For breast cancer survivors, the menopause experience can be extra complex. Not only does breast cancer treatment sometimes trigger menopause, it can also be a blocker of our first-line menopause medications. Fortunately, there are still safe and highly effective options available, including SSRI/SNRI medications and lifestyle adjustments. But before we dive into those options, let’s explore the relationship between menopause and breast cancer.

Understanding menopause & breast cancer

Menopause doesn’t cause breast cancer. But your risk of breast cancer (like many other cancers) increases with your age. For some people, that means breast cancer and menopause coincide naturally. On the other hand, if you haven’t yet entered menopause when you’re diagnosed with breast cancer, certain treatments might push you into either temporary or permanent menopause. This is called treatment-induced menopause. 

Chemotherapy, for example, may inadvertently damage the ovaries, bringing menstruation to a halt and triggering all the hormonal changes associated with menopause. This experience is very similar to natural menopause, with symptoms like hot flashes, insomnia, mood shifts, and sexual changes. There are drugs which limit this damage (such as goserelin, brand name Zoladex) which work by temporarily “shutting down” the ovaries. These drugs, however, have the same impact: By blocking menstruation, they trigger menopause. This menopause is usually temporary, but it may be permanent in people who were already nearing the age of natural menopause. 

Other kinds of treatment-induced menopause are always permanent, such as the removal of the ovaries (oophorectomy). This can increase your chances of survival after breast cancer by lowering your estrogen levels, which puts you into immediate menopause. Regardless of whether it’s temporary or permanent, menopause can be extremely uncomfortable and disruptive.

“No one should have to ‘tough out’ menopause symptoms,” says Dr. Leah Millheiser, Clinical Professor of OB/GYN and Chief Medical Officer of Evernow.

“These are significant quality-of-life issues that deserve care and attention. If you’re a breast cancer survivor, Evernow has treatments that can help you.” – Dr. Leah Millheiser

Medication options for breast cancer survivors

There are several medications that are prescribed and proven to treat many bothersome symptoms of menopause. SSRIs (Selective Serotonin Reuptake Inhibitors) and SNRIs (Selective Norepinephrine Reuptake Inhibitors) are drugs that were originally developed for the treatment of depression and anxiety. They work by changing the balance of neurotransmitters in your brain, which can have a significant influence on your mood. 

For menopausal treatment, these drugs are used at lower doses and have a very different impact: they reduce vasomotor symptoms of menopause (VMS) like hot flashes. Although we still don’t fully understand the mechanism behind VMS, they seem to be linked to changes in your hypothalamus—a part of the brain that regulates body temperature which undergoes changes during menopause due to falling estrogen levels. By adjusting your neurotransmitter balance, it’s believed SSRIs and SNRIs offset these changes in your hypothalamus, helping stave off VMS.

Scientific research shows that these medications are highly effective and typically take effect within two weeks. They reduce the frequency and severity of hot flashes and night sweats, and can significantly improve VMS-related insomnia. Only one SSRI has been formally approved by the FDA for the treatment of VMS—paroxetine (brand name Brisdelle). But many other SSRIs and SNRIs are prescribed by doctors on an off-label basis for the same reason. 

It’s important to note that paroxetine and fluoxetine may interfere with tamoxifen, so combining these drugs is not recommended. If you’re taking tamoxifen as part of your breast cancer treatment strategy, an SNRI like venlafaxine may be an equally effective substitute.

Is there hormone therapy for breast cancer survivors?

For survivors of breast cancer and other reproductive cancers, hormone therapy is typically not recommended. In about 70% of breast cancer cases, the tumor is “hormone sensitive.” That means it contains estrogen receptors (ER) or progesterone receptors (PR) which detect your body’s hormones and can trigger growth in the cancer. In other words, the cancer “feeds on” estrogen and progesterone, making hormone therapy untenable. 

In fact, many breast cancer survivors take medication to do the exact opposite: lower estrogen levels as much as possible. Drugs like tamoxifen (a selective estrogen receptor modulator) and anastrozole (an aromatase inhibitor) prevent the recurrence or growth of breast cancer. 

Lifestyle adjustments & alternative therapies

For many people during menopause, lifestyle changes are a helpful tool that is easy to overlook. And while no single change in your lifestyle may seem particularly impactful, when used together they can be extremely effective. Critically, these changes will not interfere with your cancer treatment or cancer survivorship plan. In fact, some of them will help.

• Stay hydrated: Drinking water isn’t just important to replenish what you lose during hot flashes and night sweats—it’s anecdotally reported to help prevent hot flashes in the first place.
• Avoid stressors: Many people find that stress can trigger hot flashes, and “negative affect” (a catch-all term used by researchers for sadness, anxiety, and stress) has been linked to VMS in a major longitudinal menopause study.
• Avoid smoking: Cigarette smoking is one of the most powerful variables affecting the frequency and severity of your VMS. Of course, it’s also extremely important to avoid smoking for cancer prevention.
• Limit alcohol, hot drinks, and spicy food: There is less scientific evidence to support this practice, but many patients and healthcare providers find that it helps prevent VMS.
• Stay equipped: Dress in light, layered clothing that’s easy to remove when a hot flash begins. Keep an insulated bottle of ice water and a hand fan in your handbag or car. At night, sleeping with an ice pack under your pillow can also be helpful.
• Prioritize sleep: Research has shown that the negative impact of VMS on your day-to-day mood may be due to the insomnia it causes. And while you can’t entirely prevent insomnia and night sweats, you can practice good sleep hygiene to get the best sleep possible. That means sleeping in a completely darkened room, limiting your use of electronics before bed, avoiding caffeine after 3pm, and only using your bed for sleep.

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There are also a number of alternative and complementary therapies that can be used to treat VMS. These include:

• Cognitive-behavioral therapy (CBT): CBT is a type of psychological therapy that aims to help you identify and change your own thought patterns. Research has found that it’s effective for limiting insomnia after night sweats, thus improving overall sleep quality.
• Hypnotherapy: The North American Menopause Society (NAMS) has stated that hypnosis is a viable tool for VMS symptoms (though they note it is less effective than CBT).
• Acupuncture: One study found that a course of acupuncture improved VMS symptoms by nearly 30% after one year.
• Yoga: A review of many smaller studies found that, although the data was limited, yoga may be an effective way to improve VMS.

The importance of self-advocacy

Menopause symptoms can be incredibly disruptive, taking a toll on your work, sleep, daily mood, and relationships. Researchers have acknowledged this fact, stating that the physical and financial cost of VMS is “immense.” 

But despite the magnitude of the problem, only a minority of patients (around 18%) actually receive treatment for VMS from their healthcare team.

In fact, a recent survey of cancer healthcare providers found that many are unsure which VMS treatments are effective and aren’t confident in their ability to manage VMS. This lack of decisive, high-quality care may be heightened among breast cancer survivors. 

“The clinicians focused on your cancer journey may not be thinking about side-effects like menopausal symptoms. But as the patient, you have the right to speak up and ask for help,” says Dr. Leah Millheiser. “These are serious concerns with a very real impact on your quality of life, and it’s important to be open about that with your clinician.”

In other words, the more communicative you are about menopause symptoms, the more your healthcare team can do to help you. For tips on self-advocacy during the cancer journey, check out the National Coalition for Cancer Survivorship.

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Reviewed by Dr. Leah Millheiser, MD, Evernow Chief Medical Officer, May 2022