A 58-Year-Old Postmenopausal Woman Has Been Taking Hormone Replacement Therapy

A 58-year-old postmenopausal woman has been taking hormone replacement therapy with combined estrogen and progestin for the past 4 years because she was told it would decrease her risk for heart disease. Her father died at age 65 years of heart disease, and she is concerned that she is also at risk. Recently, her sister has been diagnosed with breast cancer. Her mother died of breast cancer. Three years ago, the patient had a breast biopsy that showed atypical hyperplasia. She has not had a hysterectomy. The patient is considering chemoprevention for breast cancer, but is nonetheless concerned about heart disease. Her calculated risk of breast cancer is 10.4% over the next 5 years. Which of the following options is reasonable to consider for this patient?

A) Continue hormone replacement therapy alone for primary prevention of heart disease
B) Continue hormone replacement therapy and add tamoxifen
C) Discontinue hormone replacement therapy and start tamoxifen
D) Change her hormone replacement therapy to estrogen alone and add tamoxifen