The FDA recently announced it will be removing black box warnings for systemic menopausal hormone therapy (MHT), reflecting evolving evidence since initial reporting of the notorious Women’s Health Initiative. Subsequent data suggest estrogen alone does not increase breast cancer risk, certain progestins carry higher risk (old school medroxyprogesterone acetate) than others (newer micronized progesterone), and initiation before age 60 or within 10 years of menopause is more likely to offer a net benefit, including symptom relief, fracture reduction, and possible cardiovascular and quality-of-life gains. This editorial raises the right questions: how should our deeper understanding of the impact of MHT affect recommendations for the growing population of breast cancer survivors for whom MHT has traditionally been contraindicated–despite this precise population suffering frequent early or treatment-induced menopause. A large body of observational studies, randomized trials, and meta-analyses largely shows no increased risk of breast cancer recurrence or mortality with MHT, with conflicting signals driven mainly by the HABITS trial, whose limitations and later pooled analyses temper its conclusions. Ultimately, there are many women–particularly those with very low risk breast cancer–who may see more benefit than risk with thoughtful MHT, and sweeping views of any breast cancer history as an absolute contraindication should be reimagined. | Pleasant, JAMA 2026
