A guide to menopause if you’ve had breast cancer

Answering common questions about menopause treatment if you have a history of breast cancer

• One in seven women will develop breast cancer during their lifetime
• Some treatments for breast cancer can lead to menopause
• Advice on menopause treatment options if you have a history of breast cancer

If you’ve had breast cancer and are wondering what your treatment options are for menopausal symptoms and future health, this guide is for you. It has been written by healthcare professionals and includes contributions from women affected by breast cancer.

Breast cancer and hormones

Breast cancer is the second most common type of cancer in the UK: about one in seven women will develop the disease over their lifetime [1].

Breast cancer is a complex disease, and there are many different types, and the role of oestrogen in the disease is still poorly understood.

When cancerous cells are examined after a biopsy or surgery, it’s established whether or not they have receptors for oestrogen. If they do, it’s known as oestrogen-receptor-positive (ER-positive) breast cancer; if they don’t, it’s ER-negative. This is important when it comes to deciding on treatments for menopause symptoms: knowing whether your cancer was ER positive or negative may influence your decision about taking HRT or not.

All cells in your body have oestrogen receptors on them, so having an ER-positive breast cancer does not mean that oestrogen has caused breast cancer.

RELATED: Dr Corinne Menn: I’m a doctor who’s had breast cancer: here’s what I want you to know

Menopause explained

The usual definition of menopause is a year after a woman’s last menstrual period.

Menopause is related to a decline of the hormones oestrogen, progesterone and testosterone, which are produced in the ovaries and also other organs and tissues, including your brain.

Hormones work as chemical messengers throughout your entire body – reaching and having an effect on every single cell. The hormones oestradiol (the beneficial type of oestrogen), progesterone and testosterone have been shown to improve thousands of cellular actions which then improves function of your body systems and organs. In particular, they have many beneficial actions on bone, brain, circulation, urinary, genital and nervous systems.

When might menopause happen for me?

The average age a woman in the UK experiences menopause is 51 [2]. However, it can occur earlier or later than this – health conditions, genetics, ethnicity and your social economic background can influence the age you experience it, as well as treatment for cancer.

Your menopause may occur at a younger age as some treatments for cancer, such as chemotherapy or radiotherapy, affect ovarian function resulting in hormones levels reducing. This might be a permanent or temporary menopause depending on the type of treatment you have.

RELATED: Surgical and chemical menopause

What kind of symptoms can menopause bring?

Common symptoms of menopause include:

• Night sweats
• Hot flushes
• Mood changes
• Memory problems
• Fatigue and poor sleep
• Brain fog
• Loss of interest in sex or relationships
• Joint pains and muscle aches
• Hair and skin changes
• Worsening migraines and headaches
• Vaginal and urinary symptoms.

It can be difficult to know which symptoms are due to side effects of treatment for cancer, and which are menopausal symptoms.

RELATED: Surprising menopause symptoms

Spotlight on aromatase inhibitors, tamoxifen and menopause symptoms

Tamoxifen is a type of hormone therapy used for the prevention and treatment of breast cancer. It is a selective oestrogen receptor modulator (SERM), which means it blocks oestrogen on some cells, including in the breast, but not on others.

Aromatase inhibitors are a type of hormone therapy used to treat breast cancer in post-menopausal women whose ovaries are no longer producing oestrogen. Sometimes they are used in those who are pre-menopausal, but usually only if their ovaries are ‘switched off’, which is usually done with a hormone injection. The purpose of taking aromatase inhibitors is to prevent the production of oestrogen anywhere in your body.

If you are taking an aromatase inhibitor and experiencing severe menopause symptoms or side effects, you could talk to your breast specialist about the possibility of either stopping your medication for a few weeks to see if this improves your symptoms or taking tamoxifen or another alternative treatment.

RELATED: Podcast: breast cancer treatment and HRT

How can I mange my menopause?

Every woman’s experience of menopause is different and your decisions regarding menopause treatment may change over time.

Your menopause may be temporary due to one of your treatments, for example if you are taking an aromatase inhibitor, or it may be permanent, for example if you have had your ovaries removed or you are at the age of menopause.

Optimal menopause care involves both improving symptoms and safeguarding your future health. Lifestyle changes such as optimising your nutrition, exercise and wellbeing are key, though this can of course be challenging if you are struggling with menopause symptoms or side effects of your cancer treatment.

Here are some lifestyle strategies that can be beneficial:

Keep active

Movement and exercise are important for your general health and also help to keep your bones and heart strong. Ideally you should aim for a combination of activity that raises your heart rate but also impacts through your joints. If fatigue is still a factor, start with a gentle, lower impact activity such as walking, and gradually build up the duration and frequency you are active for. This can improve your emotional wellbeing too.

Make time for you

Spending time doing things you enjoy is beneficial for your mental health. Whether that is going for a walk, catching up with a friend, or spending some much-needed time by yourself enjoying a hobby. Learn to value time just for you.

Eat well – and cut out unhealthy habits

Foods that are beneficial include are those rich in calcium for your bones, friendly to the gut containing prebiotics and probiotics, carbohydrates that have a low glycaemic index (GI) and are broken down more slowly, and foods rich in omega 3 oils. Prioritise fresh fruit and vegetables and adequate protein, as well as trying to limit the amount of processed food you eat.

Some women find that alcohol, particularly red wine, triggers hot flushes and night sweats, though the evidence is mixed in this regard [3,4].

Smoking can worsen hot flushes [5] and increases your risk of developing more than 50 serious health conditions including many types of cancer, heart and blood vessel diseases, and conditions affecting your breathing and lungs [6].

How might the menopause affect my future?

After menopause, your levels of the hormones oestradiol, progesterone and testosterone will remain low forever, unless you take hormone replacement therapy (HRT). Menopausal women have an increased risk of developing heart disease, osteoporosis, type 2 diabetes, clinical depression and dementia.

An earlier than expected menopause may also impact any plans you had to start or add to your family: if you’re struggling with an early menopause and prospect of infertility, The Daisy Network is a charity you may find useful. They have lots of helpful information on their website at www.daisynetwork.org about all these issues, including forums to chat with other young women facing similar issues.

Menopause treatments

Talking therapies

There is some evidence that cognitive behavioural therapy (CBT) can improve some symptoms and improve your quality of life. However, CBT will not improve future health and has not been shown to improve all menopausal symptoms.

Non-hormonal prescription medications

There are numerous preparations marketed for menopausal women either to buy or available on prescription. There is little evidence to support their use for many of them and many of these preparations have not been tested in studies on women who have had breast cancer.

Some types of medication, including gabapentin, pregabalin and antidepressants, such as venlaflaxine have been shown in some studies to improve hot flushes, night sweats and for some women, mood. However, they will not improve all symptoms nor improve future health and many women experience side effects with them. Fezolinetant is a new drug that has been approved to treat moderate to severe vasomotor symptoms in menopausal women. Fezolinetant does not treat other menopausal symptoms, and there is no long-term data regarding the impact of fezolinetant on cardiovascular and bone health, or breast cancer incidence. There are no studies involving women with breast cancer taking fezolinetant. The have been concerns about risks of liver disease and also cancer in some women taking this medication [7, 8].

RELATED: Fezolinetant explained

Hormone treatments

Hormone replacement therapy (HRT) is usually the first line treatment for the management of perimenopausal and menopausal symptoms [9]. There are systemic and local (vaginal) hormones – these have different effects, benefits and risks.

It is important to see a doctor who has clinical experience and knowledge both in managing women who have had breast cancer and menopause – often more than one clinician will be involved in your treatment decisions. It is essential that you are involved in all treatment decisions.

The type of hormones you need and the doses you’re given vary between each woman – it is not a ‘one type fits all’ prescription. HRT will usually contain oestradiol, progesterone and sometimes testosterone. These hormones are usually prescribed separately and it is important that you are given the right type and dose.

RELATED: Getting to the truth around HRT and breast cancer with Dr Avrum Bluming

Women are prescribed hormones to both improve their symptoms as well as their future health. HRT can include the following three hormones:

Oestradiol: this hormone is produced predominantly by your ovaries, but it is also made in your brain and other tissues. Levels fluctuate during perimenopause before declining in menopause and staying low for the rest of your life. Oestradiol helps to regulate your menstrual cycle, plays an important role in bone health, memory and cognition and cardiovascular health and is essential for many bodily functions.

Progesterone: if you still have your uterus (womb), taking oestrogen can cause the lining (endometrium) to thicken. To prevent this, you will usually need to take progesterone to keep the lining of your womb thin and regulate or stop bleeding. Progesterone can also relieve perimenopausal and menopausal symptoms such as sleeping problems, low mood and anxiety, and can be taken by women who have had a hysterectomy or use a Mirena coil as part of an individualised consultation for their symptom control.

Testosterone: this hormone is perhaps best known for improving libido, but you have testosterone receptors all over your body so the decline in levels can also lead to a loss of energy and brain fog, muscle and joint pains, low energy, poor sleep as well as other symptoms.

Can I take HRT if I have a history of breast cancer?

NICE guidance on early and locally advanced breast cancer states HRT should not be routinely offered women with menopausal symptoms and a history of breast cancer [10]. In exceptional circumstances, it adds, that HRT can be offered to women with severe menopausal symptoms and with whom the associated risks have been discussed.

Some women may choose to accept an increased risk of relapse in exchange for relief from menopausal symptoms and an improved quality of life, and that preferences may vary according to individual circumstances and the absolute risk of relapse, which is uncertain due to lack of solid evidence and research in this area.

The lack of evidence from prospective studies and randomised controlled trials highlights the importance of shared decision making in this highly complex area.

What does the research show about HRT in women who have had breast cancer?

The research that has been undertaken regarding taking HRT after breast cancer shows conflicting results: many studies are of poor quality and so the results are difficult to interpret properly. In addition, the studies have often involved older formulations of HRT to the types often prescribed now.

Since 1980, there have been 26 studies published on this area (25 studies have shown no increased risk and 5 showed benefit; 4 reported decreased mortality) [11,12]. Only one, the Hormone Replacement After Breast Cancer – Is It Safe? (HABITS) trial, reported an increased risk of local recurrence, but not metastatic disease or breast cancer death [13]. This study also used older and synthetic types of HRT.

There is a lack of robust evidence on giving HRT and testosterone to women who have had a past history of breast cancer and their risk of recurrence. There is some evidence that testosterone may be beneficial for women who have had breast cancer [14]. However, some women chose to take HRT and/or testosterone as their quality of life is suffering without it. They are also keen to obtain the future health benefits of taking natural, body identical HRT, as women who take HRT have a lower future risk of osteoporosis, diabetes, coronary heart disease, clinical depression, dementia and also some cancers [15].

What is key is that all treatment decisions are based on your individual circumstances, and if you decide you may want to take hormonal treatment, this should be a shared decision-making process with you and your healthcare team.

There are different types and doses of hormones. Testosterone has been shown in some studies to be beneficial to women who have had breast cancer, including those women who are also taking an aromatase inhibitor [16,17].  

Hormones used in HRT are much lower that the doses of hormones in contraceptives and they are also natural (they are synthetic in all contraceptives) – so the same chemical structure as the hormones you produce when you are younger. They are also short acting in your body, so do not build up with time.

Some women decide to take HRT for a few months and then assess how they are feeling and how many of their symptoms improve. They feel reassured knowing that they can stop taking HRT at any time and the hormones will all be out of their body within a day of stopping them.

What are the risks of systemic HRT if I’ve had breast cancer?

It is not possible to quantify risks as they vary between different people and are likely to be different for different types of breast cancer in the past too. If you have had breast cancer, your healthcare team should explain any potential individual risks when it comes to taking HRT, so you can weigh up the pros and cons of any decisions around possible treatment.

It’s important you are informed about benefits and any potential risks and how treatment might impact your quality of life and future health, so you have enough information make an informed decision.

Ductal Carcinoma in Situ (DCIS) and Lobular Carcinoma in Situ (LCIS)

It is unlikely that women taking HRT after DCIS and LCIS have increased risks, however studies have not been undertaken in this area.

ER-negative breast cancer

If you have had an ER-negative breast cancer in the past, then some women consider taking HRT as this cancer does not have receptors for oestrogen in it and so taking HRT is unlikely to be detrimental to future health or risk. 

ER-positive breast cancer

If you have ER-positive breast cancer, you should talk to healthcare professionals who are experts in treating people for the menopause after breast cancer – it’s usually advisable to talk to a menopause specialist, as well as a breast specialist oncologist to talk about your individual circumstances.

HRT and aromatase inhibitors and tamoxifen

Tamoxifen works differently in different women and does not block oestrogen throughout your body. Research has shown that some women who take tamoxifen actually have more oestradiol in their bodies than women who do not take tamoxifen [18]. Some women take HRT with tamoxifen with benefit to both their symptoms and their future health.

Taking HRT containing oestrogen will not usually have any benefit to your symptoms if you are taking an aromatase inhibitor. However, some women take testosterone with their aromatase inhibitor with beneficial effects to their symptoms and possibly their future health [19].

Spotlight on vaginal hormones

Vaginal hormones, also known as local hormones, are different to HRT as they are very low dose and do not get absorbed into your body. They can usually safely be prescribed for women who have had any type of breast cancer [20,21,22,23].

Vaginal hormones can improve symptoms of vaginal dryness, soreness, irritation, pain as well as improve urinary symptoms such as cystitis, recurrent urinary tract infections, increased frequency of passing urine, incontinence and urgency.

They can be given as an oestrogen pessary, vaginal tablet, gel, cream or ring, or as a daily pessary called prasterone. The prasterone pessary contains a hormone called dehydroepiandrosterone (DHEA), which converts to both oestrogen and testosterone in the vagina and surrounding tissues. Vaginal hormones can often be beneficial in women who take aromatase inhibitors or tamoxifen [24].

Managing vaginal and urinary symptoms

Whether you use vaginal hormones or not, if you are experiencing localised symptoms then you may find the following measures help:

• Avoid using soap, shower gels, deodorants, or ‘intimate’ products, and try a gentle emollient wash instead
• Panty liners, spermicides and many brands of lubricants can contain irritants which can make symptoms worse
• Tight-fitting clothing and long-term use of sanitary pads or synthetic materials can also worsen symptoms
• Vaginal moisturisers such as YES VM, Sylk Intimate, or Regelle can help hydrate your tissues and reduce soreness and discomfort throughout the day
• Specialist lubricants for when having sex, such as Sylk, YES OB or YES WB can ease discomfort and make the experience more enjoyable. If you’re using a barrier method of contraception, water-based lubricants are usually best.

Speaking to your healthcare team about managing your menopause

You should be able to make decisions about treatment with your doctor or other healthcare professional. Guidelines from the General Medical Council and recommendations from NICE show how decisions should be made between a patient and doctor and specify that a shared decision-making process should be used.

This involves:

• Encouraging you, the patient, to take an active role in making decisions about their treatment

• Taking into account what is most important to the patient, their expressed needs and priorities and treatment options are explained in light of these

• Open discussion of the risks, benefits, and consequences of each treatment option, including doing nothing, with the acceptance that the patient’s views can differ to the professional’s

• Allow time to answer questions and time to make decisions, making it clear that the patient can change their mind down the line

• Come to a joint decision that is satisfactory to you, the patient.

Here are some other strategies that can help menopause conversations with your healthcare team.

Be your own advocate: being informed means about symptoms and treatment options allows you to be more involved in treatment choices that are right for you – just ensure you uses reputable sources

Keep a record of your symptoms: recording the range, frequency and severity of menopause symptoms helps to build a picture for your healthcare team – the balance menopause support app has a free symptom diary.  You can also use these tools to measure any improvement in your symptoms once you start a treatment.

Plan ahead for your appointment: you might want to ask for a double appointment. Write comments or questions down beforehand and inform your healthcare professional what you want to discuss in advance: this ensures you get the most out of your consultation and gives them an opportunity to do their own research.

Also remember that if you do not get the desired outcome at the first appointment, you do have a right to ask for a second opinion. You can ask to see another clinician within your practice or for a referral to an NHS menopause specialist clinic in your area. Another option is having an appointment with a private menopause specialist.

RELATED: How to talk to your doctor about HRT – and get results

Real life stories from women who have had breast cancer

Caroline went through breast cancer, surgery and chemotherapy and became menopausal when she was 39. She says of her experience:

‘In hindsight, much of my anxiety around taking HRT was due to the symptomatic effects of the menopause. I couldn’t think straight and needed time, the right information and guidance. In the end, small steps worked. Since going on HRT, my anxiety has dramatically reduced, and I can make clearer decisions that are driven by logic rather than fear’

Mel decided to try vaginal oestrogen several years after her breast cancer treatment finished. She says:

‘I recently made the decision to start using vaginal oestrogen. Enough was enough. My symptoms were so severe and worsening, and it was really impacting on my quality of life. For me, it has been a great decision and it has made a huge difference.

However, I don’t regret not making the decision earlier, as I believe you have to make each decision in life based on the information available and how you feel at the time – you can’t look back with regret.

My point is, things can change, the balance can be tipped and that’s ok. The most important thing is being comfortable that it is the right decision for you. I can truly understand why women who have had breast cancer may choose to either have or not have hormones, either vaginally or systemically. But they should have the opportunity to make an informed choice, and most importantly, be at peace with that choice.’

Further resources and recommended reading

 National Institute for Health and Care Excellence (NICE) (2024)  ‘Menopause: Identification and management’

NICE (2024) ‘Early and locally advanced breast cancer: diagnosis and management’

Avrum Bluming ‘Oestrogen Matters’. Published by Piaktus, London.

British Society of Sexual Medicine, ‘Position Statement for Management of Genitourinary Syndrome of the Menopause (GSM)’

References

1. Cancer Research UK, ‘Breast cancer statistics’, https://www.cancerresearchuk.org/healthprofessional/cancer-statistics/statistics-by-cancer-type/breast-cancer#:~:text=Breast%20cance r%20is%20the%20most,year%20(2016%2D2018)

2. National institute for Health and Care Excellence (NICE) (2024), ‘Menopause: what is it?’

3. Sievert, L. L., Obermeyer, C. M., Price, K. (2006). ‘Determinants of hot flashes and night sweats’, Annals of Human Biology, 33(1), pp.4–16. doi.org/10.1080/03014460500421338

4. Schilling C., Gallicchio L., Miller S.R., Langenberg P., Zacur H., Flaws J.A. (2007), ‘Current alcohol use, hormone levels, and hot flashes in midlife women’, Fertility and Sterility, 87 (6), pp.1483-6. doi: 10.1016/j.fertnstert.2006.11.033

5. Butts S.F, et al (2012), ‘Joint effects of smoking and gene variants involved in sex steroid metabolism on hot flashes in late reproductive-age women’, The Journal of Clinical Endocrinology and Metabolism, 97 (6), E1032–E42, doi.org/10.1210/jc.2011-2216

6. NHS.uk (2018), ‘What are the health risks of smoking?’, www.nhs.uk/common-health-questions/lifestyle/what-are-the-health-risks-of-smoking

7. Douxfils J., Beaudart C., Dogne J.M. (2023), ‘Risk of neoplasm with the neurokinin 3 receptor antagonist fezolinetant’, Lancet, 402(10413):1623-5. doi.org/10.1016/S0140-6736(23)01634-3

8. Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012–. Fezolinetant. 2024 Oct 10. PMID: 39441946

9. National Institute for Health and Care Excellence (NICE) (2024) ‘Menopause: identification and management’

10. NICE (2018), ‘Early and locally advanced breast cancer: diagnosis and management’

11. Cold, S, Cold, F, Jensen, M, Cronin-Fenton,D, Christiansen, P, Ejlertsen, (2022), ‘Systemic or Vaginal Hormone Therapy After Early Breast Cancer: A Danish Observational Cohort Study’, JNCI: Journal of the National Cancer Institute, doi.org/10.1093/jnci/djac112

12. Bluming, A, (2022) ‘Hormone replacement therapy after breast cancer: it is time’, The Cancer Journal, 28 (3), pp. 183-90, doi: 10.1097/PPO.0000000000000595

13. Holmberg L, Anderson H, (2004), ‘HABITS steering and data monitoring committees. HABITS (hormonal replacement therapy after breast cancer–is it safe?), a randomised comparison: trial stopped’, Lancet, 7;363(9407) pp.453-5. doi: 10.1016/S0140-6736(04)15493-7. PMID: 14962527.

14. Glaser R.L., York A.E., Dimitrakakis C. (2019), ‘Incidence of invasive breast cancer in women treated with testosterone implants: a prospective 10-year cohort study’, BMC Cancer, 19(1):1271. doi: 10.1186/s12885-019-6457-8

15. Gambacciani, M., Cagnacci, A., Lello, S. (2019), ‘Hormone replacement therapy and prevention of chronic conditions’, Climacteric, 22(3), 303–306. doi.org/10.1080/13697137.2018.1551347

16. Glaser R.L., Dimitrakakis C. (2013), ‘Reduced breast cancer incidence in women treated with subcutaneous testosterone, or testosterone with anastrozole: a prospective, observational study’, Maturitas, 76(4):342-9. doi: 10.1016/j.maturitas.2013.08.002

17. Glaser R., Dimitrakakis C. (2015), ‘Testosterone and breast cancer prevention’, Maturitas, 82(3):291-5. doi: 10.1016/j.maturitas.2015.06.002

18. Berliere M. et al. (2013), ‘Tamoxifen and ovarian function’, PLoS One. doi: 10.1371/journal.pone.0066616

19. Glaser R., Dimitrakakis C. (2015), ‘Testosterone and breast cancer prevention’, Maturitas, 82(3):291-5. doi: 10.1016/j.maturitas.2015.06.002. Epub 2015 Jun 24. PMID: 26160683.

20. Agrawal P. et al. (2023), ‘Safety of vaginal estrogen therapy for genitourinary syndrome of menopause in women with a history of breast cancer’, Obstet Gynecol,142(3):660-668. doi: 10.1097/AOG.0000000000005294

21. McVicker L. et al (2024), ‘Vaginal estrogen therapy use and survival in females with breast cancer’, JAMA Oncol, 10(1):103-108. doi: 10.1001/jamaoncol.2023.4508

22. The 2022 hormone therapy position statement of the North American Menopause Society advisory panel (2022), ‘the 2022 hormone therapy position statement of The North American Menopause Society’, Menopause, 29(7):767-794. doi: 10.1097/GME.0000000000002028

23. Hussain I., Talaulikar V.S. (2023), ‘A systematic review of randomised clinical trials – the safety of vaginal hormones and selective estrogen receptor modulators for the treatment of genitourinary menopausal symptoms in breast cancer survivors’, Post Reprod Health, 29(4):222-231. doi: 10.1177/20533691231208473

24. Mension E. et al (2022), ‘Safety of prasterone in breast cancer survivors treated with aromatase inhibitors: the VIBRA pilot study’, Climacteric, 25(5):476-482. doi: 10.1080/13697137.2022.2050208