The Who, What, Where, When and Sometimes, Why.

Treating Menopausal Symptoms

This page discusses the treatment of menopausal symptoms for breast cancer survivors.

Some information may also be helpful for women who have never been diagnosed with breast cancer.

Menopausal symptoms

Common menopausal symptoms in breast cancer survivors include:

Types of menopausal hormone therapy

There are different types of menopausal hormone therapy (MHT) used to relieve menopausal symptoms. Some are pills, some are used vaginally and others are patches (similar to a nicotine patch).

Oral MHT

Oral MHT is usually not recommended for breast cancer survivors because findings from randomized controlled trials have shown MHT use increases the risk of [51-52]:

  • Local breast cancer recurrence
  • Metastasis (distant recurrence)
  • Cancer in the opposite breast

Learn about oral MHT and breast cancer risk in women who have never been diagnosed with breast cancer

 

For a summary of research studies on oral MHT therapy and breast cancer recurrence, visit the Breast Cancer Research section.

 

Vaginal MHT

Vaginal hormone therapies do not appear to increase the risk of breast cancer [53-56,212].

However, some of these therapies may increase blood estrogen levels [57-58]. If your breast cancer was hormone receptor-positive, vaginal estrogen rings and suppositories are preferred over vaginal estrogen creams [28].

Talk with your provider about whether these products may be safe options for you.

Hormone patch

Whether hormone patches affect breast cancer recurrence (or breast cancer risk) is under study.

Menopausal symptom treatment options

Treatment options for vaginal symptoms and hot flashes are discussed below. Some contain hormones and others do not.

Talk with your health care provider about the best methods for you.

 

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Komen Perspectives

Read our perspective on managing menopausal symptoms
(April 2012).*

 

Vaginal symptoms

One of the most common symptoms of menopause is vaginal dryness, which can cause pain during intercourse, vaginal soreness and itching.

Breast cancer survivors have options for the relief of vaginal dryness. Talk with your health care provider about which option is best for you.

Vaginal therapies that contain hormones

Hormonal options for the relief of vaginal symptoms include:

  • Estrogen-containing soft ring (put into the vagina like a diaphragm)
  • Vaginal estrogen suppositories
  • Vaginal estrogen cream

Vaginal estrogen rings and suppositories may slightly increase blood estrogen levels, but for only a short time [57-58].

Creams may slightly increase blood estrogen levels for a longer time [58]. If your breast cancer was hormone receptor-positive, vaginal estrogen rings and suppositories are preferred over vaginal estrogen creams [28].

Talk with your provider about whether these products may be safe options for you. All require a prescription.

Vaginal therapies that don’t contain hormones

A non-hormonal option for vaginal symptoms is an estrogen-free vaginal moisturizer (such as Replens or Hyalo Gyn).

These products are different from vaginal lubricants (such as K-Y Jelly and Astroglide), which only make the vaginal area slippery, rather than moisturized.

Moisturizers need to be used regularly (several times a week), rather than just around the time of intercourse. Since they don’t contain estrogen, they’re safe for breast cancer survivors.

Vaginal moisturizers are available over the counter (without a prescription).

Talk with your provider about the benefits and risks for each of these options.

Oral medications that have hormonal effects

The drug ospemifene (Osphena) is FDA-approved for postmenopausal women who have pain during intercourse due to vaginal dryness.

However, because ospemifene has some hormonal effects, it’s not currently recommended for breast cancer survivors.

Lidocaine

The pain-relieving drug lidocaine may be helpful for breast cancer survivors who have pain during intercourse due to vaginal symptoms.

One small study of survivors found that a compress of lidocaine to the vaginal area eased pain during intercourse [59]. This helped make sex comfortable again for most women in the study [59].

Talk with your provider about this option and the correct way to apply the medication.

Hot flashes and night sweats

Breast cancer survivors who go through early menopause due to treatment may have hot flashes and night sweats. These women may have worse symptoms than those who go through menopause at later ages.

Hot flashes can also be a side effect of hormone therapy.

Ways to relieve hot flashes in breast cancer survivors are under study. These include:

Medications that don’t contain hormones

Figure 6.2 below gives a summary of some of the non-hormonal medications studied for the treatment of hot flashes and other menopausal symptoms.

Anti-depressants

Among the most promising medications for treating hot flashes are 2 groups of anti-depressants called selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).

SSRIs include:

  • Citalopram (Celexa)
  • Escitalopram (Lexapro)
  • Fluoxetine (Prozac)
  • Fluvoxamine (Luvox)
  • Paroxetine (Brisdelle, Paxil)
  • Sertraline (Zoloft)

SNRIs include:

  • Venlafaxine (Effexor)
  • Desvenlafaxine (Pristiq)

SSRI and SNRI anti-depressants have been shown to decrease the frequency and strength of hot flashes by 50-60 percent, with few side effects [60-65].

Tamoxifen and anti-depressants

Tamoxifen is a hormone therapy drug. Some SSRI anti-depressants (such as fluoxetine, paroxetine and sertraline) can interfere with the metabolism of tamoxifen (how tamoxifen works in the body) [66].

However, it’s not known whether these drugs might affect tamoxifen treatment for breast cancer.

If you are taking tamoxifen, talk with your health care provider about possible drug interactions and other options for treating hot flashes.

Gabapentin

A few studies have shown gabapentin (Neurontin), a drug used to treat seizures and pain, may greatly reduce hot flashes [67-70].

Megestrol acetate

At high doses, the drug megestrol acetate is used to treat metastatic breast cancer. At these high doses, it can cause side effects, such as blood clots or weight gain.

In low doses, megestrol acetate may reduce hot flashes in breast cancer survivors [71]. However, the safety of lower doses in women with early breast cancer has not been proven.

 

For a summary of research studies on anti-depressants and other non-hormone medications for menopausal symptoms, visit the Breast Cancer Research section

 

Vitamin E and plant-based remedies

To date, there’s little evidence vitamins and plant-based remedies reduce hot flashes in breast cancer survivors.

Figure 6.2 below gives a summary.

Vitamin E

Although one small, randomized controlled trial found vitamin E slightly reduced hot flashes, most studies have not shown this benefit [68,72].

Soy and black cohosh

In randomized controlled trials, women (including breast cancer survivors) who took soy or black cohosh were no less likely to have hot flashes than those who took a placebo [73-78].

Although these studies did not show any harmful side effects of soy or black cohosh for breast cancer survivors, there are no long-term safety data.  

Learn more about soy and breast cancer risk

 For a summary of research studies on soy for menopausal symptoms, visit the Breast Cancer Research section.
 For a summary of research studies on black cohosh for menopausal symptoms, visit the Breast Cancer Research section.  
For a summary of research studies on other supplements for menopausal symptoms, visit the Breast Cancer Research section.

Figure 6.2: Non-hormonal therapies used to treat menopausal symptoms

It’s important to talk with your health care provider before taking any of the medications or remedies in the table below. 

 

Summary of Evidence from Randomized Controlled Trials

Short-term Health Risks

Long-term Health Risks

Medications

Clonidine

Some evidence of:

  • Reduced frequency of hot flashes among breast cancer survivors

 

  • Constipation
  • Dry mouth
  • Low blood pressure
  • Sleeping problems

 

Unknown

DHEA

No benefit over placebo for hot flashes

Unknown          

Unknown

Gabapentin (Neurontin)

Some evidence of:

  • Reduced strength and frequency of hot flashes 
  • Relief of sleeping problems

 

  • Dizziness
  • Drowsiness
  • Swelling in arms and legs

 

Unknown

Ospemifene (Osphena)

Strong evidence of:

  • Improved vaginal symptoms
  • Reduced pain during intercourse

Not recommended for breast cancer survivors

  • Excessive sweating
  • Hot flashes
  • Muscle spasms
  • Vaginal discharge

In rare cases:

Should not be used long-term

Unknown

SSRI anti-depressants

Strong evidence of:

  • Reduced strength and frequency of hot flashes

 

  • Constipation
  • Dry mouth
  • Headache
  • Nausea
  • Reduced sexual desire
  • Sleeping problems

May interact with tamoxifen

May have withdrawal symptoms if stopped too quickly

Unknown

SNRI anti-depressants

Strong evidence of:

  • Reduced strength and frequency of hot flashes

Some evidence of:

  • Increase in sexual desire

 

  • Constipation
  • Dry mouth
  • Nausea

May have withdrawal symptoms if stopped too quickly

Unknown

Zolpidem (Ambien)

Some evidence of:

  • Reduced sleeping problems.

 

  • Dizziness
  • Drowsiness
  • Headache
  • Respiratory infection

Cannot be used long-term

Unknown

 

Summary of Evidence from Randomized Controlled Trials

Short-term Health Risks

Long-term Health Risks

Vegetable or plant-based remedies

Black cohosh

No benefit over placebo for hot flashes

  • Dizziness
  • Headache
  • Nausea

In rare cases:

  • Liver damage

 

Unknown

Chinese herbal medicine

No benefit over placebo for hot flashes

  • Breast tenderness
  • Diarrhea
  • Stomachache

 

Unknown

Dong quai root

No benefit over placebo for hot flashes

Can interact with warfarin and lead to bleeding problems

Unknown

Evening primrose oil

No benefit over placebo for hot flashes

  • Bloating
  • Diarrhea
  • Nausea

May worsen some types of epilepsy

Unknown

Flaxseed

No benefit over placebo for hot flashes

None

Unknown.

Ginseng root

Most studies report no benefit over placebo for hot flashes or vaginal dryness

Some evidence of:

  • Reduced sleeping problems

 

None

Unknown

Omega-3 fatty acid

Some evidence of:

  • Reduced strength and frequency of hot flashes

 

  • Constipation

 

Unknown

Red clover extract

No benefit over placebo for hot flashes

None

Unknown

Soy

Most studies report no benefit over placebo for hot flashes or vaginal symptoms

Breast cancer survivors should discuss taking high doses of soy with their health care providers

Unknown

Vitamin E

Some evidence of:

  • A small decrease in frequency of hot flashes among breast cancer survivors

 

None

Unknown

Adapted from the North American Menopause Society and selected studies [60-65,67-87].

Acupuncture

Small randomized controlled trials have studied whether acupuncture can reduce hot flashes in breast cancer survivors and other women.

Studies compared the benefit of true acupuncture to sham (fake) acupuncture. With sham acupuncture, the needles are placed at non-acupuncture points on the body.

Some findings showed acupuncture reduced hot flashes more than the sham treatment, while others found no difference between the two [88-92].

At this time, data are too limited to draw conclusions on the benefit of acupuncture for the relief of hot flashes in breast cancer survivors. This topic is still under study.

 For a summary of research studies on acupuncture for menopausal symptoms, visit the Breast Cancer Research section

Cognitive behavioral therapy

Cognitive behavioral therapy is a special type of mental health counseling. Group sessions are led by a mental health provider (such a psychologist or social worker) and may include techniques such as relaxation exercises.

A few, small randomized controlled trials have studied whether cognitive behavioral therapy can ease menopausal symptoms in breast cancer survivors. Some findings have shown it may decrease hot flashes for breast cancer survivors [87,93-94,218].

Cognitive behavioral therapy is also under study for reducing fatigue and insomnia in breast cancer survivors.

At this time, few people are trained to give cognitive behavioral therapy and it’s not widely available.

Sex, sexuality and intimacy

Cognitive behavioral therapy may also improve sexual functioning in breast cancer survivors [95-96].

A randomized controlled trial studied an internet-based cognitive therapy program [96]. Women who got therapy reported better overall sexual functioning including improved pleasure, desire, arousal and vaginal lubrication compared to women who did not [96]. They also reported reduced discomfort during intercourse [96].

Learn more about sex, sexuality and intimacy.

Tips for managing hot flashes

Although studies are limited at this time, the following tips may help relieve hot flashes [97].  

 Tips for relieving hot flashes

  • Quit smoking
  • Limit alcohol intake
  • Dress in layers
  • Avoid caffeine and hot drinks
  • Avoid hot or spicy foods
  • Keep a bottle or glass of cold water handy
  • Take a cool shower before bed
  • Keep an ice pack under your bed pillow (to use to cool down if you wake up with night sweats)
  • Keep your home or bedroom cool

 

Adapted from the North American Menopause Society [97].

Bio-identical hormones

There is no medical or scientific definition for the term “bio-identical hormones.” So, you may hear this term used in different ways.

Some people use it to describe hormone drugs that have the same chemical and molecular structure as hormones found in the body. (Not all products that claim to be bio-identical meet this definition.)

Compounded bio-identical hormones

“Bio-identical” may also refer to hormone therapies that are custom compounded (when a pharmacist makes a mixture of hormones according to a physician’s instructions on a prescription) [98-99].

It’s important to remember [98]:

  • Compounded bio-identical hormones have not been shown to be safer than FDA-approved oral MHT.
  • There’s no evidence compounded bio-identical hormones have fewer health risks than FDA-approved MHT.
  • Because they have not been well-studied, compounded bio-identical hormones may have more health risks than FDA-approved MHT.
  • Compounded bio-identical hormones have not been shown to be more effective at treating menopausal symptoms than FDA-approved MHT.
  • Compounded bio-identical hormones are not more “natural” than FDA-approved MHT.
  • There’s no scientific evidence that saliva tests to check hormone levels are useful in making custom compounded hormone therapies.

 

quote_icon

Komen Perspectives

Read our perspective on managing menopausal symptoms
(April 2012).*

*Please note, the information provided within Komen Perspectives articles is only current as of the date of posting. Therefore, some information may be out of date at this time.

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