Although postmenopausal hormone use is approved for the short-term relief of menopausal symptoms, the U.S. Food and Drug Administration (FDA) recommends that women use only the lowest dose that eases symptoms for the shortest time needed [91]. The use of postmenopausal hormone increases the risk of breast cancer [88-90]. So, for breast cancer survivors, who have an increased risk of getting a second breast cancer, avoiding postmenopausal hormones may be even more important than for other women.
Women can get relief from menopausal symptoms, such as vaginal dryness and hot flashes, through other treatments. If you are having symptoms, 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. Estrogen-free vaginal moisturizers (such as Replens and Astroglide) are similar to natural vaginal lubricants and are available over the counter (without a prescription). Because they do not contain estrogen, they're safe for women with breast cancer.
Other options for vaginal symptoms are an estrogen-containing soft ring (put into the vagina like a diaphragm) and vaginal estrogen suppositories. These products slightly increase the level of estrogen in the blood, but for only a short time and most breast oncologists believe they are safe. Talk to your health care 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
SSRI and non-SSRI antidepressants
A number of medications have been studied for the treatment of hot flashes. Among the most promising 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 a non-SSRI antidepressant called venlafaxine (Effexor), have been shown to decrease the frequency and strength of hot flashes by 50 to 60 percent, with few side effects [99-104].
Some SSRIs can interfere with tamoxifen [105-106]. If you are taking tamoxifen, talk to your health care provider before taking an SSRI. Figure 6.2 below provides a summary of these non-hormone therapies for menopausal symptoms.
Gabapentin
A few studies have shown gabapentin (Neurontin), a drug used to treat seizures and pain, can reduce hot flashes, to varying degrees [107-109].
Megestrol acetate
The drug megestrol acetate is used at high doses to treat metastatic breast cancer. In low doses, it has been shown to reduce hot flashes in breast cancer survivors [110-113]. 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 weight gain or blood clots.
Vitamin E and plant-based remedies
To date, there is little evidence 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 [109,112].
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 [108-117]. Although these studies did not show any harmful 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.
Figure 6.2: Non-hormonal therapies used to treat common menopausal symptoms
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Summary of Evidence from Randomized Controlled Trials
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Short-term Health Risks
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Long-term Health Risks
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Medications
(It is important to talk to your health care provider before taking any of these medications.)
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| Clonidine |
Studies have shown mixed results. Some evidence of reduced frequency of hot flashes among breast cancer survivors. |
Sleeping problems, constipation and dry mouth. |
Unknown. |
DHEA
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No benefit over placebo for hot flashes. |
Unknown.
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Unknown.
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| Gabapentin (Neurontin) |
Some evidence of reduced strength and frequency of hot flashes and relief of sleeping problems. |
Dizziness, drowsiness, rash and swelling in arms and/or legs.
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Unknown. |
| SSRI antidepressants |
Evidence of reduced strength and frequency of hot flashes. |
Dry mouth, constipation, reduced sexual desire, sleeping problems, headache and nausea. May interact with tamoxifen. May have withdrawal symptoms. |
Unknown. |
| Venlafaxine |
Evidence of reduced strength and frequency of hot flashes. Some evidence of increase in sexual desire. |
Dry mouth, constipation and nausea. May have withdrawal symptoms.
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Unknown. |
Zolpidem (Ambien)
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Some evidence of relief of sleeping problems.
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Headache, respiratory infection, drowsiness and dizziness.
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Unknown.
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Vegetable or plant-based remedies
(It is important to talk to your health care provider before taking any of these products.) |
Black cohosh
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No benefit over placebo for hot flashes.
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Nausea, headache, dizziness and in rare cases, liver damage.
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Unknown.
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Dong quai root
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No benefit over placebo for hot flashes.
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Can interact with warfarin and lead to bleeding problems.
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Unknown.
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Evening primrose oil
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No benefit over placebo for hot flashes.
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Mild nausea, diarrhea and bloating. May worsen some types of epilepsy.
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Unknown.
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Flaxseed
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No benefit over placebo for hot flashes.
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None.
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Unknown.
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Ginseng root
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Some evidence that relieves vaginal dryness and sleeping problems.
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Side effects similar to placebo.
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Unknown.
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Red clover extract
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No benefit over placebo for hot flashes.
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Side effects similar to placebo.
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Unknown.
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Soy
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Studies have shown mixed results. Most report no benefit over placebo for hot flashes or vaginal symptoms.
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Breast cancer survivors should discuss taking high doses of soy with their health care provider.
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Unknown.
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Vitamin E
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Some evidence of a small decrease in frequency of hot flashes among breast cancer survivors.
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None.
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Unknown.
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Adapted from National Institutes of Health, North American Menopause Society and selected studies [118-124].
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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 [125-127].
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.
Bio-identical hormones
There is no medical or scientific definition for the term “bio-identical hormones”, so you may hear the 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 the prescription) [96-98]. No matter the definition, it is important to remember:
- Bio-identical hormones have not been shown to be safer than FDA-approved postmenopausal hormone therapies. There is no evidence these hormone therapies have fewer health risks than FDA-approved hormones. And, because they have not been well-studied, they may have more health risks [96-97].
- Bio-identical hormones have not been shown to be more effective at treating menopausal symptoms than FDA-approved postmenopausal hormone therapies [96-97].
- There is no scientific evidence that saliva tests to check hormone levels are useful in making custom compounded hormone therapies [96-97].
To learn more about bio-identical hormone therapies, visit the FDA website.
Updated 01/20/12
