Treating Menopausal Symptoms

Menopausal hormone therapies (oral versus vaginal therapies)

There are different types of menopausal hormone therapies (MHT) used to relieve menopausal symptoms (such as hot flashes). Some are taken orally (in pill form), some are used vaginally and others are used in a patch form (similar to a nicotine patch). Oral MHT use (also known as postmenopausal hormone use and hormone replacement therapy) increases the risk of breast cancer, but vaginal hormone therapy use does not appear to increase risk [110,154-155,158]. Whether hormone patches affect breast cancer risk is under study.  

Although oral menopausal hormone therapy (MHT) use is approved for the short-term relief of menopausal symptoms, the U.S. Food and Drug Administration (FDA) recommends women use only the lowest dose that eases symptoms for the shortest time needed [106]. The use of oral MHT increases the risk of breast cancer [103-105]. Because it may also increase the risk of recurrence, oral MHT is not usually recommended for breast cancer survivors [110].  

Vaginal hormone therapies however, do not appear to increase the risk of breast cancer (learn more) [154-155].  

Other treatments may offer relief from menopausal symptoms, such as vaginal dryness and hot flashes. Talk to your health care provider about the best methods for you.  

Some common menopausal symptoms and treatment options for breast cancer survivors are discussed below.  

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 several options for the relief of vaginal dryness. Some methods contain hormones and some do not. Talk to 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 an estrogen-containing soft ring (put into the vagina like a diaphragm), vaginal estrogen suppositories and vaginal estrogen cream. These products may slightly increase blood estrogen levels, but for only a short time and most physicians believe they are safe for breast cancer survivors [154-155]. These products require a prescription.

Vaginal therapies that do not contain hormones

A non-hormonal option for vaginal symptoms 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. Because they do not contain estrogen, they're safe for breast cancer survivors. Vaginal moisturizers are available over the counter (without a prescription).

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

Hot flashes

Breast cancer survivors may have hot flashes if they go through early menopause due to chemotherapy. These women may have worse symptoms than those who go through menopause at later ages. (Learn more about early menopause.) Hot flashes can also be a side effect of hormone therapy.  

Some medications, vitamin E and plant-based remedies have been studied for the relief of hot flashes in breast cancer survivors.  

Medications

A number of medications have been studied for the treatment of hot flashes and other menopausal symptoms. Figure 6.2 below provides a summary of some of these medications.  

SSRI and non-SSRI antidepressants 

Among the most promising medications for treating hot flashes is a group of antidepressants called selective serotonin reuptake inhibitors (SSRIs). SSRIs include citalopram (Celexa), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil) and sertraline (Zoloft). These drugs, and the non-SSRI antidepressants venlafaxine (Effexor) and desvenlafaxine (Pristiq), have been shown to decrease the frequency and strength of hot flashes by 50 to 60 percent, with few side effects [114-121].  

Some SSRIs can interfere with tamoxifen [122-123]. If you are taking tamoxifen, talk to your health care provider before taking an SSRI.

Gabapentin 

A few studies have shown gabapentin (Neurontin), a drug used to treat seizures and pain, can reduce hot flashes, to varying degrees [124-127].  

Megestrol acetate

At high doses, the drug megestrol acetate is used to treat metastatic breast cancer. In low doses, it may reduce hot flashes in breast cancer survivors [128-129]. However, the safety of lower dose megestrol acetate in women with early breast cancer has not been proven. At higher doses, this drug can cause side effects, such as blood clots or weight gain.

Vitamin E and plant-based remedies

To date, there is little evidence that vitamins and plant-based remedies can reduce hot flashes in breast cancer survivors. Figure 6.2 below gives a summary of some vitamin and plant-based remedies.

Vitamin E

Although one small randomized controlled trial found that vitamin E slightly reduced hot flashes, most studies have not shown this benefit [126,130].

Learn more about vitamin E.

Soy and black cohosh

In randomized controlled trials, breast cancer survivors who took soy or black cohosh were no less likely to have hot flashes than those who took a placebo [131-135]. 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 black cohosh.

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 common menopausal symptoms

Acupuncture

A few, small randomized controlled trials have studied whether acupuncture may offer relief from hot flashes in breast cancer survivors. Studies comparing the benefit of true acupuncture to sham acupuncture have found mixed results. Some findings showed acupuncture reduced hot flashes more than the sham treatment, while others found no difference between the two [143-145].  

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.  

Learn more about acupuncture.

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. Some findings show cognitive behavioral therapy may improve sexuality for breast cancer survivors [157]. It is under study for the treatment of hot flashes and other menopausal symptoms. At this time, few people are trained to give cognitive behavioral therapy and it is not widely available.

Tips for managing hot flashes

Although studies are limited at this time, the following tips may help relieve hot flashes [159]. 

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.) “Bio-identical" may also refer to hormone therapies that are custom compounded (when a pharmacist makes a mixture of hormones according to the physician’s instructions on a prescription) [111-113]. No matter the definition, it is important to remember:

• Bio-identical hormones have not been shown to be safer than FDA-approved oral MHT. There is no evidence bio-identical hormones have fewer health risks than FDA-approved MHT. And, because they have not been well-studied, bio-identical hormones may have more health risks [111-112].
• Bio-identical hormones have not been shown to be more effective at treating menopausal symptoms than FDA-approved MHT [111-112].
• There is no scientific evidence that saliva tests to check hormone levels are useful in making custom compounded hormone therapies [111-112].

To learn more about bio-identical hormone therapies, visit the FDA website.    

*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. 

Updated 04/30/13

Menopausal Hormone Therapy (Postmenopausal Hormone Use)

Concern for Family Members