Menopause After Breast Cancer
- purity carr
- 11 minutes ago
- 8 min read
Understanding Your Options
Introduction
Many women tell me:
"I survived breast cancer, but I don't feel like myself anymore."
After breast cancer treatment, many women experience troublesome menopausal symptoms including hot flushes, night sweats, poor sleep, anxiety, brain fog, joint pains, vaginal dryness, bladder symptoms, painful intercourse and loss of libido.
These symptoms may result from natural menopause, chemotherapy-induced menopause, ovarian suppression, aromatase inhibitors or tamoxifen.
The good news is that there are many management options available.
Although many women believe that "nothing can be done", this is rarely the case. Every woman's breast cancer and menopause journey is unique, and treatment should always be individualised.
Understanding Your Breast Cancer
Breast cancer is not one disease. Different breast cancers behave differently and this determines treatment, prognosis and future recurrence risk.
The main types include:
Oestrogen Receptor Positive (ER Positive)
Approximately 70% of breast cancers are ER positive.
These cancers grow in response to oestrogen and are commonly treated with Tamoxifen or aromatase inhibitors such as Letrozole, Anastrozole or Exemestane.
Progesterone Receptor Positive (PR Positive)
These cancers also contain progesterone receptors and often accompany ER-positive disease.
HER2 Positive
HER2-positive cancers produce excess HER2 protein, causing faster tumour growth.
Targeted medicines such as trastuzumab (Herceptin®) have dramatically improved outcomes.
Triple Positive Breast Cancer
These cancers are:
• ER positive
• PR positive
• HER2 positive
Several treatment options are available including hormone therapy and HER2-targeted therapy.
Triple Negative Breast Cancer
These cancers do not contain:
• Oestrogen receptors
• Progesterone receptors
• HER2 receptors
Hormone therapy does not work.
Treatment usually involves surgery, chemotherapy and sometimes immunotherapy.
Triple-negative breast cancer has the greatest risk of recurrence during the first three to five years. If recurrence has not occurred by then, the future risk falls considerably.
What Determines the Risk of Recurrence?
Every woman's situation is different.
Important factors include:
• Tumour size.
• Cancer grade.
• Lymph node involvement.
• Whether the cancer had spread before diagnosis.
• Hormone receptor status.
• HER2 status.
• Genetic mutations such as BRCA1 or BRCA2.
• Whether chemotherapy, radiotherapy or endocrine therapy was required.
The longer you remain cancer-free, the more reassuring this becomes.
Women with ER-positive breast cancer have a small ongoing risk of recurrence that may continue for many years.
Women with triple-negative breast cancer have the highest recurrence risk during the first three to five years, after which the risk falls substantially.
BRCA1 and BRCA2 Gene Mutations
Some women carry an inherited BRCA1 or BRCA2 gene mutation.
These mutations greatly increase the lifetime risk of developing both breast cancer and ovarian cancer.
Importantly, having a BRCA mutation does not mean you have cancer.
It means your lifetime risk is much higher than average.
Preventing Breast and Ovarian Cancer
Some women choose risk-reducing (prophylactic) surgery.
This may include:
• Bilateral prophylactic mastectomy (removal of both breasts before cancer develops).
• Bilateral salpingo-oophorectomy (BSO), which removes both ovaries and fallopian tubes.
Preventive mastectomy can reduce the risk of breast cancer by more than 90%.
Because there is currently no reliable screening test for ovarian cancer, women with BRCA mutations are often advised to consider removal of their ovaries and fallopian tubes once their family is complete.
In general:
BRCA1
• BSO is usually recommended between 35 and 40 years of age.
BRCA2
• BSO is usually recommended between 40 and 45 years of age, as ovarian cancer tends to occur later.
Can Women With a BRCA Mutation Have HRT?
Yes.
Women with a BRCA1 or BRCA2 mutation who have never had breast cancer and who undergo preventive removal of their ovaries usually can have HRT until the average age of natural menopause (approximately 50–51 years), provided there are no other contraindications.
Current evidence suggests that HRT does not appear to remove the breast cancer risk reduction achieved by prophylactic surgery.
If the uterus has been removed, oestrogen alone is usually prescribed.
If the uterus remains, both oestrogen and a progestogen are required to protect the lining of the womb.
This situation is very different from women who have previously had hormone receptor-positive breast cancer.
Can I Have HRT After Breast Cancer?
This is one of the most common questions I am asked.
For women with ER-positive breast cancer, systemic HRT is generally not recommended, as it may increase the risk of recurrence.
For women with triple-negative breast cancer, the decision is less straightforward because these cancers are not driven by oestrogen receptors.
Management should always be individualised, considering:
• Your type of breast cancer.
• Stage of disease.
• Lymph node involvement.
• Time since diagnosis.
• Current recurrence risk.
• Severity of menopausal symptoms.
• Your quality of life.
• Your own wishes and priorities.
If HRT Is Not Suitable, What Can Help?
There are many effective non-hormonal treatments.
Hot Flushes
• Fezolinetant
• Clonidine
• Low-dose SSRIs or SNRIs
• Gabapentin
Sleep
• Good sleep hygiene
• Melatonin
• Clonidine
• Low-dose doxepin
• Valdoxan (agomelatine)
Vaginal Dryness and Bladder Symptoms
Management options include:
• Vaginal moisturisers
• Lubricants
• Vagifem®
• Ovestin®
• Intrarosa®
These treatments have minimal systemic absorption and may be appropriate for selected women after discussion with their oncology team.
Brain Fog and Fatigue
Management may include:
• Exercise
• Optimising sleep
• Managing anxiety or depression
• Treating ADHD where appropriate
MCAS and Histamine Symptoms
Some women notice worsening flushing, itching, headaches, reflux or bowel symptoms following breast cancer treatment.
Management may include:
• Trigger identification.
• Sleep optimisation.
• Stress reduction.
• Low-histamine dietary strategies where appropriate.
• Individualised MCAS treatment.
Reducing the Risk of Recurrence
Lifestyle matters.
Current evidence supports:
• Regular exercise (150–300 minutes each week).
• Maintaining a healthy weight.
• Avoiding or limiting alcohol.
• Not smoking.
• Eating a Mediterranean-style diet.
• Prioritising good quality sleep.
• Managing diabetes, blood pressure and cholesterol.
• Taking prescribed endocrine therapy consistently.
These measures improve overall health and may also reduce the risk of recurrence.
Working With Your Oncologist
If your oncologist is still involved in your care, I will usually write to them outlining any proposed menopause treatment.
Many oncologists remain understandably cautious about systemic HRT after breast cancer, particularly for women with hormone receptor-positive disease.
Working together allows us to balance quality of life with the safest evidence-based treatment approach.
Further Information
Women wishing to understand more about breast density, breast cancer risk, breast screening and menopause after breast cancer may find the educational resources developed by Professor Stephen Birrell, Breast Surgeon and Founder of Wellend Health, extremely helpful.
Professor Birrell provides evidence-based information on:
• Breast density.
• Individual breast cancer risk assessment.
• Mammography, ultrasound and breast MRI.
• Breast cancer screening.
• Personalised breast health care.
• Menopause after breast cancer.
Wellend Health Education Centre
This resource complements, but does not replace, advice from your breast surgeon, oncologist, GP or menopause clinician.
Dr Purity's Clinical Perspective
Every woman who has had breast cancer deserves an individualised menopause consultation.
The question is rarely simply:
"Can I have HRT?"
The more important questions are:
• What type of breast cancer did you have?
• Was it hormone receptor positive or negative?
• Were lymph nodes involved?
• How many years have you remained cancer-free?
• What treatment have you received?
• How severe are your menopausal symptoms?
• What are your priorities and quality-of-life goals?
Women who carry a BRCA1 or BRCA2 mutation but have never developed breast cancer should not automatically assume they cannot have HRT. Following prophylactic removal of the ovaries, HRT is commonly recommended until the average age of natural menopause to improve quality of life and protect bone, heart and brain health. This situation is very different from women who have previously had hormone receptor-positive breast cancer.
For many women, non-hormonal treatments provide excellent symptom relief. For others, particularly those with severe symptoms, a more detailed discussion involving their oncologist is appropriate.
My goal is to help you understand all of your management options, improve your quality of life and work collaboratively with your oncology team whenever appropriate.
Dr Purity's Key Messages
• Breast cancer is not one disease. Management depends on the biology of your tumour.
• BRCA1 and BRCA2 mutations increase the lifetime risk of both breast and ovarian cancer.
• Women with BRCA mutations who have not had breast cancer can usually take HRT after prophylactic removal of the ovaries until the natural age of menopause.
• ER-positive and triple-negative breast cancers have different recurrence patterns.
• The longer you remain cancer-free, the more reassuring this becomes, although ER-positive cancers can recur many years later.
• Systemic HRT is generally avoided after ER-positive breast cancer, but every woman deserves an individual assessment.
• Many highly effective non-hormonal treatments are available for menopausal symptoms.
• Healthy lifestyle choices, including regular exercise, maintaining a healthy weight, limiting alcohol, prioritising sleep and not smoking, may improve overall health and help reduce the risk of recurrence.
• Menopause care after breast cancer should always be personalised and, where appropriate, undertaken in collaboration with your oncologist.
References
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Breast Cancer. Current version.
European Society for Medical Oncology (ESMO). ESMO Clinical Practice Guideline for Diagnosis, Treatment and Follow-up of Early Breast Cancer. Annals of Oncology.
American Society of Clinical Oncology (ASCO). Management of Menopausal Symptoms in Breast Cancer Survivors.
The North American Menopause Society (NAMS). The 2022 Hormone Therapy Position Statement of The North American Menopause Society. Menopause. 2022;29:767-794.
British Menopause Society (BMS). Tools for Clinicians: HRT After Breast Cancer. Current guidance.
International Menopause Society (IMS). Recommendations on Menopausal Hormone Therapy in Breast Cancer Survivors.
National Institute for Health and Care Excellence (NICE). Menopause: Diagnosis and Management (NG23). Updated guidance.
National Institute for Health and Care Excellence (NICE). Familial Breast Cancer: Classification, Care and Managing Breast Cancer Risk (CG164).
Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of Women at Increased Genetic Risk of Breast and Ovarian Cancer.
eviQ Cancer Treatments Online. BRCA1 and BRCA2 Risk Management Guidelines.
National Cancer Institute (USA). BRCA Gene Mutations: Cancer Risk and Genetic Testing.
Rebbeck TR, Friebel TM, Friedman E, et al. Bilateral Prophylactic Mastectomy Reduces Breast Cancer Risk in BRCA1 and BRCA2 Mutation Carriers. Journal of Clinical Oncology.
Domchek SM, Friebel TM, Singer CF, et al. Association of Risk-Reducing Surgery in BRCA1 and BRCA2 Mutation Carriers with Cancer Risk and Mortality. JAMA.
Marchetti C, De Felice F, Palaia I, et al. Risk-Reducing Salpingo-oophorectomy: A Meta-analysis on Breast and Ovarian Cancer Risk Reduction in BRCA Mutation Carriers. BMC Women's Health.
Kotsopoulos J, Gronwald J, Karlan B, et al. Hormone Replacement Therapy After Oophorectomy and Breast Cancer Risk Among BRCA1 Mutation Carriers. Journal of the National Cancer Institute.
The HABITS Trial Group. Hormone Replacement Therapy After Breast Cancer—Is It Safe? Journal of the National Cancer Institute.
Holmberg L, Anderson H. HABITS (Hormonal Replacement Therapy After Breast Cancer): Randomised Comparison Between HRT and No HRT. Lancet.
Fahlén M, Fornander T, Johansson H, et al. Hormone Replacement Therapy After Breast Cancer: Ten-Year Follow-up of the Stockholm Randomised Trial. Journal of the National Cancer Institute.
Santen RJ, Loprinzi CL, Casper RF, et al. Managing Menopause in Breast Cancer Survivors. Journal of Clinical Endocrinology & Metabolism.
American Cancer Society. Breast Cancer Survivorship Care Guidelines.
Breast Cancer Network Australia (BCNA). Menopause After Breast Cancer Resources.
Cancer Australia. Management of Menopausal Symptoms in Women with a History of Breast Cancer.
BreastScreen Australia. Breast Cancer Screening Guidelines.
Professor Stephen Birrell. Wellend Health Education Centre – Breast Density, Breast Cancer Risk and Menopause Education.
Wellend Health Education Centre:Professor Stephen Birrell – Wellend Health Education Centre
Purity Health Menopause & Wellbeing CentreDr Purity Carr | GP | Menopause Doctor
“Personalised, evidence-based care.”
Reach out to Dr Purity
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