Patients experiencing menopause may have questions about the safety and cancer risks of using hormone therapy or other treatments, to control menopause symptoms. Patients who have had breast cancer might wonder if the use of hormone therapies could affect the risk of recurrence.
These recommendations are about menopause symptoms in general, and are not about "early menopause," which is experienced when treatment for cancer stops a patient's period before it would have stopped on its own. Symptoms of early menopause may be managed in a similar way.
The BC Cancer Breast Tumour Group does not recommend hormone therapy to relieve menopause symptoms for patients who have had breast cancer. Other options to relieve symptoms should be tried first.
If nothing else has worked and if you make an informed decision to take hormone therapy for quality of life issues, you should take the lowest effective dose for the shortest amount of time. In some situations, local therapy such as vaginal estrogens may be preferable, to minimize exposure to hormones.
These recommendations are based on studies of hormone therapy after a diagnosis of breast cancer and on the known risks of hormone therapy.
Patient experience suggests that symptoms and concerns may be minimized with possible non-hormonal treatment as follows:
Avoid things that trigger the flushes. These can be alcohol, caffeine (from coffee, tea, cola) chocolate, stress or hot weather.
An effective non-hormonal treatment for hot flushes is clonidine HCL (Dixarit®). This is a low dose of a blood pressure pill that is active in the region of the brain that makes hot flushes. The dose is small at first, and is slowly increased by your family physician until it is effective. This makes sure that the lowest possible dose is used.
Effexor® is an antidepressant which helps in low doses. The usual dose for hot flushes is 37.5 mg once or twice a day, and your doctor can increase it to 37.5 mg twice a day.
Gabapentin may be effective. It is a drug that is used for both epilepsy and neuropathic pain. The usual dose for hot flushes is 300 mg at night.
A study from the Mayo clinic suggests that a high dose of Depo Provera® (progesterone) may help patients with flushes that don't respond to other treatments. The dose is given one time only. As progesterone is known to stimulate breast cancer cells in the lab and also has been associated with an increased risk of breast cancer in some studies, continued or long term treatment is not recommended.
Many herbal remedies claim to treat menopausal symptoms, and may contain plant estrogens called phytoestrogens. Some of these include evening primrose oil (some formulations), soy, black cohosh, etc. The safety of phytoestrogens compared to the hormone estrogen in breast cancer patients has not been established. No herbal remedy should be taken long term.
Exercise for 1/2 hour, 3 – 5 times/week.
You need 1200 mg/day of calcium, plus 600 IU of vitamin D if you are 19-70 years old, and 800 IU if you are over 70 years old. These amounts indicate the total combination from all food sources and supplements.
Bisphosphonate medications have recently been shown to increase bone mass. If a bone density test shows significant bone loss, these medications are safe and can be prescribed by your family doctor. Fosamax® (Alendronate) can be given as a 70 – 80 mg dose once a week, which is often well tolerated.
Water soluble lubricant (K-Y Jelly, Muko Jel) (avoid Vaseline) applied to the head of the penis and the opening of the vagina.
Replens® can be effective in some people.
Local or low-dose hormonal options:
If the above don't work, local application of a small amount of estrogen-containing vaginal cream to the opening of the vagina, (rather than inside) may be recommended after talking with your doctor. After daily treatment for 1-2 weeks, the cream is usually only needed once per week. Vagifem® may also be used, 1-2 ampules once or twice a week.
Estring® is a ring that stays in the vagina for three months at a time and provides low levels of estrogen to the vagina.
Adapted from: Theme Issue: Menopause. BC Medical Journal vol. 35 (9) Sept. 1993: 650-664. and, Gelmon K and Kim-Sing C, "Hormone therapy and breast cancer." BC Medical Journal vol. 43 (9) 2001: 511-516.
Symptoms of menopause may best be treated by hormone replacement therapy (HRT).
However, patients with the following conditions should not be treated with estrogen-containing hormone treatments:
- Known or suspected breast cancer or other untreated estrogen dependent cancer, such as endometrial cancer.
- Pregnancy.
- Undiagnosed vaginal bleeding (could be endometrial cancer).
- Active thrombophlebitis (blood clots) or a history of thrombophlebitis related to birth control pills or during pregnancy.
Menopausal hormone treatment benefit is greatest for the first 5-10 years of use, and does not significantly increase the risk of developing breast cancer when taken for this length of time at a dosage of 0.625 mg of conjugated estrogens. Use of estrogens for longer than 10-15 years does increase the chance that you will develop breast cancer by about 1.5 times.
Diet and exercise are also helpful for menopausal symptoms, to prevent osteoporosis and heart disease.
