Menopause begins most often in the late forties or early fifties. Medically, a woman is considered in menopause 12 months after her menstrual periods have stopped. However, hot flashes and other symptoms may occur a few years before menopause begins and may continue for five or more years.1 The severity and duration of symptoms vary from woman to woman.
The most common menopausal symptoms are hot flashes (including night sweats) and vaginal dryness. If you are having menopausal symptoms, talk to your health care provider about what you can do to try and get relief. To help with that discussion, we offer a summary of the safest, most effective ways to relieve menopausal symptoms for women with and without a history of breast cancer.
Postmenopausal hormone use for women without a history of breast cancer
Many women use postmenopausal hormones (also known as menopausal hormone therapy or hormone replacement therapy) to relieve hot flashes and other menopausal symptoms. These therapies are approved for the short-term relief of menopausal symptoms, but there are possible health risks with longer term use (see below). The U.S. Food and Drug Administration (FDA) recommends women use only the lowest dose that eases symptoms for the shortest time needed.2
There are two main types of postmenopausal hormone therapy:
- Estrogen plus progestin is used by women who have a uterus.
- Estrogen alone is used by women who no longer have a uterus (who have had a hysterectomy). It is not safe for women with a uterus to take estrogen alone. Progestin is needed to prevent uterine cancer.
Estrogen plus progestin
Postmenopausal hormone therapy with estrogen plus progestin increases the risk of getting breast cancer.3-8 In randomized controlled trials, women who took estrogen plus progestin therapy had an increased risk of: 3-16
- Breast cancer within the first five years of use
- Having an abnormal mammogram within the first five years of use
- Ovarian cancer after five years of use
- Heart disease after five years of use
- Stroke after five years of use
- Blood clots (in the legs or lungs) after five years of use
When women stop taking estrogen plus progestin therapy, their risk of breast cancer starts to decline and over time returns to that of a woman who has never used hormones.4,6-7,9
At this time, it is unclear how postmenopausal hormone therapy with estrogen alone affects breast cancer risk. The Women’s Health Initiative randomized controlled trial found a decreased risk of breast cancer with estrogen alone compared to placebo after an average of six years of use.17 However, other studies showed an increased risk, but mainly after longer-term use (10 to 20 or more years).4-5,7-8,18-19 Estrogen alone therapy also may increase the risk of stroke, dementia, ovarian cancer and uterine cancer.4,15-16 Researchers continue to follow the women in studies of estrogen alone therapy to understand better how it might affect breast cancer and other health risks.
The term “bio-identical hormones” is used to describe drugs that are similar to hormones found in the body or drugs that are custom compounded (when a pharmacist makes a mixture of hormones according to a physician’s instructions on a prescription).20-21 Bio-identical hormones have not been shown to be safer or more effective at treating menopausal symptoms than FDA-approved postmenopausal hormone therapies. And, because they have not been well-studied, they may have more health risks.20-21 Learn more about bio-identical hormone therapies on the FDA website.
Postmenopausal hormone use for women with a history of breast cancer
Some breast cancer survivors go through early menopause due to chemotherapy. Hot flashes and other symptoms may be worse for these women than for women who go through menopause at later ages.22 Survivors may also have hot flashes as a side effect of hormone therapy for breast cancer treatment.
Although postmenopausal hormone use may relieve these symptoms, there is concern it might increase the risk of breast cancer recurrence in survivors. Some studies have found no link between the two.23-25 However, two randomized controlled trials found survivors taking postmenopausal hormones had more breast cancer recurrences than survivors not taking postmenopausal hormones.26-27 Currently, the best choice for most breast cancer survivors is to avoid the use of postmenopausal hormones. Some alternatives to hormones for treating the most common menopausal symptoms are described below.
Many alternatives to postmenopausal hormones have been studies for the relief of hot flashes. Some of these are discussed below. Talk to your health care provider about potential risks and benefits before using any of these therapies.
SSRI and non-SSRI antidepressants
Among the most promising medications for the relief of hot flashes is a group of antidepressants called selective serotonin reuptake inhibitors (SSRIs). SSRIs include citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft). These drugs, and the non-SSRI antidepressant venlafaxine (Effexor), have been shown to decrease the frequency and strength of hot flashes by 50 to 60 percent, with few side effects.28-34 (Breast cancer survivors taking tamoxifen should talk to their health care provider about a possible interference between SSRIs and tamoxifen.35-36)
Gabapentin (Neurontin) is a drug used to treat seizures and pain. Some studies have shown gabapentin reduced hot flashes better than a placebo.37-41
Megestrol acetate is a drug used at high doses to treat metastatic breast cancer. In low doses, studies have shown it reduced hot flashes in breast cancer survivors.42-43
The safety of these drugs for the treatment of hot flashes is still under study.
Plant-based remedies and vitamin E
Phytoestrogens are chemicals contained in certain plants (such as soy and red clover) that can mimic estrogen in the body. For this reason, phytoestrogens (in foods and in supplement form) have been studied as a way to treat menopausal symptoms. Findings to date are mixed. Most randomized controlled trials have found no benefit for menopausal symptoms from phytoestrogens.44-48 However, a few studies have shown soy can reduce hot flashes.48-49 The North American Menopause Society recommends soy (in foods or supplement form) as a reasonable treatment for hot flashes to discuss with your health care provider. If symptoms do not improve after 12 weeks, other options should be considered.50
There is little evidence that black cohosh, evening primrose or vitamin E can reduce hot flashes in women with or without a history of breast cancer.39,51-54
A few, small randomized controlled trials have shown acupuncture reduced hot flashes compared to a sham acupuncture treatment, but other studies have found no difference between the two.55-56
Lifestyle tips for managing hot flashes
Although studies are limited at this time, the following tips may help relieve hot flashes.1
- Quitting smoking (if you smoke)
- Reducing alcohol use (if you drink)
- Dressing in layers
- Keeping an ice pack under your bed pillow
- Avoiding caffeine and hot drinks
- Avoiding hot or spicy foods
- Keeping your home or bedroom cool
Another common symptom of menopause is vaginal dryness, which can cause pain during intercourse, vaginal soreness and itching. Some methods for relieving vaginal symptoms contain hormones and some do not. Talk to your health care provider about which option is best for you.
Hormonal options for vaginal symptoms include an estrogen-containing soft ring (put into the vagina like a diaphragm) and vaginal estrogen suppositories. Both slightly increase the level of estrogen in the blood, but for only a short time and most breast oncologists believe they are safe for breast cancer survivors. These products require a prescription.
A non-hormonal option for the relief of vaginal dryness is an estrogen-free vaginal moisturizer (such as Replens). These products are different from vaginal lubricants (such as K-Y Jelly and Astroglide ) which only make surfaces slippery, rather than moisturizing. For the best effect, moisturizers need to be used regularly, rather than just around the time of intercourse. They are available over the counter (without a prescription).
Many women seek relief for menopausal symptoms. Although postmenopausal hormone therapies have health risks, short-term use can offer relief for some women without a history of breast cancer safely. For breast cancer survivors or women who want to avoid postmenopausal hormones, certain antidepressants have been shown to relieve hot flashes. And, for women who want to avoid drug therapies, many lifestyle behaviors may help ease hot flashes and vaginal moisturizers can offer relief for vaginal dryness. According to Dr. Wendy Chen, Assistant Professor of Medicine at Harvard Medical School and a medical oncologist at the Dana-Farber Cancer Institute, “although the medical definition of menopause may be the same for all women, the symptoms and side effects for any one woman can be very different. So any treatment that is needed for symptoms of menopause has to be personalized to each woman.” Your health care provider can help you explore your options and find safe and effective ways to ease your symptoms.
- Col NF, Fairfield KM, Ewan-Whyte C, Miller H. In the clinic. Menopause. Ann Intern Med. 150(7):ITC4-1-15, 2009.
- U.S. Food and Drug Administration. Menopause and hormones. https://www.fda.gov/consumers/free-publications-women/menopause-medicines-help-you, 2009.
- Colditz GA, Hankinson SE, Hunter DJ, et al. The use of estrogens and progestins and the risk of breast cancer in postmenopausal women. N Engl J Med. 332: 1589-93, 1995.
- Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and hormone replacement therapy: collaborative reanalysis of data from 51 epidemiological studies of 52,705 women with breast cancer and 108,411 women without breast cancer. Collaborative Group on Hormonal Factors in Breast Cancer. Lancet. 350: 1047-59, 1997.
- Schairer C, Lubin J, Troisi R, et al. Menopausal estrogen and estrogen-progestin replacement therapy and breast cancer risk. JAMA. 283:485-91, 2000.
- Writing Group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 288(3):321-33, 2002.
- Beral V for the Million Women Study Collaborators. Breast cancer and hormone-replacement therapy in the Million Women Study. Lancet. 362:419-27, 2003.
- Bakken K, Fournier A, Lund E, et al. Menopausal hormone therapy and breast cancer risk: impact of different treatments. The European Prospective Investigation into Cancer and Nutrition. Int J Cancer. 128(1):144-56, 2011.
- Chlebowski RT, Hendrix SL, Langer RD, et al. Influence of estrogen plus progestin on breast cancer and mammography in healthy postmenopausal women: the Women’s Health Initiative Randomized Trial. JAMA. 289:3243-53, 2003.
- Chlebowski RT, Wactawski-Wende J, Ritenbaugh C, et al. Estrogen plus progestin and colorectal cancer in postmenopausal women. N Engl J Med. 350:991-1004, 2004.
- Cauley JA, Robbins J, Chen Z, et al. Effects of estrogen plus progestin on risk of fracture and bone mineral density: the Women’s Health Initiative randomized trial. JAMA. 290:1729-38, 2003.
- Anderson GL, Judd HL, Kaunitz AM, et al. Effects of estrogen plus progestin on gynecologic cancers and associated diagnostic procedures: the Women’s Health Initiative randomized trial. JAMA. 290:1739-48, 2003.
- Manson JE, Hsia J, Johnson KC, et al. Estrogen plus progestin and the risk of coronary heart disease. N Engl J Med. 349:523-34, 2003.
- Wassertheil-Smoller S, Hendrix SL, Limacher M, et al. Effect of estrogen plus progestin on stroke in postmenopausal women: the Women’s Health Initiative: a randomized trial. JAMA. 289:2673-84, 2003.
- Lacey JV, Jr., Mink PJ, Lubin JH, et al. Menopausal hormone replacement therapy and risk of ovarian cancer. JAMA. 288:334-41, 2002.
- Grodstein F, Manson JE, Stampfer MJ, Rexrode K. Postmenopausal hormone therapy and stroke: role of time since menopause and age at initiation of hormone therapy. Arch Intern Med. 168(8):861-6, 2008.
- Lacroix AZ, Chlebowski RT, Manson JE, et al. for the WHI Investigators. Health outcomes after stopping conjugated equine estrogens among postmenopausal women with prior hysterectomy: a randomized controlled trial. JAMA. 305(13):1305-1314, 2011.
- Chen WY, Manson JE, Hankinson SE, et al. Unopposed estrogen therapy and risk of invasive breast cancer. Arch Intern Med. 166(9):1027-1032, 2006.
- Brinton LA, Richesson D, Leitzmann MF, et al. Menopausal hormone therapy and breast cancer risk in the NIH-AARP Diet and Health Study Cohort. Cancer Epidemiol Biomarkers Prev. 17(11):3150-60, 2008.
- U.S. Food and Drug Administration (FDA). FDA Consumer health information-Bioidenticals: sorting myths from facts. https://www.health.harvard.edu/womens-health/fda-approved-bioidentical-hormones-for-menopausal-symptoms, 2008.
- U.S. Food and Drug Administration (FDA). Compounded menopausal hormone therapy questions and answers. http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/PharmacyCompounding/ucm339764.htm, 2015.
- Howard-Anderson J, Ganz PA, Bower JE, Stanton AL. Quality of life, fertility concerns, and behavioral health outcomes in younger breast cancer survivors: a systematic review. J Natl Cancer Inst. 2012 Jan 23. [Epub ahead of print].
- Col NF, Hirota LK, Orr RK, et al. Hormone replacement therapy after beast cancer: a systematic review and quantitative assessment of risk. J Clin Oncol. 19(8):2357-2363, 2001.
- Dew JE, Wren BG, Eden JA. Tamoxifen, hormone receptors and hormone replacement therapy in women previously treated for breast cancer: a cohort study. Climacteric. 5(2):151-5, 2002.
- von Schoultz E and Rutqvist LE on behalf of the Stockholm Breast Cancer Study Group. Menopausal hormone therapy after breast cancer: the Stockholm randomized trial. J Natl Cancer Inst. 97(7):533-5, 2005.
- Holmberg L, Iverson OE, Rudenstam CM, et al., for the HABITS Study Group. Increased risk of recurrence after hormone replacement therapy in breast cancer survivors. J Natl Cancer Inst. 100(7):475-82, 2008.
- Kenemans P, Bundred NJ, Foidart JM, et al. for the LIBERATE Study Group. Safety and efficacy of tibolone in breast-cancer patients with vasomotor symptoms: a double-blind, randomised, non-inferiority trial. Lancet Oncol. 10(2):135-46, 2009.
- Loprinzi CL, Kugler JW, Sloan JA, et al. Venlafaxine in management of hot flashes in survivors of breast cancer: a randomised controlled trial. Lancet. 356: 2059-63, 2000.
- Loprinzi CL, Sloan JA, Perez EA, et al. Phase III evaluation of fluoxetine for treatment of hot flashes. J Clin Oncol. 20(6):1578-83, 2002.
- Stearns V, Slack R, Greep N, et al. Paroxetine is an effective treatment for hot flashes: results from a prospective randomized clinical trial. J Clin Oncol. 23(28):6919-30, 2005.
- Freeman EW, Guthrie KA, Caan B, et al. Efficacy of escitalopram for hot flashes in healthy menopausal women: a randomized controlled trial. JAMA. 305(3):267-74, 2011.
- Kimmick GG, Lovato J, McQuellon R, Robinson E, Hyman B. Randomized, double-blind, placebo-controlled, crossover study of sertraline (Zoloft) for the treatment of hot flashes in women with early stage breast cancer taking tamoxifen. Breast J. 12(2):114-22, 2006.
- Buijs C, Mom CH, Willemse PHB, et al. Venlafaxine versus clonidine for the treatment of hot flashes in breast cancer patients: a double-blind, randomized cross-over study. Breast Cancer Res Treat. 115(3):573-80, 2009.
- Barton DL, LaVasseur BI, Sloan JA, et al. Phase III, placebo-controlled trial of three doses of citalopram for the treatment of hot flashes: NCCTG trial N05C9. J Clin Oncol. 28(20):3278-83, 2010.
- Goetz MP, Knox SK, Suman VJ, et al. The impact of cytochrome P450 2D6 metabolism in women receiving adjuvant tamoxifen. Breast Cancer Res Treat. 101(1):113-21, 2007.
- Kelly CM, Juurlink DN, Gomes T, et al. Selective serotonin reuptake inhibitors and breast cancer mortality in women receiving tamoxifen: a population based cohort study. BMJ. 340:c693, 2010.
- Pandya KJ, Morrow GR, Roscoe JA, et al. Gabapentin for hot flashes in 420 women with breast cancer: a randomised double-blind placebo-controlled trial. Lancet. 366(9488):818-24, 2005.
- Loprinzi CL, Kugler JW, Barton DL, et al. Phase III trial of gabapentin alone or in conjunction with an antidepressant in the management of hot flashes in women who have inadequate control with an antidepressant alone: NCCTG N03C5. J Clin Oncol. 25(3):308-12, 2007.
- Biglia N, Sgandurra P, Peano E, et al. Non-hormonal treatment of hot flushes in breast cancer survivors: gabapentin vs. vitamin E. Climacteric. 12(4):310-8, 2009.
- Loprinzi CL, Sloan J, Stearns V, et al. Newer antidepressants and gabapentin for hot flashes: an individual patient pooled analysis. J Clin Oncol. 27(17):2831-7, 2009.
- Toulis KA, Tzellos T, Kouvelas D, Goulis DG. Gabapentin for the treatment of hot flashes in women with natural or tamoxifen-induced menopause: a systematic review and meta-analysis. Clin Ther. 31(2):221-35, 2009.
- Quella SK, Loprinzi CL, Sloan JA, et al. Long term use of megestrol acetate by cancer survivors for the treatment of hot flashes. Cancer. 82: 1784-8, 1998.
- Goodwin JW, Green SJ, Moinpour CM, et al. Phase III randomized placebo-controlled trial of two doses of megestrol acetate as treatment for menopausal symptoms in women with breast cancer: Southwest Oncology Group Study 9626. J Clin Oncol. 26(10):1650-6, 2008.
- Quella SK, Loprinzi CL, Barton DL, et al. Evaluation of soy phytoestrogens for the treatment of hot flashes in breast cancer survivors: A North Central Cancer Treatment Group Trial. J Clin Oncol. 18(5): 1068-74, 2000.
- van Patten CL, Olivotto IA, Chambers GK, et al. Effect of soy phytoestrogens on hot flashes in postmenopausal women with breast cancer: a randomized, controlled clinical trial. J Clin Oncol. 20(6):1449-55, 2002.
- Tice JA, Ettinger B, Ensrud K, Wallace R, Blackwell T, Cummings SR. Phytoestrogen supplements for the treatment of hot flashes: the Isoflavone Clover Extract (ICE) Study: a randomized controlled trial. JAMA. 290(2):207-14, 2003.
- Lethaby AE, Brown J, Marjoribanks J, Kronenberg F, Roberts H, Eden J. Phytoestrogens for vasomotor menopausal symptoms. Cochrane Database Syst Rev. (4):CD001395, 2007.
- Bolaños R, Del Castillo A, Francia J. Soy isoflavones versus placebo in the treatment of climacteric vasomotor symptoms: systematic review and meta-analysis. Menopause. 17(3):660-6, 2010.
- Nelson HD, Vesco KK, Haney E, et al. Nonhormonal therapies for menopausal hot flashes: systematic review and meta-analysis. JAMA. 295(17):2057-71, 2006.
- North American Menopause Society. The role of soy isoflavones in menopausal health: report of The North American Menopause Society. Menopause. 18(7):732-53, 2011.
- Chenoy R, Hussain S, Tayob Y, O’Brien PM, Moss MY, Morse PF. Effect of oral gamolenic acid from evening primrose oil on menopausal flushing. BMJ. 308(6927):501-3, 1994.
- Barton DL, Loprinzi CL, Quella SK, et al. Prospective evaluation of vitamin E for hot flashes in breast cancer survivors. J Clin Oncol. 16: 495-500, 1998.
- Jacobson JS, Troxel AB, Evans J, et al. Randomized trial of black cohosh for the treatment of hot flashes among women with a history of breast cancer. J Clin Oncol. 19(10):2739-45, 2001.
- Pockaj BA, Gallagher JG, Loprinzi CL, et al. Phase III double-blind, randomized, placebo-controlled crossover trial of black cohosh in the management of hot flashes: NCCTG Trial N01CC1. J Clin Oncol. 24(18):2836-41, 2006.
- Deng G, Vickers A, Yeung S, et al. Randomized, controlled trial of acupuncture for the treatment of hot flashes in breast cancer patients. J Clin Oncol. 25(35):5584-90, 2007.
- Lee MS, Kim KH, Choi SM, Ernst E. Acupuncture for treating hot flashes in breast cancer patients: a systematic review. Breast Cancer Res Treat. 115(3):497-503, 2009.