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Nonhormonal therapies recommended for menopausal symptoms after breast cancer
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Women who experience clinical manifestations of estrogen deficiency during or after breast cancer treatment should consider lifestyle modification and nonpharmacologic therapies to manage bothersome menopausal symptoms, according to a review published in The Journal of Clinical Endocrinology & Metabolism.
“Following breast cancer, women should generally not be treated with menopausal hormone therapy, but should instead focus on lifestyle modifications, such as smoking cessation, weight loss and regular physical activity,” Richard J. Santen, MD, of the University of Virginia Health System in Charlottesville, said in a press release. “Pharmacologic agents are also available to treat women with severe symptoms. The most important thing to remember is that therapy must be individualized based on each woman’s needs and goals.”
A large proportion of the world’s estimated 9.3 million breast cancer survivors experience menopausal symptoms or clinical manifestations of estrogen deficiency, Santen and colleagues wrote in the review. Premenopausal women treated with chemotherapy can develop ovarian insufficiency and severe menopausal symptoms as well as infertility. Postmenopausal women treated with aromatase inhibitors may experience arthralgia, accelerated bone loss and an increased incidence of osteoporotic fractures because of markedly suppressed estrogen levels. However, a lack of randomized, placebo-controlled trials in this population has limited the evidence upon which to base therapeutic decisions, the researchers wrote.
“Consequently, written guidelines to address menopause management in women during and after treatment of breast cancer have not sufficiently focused on treatment of this subgroup of women,” they wrote.
Santen and colleagues reviewed controlled clinical trials, observational studies, evidence-based guidelines and expert opinion from professional societies to make several recommendations for management of menopausal symptoms after breast cancer:
- Smoking cessation, weight loss (if indicated), limiting or avoiding alcohol, maintaining adequate levels of vitamin D and calcium, eating a healthy diet and participating in regular physical activity are suggested for all women with prior breast cancer.
- Nonpharmacologic therapies for vasomotor symptoms, such as cognitive behavioral therapy, hypnosis and acupuncture may be helpful, as are vaginal lubricants and moisturizers.
- Several emerging approaches, such as selective estrogen receptor modulators, tissue selective estrogen complex, estetrol and neurokinin B inhibitors, show promise as useful agents to expand options for symptom relief with less breast cancer risk; however, these therapies have not yet been tested to confirm safety in women with prior breast cancer.
Clinicians should evaluate the severity of the signs and symptoms related to estrogen deficiency and the degree of bother to the patient to individually tailor treatment, researchers noted. – by Regina Schaffer
Disclosures: Santen reports receiving research funding from Pantarhei Bioscience; one author reports receiving research funding from Therapeutics MD, and another author reports receiving research funding from Lawley Pharmaceuticals and honoraria from Abbott, Besins Healthcare and Pfizer Pharmaceuticals.
Perspective
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Life after breast cancer is so difficult for so many women, and there are few clinicians who really understand the needs of these women. Currently, 80% of the OBGYN residents in the United States and Canada receive no formal menopause didactics. Many women don't want to complain about menopause symptoms to their oncologists (most of whom haven't had training in menopause management), because they feel they should be grateful to be alive and shouldn't complain about issues that "only" affect their day-to-day feelings.
Other than the lifestyle interventions the authors mention, which are all good, almost all the medications that are alternatives to estrogen have significant side effects. For example, SSRIs, which are somewhat effective for these symptoms, often increase weight and decrease libido, which are two of the most bothersome complaints noted by menopausal women, particularly breast cancer survivors. Similarly, what do women complain of secondary to gabapentin? Bloating and sedation — two more complaints that breast cancer survivors don't want to deal with.
Vulvovaginal atrophy, now referred to as “genitourinary syndrome of menopause,” is a controversial area. Santen has been a leader in showing that the systemic absorption from vaginal estrogens is quite minimal, but not zero, whereas some are concerned that even a tiny amount of estrogen can be deleterious. Unfortunately, our two new options, systemic ospemifene and vaginal prasterone (DHEA), have not yet been studied in breast cancer survivors. There is very good reason to believe, as the researchers point out in the article, that both should be safe for breast cancer survivors. We are all hopeful for forthcoming studies.
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