Estrogen receptor alpha (ERα), a key driver of breast cancer, normally requires estrogen for activation. Mutations that constitutively activate ERα without the need for hormone are frequently found in endocrine therapy-resistant breast cancer metastases and are associated with poor patient outcomes. The location of these mutations in the ER ligand-binding domain and their impact on receptor conformation suggest that they subvert distinct mechanisms that normally maintain the low basal state of wild-type ERα in the absence of hormone. Such mutations provide opportunities to probe fundamental issues underlying ligand-mediated control of ERα activity. Instructive contrasts between these ER mutations and those that arise in androgen receptor (AR) during antiandrogen treatment of prostate cancer highlight differences in how activating functions in ER vs. AR control receptor activity, how hormonal pressures (deprivation vs. antagonism) drive the selection of phenotypically different mutants, and how altered protein conformations can reduce antagonist potency and altered ligand-receptor contacts can invert the response that a receptor has to an agonist vs. an antagonist. A deeper understanding of how ligand regulation of receptor conformation is linked to receptor function offers a conceptual framework for developing new antiestrogens that might be more effective in preventing and treating breast cancer.