Last month I launched a new Substack series called Cancer Cases where we go through some example cases of people with a history of cancers that are commonly excluded from hormone therapy. In these posts, we go deep to discuss the data related to management of their menopause. The first in the series was about treatment of menopause after Triple Negative Breast Cancer.

Today we will talk about another cancer history that commonly translates into confusion surrounding menopause management: endometrial cancer.

All Cancer Cases In the Series:

Triple Negative Breast Cancer

Endometrial Cancer 101

Before we jump into the cases, let’s go through the basics of endometrial cancer. The endometrium is the lining of the uterus that grows and sheds during a menstrual cycle in accordance with hormonal influence. There are more than just these hormone sensitive endometrial cells there though, there are also supportive tissues. All of these types of cells can grow abnormally into a cancer.

Endometrial cancer is the most common cause of gynecologic malignancy in developed countries and the second most common cancer in women after breast cancer. Nearly 70,000 women every year are diagnosed with endometrial cancer in the US.1

There are two broad categories of endometrial cancer: Type 1 and Type 2. Type 1 endometrial cancers (otherwise called endometrioid) make up 80% of all endometrial cancers. Type 1 endometrial cancers are estrogen sensitive and grow due to overstimulation of the endometrium from estrogen. When people have heard of the increase in endometrial cancer with unopposed estrogen for HRT (estrogen without progesterone), it is this type of endometrial cancer. The number one risk factor for Type 1 endometrial cancers is obesity, as fat tissue produces estrone which hyperstimulates the endometrial lining. Type 1s are graded from 1-3 with grades 1 and 2 being considered “low risk” and grade 3 being “high risk”.

Type 2 endometrial cancers arise from all the other cells in the endometrial lining and importantly are not estrogen sensitive. They are associated with worse survival than Type 1 endometrial cancers. Examples would include serous carcinoma, clear cell carcinoma, and carcinosarcoma. By definition, all Type 2 endometrial cancers are considered high risk.

Nearly 50-60% of all women diagnosed with endometrial cancer have low grade, early stage Type 1 endometrial cancer. This is important because 5 and 10 year survival for this type of endometrial cancer is 97-100%. On the other hand, high risk endometrial cancers have significantly worse survival. When endometrial cancers recur, the most common site for low grade tumors is at the vaginal cuff (where the top of the vagina is sowed together after hysterectomy) whereas for high grade and advanced stage tumors distant metastases are more common. Recurrence is usually within the first 3 years from diagnosis, although high risk tumors usually recur sooner.

Treatment for endometrial cancer nearly always involves a hysterectomy with removal of the fallopian tubes and ovaries. Depending on someone’s age, grade, and staging, chemotherapy and radiation may also be part of the treatment. For early low grade tumors, sometimes these can be temporarily treated with a progestin IUD or oral progestin if someone desires fertility in the future, but eventually surgery is still recommended.

Roughly 20-25% of women with endometrial cancer are diagnosed before menopause and most of them will go into surgical premature menopause as a result of their treatment. Although preserving the ovaries has been found to be safe for women with early stage low grade endometrial cancers, the rate of ovarian preservation during cancer surgery is actually declining.2

A Tale of Two Cases

So now armed with this knowledge, let’s go through two patient cases with Type 1 endometrial cancer and discuss their menopause management.

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Last week, the new 2026 ACC/AHA Guideline on the Management of High Cholesterol was released. This is a comprehensive overhaul that retires the previous 2018 guidelines entirely. It is the most significant update to cholesterol management in nearly a decade and there are several things in it that are seriously cool.

It takes a lot to for me to get excited about medical guidelines. In general I find them to be overly conservative and narrow. But these guidelines are different. They are forward thinking, personalized, and for the first time incorporate important risk modifiers that affect women specifically.

The entire guidelines are structured around a nifty acronym, C.P.R.:

• Calculate your risk

• Personalize the assessment with risk modifiers

• Reclassify with Coronary Artery Calcium testing/Reassess treatment recommendations

The whole document is a validation that a one size fits all approach to heart disease prevention no longer works.

Let’s break it down.

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Primary (or Premature) ovarian insufficiency (POI), colloquially known as early menopause, is when the ovaries cease normal functioning much earlier than the typical age of menopause.

But unless someone has undergone surgical menopause where the ovaries are removed early, casually calling POI “early menopause” is a little reductive. There are some unique factors to take into account for POI that may not be true for surgical menopause. There are also some shared principles between the two.

The diagnostic criteria are specific: disordered menstrual cycles for at least 4 months plus follicle stimulating hormone greater than 25-30 IU/L on two occasions at least one month apart, in a woman under 40.1 Despite clear guidance, the typical blind spots that affect women’s health leads to delays in care and real health consequences.

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Without a doubt, our collective notion of what a heart attack means applies much more to men than to women. In fact, less than a third of women with heart attacks have chest pain.

This translates into real negative outcomes. While women on average have a slightly lower lifetime risk of heart attack than men, they have a 30% higher chance of dying from a heart attack. Additionally, after a heart attack women have a higher risk of a second heart attack in the future compared to men and are less likely to be started on appropriate preventative treatments. This disparity is primarily due to misdiagnosis, delays of treatment, and good ole’ medical misogyny.

Heart disease is the number one cause of death for women and half of those deaths are from heart attacks. Understanding how heart attacks are different for women is the first step towards ameliorating this massive discrepancy.

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Today is the last day of the annual conference for ISSWSH (the International Society for the Study of Women’s Sexual Health).

I’ve talked about ISSWSH before but it is without a doubt the most impressive organization I’ve ever been a part of and is filled with people devoted to the health of all people with vulvas. As one colleague described at the meeti…

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People with cancer are the most excluded from the menopause revolution. It’s shocking because 40-90% of women with cancer experience menopause as a direct result of their cancer treatment, depending on their age and type of cancer. In my view, menopause consultations should be a part of every single cancer treatment plan for all women. Maybe one day.

There are a lot of reasons why these women are not treated for their induced menopause but a huge part is fear. Even for cancers that have no hormone dependent pathways, oncologists, OB/GYNs and PCPs alike decide that treating menopause would be riskier just in case. The assumption is that menopause treatment, with hormones in particular, might cause problems so it is best to just stay away from it. What is ignored here though is that not treating menopause is also risky, with significant harms related to not just quality of life but also the heart, bones, and nearly all other body systems.

In 2026 it’s time we stop deciding for women what is right and what is wrong for their own bodies. While there may be genuine circumstances where hormone therapy is inappropriate, that does not mean we do not treat menopause writ large. We have a responsibility to discuss all available treatments with patients, review the data on risks and benefits of each, and let people decide how they want to live their life. It is no longer enough to help people survive cancer. We also have a responsibility to ensure that the life saved is a life people want to live. That means at the very least having the discussion about options, rather than telling women to “suck it up and just be grateful they are alive”.

With this in mind I’ve been excited to start this new Substack series where we will go through various types of cancer histories via some example cases and review how these treatments may pan out. These cases are all made up to protect patient privacy but are examples of common situations that may be encountered. Some of these situations are very straightforward, some are extremely nuanced and there might be no “right” answer. But by prioritizing available data and patient autonomy, everyone can come out with a plan that works for their life, their risk tolerance, and their priorities.

We’re going to start this series with a situation that women are nearly always unnecessarily excluded from menopause treatment (including hormone therapy): estrogen receptor negative breast cancer.

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If you haven’t heard of it before, a coronary calcium scan is a fast and easy CT scan without IV contrast of the arteries surrounding the heart that looks for the presence of calcified plaques that could lead to a heart attack. When plaques rupture, this is usually what leads to a heart attack. This scan is often covered by insurance but if not it is otherwise readily available and can be obtained for about $100 cash pay.

It’s a great tool for assessing someone’s cardiac risk category and whether they might need medication to address their cholesterol. But there’s a lot of confusion about what the results actually mean.

As an example, I recently saw a note from a doctor telling a patient that her positive coronary calcium scan, indicating the presence of plaques, was not a concern because these were calcified plaques which do not rupture and cause a heart attack.

This is technically true but extraordinarily misleading.

Let’s get into why.

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As of February 1st, this Substack is now reader-supported (read more here). As a thank you for your support thus far, if you sign up for a one year subscription you’ll get 25% off. Thank you for considering!

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For the past few months, I’ve been sharing everything I know about menopause care and women’s longevity for free. Hundreds of you have read my posts, shared them, and messaged me your stories and questions. Building this community on Instagram and Substack has been so meaningful to me. Knowing that my work is making a difference for your …

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What followed was a lot of messages about other “ironclad” reasons why they were denied hormone therapy or other things that should also be included on the list. The most common being: people with history of clot or elevated clot risk, people with endometriosis (especially deep infiltrating endometriosis), and people with …

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As many of you know, my wife just delivered our second son a few weeks ago. So postpartum has been on my mind a lot lately.

In my training to be an OB/GYN, as is the case for a lot of OB/GYNs, postpartum was pretty overlooked. There’s a checklist of the “7 Bs” you cover at a 6 week appointment: Blues (Mental Health), Breasts, Bleeding, Bottom (perineal l…

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There are 3 groups of women who are most commonly told that they cannot use hormone therapy for menopause management but actually can: women with a high risk for clot (which we have previously addressed here), those with a genetic risk for breast cancer (aka “previvors”, such as BRCA mutation carriers), and women with endometriosis.

The lack of accurate …

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Yesterday I talked about the five best financial investments to prioritize your health this year.

But what if you don’t have the money right now to invest into your health?

Well you might remember that a financial investment doesn’t mean anything if you don’t invest your time and intention as well. And there are numerous free (in some cases cost saving) a…

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Fair warning, there’s a little bit of tough love in this post.

If you’ve set a New Year’s resolution, odds are you’ll drop whatever it is in the next 2 weeks. Eighty eight percent of resolutions are broken by the second Friday in January (thusly known as “quitters day”).

Two weeks. That is how long most people make it through behavioral changes.

Despite t…

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Lichen sclerosus is one of the most underdiagnosed conditions in all of gynecologic practice. After my vulvar anatomy video this week, multiple people wanted to know more about this common condition. Even among those who have a diagnosis, it can be confusing and the idea of being on treatment forever can be very off-putting.

Lichen sclerosus is a chroni…

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But in all of my schooli…

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This is a very common concern with very poor guidance.

In a 2024 review of professional society guidelines on whether hormone therapy should be discontinued prior to knee arthroscopy, the authors found that some organizations have zero guidance for surgeons on this topic and many other have conflicting guidelines.1

The problem with having no clear guidance…

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It’s the week of Thanksgiving which of course means the beginning of holiday shopping. Whether you’re shopping for a friend, a partner, a family member, or even yourself, I can guarantee you that you know someone in menopause and I can guarantee they have had their eye on at least one of the things on this list.

All of the products/services recommended h…

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One of my recent videos went viral explaining the natural increase in cholesterol that happens during the menopause transition. This increase has been confirmed across multiple research studies but most notably in the robust SWAN study where LDL and total cholesterol both increase in the 6 years surrounding a woman’s final period. I explained in the vid…

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On Monday November 10th, I listened in awe to the Food and Drug Administration (FDA) press conference announcing the end of nearly all the black box warnings on estrogen products that have held back the field of menopause medicine for more than 20 years.

I was literally scrubbed into surgery, asking the nurse in the room to turn up the volume on my phone…

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