Medical Oncologist
Deciding on chemotherapy
Genomic testing in premenopausal and postmenopausal women
In women who have not reached menopause, the same recurrence score is treated more cautiously. Part of the benefit chemotherapy appeared to give younger women may have come from its effect on the ovaries rather than on the cancer. That opens a different option. This page explains what changes, and why fertility has to be discussed before anything starts.
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Medically reviewed by Dr. Naresh GunduConsultant Medical Oncologist · MBBS, DNB (Internal Medicine), DM (Medical Oncology, AIIMS) · last reviewed September 2026, next review due September 2027
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The short answer
Why is my score read differently because of my age?
In women who have not yet reached menopause, the same recurrence score is treated more cautiously. When these tests were followed up over several years, younger women with middling scores appeared to gain from chemotherapy where older women with the same score did not.
The likely reason
Chemotherapy often stops the ovaries working, either for a time or permanently. In a hormone sensitive cancer, shutting down the main source of oestrogen is itself a treatment. So part of what chemotherapy appeared to be doing in younger women may have been hormonal rather than anti-cancer.
Why that matters to your decision
If the benefit comes from switching off the ovaries, it may be possible to get the same effect directly, with an injection that suppresses them, rather than with chemotherapy. That is a very different treatment with a very different set of effects.
This is one of the most important conversations a younger woman can have about her plan. Ask for it explicitly.The vocabulary
The words used in this conversation
- Premenopausal
- Still having periods, or recently stopped and not yet confirmed as through menopause. Your ovaries are still producing oestrogen.
- Postmenopausal
- Periods have stopped permanently. Oestrogen now comes mainly from other tissues rather than the ovaries.
- Ovarian suppression
- Switching off the ovaries deliberately, usually with a monthly or three-monthly injection. It is reversible in most cases.
- Ovarian ablation
- Removing or permanently stopping the ovaries, usually by surgery. This is not reversible.
- Chemotherapy-induced menopause
- Periods stopping because of chemotherapy. It may be temporary in younger women and permanent in those closer to menopause.
- Aromatase inhibitor
- A hormone tablet that works only when the ovaries are not producing oestrogen, so it is used after menopause or alongside suppression.
What to weigh
What this changes for a younger woman
Three things are on the table, and they interact. Taking them one at a time makes the decision manageable.
Whether chemotherapy is the right tool
If the expected benefit comes largely from its effect on your ovaries, ovarian suppression may achieve something similar without the rest of what chemotherapy brings.
Your fertility
Chemotherapy can end fertility permanently, particularly closer to forty. If you may want children, this has to be discussed before treatment starts, not after.
Ask for a fertility referral before the first cycle.What menopause at your age means
An early menopause brings its own long-term effects on bones, heart and sexual health. These are manageable, but they should be part of the conversation rather than a surprise afterwards.
How long you stay on treatment
Hormone treatment in younger women often runs for a long time, and combinations differ from those used after menopause. Ask what the whole plan looks like, not only the next step.
Ask about
- Ovarian suppression as an option
- Fertility preservation before treatment
- The full length of the hormone plan
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Side by side
How the same score is read at different ages
Before menopause
After menopause
A middling score is read more cautiously
A middling score more often supports skipping chemotherapy
Ovarian suppression is part of the conversation
The ovaries are already inactive, so this does not arise
Fertility has to be addressed before treatment
Not applicable
Tablet choice depends on whether the ovaries are suppressed
A wider choice of tablets is available immediately
A low score is still strong grounds for skipping chemotherapy
A low score is read the same way
Being straight with you
What is still genuinely uncertain
Whether ovarian suppression can fully replace chemotherapy for a younger woman with a middling score is not completely settled. Trials point in that direction for many women, and oncologists differ in how far they take it.
Why you will hear different advice
Two competent oncologists can look at the same score in the same thirty-eight-year-old and reach different recommendations, because the evidence genuinely allows both. If you get conflicting advice, that usually reflects real uncertainty rather than one of them being wrong.
This makes your own view more important, not less
Where the evidence is balanced, what you want carries real weight. Be clear with your oncologist about what matters most to you: fertility, avoiding chemotherapy, minimising the chance of recurrence, or getting back to work. That is information they need.
What to do before you decide
Ask for the benefit figure in percentage points. Ask whether ovarian suppression is a realistic alternative in your case. Ask for a fertility referral if children are a possibility. Then take a few days. Almost nothing in early breast cancer is decided in a single appointment.
What this page cannot tell you
It cannot tell you which way to go. That needs your own score, your node result, your grade and an honest account of what you are willing to live with. What it can do is make sure you walk into the appointment knowing that ovarian suppression and fertility preservation exist, because the women who are not offered them are usually the ones who did not know to ask.
Commonly believed
What younger women are often told
Young women always need chemotherapy.
Age alone does not decide it. Plenty of younger women with low scores are treated with hormone therapy and no chemotherapy at all. Being under forty makes the conversation more careful, not the answer automatic.
Fertility can be discussed after treatment starts.
It cannot, in any useful sense. Preserving eggs or embryos has to happen before chemotherapy begins, and the window is usually a couple of weeks. Ask for the referral at the first appointment, even if you are unsure.
Ovarian suppression is the easy option.
It brings on menopause, with hot flushes, joint aches, bone thinning and effects on sexual health, often for years. Many women prefer it to chemotherapy, but it is a serious treatment and should be described honestly.
Periods stopping means the treatment is working.
It means your ovaries have been affected. It is not a measure of whether the cancer is responding. Some women keep their periods throughout and do just as well.
Questions we are asked
Common questions from younger women
Can I have ovarian suppression instead of chemotherapy?
For some women with lower or middling scores it is a genuine alternative, and it is one of the most important questions to raise. Whether it applies to you depends on your score, your nodes and your grade, so ask your oncologist directly.
Will chemotherapy make me infertile?
It can, and the risk rises with age. Periods sometimes return afterwards in younger women and sometimes do not. If children are a possibility, ask for a fertility referral before the first cycle rather than hoping for the best.
Is the test less accurate in younger women?
It is not inaccurate, but it is interpreted more cautiously, because the evidence in premenopausal women is less settled than it is after menopause. Ask your oncologist how your age shaped their reading of your result.
Will my periods come back after treatment?
Often in women in their twenties and thirties, less often closer to forty-five. It can take many months. Do not assume you cannot conceive during that time, and discuss contraception with your team because some treatments are unsafe in pregnancy.
Does suppressing my ovaries cause early menopause permanently?
Suppression by injection is usually reversible and the ovaries often recover after it stops. Surgical removal is permanent. Make sure you know which is being proposed, because they are very different decisions.
Should I get a second opinion?
It is reasonable here, because the evidence genuinely allows different recommendations for a younger woman with a middling score. Take the genomic report and the full pathology report, and ask the second oncologist to explain their reasoning rather than just their conclusion.
What about my bones if I go through early menopause?
Bone thinning is a real consequence and it is managed rather than ignored. Ask about a baseline bone density scan, about calcium and vitamin D, and about weight-bearing exercise. Raise it at the start rather than years later.
Can I still work through this?
Many women do, particularly on hormone treatment alone. Chemotherapy is harder to work through, though schedules can often be arranged around a working week. Tell your oncologist what your work involves, because it can change the plan.
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Sources
- National Cancer Institute — Breast cancer gene expression tests
- Cancer Research UK — Ovarian suppression for breast cancer
- Breast Cancer Now — Fertility and breast cancer treatment
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.