Navigating menopause after cancer

It’s a war-of-the-worlds scenario: you’ve survived cancer, and now you’re traversing menopause — and dealing with debilitating symptoms. You don’t want to suffer unnecessarily, of course, but you’ve heard treating menopause symptoms with hormone therapy might be risky for women in your situation. What to do?

You’re certainly not alone. More than 10 million of the nation’s 19 million cancer survivors are women, 80% of whom are 60 or older, according to the American Cancer Society. Meanwhile, eight in 10 menopausal women deal with disruptive hot flashes and night sweats, for which hormone therapy is widely considered the most effective remedy.

When the two circumstances collide, weighty decisions may be at hand. Certain types of cancer are hormone-driven, making it potentially perilous to introduce additional hormones into a survivor’s system when she enters menopause later. The same problem may face women who experience sudden menopause when their ovaries are removed as part of their cancer treatment.

Can these women use hormone therapy? It depends, says Dr. Tara Iyer, director of the Menopause and Midlife Clinic at Harvard-affiliated Brigham and Women’s Hospital. “It’s a very complicated discussion to have,” she says.

Thorny dilemma

Only a few malignancies affecting women are fueled by hormones such as estrogen, including specific types of breast, uterine, and ovarian cancers, Dr. Iyer explains.

There’s concern that hormone therapy could promote cancer recurrence in these women, but “current research doesn’t show this definitively,” she says. Even low-dose systemic estrogen treatment — whether delivered through pills, patches, or creams — is potentially problematic.

“The data we have are conflicting. Some show an increased risk of cancer recurrence, but others don’t,” Dr. Iyer says. Most doctors, she says, won’t recommend hormone therapy, particularly for survivors of breast cancer.

But if hot flashes, sleep disturbances, mood swings, and other menopause woes are disrupting normal life, you may feel you’re asked to choose between enduring debilitating symptoms or risking a cancer relapse.

These are some of the questions that shape a yes-or-no answer to hormone therapy:

• What type of cancer did you have?
• What stage and grade was your cancer?
• How long ago were you diagnosed, and at what age?
• What type of treatment did you undergo, and how did you respond?
• How severe are your menopause symptoms? What other treatments have you tried?

That last pair of questions is particularly relevant when deciding next steps, Dr. Iyer says. “There’s no black or white for any of these discussions,” she adds. “I’d never tell every woman she can absolutely not take estrogen. We’d have a more nuanced discussion about potential risks versus benefits, alternative options, and the gaps in research.”

Effective alternatives

If your doctor says systemic hormone therapy isn’t an option, a variety of medications and lifestyle measures can relieve the following menopause symptoms:

Hot flashes. The nonhormonal drug fezolinetant (Veozah) was approved by the FDA in 2023 specifically for hot flashes and night sweats. Other medications are prescribed off-label for this purpose, including certain antidepressants; gabapentin (Horizant, Gralise), which typically treats nerve pain or seizures; and oxybutynin (Oxytrol), which primarily treats overactive bladder.

Dr. Iyer also recommends various lifestyle modifications to ease hot flashes and night sweats, including weight loss (if needed), cognitive behavioral therapy (CBT), meditation, acupuncture, and avoiding triggers such as alcohol. The latter three measures are backed by varying degrees of evidence, she says, but are believed to be helpful.

Vaginal dryness or painful sex. Some women who can’t use systemic hormone therapy can still try vaginal estrogen, which is delivered via a cream, tablet, or ring. Unlike systemic estrogen, these methods deliver a low dose directly to the vagina and vulva, minimizing absorption into the bloodstream. Ask your doctor if it’s safe for you.

Mood changes, sleep disruption, and painful joints. Regular exercise, including stretching and yoga, can mitigate these and a variety of other disruptive symptoms, Dr. Iyer says. CBT can also help boost mood.

Dr. Iyer strongly recommends that cancer survivors speak to a menopause expert, not a general practitioner, to weigh the pros and cons of hormone therapy and explore other ways to ease menopause symptoms. Add a breast oncologist to the discussion if you’re a breast cancer survivor, she says.

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