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Managing menopause after a diagnosis of breast cancer
Managing menopause after a diagnosis of breast cancer
A consensus statement by the British Menopause Society (BMS) advises how we should approach the management of oestrogen deficiency symptoms, arthralgia and menopause diagnosis in women treated for early breast cancer; we have summarised this in the article below (Post Reproductive Health, 2022;28:199). Other sources are referenced where used.
This article was updated in June 2025.
Breast cancer is the commonest cancer in women. It affects predominantly postmenopausal women, but 9% of breast cancers occur in premenopausal women (aged <45y), and 32% occur in women who are perimenopausal or recently menopausal (aged 45–59y) (Cancer Research UK – breast cancer incidence: invasive statistics) accessed May 2025.
For premenopausal and perimenopausal women with breast cancer, the diagnosis alone can be difficult to cope with, but there are additional considerations, including:
Wider implications on fertility and sexual health.
Treatment for the disease can induce a hypo-oestrogenic state, giving rise to, or worsening, menopausal symptoms.
Discussion of symptoms can be therapeutic. The British Menopause Society:
Advises that simply discussing the nature, cause and duration of these symptoms with an informed healthcare professional can be of therapeutic benefit.
Recommends that we refer breast cancer patients to healthcare professionals with an expertise in menopause for counselling and managing symptoms. This will often involve liaising with the patient’s breast cancer team.
Lifestyle measures and non-hormonal treatments are first-line management options. HRT is generally contraindicated, but hormonal treatment may be considered if first-line management is ineffective and symptoms very severe – only after taking specialist advice.
Breast cancer treatments
To understand the impact of breast cancer treatments on hormonal status and menopause, here’s an overview of breast cancer management:
Aims
The aims of breast cancer treatment are to:
Remove the primary tumour and prevent local spread using surgery and, sometimes, radiotherapy.
Use ongoing adjuvant systemic therapies to eradicate dormant occult micro-metastases – it is this treatment which improves long-term cancer survival.
Choice of treatment
Most women will receive a combination of systemic treatments.
An individualised management plan will be made based on:
Age.
Tumour size, grade and genomics.
Lymph node status and presence of lympho-vascular invasion.
Oestrogen-receptor status.
HER2-receptor expression.
Oncologists may also use PREDICT to guide treatment decisions. PREDICT is an online tool which estimates a patient’s survival rate based on existing breast cancer treatment data.
(Post Reproductive Health, 2022;28:199)
Adjuvant treatments: therapeutic actions and indications
Chemotherapy
Has cytotoxic effect on malignant cells, but also affects other body cells.
Cytotoxic effect on ovarian follicles may have therapeutic benefit for premenopausal women with hormone-sensitive cancer as it will reduce endogenous hormone production (but may also increase symptoms of hypo-oestrogenism).
For early-stage disease: given after surgery as 3-weekly cycles, usually 6–8 in total.
Anti-oestrogenic endocrine therapy
Most breast cancers are oestrogen receptor-positive so endocrine therapy is indicated in the majority of cases and is continued for at least 5y. Extended treatment for up to 10y may be offered on an individual basis. There are two main classes of drugs that are used in this situation:
Tamoxifen
Selective (o)estrogen receptor modulator (SERM) which has antagonistic activity on breast tissue oestrogen receptors.
Offered as initial therapy to all premenopausal women, irrespective of risk of recurrence.
Recommended for postmenopausal women at low risk of recurrence, or those at higher risk who are unable to tolerate the side-effects from aromatase inhibitors.
Aromatase inhibitors
e.g. letrozole (Femara), anastrazole (Arimidex), exemestane (Aromasin).
Reduce oestrogen synthesis in peripheral fat (hence only for POSTmenopausal women who have no ovarian oestrogen production).
Recommended for postmenopausal women at moderate/high risk of recurrence (trials suggest superiority over tamoxifen in this age group – you can read more about this in the online article Breast cancer: after treatment).
Gonadotrophin-releasing hormone agonists
e.g. goserelin (Zoladex).
Used in combination with aromatase inhibitors in younger women at higher risk of recurrence (associated with less recurrence than tamoxifen).
Treatment duration is usually 2–5y.
Targeted therapy
e.g. Herceptin (trastuzomab), a monoclonal antibody which blocks the HER2 receptor and is indicated for cancers which over-express this receptor.
Herceptin is used alongside chemo and radiotherapy; treatment duration is 1y.
Bisphosphonates
Prescribed primarily to manage treatment-induced bone loss.
Data has shown that bisphosphonate use is associated with reduced bone recurrence and breast cancer mortality so it is now recommended for postmenopausal women at higher risk of recurrence (e.g. those with node-positive disease).
(Post Reproductive Health, 2022;28:199)
Follow-up and ongoing care following breast cancer treatment
For many women in recent years, breast cancer follow-up has moved from secondary care to patient-led monitoring with primary care support. High-risk women may stay under secondary care, and different localities have different pathways agreed between primary and secondary care.
At the end of initial ‘active’ treatment (i.e. surgery, chemotherapy/radiotherapy/immunotherapy), patients should be issued with a care plan which is shared with primary care. It should include:
Dates for review and duration of adjuvant endocrine therapy. (Tip: it is useful to add these as duration and indication prescribing, e.g. tamoxifen 20mg daily to reduce the risk of breast cancer recurrence. Take for 5 years, review March 2024.)
Details of surveillance mammography.
Information about symptoms/signs of recurrence and treatment side-effects (including those related to oestrogen-deficiency symptoms, e.g. menopause and osteoporosis).
Contact/referral details for specialist support services if problems arise, including a pathway for women experiencing menopausal symptoms.
Once received, this information should support cancer care reviews and medication reviews going forward.
Adjuvant treatments: side-effects
The menopausal symptoms induced by adjuvant treatments tend to occur within a few months of starting treatment, and can be more problematic and long-lasting than those associated with natural menopause.
These symptoms may be overlooked by healthcare professionals who focus primarily on cancer outcomes… and yet many women consider stopping their treatment due to side-effects for which management has never been discussed!
The table below summarises common side-effects that we should consider:
Vasomotor symptoms
In premenopausal women:
Symptoms following chemotherapy or GnRH-induced ovarian suppression are usually more severe than those associated with tamoxifen.
Persistence of symptoms following cessation of tamoxifen is likely to be due to early menopause induced by previous chemotherapy.
In postmenopausal women:
Both tamoxifen and aromatase inhibitors are associated with vasomotor symptoms, but severity may reduce with time.
Vaginal symptoms and sexual dysfunction
Ask about sexual issues as patients may not raise them without prompting.
Iatrogenic ovarian suppression, tamoxifen and aromatase inhibitors are all associated with vulvovaginal atrophy, which may lead to vaginal dryness, dyspareunia and reduced sexual desire.
In some women, tamoxifen can cause increased vaginal discharge; this is likely to be due an oestrogenic effect on the cervix and vagina.
Chemotherapy may adversely affect sexual function due to hair loss, fatigue, weight gain and negative body image.
Endometrial cancer risk
Tamoxifen is associated with a small elevation in endometrial cancer risk in postmenopausal women due to its oestrogenic stimulatory effect, but it does NOT appear to increase the risk in premenopausal women.
Aromatase inhibitors are associated with a neutral or reduced risk of endometrial cancer.
Musculoskeletal symptoms
Present in around half of women treated with aromatase inhibitors, and more likely if previously treated with taxane-based chemotherapy.
Believed to be caused by oestrogen deprivation, inflammatory pathways and fluid retention.
Problems include morning stiffness and pain affecting hands, knees, hips, back and shoulders (it may be confused with fibromyalgia).
Amenorrhoea
Chemotherapy:
Suppresses ovarian function, resulting in amenorrhoea which may be permanent.
Can increase the likelihood of early menopause: this is higher in women >40y and with certain regimens (e.g. alkylating agents are more gonadotoxic than taxanes).
Most women who resume menstrual bleeding do so within 2y of completing chemotherapy, although menses can return up to 3–5y later .
Tamoxifen may be associated with a small increased risk of early menopause.
GnRH agonist causes only temporary ovarian suppression, and, if given with chemotherapy, appears to reduce the risk of chemotherapy-induced premature ovarian insufficiency.
(Post Reproductive Health, 2022;28:199)
Management of menopausal symptoms in women with a history of breast cancer
Discuss lifestyle changes and non-hormonal treatments first line as per the British Menopause Society recommendations below.
In postmenopausal women, switching from an aromatase inhibitor to tamoxifen may alleviate menopausal symptoms, but this should only be done in discussion with the breast specialist/oncologist.
Treatments
Details
Vasomotor symptoms
Lifestyle measures
Use of portable fans.
Dressing in easily-shed layers.
Weight loss.
Avoiding triggers (spicy food, alcohol).
Non-hormonal medication:
SSRIs.
SNRIs.
Gabapentin/pregabalin (note: these are controlled drugs!).
Clonidine.
Some data supports mild/moderate efficacy.
Counsel regarding side-effects.
Avoid paroxetine and fluoxetine in women on tamoxifen due to inhibitory effect on tamoxifen.
The BMS recommends venlafaxine 75mg for women on tamoxifen.
Psychological therapies
Relaxation therapy or mindfulness.
CBT and other behaviour-based therapy may be useful in coping with symptoms.
CBT can alleviate low mood or anxiety relating to menopause.
Complementary and other therapies Note: the absence of regulation means that these products may vary in their constituent ingredients; furthermore, there is little clinical data supporting safety or efficacy. Most are therefore NOT recommended.
Avoid in women on tamoxifen or docetaxel:
St John’s wort (although it may be effective for vasomotor symptoms in women not using these treatments (NICE, 2015 (updated 2024), NG23).
Avoid in all women:
Red clover (isoflavones) and soy (oestrogenic properties).
Black cohosh, vitamin E and magnetic devices (absence of evidence of efficacy).
Bio-identical hormone preparations (contraindicated in women with breast cancer).
Potential future options:
Research is currently looking at the safety and efficacy of other interventions, e.g. acupuncture, stellate ganglion block, neurokinin 3 receptor antagonists and oxybutynin.
Vulvo-vaginal atrophy and sexual dysfunction
Supportive advice
Consider:
Psychosexual counselling.
Vaginal dilators.
Pelvic floor relaxation techniques (women’s health physio can help with this).
Psychological support surrounding body image.
Vaginal moisturisers and lubricants
Offer first line.
Suggestions that paraben-containing preparations (e.g. KY jelly, Replens, Astroglide) are oestrogenic have not been backed-up by evidence.
Low-dose topical oestrogens
If symptoms persist after a trial of first-line treatments:
NICE says that low-dose topical oestrogen preparations may be considered unless they are taking an aromatase inhibitor (NICE, 2015 (updated 2024), NG23).
The BMS recommends that initiation of topical oestrogens should be done following advice or discussion from a specialist.
There is no clinical data confirming safety (only 4 trials have looked at this and they all had methodological flaws), but the amount of oestrogen absorbed systemically from vaginal oestrogens is very low; NICE therefore says this is unlikely to be harmful.
NICE states that:
Vaginal oestrogens are likely to be safe in women with a history of an oestrogen receptor-negative tumour.
The risk associated with topical oestrogen use in women with a history of an oestrogen receptor-positive tumour is unknown. In women on tamoxifen, use of vaginal oestrogens is likely to be safe.
Do not prescribe for women on aromatase inhibitors due to potential systemic absorption of oestrogen, which negates the effect of treatment – always refer to specialist for advice.
If appropriate, women on aromatase inhibitors could be switched to tamoxifen (specialist decision).
Alternative treatments – these are NOT currently recommended due to lack of supportive data
Vaginal laser treatment.
Intra-vaginal dehydroepiandrosterone (DHEA).
Ospemifene (note: this is licensed for use in women who have completed breast cancer treatment, although there is lack of long-term safety data. If considered, the BMS recommends discussion with the breast team first).
Musculoskeletal symptoms
Lifestyle advice
This is first line:
Exercise.
Yoga.
Weight loss.
Paracetamol and NSAIDs.
Medication changes (only to be implemented by specialist)
Can women with a history of breast cancer ever be prescribed HRT?
The BMS position
In exceptional cases, women with a history of breast cancer may be prescribed HRT if they have severe symptoms and other treatments have failed.
The decision should be agreed with the patient’s specialist breast team, and the patient should be fully counselled and consented regarding the risks and off-licence nature of prescribing, with this documented.
If the patient is no longer under the care of a breast team, we should liaise with the local breast unit for advice and onward referral.
HRT should not be prescribed to women taking aromatase inhibitors.
In its breast cancer guidance, NICE concurs that HRT may be offered to women with severe symptoms, following a discussion of the risks (NICE 2018 (updated 2025), NG101).
So, this is not a decision we should take in primary care. If you want to understand more or work as a clinician with a special interest in menopause, read on.
Potential risks of HRT in women with a history of breast cancer
Treatments for oestrogen receptor-positive breast cancer work by eliminating oestrogen production (aromatase inhibitors) or blocking oestrogenic stimulation of breast tissue (tamoxifen).
It therefore seems counterintuitive to give oestrogen in the form of HRT to women with a history of breast cancer – especially if she is on an aromatase inhibitor.
For women with oestrogen receptor-negative disease, there is a small risk of oestrogen receptor-positive recurrence or development of a new primary tumour in the contralateral breast.
Would tamoxifen be breast-protective if given alongside HRT
We know that:
Tamoxifen is effective in reducing risk of breast cancer recurrence in premenopausal women with a history of breast cancer and who have raised endogenous oestrogen levels.
Tamoxifen is also effective as a chemoprophylactic agent in women at increased risk of breast cancer.
So, in theory, tamoxifen could be used as an oestrogen receptor blocker for women with a history of breast cancer who take HRT. However, there is no substantial data to show that tamoxifen would be effective in reducing the risk of recurrence if given alongside HRT, nor data to show that HRT is effective in women on tamoxifen (see evidence below).
Evidence looking at HRT in women with a history of breast cancer
There is limited trial data looking at the safety of topical or systemic HRT in women with a history of breast cancer, and some of the studies were stopped prematurely due to concerns about safety. A summary of existing data is listed in the table below:
Studies
Findings
HABITS (JNCI, 2008;100:475)
A Scandinavian open-label RCT which looked at the safety of HRT in women with a history of breast cancer.
442 women were studied: half were given HRT for menopausal symptoms, and half managed non-hormonally.
Most women were prescribed combined regimens containing oestradiol with norethisterone.
The study ran from 1997–2003 and was stopped prematurely as interim analysis suggested a harmful effect.
The women were followed-up for a median of 4y.
39/221 women who took HRT had a recurrence compared with 17/221 of the control group: HR = 2.4 (CI 1.3-4.2).
33% of women in both groups were taking tamoxifen and this didn’t appear to impact results.
There was no evidence of increased breast cancer mortality from the limited data.
The increased rate of recurrence has been attributed to the progestogen exposure, but this cannot be proved from the limited data.
Stockholm trial (Eur J Cancer,2013;49:52)
A Scandinavian open-label RCT which studied the safety of low progestogen dose HRT in women with a history of breast cancer.
188 women took HRT and 190 did not.
The HRT group were given 2mg oestradiol. Those with a uterus were also given medroxyprogesterone acetate in a low-dose regimen.
The trial ran from 1997–2003 and was stopped prematurely due to the analysis of the HABITS data above.
There was no excess risk after 4y of follow-up.
After an extended 11y follow-up, there was no difference in breast cancer recurrence incidence between the HRT group and controls: HR = 1.3 (CI 09–1.9).
Around 50% of women in each group were taking tamoxifen.
There was no difference in mortality from breast cancer.
No firm conclusions can be drawn because the trial was closed prematurely.
UK trial of HRT in early breast cancer (Maturitas 2017;100:132)
UK-based open-label RCT which looked at the safety of HRT in women with early breast cancer.
197 women were recruited: 97 were given HRT and 100 were given information about non-hormonal menopausal treatments.
The trial closed prematurely in 2004 after 2y due to analysis of the HABITS data.
Median follow-up of 12y showed no difference in disease-free survival: HR = 1.02 (CI: 0.56–1.84).
Around 69% of HRT users and 65% of non-HRT users were taking tamoxifen.
A multicentre double-blind RCT which looked at the safety of tibolone in women with a history of breast cancer.
3098 women were included (1556 in the tibolone group and 1542 in the placebo group).
The trial was stopped prematurely at 3y after increased recurrence rates were found in the tibolone group.
71% of participants were oestrogen receptor-positive.
67% of women were on tamoxifen and 6.5% were on aromatase inhibitors.
After a median follow-up of 3y, 15% of women on tibolone had a recurrence compared with 11% on placebo, which equated to a significantly increased risk: HR =1.4 (CI:1.14–1.70).
This looked at existing RCT evidence, which consisted of 4 trials: HABITs, Stockholm, LIBERATE and a smaller study involving 300 women (Cancer 2002;95:1817).
4000 patients were included in the meta-analysis, most of whom were from the LIBERATE trial.
HRT significantly increased breast cancer recurrence compared with placebo: HR = 1.46 (CI 1.12–1.91).
Subgroup analysis of the data showed:
The risk was significantly higher in those with hormone receptor-positive tumours who used HRT compared with placebo.
The risk was not increased in those with hormone receptor-negative tumours who used HRT.
When the tibolone data was excluded, there was no significantly increased risk of breast cancer recurrence in those who used oestrogen-only or combined HRT.
Nevertheless, overall, the authors concluded that HRT is associated with a poorer prognosis in breast cancer survivors.
Eligibility criteria for using menopausal hormone therapy in breast cancer survivors: a safety report based on a systematic review and meta-analysis (Menopause 2024;31(3):234)
This review sought to use existing data to devise eligibility criteria for HRT use in women with a history of breast cancer.
It included 12 studies: 3 RCTS and 9 observational trials.
Combined analysis of all the data found no elevated risk of recurrence: RR 0.85 (CI 0.54–1.33).
However, the authors cautioned that the quality of data ranged from low to moderate, much of it subject to bias, confounding factors and heterogeneity.
The data appeared most reassuring on hormone receptor-negative tumours.
The study concluded that HRT should not be absolutely contraindicated in a history of breast cancer, and the decision to prescribe should be individualised.
Using the data, it devised medical eligibility criteria (MEC) to help guide decisions regarding HRT prescribing following breast cancer.
It categorised risk from 1 to 4 (as with contraception MEC) and strength of evidence from A to D (high quality to very poor data).
It recommended:
Based on good data, tibolone should not be prescribed following hormone receptor-positive disease (MEC 4A).
Based on moderate-/low-quality data, in women who have had hormone receptor-positive tumours, the risks of taking combined or oestrogen-only HRT are likely to outweigh the benefits (MEC 3B and 3C respectively). For those who have had hormone receptor-negative disease, moderate-/low-quality data suggests the benefits of any HRT are likely to outweigh the risks (MEC 2B for combined HRT and tibolone, and 2C for oestrogen-only HRT).
Breast cancer treatments and fertility/contraception
The impact of breast cancer treatment on fertility should be discussed at diagnosis. Some women may opt to have their eggs harvested and frozen prior to initiating treatment.
Hormonal contraception is generally contraindicated in women with a history of breast cancer, but oral emergency contraception may be used as it is unlikely to be harmful.
The FSRH recommends the copper IUD or sterilisation as first-line contraception options for women with a history of breast cancer. It is not possible to predict which women have been rendered infertile by breast cancer treatment so the FSRH also gives guidance on when contraception is no longer required (for more information, see article Contraception requirements and options following a diagnosis of breast cancer).
Managing menopause after a diagnosis of breast cancer
Breast cancer is the commonest cancer in women, and treatment can cause debilitating menopausal symptoms.
We should ask women about treatment side-effects and menopausal symptoms as discussion of these can have a therapeutic effect.
First-line options for menopausal symptoms in women with breast cancer are lifestyle advice and non-hormonal medications (SSRIs, SNRIs and clonidine).
Avoid paroxetine and fluoxetine in women on tamoxifen due to interactions.
HRT is generally contraindicated unless symptoms are severe and do not improve with other treatments, BUT this is a specialist decision.
Systemic and topical oestrogens should not be prescribed to women on aromatase inhibitors as they potentially negate the therapeutic effect.
Fertility after breast cancer treatment may be unpredictable, and we should recommend non-hormonal contraceptive options to women.
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Printed on: October 2nd, 2025
