Women with treated breast cancer and menopausal symptoms – Information for GPs and patients.
- There is some evidence that prescription of HRT in patients with previous oestrogen receptor positive (ER +ve) breast cancer increases mortality (death from breast cancer). (Seek advice in ER –ve patients)
- 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.
- For women taking tamoxifen, low dose vaginal oestrogens may be safe for use in atrophic vaginitis. Vaginal lubricants such as “sensalube” have an equally good effect on vaginal dryness.
Hot flushes
Lifestyle interventions
Advise easily removable top layers.
Cooling core temperature with cold drinks can prevent/lessen flushes
Avoid precipitants such as caffeine and alcohol
Increase exercise and stop smoking (sedentary women and smokers tend to get more severe flushes)
Complementary medicine
No significant RCT (randomised control trial) 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. Vitamin E 800 IU/d is useful as a first line intervention and is safe.
Consider Sage or evening primrose oil.
Pharmacological intervention
Mild to moderate flushes
Vitamin E 800 IU/d
Paroxetine* 10mg OD (double if no effect within 7 days)
Megesterol 20mg BD for short term use only
Moderate to severe flushes Vitamin E 800 IU/d
Paroxetine* 10mg OD (double if no effect within 7 days)
Megesterol 20mg BD for short term use only
(Consider oestrogen at lowest possible dose. This is a quality of life over possible local or distant relapse consideration. Discuss with Breast Unit.)
*Also consider Citalopram & Mirtazapine. The use of Venlafaxine is now restricted.
Clonidene and bromocriptine can be used but they have significant side effects. Gabapentin 300mg OD increasing to BD or TDS if no effect, may be useful
Osteoporosis prevention
Oestrogen replacement therapy is not indicated. Raloxifene not licensed for adjuvant therapy in breast cancer. Tamoxifen is bone protective so no additional checks are required in post menopausal women.
Bisphosphonates may protect bone from breast cancer metastases to bone (data not clarified enough for general recommendation)
Lifestyle interventions – advice for all.
Increase weight bearing exercise, stop smoking etc.
Calcium and vitamin D for those at moderate risk.
While awaiting guidelines and formal funding discussion with PCT, consider;
1. Premenopausal women at start of treatment - check BMD if premature menopause induced (usually within 6 months of chemotherapy) even if tamoxifen prescribed..
2. Post menopausal women at start of treatment –
i. Check BMD within 1 year if family or personal history of osteoporosis and prescribed aromatase inhibitors (AI)
ii. Check BMD at 2 years if AI prescribed. (Maximal effect of AI on BMD within 2 years.
The usual non hormonal osteoporosis therapies can be used without compromising the safety of breast cancer survivors.
Winchester and Eastleigh Healthcare Trust