Treating Menopausal Symptoms in Breast Cancer Survivors

• Vaginal symptoms  
• Hot flashes and night sweats  

Types of menopausal hormone therapy

There are different types of menopausal hormone therapy (MHT) used to relieve menopausal symptoms. Some are pills, some are used vaginally, and others are patches (similar to nicotine patches).

MHT is also called postmenopausal hormone therapy and hormone replacement therapy (HRT).

Oral MHT (pills)

Oral MHT is not usually given to women who’ve had breast cancer because findings from randomized controlled trials have shown using oral MHT increases the risk of [49-52]:

• Local breast cancer recurrence (a return of breast cancer to the original site in the breast)
• Metastasis (distant recurrence)
• Cancer in the opposite breast

Learn about oral MHT and breast cancer risk in women who’ve never been diagnosed with breast cancer. 

For a summary of research studies on oral MHT and breast cancer recurrence, visit the Breast Cancer Research section.

 Vaginal MHT

Vaginal estrogen therapies include vaginal suppositories, vaginal rings and vaginal creams.

Vaginal estrogen therapies do not appear to increase the risk of breast cancer [53-57]. However, there are some questions about breast cancer survivors using vaginal estrogen therapies, especially those taking an aromatase inhibitor [57-58].

A few vaginal estrogen therapies may increase blood estrogen levels [59-60]. Using vaginal estrogen suppositories or a vaginal estrogen ring is preferred over a vaginal estrogen cream, especially if your breast cancer was estrogen receptor-positive [3].

Talk with your health care provider about whether vaginal estrogen products may be safe options for you. All require a prescription.

Learn more about treating vaginal symptoms of menopause.

Hormone patch

Whether hormone patches, containing estrogen alone or estrogen plus progestin, affect breast cancer recurrence (or breast cancer risk) is under study.

Hormone patches are not recommended for breast cancer survivors because of concerns over a possible risk of recurrence [121].

Menopausal symptom treatment options

Treatment options for vaginal symptoms and hot flashes are discussed below. Some treatments contain hormones and others do not.

Talk with your health care provider about the best methods for you. 

Vaginal symptoms

Watch our MBC Impact Series webinar on metastatic breast cancer and sexual health. Although this webinar was created for women who have metastatic breast cancer, it has helpful information for women with any stage of breast cancer. We encourage all to watch.

One of the most common symptoms of menopause is vaginal dryness, which can cause pain during intercourse, vaginal soreness and itching.

Women treated for breast cancer have options to relieve vaginal dryness. Talk with your health care provider about which option is best for you.

If the first method doesn’t improve your symptoms, let your provider know so you can consider other options.

Learn about sex, sexuality and intimacy after a breast cancer diagnosis.

Vaginal therapies that don’t contain hormones

A non-hormonal option for vaginal symptoms is an estrogen-free vaginal moisturizer (such as Replens). Vaginal moisturizers are inserted into the vagina with an applicator. They need to be used regularly, rather than just around the time of intercourse.

For best results, you may need to use a vaginal moisturizer 3-5 times a week. The vagina only absorbs the amount of moisturizer it needs, and the rest passes out of the vagina. So, you may want to wear a panty liner while using a vaginal moisturizer.

Vaginal moisturizers are different from vaginal lubricants (such as K-Y Jelly), which only make the vaginal area slippery, rather than moisturized. Vaginal lubricants can be used around the time of intercourse.

Since vaginal moisturizers and lubricants don’t contain estrogen, they’re safe for women who’ve had breast cancer.

Both vaginal moisturizers and lubricants are available over the counter (without a prescription).

Talk with your health care provider about the benefits and risks for each of these options.

Vaginal therapies that contain hormones

Hormonal options for the relief of vaginal symptoms include:

• Vaginal estrogen suppositories
• An estrogen-containing soft ring (put into the vagina like a diaphragm and stays in place for 90 days)
• Vaginal estrogen cream

Vaginal estrogen rings and suppositories may slightly increase blood estrogen levels, but for only a short time [3,57,59-60].

Vaginal estrogen creams may slightly increase blood estrogen levels for a longer time [60]. If your breast cancer was estrogen receptor-positive, using a vaginal estrogen ring or vaginal estrogen suppositories is preferred over a vaginal estrogen cream [3].

Talk with your health care provider about whether these products may be safe options for you. All require a prescription.

Oral medications that have hormonal effects

The drug ospemifene (Osphena) is FDA-approved for postmenopausal women who have pain during intercourse due to vaginal dryness.

However, because ospemifene has some hormonal effects and hasn’t been studied in women who’ve had breast cancer, it’s not recommended for breast cancer survivors [3].

Lidocaine

The pain medication lidocaine may be helpful for women treated for breast cancer who have pain during intercourse due to vaginal symptoms.

One small study of breast cancer survivors found a compress of lidocaine to the vaginal area eased pain during intercourse [61]. This helped make sex comfortable again for most women in the study [61].

Talk with your health care provider about this option and the correct way to apply the medication.

Hot flashes and night sweats

Women who go through early menopause or have temporary ovarian suppression due to breast cancer treatment may have hot flashes and night sweats. They may have worse symptoms than women who go through menopause at later ages.

Hot flashes can also be a side effect of hormone therapy.

Some ways to relieve hot flashes include [3]:

• Non-hormonal medications
• Acupuncture
• Cognitive behavioral therapy
• Exercise (physical activity), including yoga
• Weight loss, if you’re overweight
• Some complementary and integrative therapies, such as hypnosis

If drinking alcohol triggers hot flashes, limit alcohol intake [3].

Plant-based remedies, such as soy, are also under study for the treatment of hot flashes. However, most studies show no benefit compared to a placebo.

Tips for managing hot flashes

Although studies are limited, the following tips may help relieve hot flashes [62].

Tips for relieving hot flashes

Quit smoking Dress in layers Avoid caffeine Avoid spicy foods Keep a bottle or glass of cold water handy Take a cool shower before bed Keep an ice pack under your bed pillow (use it to cool down if you wake up with night sweats) Keep your home or bedroom cool

Adapted from the North American Menopause Society [62].

Medications that don’t contain hormones

The table below below describes some non-hormonal medications used to treat hot flashes and other menopausal symptoms.

Talk with your health care provider about whether any of these medications may be right for you.

Antidepressants

Some antidepressants called selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) may be used to treat hot flashes [3]. These drugs may be prescribed in low doses to treat hot flashes [3].

SSRIs used to treat hot flashes include:

• Citalopram (Celexa)
• Escitalopram (Lexapro)
• Fluoxetine (Prozac)
• Paroxetine (Brisdelle, Paxil)
• Sertraline (Zoloft)

SNRIs used to treat hot flashes include:

• Venlafaxine (Effexor)
• Desvenlafaxine (Pristiq)

Studies show SSRI and SNRI antidepressants may decrease the frequency and strength of hot flashes by 50% to 60%, with few side effects [63-69].

Tamoxifen and antidepressants

Tamoxifen is a hormone therapy drug. Some SSRI antidepressants (such as fluoxetine, paroxetine and sertraline) can interfere with the metabolism of tamoxifen (how tamoxifen works in the body) [70].

These drugs don’t appear to reduce the effectiveness of tamoxifen treatment for breast cancer [3]. However, if you’re taking tamoxifen, talk with your health care provider about possible drug interactions and other options for treating hot flashes.

For a summary of research studies on antidepressants and other non-hormone medications for menopausal symptoms, visit the Breast Cancer Research section.

Gabapentin (Neurontin) and pregabalin (Lyrica)

Gabapentin and pregabalin are drugs used to treat neuropathic pain. They may also be used to treat hot flashes [3]. Studies show the use of gabapentin or pregabalin may greatly reduce hot flashes [63,67,71-74].

For a summary of research studies on non-hormone medications including gabapentin and pregabalin for menopausal symptoms, visit the Breast Cancer Research section.

Fezolinetant (Veozah)

The drug fezolinetant (Veozah) is FDA-approved for the treatment of hot flashes in women [219]. Studies show the use of fezolinetant may reduce hot flashes [223-224].

However, fezolinetant hasn’t been studied in women who’ve had breast cancer.

Non-hormonal medications used to treat menopausal symptoms

Talk with your health care provider about the benefits and risks of taking any of the medications in the table below.

Non-Hormonal Medications to Treat Menopausal Symptoms
Medication	Summary of Evidence from Randomized Controlled Trials	Short-term Health Risks	Long-term Health Risks
Clonidine (Catapres, Kapvay and others)	Some evidence of: Reduced frequency of hot flashes among women who’ve had breast cancer	Constipation Dry mouth Low blood pressure Sleeping problems	Unknown
Gabapentin (Neurontin) and pregabalin (Lyrica)	Some evidence of: Reduced strength and frequency of hot flashes	Dizziness Drowsiness Swelling in arms and legs	Unknown
Oxybutynin (Ditropan)	Some evidence of: Reduced strength and frequency of hot flashes	Abdominal pain Difficulty urinating Dry mouth	Unknown
SSRI antidepressants	Strong evidence of: Reduced strength and frequency of hot flashes	Constipation Dry mouth Headache Nausea Reduced sexual desire Sleeping problems May interact with tamoxifen May have withdrawal symptoms if stopped too quickly	Unknown
SNRI antidepressants	Strong evidence of: Reduced strength and frequency of hot flashes Some evidence of: Increase in sexual desire	Constipation Dry mouth Nausea May have withdrawal symptoms if stopped too quickly	Unknown
Adapted from the North American Menopause Society and selected studies [63-78,219-220].

Acupuncture

Acupuncture may be considered for the treatment of hot flashes in people who’ve had breast cancer [3].

Small randomized controlled trials have studied whether acupuncture can reduce hot flashes in women who’ve had breast cancer and other women.

Studies compared the benefit of true acupuncture to sham (fake) acupuncture. With sham acupuncture, the needles are placed at non-acupuncture points on the body.

Some studies found acupuncture reduced hot flashes more than the sham treatment, while others found no difference between the two [79-82].

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. Cognitive behavioral therapy may be considered for the treatment of hot flashes in women who’ve had breast cancer [3].

A few randomized controlled trials have studied whether cognitive behavioral therapy can ease menopausal symptoms in breast cancer survivors. Some findings have shown it may decrease hot flashes for breast cancer survivors [83-85].

Cognitive behavioral therapy may also help reduce fatigue and insomnia as well as anxiety in breast cancer survivors [3,84].

Cognitive behavioral therapy can be done remotely. However, not all mental health providers are trained to give cognitive behavioral therapy.

Sex, sexuality and intimacy

Cognitive behavioral therapy may improve sexual functioning in breast cancer survivors [86].

A randomized controlled trial studied an internet-based cognitive therapy program [86]. Women who got therapy reported better overall sexual functioning including improved desire, arousal and vaginal lubrication compared to women who did not [86]. They also reported reduced discomfort during intercourse [86].

Learn more about sex, sexuality and intimacy.

Diet supplements and plant-based remedies

There’s little evidence that diet supplements or plant-based remedies reduce hot flashes or vaginal symptoms.

Randomized controlled trials of the following dietary supplements have found no benefit over a placebo for hot flashes or vaginal symptoms [87-94]:

• Black cohosh
• Chinese herbal medicine
• Flaxseed
• Omega-3 fatty acid
• Red clover extra
• Soy

There are no long-term safety data for any of these supplements or remedies.

Talk with your health care provider before taking a dietary supplement or other remedy to treat menopausal symptoms.

	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.

Bio-identical hormones

There’s 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.)

Compounded bio-identical hormones

“Bio-identical” may also refer to hormone therapies that are custom compounded (when a pharmacist makes a mixture of hormones according to a doctor’s instructions on a prescription) [95-96].

It’s important to remember [3,95-96]:

• Compounded bio-identical hormones haven’t been shown to be safer than FDA-approved oral MHT. They may even be harmful.
• There’s no evidence compounded bio-identical hormones have fewer health risks than FDA-approved MHT.
• Because they haven’t been well-studied, compounded bio-identical hormones may have more health risks than FDA-approved MHT.
• Compounded bio-identical hormones haven’t been shown to be more effective at treating menopausal symptoms than FDA-approved MHT.
• Compounded bio-identical hormones aren’t more “natural” than FDA-approved MHT.
• There’s no scientific evidence that saliva tests to check hormone levels are useful in making custom compounded hormone therapies.

 

*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.

Updated 05/03/24