Mammograms, Dense Breasts, HRT Risks—A Breast Surgeon’s Guide

Are there reliable alternatives to mammograms? What to do if you have 'dense' breasts? How to reduce breast cancer risk on HRT? Dr Kristi Funk answers your questions!

This is the highly anticipated part 2 of the series I’m doing with Dr Kristi Funk, a board-certified breast cancer surgeon, bestselling author, and dedicated women’s health advocate. Here’s the link to part 1, where we dived into the risks of HRT.

So many of you had questions about mammograms, screening options for dense breasts, and practical tips to reduce the risks of HRT, so let’s dive in!

As usual, none of this is medical advice. Dr. Funk is providing general information - Do not use the information on for diagnosing or treating a health problem or disease. Always speak with your physician or other healthcare professional before changing your healthcare plan.

🤔 Dr. Funk, are there alternatives to Mammograms?

Yes—but let’s start here: Mammograms save lives.

They are currently the only screening tool proven to reliably detect DCIS (ductal carcinoma in situ), a stage 0 cancer that doesn’t require chemo. So if you are considering other screening modalities, I suggest that you use them in addition to mammograms, but not as a substitution.

One powerful study compared breast cancer deaths in Swedish women for the 20 years before (1958-77) and the 20 years after mammography (1978-97) was introduced.¹ Among 210,000 women:

• Breast cancer deaths dropped 28% after screening began.

• In women aged 40–49, mortality dropped 48%.

To be fair, death rates also fell 16% in women who did not get imaging at all, which tells you the contribution of better treatments after 1977.

I hear the concerns over uncomfortable squashing, radiation exposure (although low), and false positives leading to unnecessary additional imaging and even biopsies, while at the same time tolerating the false negatives that we previously discussed in Part 1 regarding breast density.

Another common concern I hear is: Radiation from mammograms causes breast cancer. You know what I have to say to that? “Yes, it does.”
A number of studies employ computerized risk models to estimate the numbers of radiation-induced breast cancers and deaths.

In one such study, a lifetime's worth of mammogram screening, 8.6 out of 10,000 women will get a radiation-induced breast cancer; however, screening finds about one hundred times more cancers than it causes.² An even more important question is, "How many lives are saved by screening for every one life lost because of screening?" Numbers vary, but a risk model from England calculated 312 saved lives, and an American one concluded 61.5 saved lives for each single radiation-induced death.³⁴

🧪 What else works?

Two of the most well-studied tools that complement mammograms are:

• Breast MRI

• Whole breast ultrasound

Ultrasound

A 2018 meta-analysis showed ultrasound detected 40% more cancers in dense breasts compared to mammography alone.⁵ Ultrasound comes in a few forms:

• Handheld

• Automated

• QT imaging (offers 3D images)

I like them all! One version of a handheld ultrasound that has made the rounds on social media is the HerScan. These “pop-ups” will rent a room for a day or two (usually in a nice hotel) and offer screening ultrasounds performed by a certified technician, and then the images are read off-site by a board-certified radiologist. So, it’s a legitimate service and very useful for screening.

The only downside is that when something is seen on your ultrasound that needs follow-up and a possible biopsy, you’re simply told to get that done… yep, no explanations about what they see or where to go to get it evaluated. This can panic a woman, who then must figure out her next steps all on her own or with her doctor (who might not be able to see her in a timely manner.)

Breast MRI

MRI uses contrast dye and powerful magnets—no radiation. It’s especially useful because it’s not affected by breast density and has a >90% detection rate, higher than 2D mammograms, 3D tomosynthesis, or ultrasound.

The catch?

• It costs up to 8x more than a mammogram.

• The test takes ~45 minutes in a noisy, enclosed space.

• It leads to more callbacks and up to 3x more unnecessary biopsies.

So, while powerful, MRI isn’t sustainable for population-wide screening. But for high-risk women, it’s essential.

According to NCCN guidelines, MRI is recommended for those with:

• >20% lifetime risk

• Radiation to the chest wall before age 30

• Untested first-degree relatives of BRCA, Li-Fraumeni, and Cowden carriers

• Gene mutation carriers, starting at the ages noted below or ten years before the youngest breast cancer in the family: BRCA carriers (start age 25), Li-Fraumeni (20-29), Cowden (30-35), ATM (40), CDH1[(30), CHEK2 (40), PALB2 (30), and STK11 (30)

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Dr. Funk, what is your take on thermography?

In a word (IMHO): Useless.

Advances in infrared technology and image processing algorithms in the twenty-first century have led to a renewed interest in thermography. A camera uses infrared technology to identify skin temperature changes that allegedly guide us like a treasure map to an island of increased blood flow and metabolic activity, signifying the presence of an underlying angiogenic tumor. Heat patterns are displayed in a psychedelic swirling image of your breasts with colors indicating the levels of emitted heat. I have chased down countless swirls of hyperthermia, and I have never found them to rival all the imaging tools I already have.

By the way, what do we do with a suspicious thermogram? All the things you were probably trying to avoid by getting one - mammo, ultrasound, and breast MRI! While it's marketed as a radiation-free, painless alternative to mammography, its accuracy and clinical utility remain controversial and limited.

Studies show that the sensitivity of thermography (i.e., finding cancer when cancer is present) ranges from 25-70%, and specificity (i.e., calling the scan negative when no cancer is present) ranges from 50-85%.⁶ Until those numbers are higher with less variability, thermography will remain unadvised by me.

Dr. Kristi Funk

Contrast-enhanced spectral mammography (CESM)? Very accurate, but rarely available. My breast center, Pink Lotus, actually launched CESM in North America back in 2012, so I’m a big fan, but not many centers offer it (and my imaging center has since closed).

Other imaging (MBI, PEM, breast CT)? Not mainstream yet, and emit more radiation than mammograms.

📌 Quick tip: If your mammogram shows dense breast tissue, always add whole breast screening ultrasound (in any of the forms mentioned above). If you have additional risk factors beyond density, talk to your doctor about adding breast MRI every 1-3 years.

🩺 Dr. Funk, I’m always told I have dense breasts. Does that make screening harder for me?

Yes, it does. Dense breast tissue makes it more difficult for mammograms to detect cancer because both dense tissue and tumors show up white on the scan—like trying to find a snowball in a snowstorm.

Breast density is categorized from A to D:

• A – Fatty

• B – Scattered fibroglandular densities

• C – Heterogeneously dense

• D – Extremely dense

As of September 10, 2024, all U.S. breast imaging centers are required by law to notify you whether your breasts are “dense” or “not dense.” These letters will also explain that dense breast tissue makes cancer harder to detect and that it increases breast cancer risk. Women with dense breasts will also be told that other imaging tests in addition to a mammogram may help find cancers… and then you’re supposed to figure it out from there!

What they won’t tell you? What to actually do about it. You’re often left with no clear next step or guidance on whether your insurance will cover further testing.

If you have dense breasts, the ‘false negative’ i.e., the chance of mammograms missing a cancer, is largely offset by adding whole breast ultrasound to your annual screening. Better yet, ask for a 3D mammogram (tomosynthesis) instead of a standard 2D one. And if your lifetime risk of breast cancer is over 20%, talk to your doctor about adding MRI screening every 1–3 years.

Here’s a handy breakdown of the most common modalities from the AreYouDense.org website:

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🛡️ Dr. Funk, how can I lower my breast cancer risk if I’m on HRT?

Can I just say that this is my favorite question on planet earth to answer? Whether or not you take HRT, you have so much power and control over breast cancer occurring and/or recurring! The daily choices you make, unwittingly or not, have a consistent impact on a tumor cell’s microenvironment. Think of your cells splashing around in a bathtub all day long – the tub water contains sugar, hormones, neurotransmitters, chemicals, salts, acids, and waste materials that constantly scream out pro-cancer or anticancer. You choose. What you eat or don't eat, drink or don't drink, if you move or don't move, sleep or don’t sleep, when you think or don't think something, forgive or don’t forgive someone... You're messing with the water.

Of all the controllable things that alter this cell microenvironment, at least four choices have a much higher impact on your future risk of developing cancer than HRT ever could. So if you take HRT, you’ll want to temper that small bump in risk by following this advice.

1. Eat more plants

Every time you lift a fork to your mouth, you unleash weapons into your bloodstream that engage in the daily battle of oxidative stress, which is the war between cell-damaging free radicals and the antioxidant heroes that squelch them. Every calorie you swallow either joins the pro-cancer or the anti-cancer army. Science has revealed which antioxidant-rich foods have the biggest impact in helping to reduce cancer risk by releasing molecules that can⁷:

• Scavenge free radicals

• Eliminate carcinogens we consume and encounter.

• Prevent and repair DNA damage

• Identify and destroy harmful cells in our bodies.

• Inhibit new blood supply required by tumors to grow (angiogenesis)

• Stimulate the immune system

• Regulate hormone and glucose metabolism

• Reduce inflammation

The clear winner? PLANTS.⁸ Vegetables, legumes (i.e., lentils, beans, peas, seeds, and some nuts), fruits, and 100 percent whole grains provide, on average, 64x the nutritional armor for your cells that animal products do.⁹

2. Maintain ideal body weight

A new study published in December 2024 in the Lancet revealed that 75% of Americans are now overweight or obese.¹⁰ Adipose is so much more than jiggly; it’s literally a metabolic organ that produces cancer-stoking molecules such as estrogen and leptin, and all sorts of inflammatory mediators like TNF-a and IL-6.¹¹ The end result leads to insulin resistance (so now instead of managing sugar, insulin directly stimulates the growth and invasion of breast cancer cells), high levels of sugar and growth factors (like IGF-1 that yells at cancer cells to grow), and upregulation of VEGF (which creates the new blood vessels required to feed tumor cells).¹² Cue the good news! If you lose the excess weight, you lose the elevated cancer risk.¹³

3. Regular exercise

Emerging data continually reinforce how beneficial exercise truly is to your health and longevity, anti-cancer benefits included! So put some pep in your step, and work out 150-300 minutes a week of cardio plus at least two 20-minute strength training sessions.

4. Limit or eliminate alcohol

Each daily 10-gram drink (mind you, a 5 oz glass of wine is 14 grams, as is one 12.5 oz can of beer or 1.5 oz of liquor) increases breast cancer by an average of 7-10% per drink.¹⁴

I could dive into the published research showing how critical all these choices are, but by the time I finish talking, it might be tomorrow. Actually, I have a transformative 3-day Cancer Kicking Summit that I’d love for women to join, so I guess I would finish talking in 3 days!

Suffice to say, those are the four heavyweight contributors to breast cancer, but I also encourage women to be mindful about how adequate sleep, stress management, positive social connection, judicious use of fasting, microbiome optimization, and minimizing exposure to environmental toxicities all alter what's in that bathtub water.

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🤔Dr. Funk, are there any alternatives to HRT? I don't want ANY increased risks of breast cancer - no matter how small.

Ohh sister, I completely hear you on this one! As a breast cancer surgeon, I have joined thousands of women in the moments and decisions that follow a cancer diagnosis, so I've seen everything: horrific separation anxiety between many a woman and her precious HRT; premature and abrupt full-blown menopause in young women of all ages due to cancer treatments like chemo and tamoxifen and ovary removal; relentless menopause symptoms in women who are either cancer patients or too high risk to consider HRT or who want to embrace this natural transition in life without prescriptions - but they also don't want to hot flash their way to a divorce!

So 100%, yes!

I know many alternatives that can address nearly every menopause-related side effect. I scoured the earth for over 20 years to find effective and affordable solutions to treat the menopause misery of my patients.

Let's start by making an important acknowledgement.

Just because we know that HRT provides protection against the development of heart disease when begun in otherwise heart-healthy women within 10 years of menopause, and just because we know it staves off bone loss and subsequent osteoporotic fractures, protects against colon cancer, maintains lean muscle mass, and, of course, expertly addresses symptoms like hot flashes and insomnia, even heart palpitations, frozen shoulders, and enlarging waistlines, I want you to hear one thing loud and clear: If you decline HRT for any reason, this decision does not mean that you now must live with any or all of those medical issues. Consider our centenarian sisters in the “blue zones”, the 5 studied places on planet earth where women live to be over 100 years old with the highest frequency, and they do so maintaining an active life without chronic medical conditions or medications.¹⁵ They do not need HRT to enjoy longevity with an agile body and a sharp mind – and neither do you.

OK, so let's get to the good stuff. What supplements can you take, and what diet and lifestyle choices can you make to decrease the reading on your menopause misery meter?

Interestingly, all of the things I just discussed in terms of food, exercise, alcohol, and stress management, etc., to decrease cancer risk are the very same things that help you manage menopause. However, sometimes we could use additional help. Let’s tackle the TOP SIX most common menopausal complaints I hear.

1. Hot flashes & Night sweats

Over 80% of women experience hot flashes during menopause, which are defined as transient sensations of heat, sweating, flushing, anxiety, and chills lasting for 1–5 minutes.

Lifestyle Approaches include:

• Dressing in layers that can be peeled off to cool you off

• Using fans (pocket-sized and stationary)

• Having cooling pillows and sheets and moisture-wicking pajamas,

• Keeping a cooler bedroom at night

• Avoiding known triggers such as alcohol, caffeine, spicy foods, and stress

Mind-Body Techniques such as:

• Biofeedback (a technique that teaches voluntary control of muscle tension, temperature, heart rate, and brain activity)

• Focused breathing

• Mindfulness meditation

• Exercise

• Stretching

• Tai chi (stress reduction through gentle, flowing movements)

• Yoga

• Cognitive behavioral therapy (CBT)

Complementary medicine offers acupuncture and Chinese herbs.

Supplements & Natural Remedies:

• Black cohosh (Actaea racemosa, plant extract)

• Dong quai (Angelica sinensis, a medicinal root)

• Evening primrose oil (Oenothera biennis, wildflower seeds, an omega-6 essential fatty acid)

• Ginseng (a medicinal root)

• Melatonin (a brain hormone that regulates the sleep/wake cycle)

• Vitamin E (an antioxidant)

Prescription medications that change nerve impulses and blood flow:

• Bellergal (ergotamine)

• Catapres (clonidine)

• Neurontin (gabapentin)

Prescription medications that block brain chemicals like serotonin and norepinephrine-you know them as antidepressant and antianxiety meds:

• Effexor (venlafaxine)

• Paxil (paroxetine)

• Prozac (fluoxetine)

• Veozah (fezolinetant)

Phytoestrogens/isoflavones act preferentially on beta estrogen receptors (alpha receptors are the ones associated with breast cancer):

• Red clover extract (Trifolium pratense, an herb)

• Soy (consumed in whole foods: soybeans, tempeh, sprouted tofu, edamame)

• Diindolylmethane (DIM)

2. Mood swings, Anxiety, and Depression

Lifestyle Approaches :

• Regular exercise (aerobic + strength training improves mood and cognition)

• Sleep hygiene (consistent schedule, screen-free wind-down)

• Social connection and purposeful activity (lowers depression risk)

Natural Aids:

• Kava (start at 70 mg/day; increases GABA in the brain)

• Ginseng (a Chinese medicine root)

• Omega-3 fatty acids (EPA/DHA are linked to mood improvement)

• St. John’s Wort (increases serotonin and dopamine in the brain)

• Rhodiola rosea or ashwagandha (adaptogens for stress resilience)

Psychological Approaches:

• CBT and mindfulness-based stress reduction

• Yoga, tai chi, or qigong for mind-body balance

• Talk therapy or group counseling

Complementary medicine acupuncture and Chinese herbs

Prescription Medications: Selective serotonin reuptake inhibitors (SSRIs) are the most prescribed type of antidepressant. They work by increasing levels of serotonin in the brain. You’ve heard of them, I’m sure:

• citalopram (Celexa)

• escitalopram (Lexapro)

• fluoxetine (Prozac, Sarafem, Symbyax)

• paroxetine (Paxil, Paxil CR, Pexeva)

• sertraline (Zoloft)

3. Sleep disturbances

• Stop screens 60 minutes before bed – start a bedtime routine that could include a relaxing bath, meditation, stretching, reading a book, meal prepping for tomorrow, conversation (?!)… just no scrolling on screens and bright lights.

• Stop all caffeine intake by 12 pm (50% of the caffeine is still in your bloodstream 6 hours later, but peak levels are 45 min after consumption)

• Cut out alcohol—for a while or permanently—to see how it negatively affects your sleep. (Trust me, it does.)

• Taper off all liquids 2-3 hours before bedtime to minimize nighttime bathroom trips.

• Keep a consistent sleep-wake schedule even on days off and weekends.

• Is your mattress comfortable? How about cooling sheets? It might be time for new purchases.

• Does your partner keep you up – snoring, coughing, in pain, restless legs, etc.? This needs to get addressed, and until it does, got a spare bedroom? Yes, your sleep is that important!

• Room temperature should be lowered to 66-67 degrees.

• Create a noise-free and dark bedroom environment.

• Block out light with darkening curtains or a sleep mask.

• Use a calming sound app or earplugs (try a “pink noise” machine, enhances deep sleep more than “white noise”).

• If needed, combine these three supplements 60 minutes before bed:

  • Inositol - 900 mg

  • Theanine - 100-300 mg

  • Magnesium L-Threonate - 140 mg

• For when you REALLY can’t get good sleep, add:

  • GABA - 100 mg

  • Glycine - 2 grams

4. Vaginal dryness / Sexual Discomfort (aka Genitourinary Syndrome)

• Vaginal estrogen Yes, I realize this is clearly not a non-hormonal option here, but I want to point out that it is 100% safe for all breast cancer patients, even when on estrogen blockers, and those little tablets or creams inserted vaginally can save “everything” - so don’t rule it out for fear of breast cancer because that’s a non-issue with low dose vaginal estrogen. In fact, this 2025 study compared breast cancer patients who used local vaginal estrogen (n=800) to those who did not (n=17,820), and those using vaginal estrogen showed a statistically significant increase in overall survival (HR=0.56, p<0.0001) as well as breast cancer-specific survival (HR=0.53, p=0.014).¹⁶

• Vaginal moisturizers (use regularly like you do face cream, e.g., Replens)

• Water-based lubricants (use right before intercourse to reduce friction)

• Hyaluronic acid vaginal gels (non-hormonal option)

• Pelvic floor therapy for discomfort or atrophy

• Laser therapy (MonaLisa Touch, ThermiVa, vaginal lasers in MD office)

• Carboxy Therapy (CO2 LIFT-V, self-administered)

• Prescription Medications for low libido:

  • Addyi (flibanserin pills)

  • Vylessi (bremelanotide injections)

5. Memory lapses & Brain fog

• Exercise: enhances neuroplasticity and focus.

• Cognitive training apps or puzzles, read, learn a new skill or hobby

• Diet: Mediterranean-style with healthy fats, berries, and leafy greens.

• Avoid multitasking; use lists, reminders

• Avoid smoking and excessive alcohol.

6. Bone health

• Weight-bearing exercise (walking, dancing, weights, racquet sports)

• Calcium (1,000–1,200 mg/day) (try to get this from foods like seeds, nuts, black beans, dark leafy greens, and soybeans/tempeh/tofu since supplements can lead to kidney stones and cardiovascular disease)

• Vitamin D3 (2000–5000 IU/day)

• Creatine (5 mg/day)

• Avoid smoking and excess alcohol.

• DEXA scans for early detection of osteoporosis - if already present, your doctor might talk to you about prescription medications like:

  • Bisphosphonates - Risedronate (Actonel), Alendronate (Fosamax), Ibandronate (Boniva), Zoledronic acid (Reclast), and Pamidronate (Aredia), or Denosumab

I know that was a lot of information. In general, following these tried-and-true strategies can ameliorate a multitude of menopausal issues very effectively:

• Eat a whole-food plant-based diet: anti-inflammatory, supports mood and heart health.

• Increase fiber (at least 30 grams a day) to manage weight, cholesterol, and blood sugar.

• Always include Soy foods (tofu, tempeh, edamame).

• Limit added sugars and ultra-processed foods.

• Avoid smoking and regular consumption of alcohol.

• Exercise daily.

• Manage stress

• Attend support groups (or just get together with your besties) for validation and sharing coping strategies.

There You Have It!

The most frequently asked questions about Breast Cancer Screening and HRT, answered with current science.

Loved this and want to connect with Dr Funk?

• ​​Visit her Website: Pink Lotus

• Make an appointment: online, or call 833-800-7522

• Attend Dr. Funk’s upcoming Cancer-Kicking Summits! Sign up here today!

• Follow on IG/X: @drkristifunk

• Check out her Cancer-Kicking! Kitchen – interactive recipes and COOK LIVE episodes with Chrissy and Dr. Kristi

• Buy her bestselling book: BREASTS: The Owner’s Manual

• Explore the free Pink Lotus Power Up community, including Breast Buddies for cancer thrivers

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