What is your strategy for ovarian suppression if unable to achieve goal estradiol levels with leuprolide 3.75mg monthly dose?

Monthly therapy rarely fails to induce adequate suppression. The choice of options will depend on whether the patient planned permanent or only temporary suppression AND the risk of recurrence of the cancer. If she will accept permanent suppression and has high risk disease, oopherectomy would be the best choice. If she isn't open to permanent suppression, using tamoxifen may be the best choice.

As shown in the SOFT-EST substudy, lack of ovarian function suppression with the use of GnRHa can be observed in up to 20% of the patients receiving this treatment. Main risk factors appear to be no prior exposure to chemotherapy, very young age and high body mass index. Although the lack of ovarian function suppression is not an issue for patients receiving GnRHa plus tamoxifen, this is of concern for those receiving ovarian function suppression plus an aromatase inhibitor. Therefore, if no ovarian function suppression is achieved with GnRHa use in patients receiving tamoxifen, I would not modify my strategy. On the other hand, if this happens in patients receiving an aromatase inhibitor, I would switch to tamoxifen continuing ovarian func...

I agree with @Dr. First Last—if the patient has no desire for future pregnancy, I usually advocate for BSO. If future pregnancy is a possibility, I switch to tamoxifen or tamoxifen +OFS.