The recommendations are based on evidence statements that were developed based on a body of evidence primarily including studies in women with a history of breast cancer, but also including additional studies in the general female menopausal population. Where evidence is lacking, expert opinion has been used to provide practice points.
As a general principle these guidelines support a step-wise approach based on relative safety of the implementation of the Recommendations, with regard to the specific menopausal symptoms experienced by a woman. Accordingly, the Recommendations presented first are those for non-pharmacological therapies, followed by Recommendations for pharmacological therapies. Recommendations regarding the use of hormone therapies are presented last, reflecting the fact that hormone therapies should be reserved for severe symptoms, unresponsive to non-hormonal therapies.
The following table provides links to the individual recommendations and practice points for the management of menopausal symptoms, which are listed below.
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Vasomotor Symptoms |
Sleep disturbance |
Vulvovaginal symptoms and sexual function |
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Non-pharmacological therapies |
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Pharmacological therapies |
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Hormonal therapies |
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Non-pharmacological therapies
Vasomotor symptoms
| Number | Recommendation | Grade | Related evidence summaries |
|---|---|---|---|
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Purpose-designed cognitive behavioural therapy can be considered for the management of moderate to severe vasomotor symptoms in women with a history of breast cancer. |
C |
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Yoga can be considered for the management of vasomotor symptoms and sleep disturbance in women with a history of breast cancer noting there is inconsistent evidence regarding its effectiveness. |
D |
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Acupuncture and electro-acupuncture can be considered for the management of moderate to severe vasomotor symptoms in women with a history of breast cancer noting there is inconsistent evidence regarding their effectiveness. |
D |
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Purpose-designed hypnotherapy can be considered for the management of moderate to severe vasomotor symptoms in women with a history of breast cancer. |
D |
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Black cohosh is not recommended for the management of vasomotor symptoms in women with a history of breast cancer due to evidence that it is not effective. |
B |
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Homeopathy is not recommended for the management of vasomotor symptoms in women with a history of breast cancer due to evidence that it is not effective. |
B |
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Magnetic therapy is not recommended for the management of vasomotor symptoms in women with a history of breast cancer due to evidence that it is not effective. |
C |
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Omega-3 supplementation is not recommended for the management of vasomotor symptoms in women with a history of breast cancer due to evidence that it is not effective. |
C |
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Phytoestrogens are not recommended for the management of vasomotor symptoms as the efficacy and long-term safety in women with a history of breast cancer has not been established. |
D |
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There is evidence that exercise has no effect on vasomotor symptoms in a general population, although there are other benefits of physical activity for women with a history of breast cancer. |
Practice point |
Sleep disturbance
| Number | Recommendation | Grade | Related evidence summaries |
|---|---|---|---|
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Purpose-designed cognitive behavioural therapy can be considered for the management of sleep disturbance in women with a history of breast cancer. |
C |
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Relaxation therapy can be considered for the management of sleep disturbance in women with a history of breast cancer. |
C |
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Purpose-designed hypnotherapy can be considered for the management of sleep disturbance in women with a history of breast cancer. |
C |
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Acupuncture can be considered for the management of sleep disturbance in women with a history of breast cancer. |
C |
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Vitamin E is not recommended for the management of sleep disturbance in women with a history of breast cancer due to evidence that it is not effective. |
C |
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Isoflavones are not recommended for the management of sleep disturbance in women with a history of breast cancer due to evidence that they are not effective. |
C |
Vulvovaginal symptoms and sexual function
| Number | Recommendation | Grade | Related evidence summaries |
|---|---|---|---|
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Non-hormonal vaginal gels can be considered for the treatment of vulvovaginal symptoms in women with a history of breast cancer. |
C |
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Purpose-designed cognitive behavioural therapy can be considered for improving sexual function in women with a history of breast cancer. |
C |
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Non-hormonal vaginal moisturisers can be considered for the treatment of vulvovaginal symptoms in women with a history of breast cancer. |
Practice point |
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Water-based or silicone-based vaginal lubricants can be used to enhance the comfort and ease of sexual intercourse. |
Practice point |
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Pharmacological therapies
Vasomotor symptoms
| Number | Recommendation | Grade | Related evidence summaries |
|---|---|---|---|
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Venlafaxine (37.5 - 75 mg/day) can be considered for the management of moderate to severe vasomotor symptoms in women with a history of breast cancer. |
A |
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Paroxetine (10 - 20 mg/day) can be considered for the management of moderate to severe vasomotor symptoms in women with a history of breast cancer who are not receiving tamoxifen.
This recommendation is not generalisable to other SSRIs as there is insufficient evidence in women with a history of breast cancer that they have comparable effects on vasomotor symptoms.
Note: Paroxetine interacts with tamoxifen and reduces the serum concentration of tamoxifen and metabolites. |
B |
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Escitalopram (10 - 20 mg/d) can be considered for the management of moderate to severe vasomotor symptoms in women with a history of breast cancer, based on evidence from a general population of menopausal women.
Note: Escitalopram may reduce the efficacy of tamoxifen by slowing metabolism to the active form. There is little evidence for clinical concern resulting from their concomitant use. |
B |
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Desvenlafaxine (100 - 150 mg/d) can be considered for the management of moderate to severe vasomotor symptoms in women with a history of breast cancer, based on evidence from a general population of menopausal women.
Note: Desvenlafaxine may alter the serum concentration of tamoxifen and metabolites. There is little evidence for clinical concern resulting from their concomitant use. |
B |
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Clonidine (0.10 - 0.15 mg/day) can be considered for the management of moderate to severe vasomotor symptoms in women with a history of breast cancer. |
B |
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Gabapentin (300 - 900 mg/day) can be considered for the management of moderate to severe vasomotor symptoms in women with a history of breast cancer. |
C |
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Bupropion is not recommended for the management of menopausal symptoms in women with a history of breast cancer due to evidence that it is not effective. |
C |
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The doses of antidepressants used for the management of vasomotor symptoms are not generally associated with increases in adverse sexual symptoms. |
Practice point |
Sleep disturbance
| Number | Recommendation | Grade | Related evidence summaries |
|---|---|---|---|
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Desvenlafaxine (100 - 150 mg/d) can be considered for the management of sleep disturbance in women with a history of breast cancer, based on evidence from a general population of menopausal women.
Note: Desvenlafaxine may alter the serum concentration of tamoxifen and metabolites. There is little evidence for clinical concern resulting from their concomitant use. |
B |
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Paroxetine (10 - 20 mg/day) can be considered for the management of sleep disturbance in women with a history of breast cancer who are not receiving tamoxifen.
This recommendation is not generalisable to other SSRIs as there is insufficient evidence that they have comparable effects on sleep disturbance. Note: Paroxetine interacts with tamoxifen and reduces the serum concentration of tamoxifen and metabolites. |
C |
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The addition of zolpidem (10 mg/d) to an SSRI or SNRI can be considered for the management of sleep disturbance for women with a history of breast cancer. |
C |
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Gabapentin (300 - 900mg/d) can be considered for the management of sleep disturbance in women with a history of breast cancer. |
C |
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Gabapentin doses of up to 1200 mg/day can be considered for the alleviation of sleep disturbance in women with a history of breast cancer. |
Practice point |
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Vulvovaginal symptoms and sexual function
| Number | Recommendation | Grade | Related evidence summaries |
|---|---|---|---|
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Topical lidocaine treatments to the vulvovaginal area can be considered for women with a history of breast cancer experiencing dyspareunia.
Note: The treatment used in the included study was a 4% lidocaine solution applied to the vulvar vestibule for three minutes, followed by application of a silicone lubricant. |
C |
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Ospemifene is not recommended for the management of vulvovaginal symptoms as the efficacy and long-term safety in women with a history of breast cancer has not been established. |
C |
Hormonal therapies
Vasomotor symptoms
| Number | Recommendation | Grade | Related evidence summaries |
|---|---|---|---|
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Systemic menopause hormone therapy (oestrogen-only or combined oestrogen and progestogen) should generally be avoided in women with a history of breast cancer because it may increase the risk of new or recurrent breast cancer.
Menopause hormone therapy may be considered in exceptional cases for women with a history of breast cancer with severe, intractable vasomotor symptoms. In these cases the potential risks and benefits should be discussed with the treatment team, and treatment should only proceed with the informed consent of the woman and at the lowest effective dose for that woman. |
B
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Tibolone should be avoided in women with a history of breast cancer because it increases the risk of new and recurrent breast cancer.
Tibolone may be considered in exceptional cases for women with a history of breast cancer with severe, intractable vasomotor symptoms. In these cases the potential risks and benefits should be discussed with the treatment team, and treatment should only proceed with the informed consent of the woman and at the lowest effective dose for that woman. |
B |
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Compounded hormones (‘bioidentical’ hormones) are not recommended for the management of menopausal symptoms in women with a history of breast cancer because the evidence of their effect is inconsistent and their safety after breast cancer is not known.
Note: Compounded hormones are systemically absorbed and may contain high levels of sex steroids which may increase the risk of new or recurrent breast cancer. |
C |
Vulvovaginal symptoms and sexual function
| Number | Recommendation | Grade | Related evidence summaries |
|---|---|---|---|
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Vaginal oestrogens can be considered for the management of persistent vulvovaginal symptoms in women with a history of breast cancer who are non-responsive to non-hormonal vaginal gels or lubricants. A discussion of the potential risks and benefits between the woman and her treating team is recommended.
Note: Vaginal oestrogen may be systemically absorbed. For women taking Aromatase Inhibitors this may result in measurable increases in circulating oestrogens. The clinical significance of systemic absorption is uncertain. |
C |
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Exogenous testosterone is not recommended as a treatment to improve sexual function as the efficacy and long-term safety in women after breast cancer has not been established. |
C |