Despite being considered first line treatment for vasomotor symptoms, most women are not treated with menopausal hormone therapy (MHT) in part because of the fear (not the risk) of breast cancer. A lack of training and misunderstanding about the benefits and exaggerated risks of MHT has created barriers to women receiving appropriate and evidence-based treatments for their quality-of-life impacting menopause symptoms. The route, formulation and duration of MHT are critical issues that require clinician education. This chapter reviews these nuances, providing a practical framework for prescribing MHT in women at average risk, high risk and those who have had breast cancer. Included is a discussion of gender-affirming hormone therapy and breast cancer risk. Educating clinicians and empowering patients with evidence-based and accurate information regarding MHT and the breast will assure that women do not have to suffer unnecessarily, and clinicians can feel confident in their recommendations to patients.