For some women, menopausal symptoms can be severe and can have a significant impact on their lifestyle.
Your decision about whether to use a treatment for menopausal symptoms will depend on the severity of your symptoms and the potential effect of treatment on your risk of breast cancer coming back.
Relatively few studies have looked at how menopausal symptoms can be treated safely after breast cancer. This section provides an overview of the common medical treatments used in managing menopausal symptoms, and discusses what is known about their use in women after breast cancer.
Talk to your oncologist or your GP about your options before making a decision. You may also find it helpful to talk to a menopause specialist about the treatments that are safe and effective for you.
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Non-hormonal treatments for menopausal symptoms
There are non-hormonal treatments that have been shown to be effective in the management of menopausal symptoms.
Below is a list of the most common treatments and their side effects.
Venlafaxine and other similar antidepressants
There is now good evidence that selected antidepressants (at doses lower that those used to treat depression) can improve menopausal symptoms after breast cancer. The antidepressants that have been shown to lead to fewer and less severe hot flushes are venlafaxine, desvenlafaxine, paroxetine, and escitalopram. In addition, low doses of venlafaxine can also improve mood, and low doses of desvenlafaxine and paroxetine can also improve sleep.
Generally these antidepressants are used in low doses to treat menopausal symptoms, and side effects are less common than at higher doses. However, side effects can include nausea, decreased appetite, dry mouth, constipation, and decreased libido.
Some of these drugs, particularly paroxetine, may interfere with the way that your body breaks down tamoxifen and change its effectiveness. If you are taking tamoxifen, talk to your oncologist or general practitioner before starting treatment with antidepressants.
Ask your doctor for more information about these drugs.
Zolpidem
Zolpidem is a prescription medication used to treat insomnia. When added to venlafaxine (or other similar antidepressant drugs above) it may improve sleep and quality of life. Side effects of zolpidem can include sleep walking, sleep driving and other potentially dangerous sleep-related behaviours. Treatment with zolpidem may also interfere with your concentration in the morning, such as when driving.
Ask your oncologist for more information.
Gabapentin
Gabapentin is a drug used to treat chronic pain and epileptic fits. Studies have shown that Gabapentin can lead to fewer and less severe hot flushes, improved sleep and improvements in anxiety and mental health for some women.
Many women find gabapentin acceptable to use. However, up to half of the women who use gabapentin experience side effects including sleepiness, light-headedness, and dizziness. These side effects may resolve with time or can be reduced by adjusting the dose.
Clonidine
Clonidine is a drug used to treat high blood pressure. It can be used to reduce menopause-associated hot flushes after breast cancer, but has been found to be less effective than other treatments such as venlafaxine. Side effects of clonidine include a dry mouth, constipation, dizziness, itching, blurred vision, and sleep disorders or restless sleep.
Cognitive behavioural therapy
Psychological therapies such as cognitive behavioural therapy (CBT) aim to help you change your thought patterns to be more helpful and healthy. Studies in women who have had breast cancer have shown that CBT may improve hot flushes, sleep and sexual function.
Hormone treatments for menopausal symptoms
Menopause hormone therapy
Menopause hormone therapy, also known as hormone replacement therapy, (HRT) is a very effective treatment for menopausal symptoms. Menopause hormone therapy treatments are made up of the hormones oestrogen and progestogen, either individually or combined. Some studies have shown an increased risk of breast cancer coming back (recurrence) following treatment with menopause hormone therapy, so it is generally not recommended after breast cancer.
Menopause hormone therapy is generally avoided for women who have had breast cancer because it may increase the risk of breast cancer coming back. It is important to talk to your oncologist or general practitioner about your options.
Tibolone treatment
Tibolone is another drug used for treating menopausal symptoms. The drug acts in a similar way to menopause hormone therapy and research has shown an increased risk of breast cancer coming back (recurrence) following treatment with tibolone.
Tibolone is avoided after breast cancer because it may increase the risk of breast cancer coming back. It is important to talk to your oncologist or general practitioner about your options.
Testosterone treatment
Testosterone is produced by women as well as men. Testosterone levels fall gradually with increasing age and may be reduced by some breast cancer treatments. For some women, reduced levels of testosterone may lead to lower libido and lower energy levels. The safety and long-term effects of testosterone treatments have not been established.
Testosterone is not recommended for women who have had breast cancer. It is important to talk to your oncologist or general practitioner about your options.
Compounded or ‘bio-identical’ hormones
Compounded hormones, also known as ‘bio-identical hormones’ are hormonal preparations that are individually prepared for the treatment of menopausal symptoms or other hormonal complaints. Compounded hormone mixtures are prepared as troches (placed in the mouth) or creams (rubbed on the body). Compounded hormone preparations require a doctor’s prescription and are made up by chemists called compounding pharmacists.
Studies of compounded hormone creams have found inconsistent results and their safety after breast cancer is not known. Compounded hormone treatments can contain high levels of hormones and may increase the risk of breast cancer coming back.
Compounded hormones are not recommended for women who have had breast cancer. It is important to talk to your oncologist or general practitioner about your options.
Ineffective therapies
There is no consistent evidence to indicate that the following therapies are effective in reducing menopausal symptoms:
- Black cohosh
- Homeopathy
- Magnetic therapy
- Omega-3 supplementation
- Phytoestrogens and isoflavones
- Vitamin E
The safety of these therapies after breast cancer is unknown. In particular, the side effects of black cohosh include gastro-intestinal upsets and skin rash. There are also concerns about the safety of black cohosh after reports of liver damage.
Other 'over-the-counter' or herbal remedies
There is a wide range of ‘over-the-counter’ medications or herbal remedies available for the management of menopausal symptoms.
Examples include Dong Quai, evening primrose, ginseng, red clover and Chinese herbal preparations. There is very little evidence about the effectiveness or safety of over-the-counter menopausal remedies and very little is known about their effects in women who have had breast cancer.
Although plants and herbs are natural, this doesn’t always mean they are safe. Some herbs can interfere with cancer treatments by making them less effective or by increasing side effects. Some herbal preparations may contain oestrogen-like compounds that may increase the risk of breast cancer coming back.
If you are considering using any ‘over-the-counter’ or herbal preparations you should discuss them with your doctor first.
Memorial Sloan Kettering Cancer Center in the USA has developed a database called About Herbs with information about herbal therapies and supplements. To access this information go to www.mskcc.org. Please note that this is an American website and not all of the products listed maybe available in Australia.
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