“I have breast cancer; must I suffer through the menopausal symptoms inflected on me by my treatment?”
How many times in the past as Medical Oncologists and Gynecologists have we had our patients ask this question? In years past, we have done the best we could but treatment options were woefully inadequate or carried too much concern of risks. Today? Let’s look at the data.
Breast cancer survivors are living longer because of earlier diagnosis and better treatment.1 This means many of them are living with long term side effects of their treatment. This has led to an increased focus on the management of their side effects.
Vasomotor symptoms (VMS) are a hallmark of menopause and up to 79% in women ending their reproductive years but up to 93 % in patients on endocrine therapy for breast cancer treatment, depending on type used. (10-12)2 Interruption or discontinuation rates of these treatments in breast cancer patents are reported to be greater than 20%.2 VMS are more commonly reported with the use of tamoxifen whereas arthralgia, vaginal dryness and sexual dysfunctions are more commonly associated with aromatase inhibitors (Ais). Other notable symptoms of menopause include sleep disturbance, fatigue, difficulty concentrating, crying, irritability and musculoskeletal symptoms. In a pooled data analysis, those with breast cancer had higher symptom prevalence compared with women without a history of breast cancer.3
Menopausal hormone therapy (MHT) is usually contraindicated after breast cancer because of potential growth stimulation in hormone sensitive cancers. Large randomized clinical trials have confirmed improved survival in those breast cancer patients where estrogen exposure has been reduced or eliminated.4 In an expert panel review of available literature and consensus recommendations, it was determined that the increase risk of recurrence in ER negative cancers were highest in the first 2 years those with an ER positive cancer continued at risk of recurrence or development of new primary breast cancer for many decades after diagnosis. The risk is proportional to the original tumor diameter, nodal status and tumor grade. Use of MHT should only be started after a detailed review of the risks and benefits of the therapy given the available science and should only be initiated with shared decision making with the patient and clinicians involved in the care of women with a history of breast cancer trained to manage menopause symptoms or those with a special interest in menopause care after breast cancer.
The general consensus is that transdermal estrogen should be the preferred modality for treatment as it does not have the risk of VTE associated with oral dosing and body-identical progesterone should be considered the optimal MHT regimen to give if the patent choses MHT after breast cancer.
Genitourinary syndrome of menopause (GSM) is a particular bothersome issue for breast cancer survivors who are being treated with endocrine therapy which increase atrophic genital and lower urinary tract changes from the loss of estrogen. The common symptoms associated with GSM include frequent urinary tract infections, thinning of the vulva and vaginal mucosa, painful sexual activity leading to dysfunction, and chronic irritation of the vulvar and vaginal mucosa. Vaginal estrogen is a highly effective treatment of GSM but personal history of breast cancer is listed as a contraindication for use. In a recent meta-analysis, 24,060 patients were assessed for breast cancer recurrence. Of this group, 11.6% using vaginal estrogen had a breast cancer recurrence compared to 15.8% of patients not using vaginal estrogen. Although the data were not robust enough to indicate a clear opinion, the meat-analysis indicates that vaginal estrogen does not appear to increase the recurrence of breast cancer and does not elevate the breast-cancer specific or overall mortality.5 The analysis did reveal a statistically significant association between the use of vaginal estrogen and a reduction of overall mortality among breast cancer survivors.
In patients that are hesitant to use MHT, there are pharmacological and non-pharmacological alternatives that may offer some benefits for VMS and for GSM. For VMS the non-pharmacological alternatives include:
Purified and Specific Cytoplasmic Pollen Extract: functions similarly to SSRI antidepressants inhibiting the reuptake of serotonin at the synaptic junctions, does not contain phytoestrogens, has no effect in endometrial or breast tissue and is well tolerated. Further in vivo trials are needed.
Black cohosh: used to relieve climacteric symptoms, formulations vary and hepatic side effects are controversial, mechanism of action is not fully known, thought to have anti-inflammatory and anti-oxidant activity, serotonergic agonist or SERM action, safe with tamoxifen.
Lifestyle: Weight control, exercise, YOGA, body cooling strategies, diet rich in fruits, vegetables and dairy, avoid alcohol, caffeine, hot spices especially in the evening.
Acupuncture: reduces frequency and intensity of hot flashes
Cognitive behavioral therapy(CBT): Effective in managing symptoms of menopause in BCS and healthy post-menopausal women.6
Pharmacological therapies:
Antidepressants: SSRIs and SNRIs Mild to moderate reduction of VMS in BCS. Prescribe at the lowest effective dose
Anticonvulsants: Gabapentin and pregabalin, modulate the thermoregulatory activity of the hypothalamus through calcium channels. Up to a 50% decrease in HFs, with gabapentin 900 mg/day improves quality of sleep. Can cause drowsiness, shakiness, dizziness.
Oxybutynin: anticholinergic drug, decreases HFs and improved global sleep score
Clonidine: antihypertensive, alpha-adrenergic agonist, inhibits HFs by reducing peripheral vascular reactivity. Causes dry mouth, constipation, confusion and hypotension.
NK1-3 neurokinin receptor antagonists: Fezolinetant; causes dysregulation of the thermoregulatory center which causes the onset of HFs. Once daily oral tablet significantly reduced the frequency of HFs.6
GSM and Sexuality:
Non-Pharmacologic: Lubricants and moisturizers are first line therapies and form a film on the vaginal mucosa used 2-3 times per week.
Hyaluronic acid; helps maintain hydration, turgidity, plasticity and viscosity. Acts and an antishock molecule and efficient lubricant. Heals and promotes healing of the skin. Recommended as first line therapy.
Laser; known to induce new collagen and elastic fibers, 2 types of lasers for GSM, promising results but more data is needed, not yet considered standard treatment for GSM.
Pharmacologic: Low-dose vaginal estrogen; Systemic absorption initially the back to baseline by week 12. Low-dose local estrogen is considered to have a low risk profile. Danish study no increase incidence of recurrent breast cancer.
Prasterone (DHEA); bio-identical to endogenous DHEA, decreased dyspareunia and decreased vaginal dryness at 12 weeks. Was studied in BCS with better sexual health.
Osphemifene; SERM acts on vaginal mucosa. Safe option in BCS at the end of AET but further studies with longer follow up are needed in the BCS population.6
In conclusion, there are promising treatment options for BCS patients with VMS and GSM who can retain a meaningful, highly active life with few or no symptoms. They should be able to continue sexual function without pain if the treatment is started early in their cancer journey. The younger the BCS the more intense their symptoms tend to be and this population needs to have a team-based patient-centered approach to the total treatment of her cancer and the side effects of the treatment. It is time for our patients to no longer suffer in silence.
CONTRIBUTOR
Dr. Sandra Reed is an Assistant Professor at Emory School of Medicine where she focuses on Menopausal issues and is MSCP certified. She graduated from the Medical College of Georgia and stayed to finish her training in Obstetrics and Gynecology. She is Board Certified by the American Board of Obstetrics and Gynecology. She is currently Past Chair of The American College of Obstetrics and Gynecology for District IV. Dr. Reed has expertise in minimally invasive surgical technique, complex abdominal gynecologic surgery, and Gynecologic issues in cancer survivors, especially those with menopausal issues.
REFERENCES
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2. Zhu L, Hshieh T, Iyer T, Morgans A, Hamnvik O; Management of vasomotor symptoms in cancer patients. The Oncologist, 2025,30, oyaf002.
3. Osborne CK. Tamoxifen in the treatment of breast cancer. N Engl J Med. 2015;1998;339:1609-1618.
4. Glynne S, Simon J, Branson A, et al; Menopausal hormone therapy for breast cancer patients: what is the current evidence? Menopause. Volume 33, Number 1, January 2026.
5. Beste M, Kaunitz A, McKinney J, Sanchez-Ramos L; Vaginal estrogen use in breast cancer survivors: a systemic review and meta-analysis of recurrence and mortality risks. AJOG, March 2025
6. Bounous V, Andronico N, Govone F, et al; New challenges in treatments for menopausal symptoms in breast survivors. NEJM.org June 2, 2025.a
