Breast Cancer Survivorship Is a Menopause Problem Nobody Owns

October was Breast Cancer Awareness Month, and the 18th was World Menopause Day. But while oncology owns the cancer, and gynecology and primary care own menopause, the menopausal symptoms cancer treatment causes fall somewhere in between. 

They share a calendar, but not a conversation. In September, for example, the FDA granted priority review to Bayer’s elinzanetant for hot flashes caused by endocrine therapy, less than a year after approving it as Lynkuet for menopause. 

We know that endocrine therapy is among the most effective treatments in breast cancer care. About 80% of breast cancers are hormone receptor-positive, meaning estrogen helps them grow. Endocrine therapy blocks that signal or cuts off supply for at least five years, and the American Society of Clinical Oncology’s (ASCO) guidance supports up to 10 for many patients. 

For those women who go on estrogen therapy to manage menopausal symptoms and not cancer, however, the treatment usually means the opposite; giving women more estrogen. 

The women who enrolled in the OASIS-4 Phase 3 trial published last year, averaged more than 11 moderate-to-severe hot flashes a day, one every two hours. The cause was the treatment for all of them. 

The connection between menopausal symptoms and cancer treatment thus remains more critical than ever. A 2026 review of 34 studies, for one, found five-year adherence rates as low as 46%, with side effects included in the factors linked to stopping, from hot flashes and joint pain to sleepless nights and painful sex. 

For all the pink ribbons we see, women with breast cancer are abandoning one of the most effective treatments they have because of symptoms no one in their care team is clearly responsible for. These women fall between specialties and subspecialties’ cracks, and that is a gap both in care design and a payment problem. The good news is that payers and providers can close it. 

The dangers of a lexical simplification

Endocrine therapy is, understandably, often described as putting women into menopause. But whereas natural menopause entails the estrogen in a woman’s body running low on its own, endocrine therapy takes estrogen away or blocks it on purpose. Either way, the symptoms look much the same. 

Those symptoms start in the brain: estrogen helps calibrate the body’s thermostat, and losing it is a big part of why the range of temperatures the brain treats as normal narrows. As any postmenopausal woman would understand here, even a small rise in the body temperature then registers as overheating, and because she wasn’t actually overheated, a chill often follows. Add to that a thinning of vaginal tissue, and a potential restructuring of women’s brains, including reductions in gray matter volume and more white matter lesions.

For women going through menopause, these symptoms tend to build up over several years. The thing with endocrine therapy is that those same symptoms tend to arrive abruptly and intensified. 

So, the menopause shorthand blurs a biological process with the symptoms of endocrine therapy, which is not, in itself, one singular thing. We’re offering a lexical simplification of menopause, selective estrogen receptor modulators (SERMs) like tamoxifen, aromatase inhibitors, and ovarian suppression, to name a few, though the differences shape both the symptoms and how they can be treated. 

The treatment only works if women stay on it 

We’ve known about the harsh reality of breast cancer treatments for decades. And yet, you ask women today why they stopped, and the answer is likely the side effects.

At Johns Hopkins, 23% of surveyed women from 2012 to 2016 had stopped endocrine therapy within four years, most often because of side effects, and each clinically meaningful worsening in endocrine symptoms or sleep raised the risk. France’s national study found the same pattern with hot flashes, too. 

The consequences go beyond comfort, because protection depends on women finishing the course. Stopping treatment has been linked to a 26% higher risk of death, and among women who stayed on course in a Kaiser study, missing doses pushed that figure to 49%. 

A woman starting an aromatase inhibitor usually leaves with a prescription, a list of possible side effects and follow-up appointments months away, so when the hot flashes wake her six times per night or her joints ache too much for a morning walk, she often doesn’t know who to call. 

Her oncologist is watching her recurrence, her gynecologist may assume anything hormonal belongs to oncology, and her primary care doctor may not even have registered that she’s on the drug at all. 

And then, she accepts that this is just the cost of staying cancer-free. Eventually, she might decide the cost was simply too high. 

Every doctor is doing the job the system built for them. And that is precisely the point. Oncology visits are short and centered on recurrence, records rarely move cleanly between specialties, and no quality measure yet asks whether a woman is still taking her medication and sleeping through the night. When no part of the system is paid to manage these symptoms, the work falls to the patient. 

Discontinuation is less a personal choice than a predictable result of symptoms no one was assigned to manage. And this October is also when payers start making their decisions: Centers for Medicare & Medicaid Services (CMS), the U.S. federal agency that runs the government’s public health insurance programs, puts out its Medicare star ratings, which decide which Medicare Advantage plans earn bonus payments. Open enrollment started on the 15th, and employers are locking in 2027 benefits while bracing for costs to rise 9.2%. 

If anyone is going to decide who owns this problem, it will happen in those rooms, this month. 

What owning it would look like

Start with the refills: if payers can see when a woman stops, they can manage adherence like any other outcome and treat a lapsed refill as a reason to call her. Stopping is her right, and not every woman needs 10 years of this, but a missed refill should start a conversation about her symptoms. Too often, it’s usually followed by silence. 

Medicare’s star ratings track whether people keep filling their diabetes, blood pressure and cholesterol drugs, and whether women get mammograms. Whether women with breast cancer stay on endocrine therapy isn’t on the list. It should most certainly be. 

Then, there’s coverage. Managing menopause symptoms should be a standard part of survivorship care, paid for like the rest of it. That means non-hormonal drugs, and the behavioral treatments with real evidence behind them, too, like cognitive behavioral therapy and clinical hypnosis. 

It also means keeping cost-sharing low enough that it isn’t one more reason to quit. Plans are already paying for unmanaged menopause symptoms one way or another, and cancer sits near the top of every employer’s worry list, with 92% naming it among their top three cost drivers. 

And every woman who starts endocrine therapy should walk out knowing which clinician is responsible for the side effects. Her oncologist, an oncology nurse practitioner, her gynecologist or her primary care doctor could all do it. Someone just has to be told it’s their job. 

There will be pink ribbons next October, as there should be. The question is how many of the women seeing and wearing them will still be on the drug that’s keeping them alive.

Photo: belchonock, Getty Images

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