are at a higher risk of blood clots, so if HRT is used, transdermal estradiol (patch, gel, or spray) is the safest option.

🚫 HRT is NOT recommended for:

Low-grade serous ovarian cancer
Endometrioid ovarian cancer
Granulosa cell tumors
Sertoli-Leydig tumors

These cancers are estrogen-sensitive and are often treated with anti-estrogen therapy. For these patients, non-hormonal options may be the best approach to managing menopause symptoms. However, if these are diagnosed at stage I (patients who, for example, may have a cancer-free ovary that is therefore not removed), HRT could be considered but the data is lacking.

Final Thoughts

Every ovarian cancer survivor deserves personalized care when it comes to menopause management. While HRT may not be appropriate for everyone, the available research does not show increased recurrence risk in most cases, and in fact, suggests potential survival benefits.

Additionally, for women struggling with vaginal dryness, pain, or urinary symptoms, vaginal estrogen is likely a safe and effective option—even in many cancer survivors.

As always, the patient has the final say about what treatments she would like to receive for her menopausal symptoms. We should also partner with your oncologist as we proceed, ensuring that your treatment plan aligns with your overall health and cancer history.

If you are an ovarian cancer survivor struggling with menopause symptoms, you don’t have to suffer in silence. Let’s have a conversation about your specific cancer type, treatment history, and symptom concerns to determine the best approach for you.

At Dragonfly Menopause Care, I work closely with each patient to help them feel their best while making informed, evidence-based decisions about their care. 💙

Before Your Appointment

To make the most of our visit, please share with me:

✔ Your cancer type (what kind of ovarian cancer you had)

✔ Tumor grade (how aggressive the cancer was)

✔ Cancer stage (how far the cancer had spread)

Having this information will help guide our discussion and ensure that you receive the most personalized and informed decision about your care. Menopause symptoms can have a big impact on your daily life, and I want to help you feel your best while making the safest choice for your health. Let’s work together to find the best path forward!

For more information about this subject, check out Rachel Frankenthal, PA-C in Instagram and the Menopause and Cancer podcast with Dr. Dani Binnington