This booklet has been written by Dr Sarah Ball, GP and menopause specialist and Dr Alison Macbeth, a breast specialty doctor and menopause specialist.
Any cancer journey can be physically and emotionally challenging and is often accompanied by fear and uncertainty. You may well have been – or are still going through – your own breast cancer journey, or have a friend or family member who is.
The experience of going through breast cancer will have implications for your menopause journey yet in the past, it has often been difficult to access accurate and helpful information on this topic.
This booklet is designed to give an overview of the unique challenges of menopause in the context of having a history of breast cancer. It won’t tell you what to do but the following information will hopefully empower you to manage your menopause in a way that feels right for you.
Facts about breast cancer
Breast cancer has become increasingly common. 1 in 7 females will develop the disease at some stage in their life.[1]
Less than 10% of breast cancer cases are linked to your genes while lifestyle factors such as obesity, alcohol consumption, smoking and being sedentary (spending many hours sitting or lying down) are the significant risks.[1] Of course, many cases are simply down to ‘bad luck’.
Around 80% of cases occur in women over 50 years of age; the average age for diagnosis is in your late 60s.
1 in 5 women are younger than 50 and are premenopausal at diagnosis.
Thankfully, the vast majority of breast cancers are found in the earlier stages before the disease has had the chance to spread.
The risk of dying from breast cancer has fallen substantially over the past 30 years[2] and is predicted to decrease further. The most up to date survival data demonstrates more than 9 out of every 10 women diagnosed with breast cancer are now predicted to survive for at least 5 years. And 8 out of every 10 women to survive for 10 years.
There are at least 600,000 people in the UK living beyond breast cancer and this number is set to double by 2030.[3]
Types of breast cancer and treatment
There are different types of breast cancer, generally described as invasive and non-invasive.
Invasive breast cancer has the potential to spread to other parts of the body. Non-invasive breast cancer does not have the ability to spread, and the main types are classified as ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), and non-invasive Paget’s disease. These non-invasive types however, may be indicators of an underlying risk of future breast cancer and this risk is higher than the average woman who has not been diagnosed with either of these conditions. (There are other less common types of breast cancer too).
Within the different types of breast cancer, each person’s cancer is classified according to various properties such as its size, its grade (how different the cells look from normal cells), and whether any lymph nodes are affected. Treatment regimens are tailored according to these features and therefore they differ from person to person.
Current treatments for breast cancer broadly include surgery, chemotherapy, radiotherapy and other specific treatments based on the tumour’s hormone receptor status and a protein on the breast cancer cells called HER2 (termed as either HER2 positive or negative).
Having surgery to remove the breast cancer is by far the most important part of treatment but other elements are also offered to further reduce the future risk of breast cancer spreading or recurring and these are known as ‘neoadjuvant’ therapy if they’re given before surgery, or ‘adjuvant’ if given after surgery.
Approximately 75% of all breast cancers are estrogen-receptor positive (ER+ve) and these cancers are usually treated with various strategies to reduce or block the effects of estrogen on the cancer. This may be in the form of medication such as Aromatase Inhibitors or Tamoxifen (with or without injections such as Zoladex to ‘switch off’ the ovaries), or it might involve removal of the ovaries by surgery.
It is important to note that some people misunderstand estrogen-receptor positive (sometimes also called ‘hormone receptor positive’) to mean that their reproductive hormone – namely estrogen – has caused their breast cancer. This is not the case.
Having a tumour which is ER positive means that exposure to further estrogen may promote growth of an established tumour – hence why various strategies to block the effects of estrogen are part of current treatment approaches.
Weighing up treatment decisions
During appointments with your Breast Team, you may have been shown the Predict Breast tool, which is an algorithm designed to help support decisions with your clinician about breast cancer treatments if you have an invasive breast cancer.
Based on statistics, the tool aims to give you (as the patient) an idea of your expected survival over the course of the next 5 or 10 years depending on which adjuvant treatment you have. For example, you may be advised you have a 92% chance of being alive in the next 5 years, increasing to 94% if you were to use Tamoxifen treatment for 5 years (an ‘estrogen blocker’).
The tool should be used alongside discussions about possible side effects from any medication such as Tamoxifen for example, and the small risks associated with it, and you should then be supported by your breast team to make a decision for yourself whether to use Tamoxifen or not. It’s important to note there is no right or wrong answer for these kinds of decisions.
Making an informed choice
While some women feel supported and empowered in making decisions about their own treatment for their breast cancer, experience gained from talking to many patients suggests these discussions and decisions can be rushed. Women sometimes feel they did not have all the relevant information given to them when having to make a choice about their cancer treatments.
This can be especially problematic if you’re offered Aromatase Inhibitors. These medications profoundly suppress your own estrogen, and they can have significant implications for your quality of life and your future health. Ideally, you should have the necessary time and opportunity to discuss treatment choices on a regular basis and at any time you are experiencing difficulties.
Stages, ages and types of menopause
Menopause is technically when it has been 12 months or more since your last period. This can happen following a natural decline in your ovarian function that usually begins several years before when hormone levels start fluctuating, known as perimenopause. Or menopause can be sudden, for example if your ovaries are removed, and this would be known as a ‘surgical menopause’.
If menopause occurs naturally between the ages of 40 and 45 it is called ‘Early Menopause’, and if it occurs before the age of 40 (without being due to medical interventions), it is called Premature Ovarian Insufficiency.
Once you have reached menopause, you’ll remain postmenopausal for the rest of your life.
Menopause is mostly associated with the range of difficult symptoms it can cause, but it also has a significant influence on your future health. For example, low levels of estrogen after menopause can have a negative impact on your heart, bones, brain and your genitourinary health. The earlier menopause occurs, the more important it is to consider the impact a lack of hormones will have on your long-term health.
Menopause induced by cancer treatments
While the average age of menopause is 51, it can be brought on at an earlier age due to having various treatments for cancer that affect your ovaries. This is called a chemical or chemically induced menopause.
Chemotherapy can temporarily or permanently damage the function of the ovaries and induce an earlier menopause. If your ovaries are temporarily damaged, there may be a return of periods and improvement in menopause symptoms but not always. Your subsequent natural menopause may occur earlier if you have had chemotherapy in the past.
Medications used to minimise the effects of estrogen (for those with an ER positive tumour) can also induce an earlier menopause or they can worsen menopause symptoms if you have already had your menopause.
Symptoms of menopause
As we have receptors for our reproductive hormones throughout our bodies, symptoms of menopause can affect us in multiple ways. At least 75% of all women experience menopause symptoms and it is likely to be higher in those with a history of breast cancer.
The predominant menopausal symptom that most people think of is hot flushes and sweats but we know that there are many other symptoms that are often more problematic such as those affecting our thinking and wellbeing (, , ) and other physical symptoms such as , joint pains, migraine and very often some one of the most debilitating symptoms are the ones affecting your genitals and urinary function known as .
Menopause symptoms after breast cancer
It has been well documented that you may suffer more severe menopause symptoms if you have a history of breast cancer.[4] But understandably, when faced with a diagnosis of breast cancer, most women do not immediately think about other health issues beyond the cancer.
Your physical and emotional energy are directed into your breast cancer treatment and the potential future issue of struggling with menopause symptoms or the impact it will have on your future health are not always considered or raised by your breast cancer team.
If and when problems do arise, it is understandable that symptoms are often attributed to the cancer treatment. Fatigue, brain fog and low mood may be attributed entirely to chemotherapy, for example but it may be that it is your menopause or the estrogen blocker medication that are causing these issues, especially if they persist once chemotherapy has finished.
Having any cancer diagnosis is a source of stress and anxiety and so any psychological issues such as low mood and anxiety may also be attributed to your experience of going through the cancer journey rather than due to the effects of menopause.
The medications known as Aromatase Inhibitors (which reduce estrogen levels in the body to almost zero) are frequently associated with joint pains, vaginal dryness and urinary symptoms – all of which are common symptoms of menopause.
The challenges of getting treatment for your menopause after breast cancer
For women who struggle with menopause symptoms and have not had breast cancer, they can seek advice regarding their treatment choices and will most likely be offered Hormone Replacement Therapy (HRT) as one of the options.
However, HRT is considered a contraindication (not recommended for safety reasons) if you have had a history of breast cancer. This caution is due to the fear that any estrogen will provoke an increase in the risk of the cancer returning or that it will ‘wake up’ dormant breast cancer cells (this point will be discussed in more detail later).
The experience that many women with a history of breast cancer face is that they don’t realise the difficulties they’re experiencing relate to menopause and even if they do, they do not feel able to fully express how they feel for fear of being made to feel ungrateful for their ‘lifesaving’ breast cancer care.
Sadly, many women have shared that if they do try and explain how they’re feeling, they are frequently dismissed and not heard. Within the Breast team there is often a lack of a designated, appropriately knowledgeable person to discuss menopause issues, or women may have already been discharged from the hospital clinic by the time they realise they need support with their menopause.
Most GPs have had insufficient training around menopause in general and for patients with a history of breast cancer, this is an area that may well require more specialist input. Unfortunately, NHS menopause clinics can be helpful but are not always accessible. It is a sad reality that too many women’s experiences of seeking help for menopausal issues after breast cancer are negative.
Genitourinary symptoms
The menopause symptoms that are often the most difficult to talk about are those affecting the genitals and urinary function.
It is estimated that the majority of women during or after menopause will have changes to their vulva, vagina and bladder function. This group of symptoms is known as
These symptoms are caused by low levels of estrogen in the body and lead to multiple potential issues such as vaginal dryness, vulval soreness and itching, needing to pass urine frequently or desperately, or repeated urinary tract infections.
Women using Aromatase Inhibitors are particularly vulnerable to symptoms of GSM.
Any or all of these issues impact on daily lives as they can lead to difficulties with sitting down, sleeping, wearing certain clothing, exercising and enjoying sexual intimacy free of pain.
What can I do to help myself?
If you find yourself struggling with menopause symptoms and have had breast cancer, take a look at our top ten tips to help you navigate this journey:
1. Talk about it
Conversations about menopause have been sparse in the past but thankfully, are now more out in the open as public awareness about this time in a woman’s life improves and various strategies are in place to reduce the stigma surrounding it. The more we talk about our experiences the more each woman will learn that they’re not the only one suffering.
Acknowledging how you feel about your current health and its impact on your quality of life is a good starting point. Are you able to work? Have you needed to reduce your hours or change job? Have your relationships changed, especially in terms of intimacy, and is this putting pressure on your relationship with your partner? Do you have enough energy to enjoy activities with your family? Are you avoiding socialising? Are you more irritable with those around you?
There is a tendency to feel a sense of isolation, shame or embarrassment about such issues, but these difficulties are far more common than you may realise.
Being able to have open and honest conversations with loved ones, trusted friends and relatives is so important. While others around you may not have gone through breast cancer, there are many commonalities in experience of menopause in general, regardless of any other health conditions you may have.
Hopefully, this booklet will help you feel able to have these discussions with not only friends and family, but health professionals that you see too. Please do raise these issues with your Breast Care Nurse as they are usually experienced in understanding the challenges breast cancer patients experience.
2. Document your symptoms
As explained, it can be difficult to tease out why you’re feeling like you are – is this menopause or cancer related?It can be very helpful to complete a Menopause Symptom Checker to gauge whether your symptoms could be related to a lack of hormones. It’s especially useful to do this if you’re thinking about seeing a healthcare professional with a view to seeking help for your menopause symptoms.
There are many possible menopause symptoms and a validated questionnaire such as the Menopause Symptom Checker on the Health in Menopause website covers many of them (although not all). Completing one and sharing it with your clinician can help facilitate discussions about your menopause treatment options and also monitor your progress over time.
3. Investigate helpful resources
This booklet is designed to give you an overview of the potential issues to consider and suggest where you might seek further help. There are many other resources that provide more detail on the various aspects of living with menopause after breast cancer.
One of the most helpful books to read on this topic is ‘Oestrogen Matters’, by Professor Avrum Bluming and Carol Tarvis.[5] Prof. Bluming had a lengthy career as an oncologist caring for breast cancer patients and admits that he only really learnt the true implications of menopause when his own wife developed breast cancer. He has since devoted his esteemed career to researching the implications of using HRT as a potential treatment in this group of women.
The charity, Breast Cancer Now, has a useful range of booklets including topics such as Tamoxifen, Aromatase Inhibitors, treatment of primary breast cancer and family history of breast cancer, as well as information on menopause symptoms after breast cancer.
For those with a known BRCA mutation (a specific genetic susceptibility to breast or ovarian cancer), the Royal Marsden NHS Foundation Trust has a useful guide.
There are now numerous podcasts available on this and related topics. We would particularly recommend The Menopause and Cancer Podcast hosted by Dani Binnington, (especially episodes 6, 19, 22, 30, 34, 35, 37, 41 and 48). And the You Are Not Broken podcast by Kelly Casperson, MD, particularly episodes 187 and 213.
You can watch Health in Menopause specialist, Dr Alison MacBeth, featuring in a YouTube video from the Harley Street Emporium about Genitourinary Syndrome of Menopause.
If you’re worried about your breast cancer returning, you can read helpful guides from Macmillan Cancer Support and the charity Maggie’s and there may be courses run by cancer charities that aim to help with this aspect of recovery.
4. Try and lead a healthy lifestyle
is important for your psychological and physical health. It is important to keep your cardiovascular and skeletal systems as healthy as possible, particularly if you have had an earlier menopause or POI, or if your estrogen levels are being suppressed by medication. Studies have shown a significant beneficial effect of exercise on reduction in the risk of recurrence from breast cancer.[6]
You may find that exercise reduces the frequency and impact of hot flushes and sweats, (although evidence from clinical trials is not convincing on this specific point). It can certainly help other menopausal symptoms by improving sleep and is well known to improve your psychological wellbeing. Weight gain is common around the time of menopause due to metabolic changes related to lower estrogen levels. Addressing potential weight change via a healthy diet and regular exercise is beneficial for your general health as well as boosting your self-confidence. Being able to lose weight earlier (rather than later) in the menopause transition can also help reduce hot flushes and sweats.
Reducing your intake of alcohol and stopping smoking is also very beneficial for a large number of health reasons. Alcohol increases menopause symptoms, particularly as a trigger for hot flushes and sweats. It also increases anxiety and reduces the quality of your sleep. NICE guidelines (NG 101)[7] advise limiting alcohol to less than 5 units per week if you have a history of breast cancer.
has a crucial role in living a healthy lifestyle and a Mediterranean style diet appears to be the most beneficial. The essence of this diet is to eat lots of fruits and vegetables, wholegrains, nuts and seeds and good fats, with little meat, dairy, salt and sugar, and very few processed and refined foods.
It is also important that your gut has the right balance of good vs harmful bacteria by eating foods that are pre- and pro-biotic or taking a supplement for this. Having adequate vitamin D levels is essential for your bone health and this is more easily achieved by taking a supplement all year-round (if you live in the UK), or at least during the months from October to April.
Calcium is also important for your bones and helps your body absorb vitamin D. 700-1200 mg per day is the recommended amount of calcium to get from your diet and you can calculate this using an online calcium calculator.[8] Consider supplementation if your intake falls below this as it is important for maintaining good bone strength.
is a crucially important part of a healthy routine. When sleep is lacking and the quality is poor, it can worsen your menopausal symptoms. Try and get outdoors first thing in the morning as the natural daylight helps keep your circadian rhythms on track. Going to bed at the same time every evening and getting up at the same time in the morning are the anchors we need for stable sleeping patterns. Daily exercise, avoidance of caffeine after midday, low lights in the evening and a relaxing bedtime routine are other helpful tips to try and maintain good quality sleep.
While a healthy lifestyle is essential for all of us, making the necessary adjustments can feel extremely difficult or even impossible when struggling with menopause symptoms. You might need to seek help for your menopause symptoms first before you feel ready to make the lifestyle changes you know you need to.
5. Look after your genitourinary health
As mentioned, it is common to have dryness and soreness of the genitals and problems with your urinary function, known as Genitourinary Syndrome of Menopause (GSM). There are a number of things you can do to try and keep the vagina, vulva and bladder as healthy as possible without the need for prescription medications:
- Avoid soap, shower gel or intimate deodorants or perfumes
- Use soap substitutes like Hydromol or Cetraben ointment instead
- Avoid panty liners, bubble bath, or feminine hygiene wipes
- Coconut oil (organic) can be an effective option to apply to the vulva
- Cut down on bladder irritants (caffeine, alcohol, fizzy drinks, sugar/sweeteners, smoking)
- And drink plenty of water
For more information, see the helpful leaflet from the British Association of Dermatologists on skincare for your vulva.
Lubricants – Many popular high street brands of intimate lubricants are actually irritating to the vagina and vulva. There are some organic lubricants however, which are more suitable such as YES OB (oil based) or WB (water based), Sylk, and Sutil which avoid glycerin, glycol, parabens, dyes, perfume, alcohol and glitter. These can be helpful to reduce dryness and discomfort when having sex, and they also help reduce the risk of urinary tract or bladder infections triggered by sex (post-coital cystitis).
Moisturisers – There are vaginal moisturisers which give longer lasting comfort and hydration to the vagina and vulva (an example of this product is YES VM). These are best used 2-3 times a week. Hyalofemme is a non-hormonal vaginal moisturiser that contains hyaluronic acid which acts to keep moisture in the vagina and vulva.
6. Complementary therapies may benefit
There are various complementary therapies which can be helpful in reducing menopausal symptoms. Mind-body techniques that may be beneficial on an individual basis with some evidence of benefit are yoga, Cognitive Behavioural Therapy (CBT)[9], acupuncture, hypnotherapy, paced breathing, massage, reflexology and mindfulness-based relaxation therapy. Those with evidence that they can reduce the frequency and/or impact of hot flushes and sweats are CBT and hypnosis.[10]
7. Be wary of herbal remedies
There are a huge number of herbal remedies available to purchase. This can be a very confusing area to navigate. A common one that causes confusion is regarding phytoestrogens. These are plant-based compounds that at their molecular level, are similar to estrogen and can therefore mimic its effects in a very diluted way. Examples of phytoestrogens in food are soy, beans, peas, carrots, broccoli, coffee and tea.
Many studies[10] have found positive effects on vasomotor symptoms (flushes and sweats) in menopausal and perimenopausal women, and there is certainly interest in soy isoflavones for those with a history of breast cancer. However, when you weigh up all the evidence for soy products it is not conclusive enough to recommend them to any woman for reducing hot flushes and sweats. A sensible approach is to avoid phytoestrogens in supplement form (the commonest one being Red Clover) but there’s no need to restrict phytoestrogens in your diet.
Other popular menopause herbal remedies have a lack of evidence to support their use (as studies show they are no more effective than taking a placebo).[10,11] There are also potential concerns about the safety of herbal medications as there is much less regulation of them compared to medically prescribed medications. This includes remedies such as black cohosh, ginseng, and CBD oil.
Some potentially promising newer herbal remedies based on pollen may be beneficial and appear to be safe, but evidence is not yet sufficient to recommend these.
8. Understand your non-hormonal medication options
HRT is well established and widely recognised as being the most effective treatment for reducing menopause symptoms in the general population. For those with a history of breast cancer however, HRT is currently considered to be a contraindication (or ‘unsafe’) and there are also other women who choose not to take HRT but want to explore medications that don’t contain hormones, particularly to try and treat hot flushes and sweats.
In the UK, there is only one non-hormonal medication licensed for the treatment of hot flushes/sweats and this is Clonidine. This is an old-fashioned tablet usually used for treating high blood pressure. The collective evidence does not actually show that it is as effective as other options, and due to its risk of side effects it is rarely recommended.
The most used medical ‘alternative’ to HRT is antidepressant medication. There are a number of antidepressants that have been shown to significantly reduce hot flushes and sweats. However, it is important to note that only some of them can be used in combination with Tamoxifen. Venlafaxine and Escitalopram are regarded as the safest antidepressants to use if you’re also taking Tamoxifen.
A disadvantage of taking antidepressant medication is that they do tend to lower your libido, they can lead to weight gain and they may also have a negative effect on your bone strength (bone density).
A medication called Gabapentin, (traditionally used as an epilepsy medication) also has clinical evidence[10] to suggest it as an option for reducing hot flushes and sweats, although potential side effects are drowsiness and dizziness.
Oxybutynin has been used for many years as a treatment for ‘overactive bladder’. It has been found to reduce the number of hot flushes and sweats but it can cause a dry mouth and constipation and of more concern, Oxybutynin should be avoided in older people in the long term, due to the risk of cognitive impairment.[10]
In the US, a new drug has just become available called Fezolinetant. It specifically targets the ‘thermostat’ function in the brain which is adversely affected by low levels of estrogen and it has been demonstrated[10] to reduce the impact of hot flushes and sweats, but it is not yet available in the UK.
You may have noticed that almost all the medications and evidence listed here relates to the symptoms of hot flushes and sweats. While relief from these can be very beneficial to some sufferers, for many women it’s other symptoms which are having a far greater impact on their life. These non-hormonal medications are not likely to address the plethora of other symptoms, nor do they address future health risks such as your cardiovascular and bone health as you age.
9. Find out more about hormonal treatment options
You may be puzzled as to why this section is even included in this leaflet and feel fearful of any mention of hormones due to a belief that hormones have been a cause of your cancer and/or that you should never take any medication containing estrogen. But as with many things in life, it’s not as black and white as this.
Healthcare professionals in the UK are encouraged to follow the guidelines recommended by the National Institute for Health and Care Excellence (NICE). In the NICE guidelines for diagnosis and management of menopause (NG23)[12] healthcare professionals are reminded to:
- provide individualised care (considering each woman on a case-by-case basis)
- give information about the different types of treatments available for menopause symptoms
- include hormonal and non-hormonal treatment options in the discussion
- share the risks and benefits of those options with you
- give information about the long-term health implications of the menopause
- consider vaginal estrogen treatment, including for those where systemic HRT is contraindicated (i.e. if you’ve had breast cancer)
- offer a referral to a menopause specialist if you’re going through menopause as a result of medical or surgical treatment.
In the NICE Early and local advanced breast cancer: diagnosis and management guideline[7] it is advised that HRT should be stopped in women newly diagnosed with breast cancer and that it should not routinely be offered to women with menopausal symptoms and a history of breast cancer. However, it also states that in exceptional circumstances HRT can be offered if symptoms are severe and possible associated risks have been discussed.
Another critical NICE guideline that is relevant when discussing the use of HRT if you have had breast cancer, is the Shared Decision Making[13] set of recommendations. This guideline reminds healthcare professionals that their role is to support you to make decisions about your own health by providing up-to-date and understandable information. They should find out what matters to you and discuss the risks, benefits and consequences of all your treatment options in the light of your own history and your personal preferences and priorities.
Your decision may not always align with your healthcare professional’s opinion but this should be respected if you have had a full and frank discussion and you understand all the implications of your decision.
Does estrogen cause breast cancer recurrence?
The long-held assumption is that the future risk of a recurrence of breast cancer may be increased by the presence of estrogen. Early on in a woman’s breast cancer journey, this assumption is certainly likely to be relevant. What is not fully understood is for what length of time should estrogen be kept to very low levels and at what point in time might the risk-benefit ratio flip the other way?
As the years go by, living with low estrogen and its knock-on symptoms may become harder to cope with and take a greater toll on your cardiovascular and bone health, and with increasing length of time since the cancer occurred there is less risk of it coming back. So women are wondering should HRT be avoided forever or just for now? And when could it be considered if it is safe to do so?
Professor Avrum Bluming’s book[5] discusses in depth all of the studies which have been carried out over the past 2-3 decades in women with a history of breast cancer who have chosen to use HRT to help improve their menopausal symptoms and/or their future health outcomes. Out of all the studies that have been done (26 to date), all except one showed either no increase in risk of recurrence or a slight decrease in the risk of recurrence in women who chose to use HRT[5].
The one study[14] which appeared to demonstrate an increase in the risk of recurrence of breast cancer in those who used HRT, is generally regarded as a poorly designed trial and has been widely criticised since, therefore its data is considered as potentially misleading.
Also, none of the 26 trials ever found an increased risk of death from breast cancer in the women who chose to take HRT.
The clinical guidelines mentioned (that tend to focus purely on the idea of HRT being contraindicated) group together all types of breast cancer into one homogenised category and apply the same rules for all. This appears inappropriate given the diversity of types of breast cancer, especially the fact that some are non-invasive and some are not estrogen receptor positive. It makes logical sense that the different types of breast cancer should be dealt with separately on their own individual merits.
Approach to using HRT after breast cancer at Health in Menopause
At Health in Menopause – along with many other progressive menopause specialists who fully adopt the Shared Decision Making approach outlined earlier – we believe that:
- if a person with a history of breast cancer has a quality of life which is sufficiently reduced by her menopausal symptoms
- and has tried various alternative and/or non-hormonal options with little or no success
- and has had a fully informed and individualised consultation with one of our specialists,
- ideally in collaboration with her breast care team (if she is still under their care)
- and has taken everything into consideration, a trial of systemic HRT is an appropriate option to offer.
We would aim to use the safest types of HRT (known as body identical HRT) and this would involve estrogen replacement plus progesterone (if you still have a womb), and possibly testosterone replacement.
More details about the can be found at the Health in Menopause website.
Unfortunately, it’s impossible to say with certainty for any breast cancer patient that their breast cancer will not recur. Recurrence is always a potential risk, whether a patient chooses to use HRT or not.
The current evidence suggests that HRT does not increase that risk but there is insufficient evidence to be definitive about this. Some patients choose to have a trial of HRT for 3-6 months before making a longer-term decision about the pros and cons of continuing.
It is always difficult for patients and their healthcare professionals to make decisions where the evidence is lacking in quantity or quality. “We do not have enough data to be sure” is a common phrase in this area of medicine and much more research is required.
Safety of vaginal/local estrogen
Despite the ongoing controversy that taking systemic HRT after breast cancer attracts, there is fortunately far greater awareness now as to how safe vaginal estrogen is for managing symptoms of GSM.
Vaginal or ‘local’ estrogen is used as a pessary, cream, gel or a silicon ring and can be extremely effective at treating the vaginal, vulval and bladder symptoms which are common and debilitating.
Beyond the first 24 hours of use, there is no clinically meaningful absorption of estrogen into the blood stream. No clinical trials have ever demonstrated an increased risk of recurrence of breast cancer in those patients who use vaginal estrogen.[15]
Due to its effectiveness and safety, vaginal estrogen can be used in the long-term – and indeed has to be – in order to achieve ongoing benefits.
For more details about the various vaginal estrogen products please see the vaginal dryness booklet.
Vaginal estrogen can be used by those who are on Tamoxifen treatment. For those who are using Aromatase Inhibitors the situation is less clear. It is possible to still consider vaginal estrogen however, vaginal oestriol in the form of Blissel gel or Imvaggis are the preferred treatments as these do not convert to estradiol and there is therefore no increased levels of estradiol in your blood. Other solutions are to switch from your Aromatase Inhibitor to Tamoxifen if possible, OR to use a DHEA pessary (containing prasterone). This is metabolised in the vaginal wall, converting into testosterone and estradiol with minimal absorption, and if you’re taking an aromatase inhibitor, it should prevent conversion of the DHEA into estradiol.[16]
Vaginal estrogens can be used in tandem with vaginal lubricants and moisturisers and no progesterone is required for those using vaginal estrogen on its own (without systemic HRT). It is also possible to use systemic HRT and combine it with vaginal estrogen or prasterone if your GSM symptoms are inadequately controlled with HRT alone.
10. Be kind to yourself
And finally, it is important to reflect again on the difficult and often challenging nature of the topic of finding help for your menopause after breast cancer.
We have learnt from our patients’ experiences that fear is one of the most powerful emotions and thoughts and beliefs based on these fears can remain fixed despite emerging data and professional opinions that seek to provide reassurance to the contrary.
The experience of stress is well known to everyone, but few realise that the chemicals released in the body in response to stress have direct and indirect consequences on all the other systems in the body, including your reproductive hormones. Because of this, take time to process the information in this booklet, talk with others, do activities that bring you joy, spend time with loved ones, be out in nature, have that conversation with your good friend – as these are all truly therapeutic too.
Making decisions about your own health is always tricky and this is one of the most challenging decisions you may have to face. It can take a long time to feel sufficiently ready to make certain decisions and take action on them.
Remember, there is no right or wrong approach. Each person has their own journey to take and at Health in Menopause, we are very experienced at helping you along the path should you wish to have our assistance.
References:
- Cancer Research UK www.cancerresearchuk.org
- Taylor C, McGale P, Probert J, Broggio J, Charman J, Darby S C et al. Breast cancer mortality in 500 000 women with early invasive breast cancer in England, 1993-2015: population based observational cohort study BMJ 2023; 381 :e074684 doi:10.1136/bmj-2022-074684
- Breast Cancer UK www.breastcanceruk.org.uk
- Peate, M., Saunders, C., Cohen, P. et al. Who is managing menopausal symptoms, sexual problems, mood and sleep disturbance after breast cancer and is it working? Findings from a large community-based survey of breast cancer survivors. Breast Cancer Res Treat 187, 427–435 2021. Study (DOI)
- Oestrogen Matters: Why Taking Hormones in Menopause Can Improve Women’s Well-Being and Lengthen Their Lives – Without Raising the Risk of Breast Cancer. Avrum Bluming and Carol Tavris. 2018. 978-0349421773
- Spei ME et al. Physical activity in breast cancer survivors: A systematic review and meta-analysis on overall and breast cancer survival. Vol 44, April 2019, p 144-152. PubMed study
- NICE guidelines Early and locally advanced breast cancer: diagnosis and management (NG 101) Published: 18 July 2018 Last updated: 14 June 2023 NICE guideline 1
- International Osteoporosis Foundation: Calcium Calculator
- Women’s Health Concern Factsheet: CBT for menopausal symptoms.
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- British Menopause Society consensus statement: Non-hormonal-based treatments for menopausal symptoms British Menopause Society
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Dr Sarah Ball and Dr Alison Macbeth
Last updated: June 2026
