Women with treated breast cancer and menopausal symptoms – Information for GPs and patients.
There is evidence from clinical trials that prescription of HRT in patients with previous breast cancer leads to an increased risk of recurrent or new cancer and its use is not recommended for either oestrogen receptor positive or negative patients. For women with severe menopausal symptoms uncontrolled by other means, HRT may be the only option but careful counseling is required.
Premenopausal women on tamoxifen may continue to have monthly bleeds. PMB (bleeding after the menopause) or IMB (bleeding between periods) in patients on tamoxifen should be referred for gynaecological assessment. Tamoxifen is NOT a contraceptive and other non hormonal forms of contraception should be employed.
For women taking tamoxifen, low dose vaginal oestrogens may be safe for use in atrophic vaginitis. Vaginal lubricants such as “sensalube” have a good effect on vaginal dryness and should be tried first.
Most postmenopausal women are now prescribed aromatase inhibitors as a first choice. It can sometimes be difficult to accurately determine whether a woman is truly postmenopausal especially after chemotherapy and while on tamoxifen. Standard blood tests (FSH, LH and oestradiol) for the menopause may not be accurate in these cases. Specialist advice should be sought and newer tests such as high sensitivity oestrogen assays may be helpful if available.
Dealing with hot flushes
Lifestyle interventions
• Wear easily removable layers of clothes.
• Cooling the body from the inside (core temperature) with cold drinks can prevent/lessen flushes. Have a thermos flask of iced water near to hand.
• Avoid food and drink that can trigger flushes such as caffeine and alcohol
• Women who exercise more and who do not smoke suffer less from hot flushes.
Complementary medicine
No significant RCT (randomised control trial) has demonstrated significant benefit for any complementary therapy.
Phyto-oestrogens (particularly soy products) are not recommended in women who have previously been treated for breast cancer as the potential cancer promoting effects of phyto-oestrogens have not been sufficiently studied. Some menopause treatment remedies contain high concentrations of phyto-oestrogens eg Menopace.
Vitamin E (800 IU/d) may be useful and is safe.
Consider using sage or evening primrose oil.
Women can try different complementary therapies some of which will work for them but none have the evidence base to be wholeheartedly recommended. Most people will be less affected by flushes if they are relaxed and less anxious and most alternative practitioners are good at making their clients relax.
Take care with herbal and Chinese medicines as there are no regulations as to the amount or nature of the active ingredients.
Drug
therapy
There is no magic bullet to treat hot flushes, we can only reduce the
severity or help women to cope with symptoms.
It is worth trying Vitamin E and low dose SSRI antidepressants. Gabapentin
has also been used for this indication but the side effects need to be
discussed carefully. We have used also Megestrol with some success
especially in women also taking tamoxifen.
Osteoporosis prevention
Guidelines for osteoporosis monitoring and treatment can be found in the
current NICE guidelines.
CG80 Appendix 2
http://guidance.nice.org.uk/CG80
In general, tamoxifen confers bone protection and the aromatase inhibitors
do not.
All women should be advised on lifestyle interventions to prevent
osteoporosis which include weight bearing exercise such as walking and not
smoking.
Women taking aromatase inhibitors or who have a premature menopause from
chemotherapy should have a baseline bone density scan.
HRT should not be used to prevent osteoporosis in breast cancer survivors.
The usual non hormonal osteoporosis therapies can be used without
compromising the safety of breast cancer survivors.