The Royal Australian

and New Zealand

College of
Obstetricians and
Gynaecologists

Management of the menopause after

breast cancer
This statement has been developed and reviewed by the
Womens Health Committee and approved by the
RANZCOG Board and Council.

RANZCOG acknowledges the contribution of the Breast

Section, Royal Australian College of Surgeons (RACS) and
the Australasian Menopause Society (AMS) in the
compilation and continuous review of this statement.

A list of Womens Health Committee Members can be

found in Appendix A.

Disclaimer This information is intended to provide general

advice to practitioners. This information should not be
relied on as a substitute for proper assessment with respect
to the particular circumstances of each case and the needs
of any patient. This document reflects emerging clinical and
scientific advances as of the date issued and is subject to
change. The document has been prepared having regard to
general circumstances.

Objective: To provide advice on the management

of the menopause after breast cancer.
Target audience: All health practitioners providing
gynaecological care, and patients.
Values: The evidence was reviewed by the
Womens Health Committee (RANZCOG), and
applied to local factors relating to Australia and
New Zealand.
Background: This statement was first developed by
Womens Health Committee in March 1995 and
most recently reviewed in November 2014.
Funding: The development and review of this
statement was funded by RANZCOG.

First endorsed by RANZCOG: March 1995

Current: November 2014
Review due: November 2017

1.

Summary of recommendations

1.1

Women who have had breast cancer may need extra help and counselling around menopause.
Counselling should include discussion of the uncertain risks/ benefits of Hormone Therapy (HT)
after breast cancer.

1.2

Quality of life issues should be discussed and assessed together with the risks of developing
osteoporosis, cardiovascular disease, thromboembolism, and dementia.

1.3

Life style factors should be addressed including adequate exercise, calcium/ vitamin D intake,
avoidance of smoking, excessive alcohol and caffeine intake, optimal weight maintenance and
reduction of stress.

1.4

Sexual counselling should be considered.

1.5

Evidence-based non-hormonal options should first be considered (e.g. bisphosphonates or SERMs

for osteoporosis, cholesterol lowering agents and aspirin for cardiovascular disease). Some
individual menopausal symptoms may be ameliorated with individual selected therapies eg
venlafaxine, desvenlafaxine, escitalopram, citalopram and paroxetine, clonidine and gabapentin for
vasomotor symptoms, vaginal lubricants for superficial dyspareunia, and anticholinergics for urinary
urgency. Please note that paroxetine and tamoxifen should not be prescribed together.

1.6

Alternative medicines for which there is no established evidence are not recommended.

1.7

Local vaginal oestrogen therapy after breast cancer is a reasonable therapeutic option for the
control of urogenital symptoms. Oestriol preparations may have less systemic absorption than
oestradiol preparations. In women taking aromatase inhibitors oestriol preparations are preferred
as local oestradiol preparations may transitorily elevate serum E2 levels. When used according to
instructions supplementary progestogen therapy is not required with either preparation.

1.8

Current data do not support the use of HRT in breast cancer survivors. Two major trials (HABITS
and Stockholm) showed different outcomes with an increased risk of recurrence seen in HABITS but
not in The Stockholm trial. As women in HABITS mostly received continuous E+P therapy and
women in Stockholm mostly received unopposed estrogen or long cycle progestogen therapy( each
3 months) it may be wise, in women who find HRT necessary for quality of life reasons, for a
regimen to be developed with the lowest effective dose of estrogen combined with sequential
progestogen, ideally dydrogesterone or micronized progesterone. Evidence for the use of Mirena in
these circumstances is lacking although small studies show reduced breast density with Mirena
compared to oral norethisterone.

1.9

The prescription of HT along with tamoxifen is still inadequately studied. The cessation of tamoxifen
may lead to a reduction in vasomotor symptoms. This must be discussed in the context of
tamoxifens absolute improvement in disease free survival and impact on the contralateral breast
cancer.

1.10

The prescription of HT along with Aromatase Inhibitors (AIs) is still inadequately studied.
Theoretically, the use of systemic oestrogen-based HT may reduce the efficacy with current use of
AIs. Aromatase inhibitors are associated with an increased risk of osteoporosis and so regular bone
mineral density measurements (1-2 yearly) are advised. Adequate calcium and vitamin D intake
should be encouraged either by diet or supplement. If a drug therapy is required for osteoporosis,
bisphosphonates are the first-line option.

1.11

Tibolone (Livial) may confer the same risk as combined continuous hormone therapy with respect to
breast cancer recurrence. Tibolone may reduce the efficacy of adjuvant therapies and should not be
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used concurrently.
1.12

When HT is started the patients other treating doctors should be involved in the decision.

1.13

The effect of testosterone on breast cancer is not well studied, and in the absence of these data
should not be used for its supposed effect on libido.

1.14

Annual review including mammography is recommended for women on HT.

1.15

Management is individualised after thorough counselling about options. The patient may wish to
have her partner and family involved in the counselling and decision making.

2.

Other suggested reading

C Antoine F, Liebens B, Carly A, Pastijn S, Neusy and S Rozenberg. Safety of hormone therapy after breast
cancer: a qualitative systematic review. Human Reproduction 2007; 22: 616-22.
Consensus Statement. Treatment of Oestrogen Deficiency Symptoms in women surviving breast cancer.
Climacteric 1998; 1: 148-158.
Eden JA. Herbal Medicines for Menopause: Do they work and are they safe? Med J Aust 2001; 174: 6364.
Aniato P, Christopher S, Mellon PL. Estrogenic Activity of Herbs Commonly Used as Remedies for
Menopausal Symptoms. Menopause 2002 Mar-Apr; 9 (2): 145-50.
Loprinzi CL, Barton DL, Rhodes D. Management of Hot Flushes in Breast Cancer Survivors. Lancet Oncology
2001; 2: 199-204.
Stoll BA, Parbhoo S. Treatment of Menopausal Symptoms in Breast Cancer Patients. Eur J Cancer Clin
Oncol 1989; 25: 1909-1913.
Eden JA, Bush T, N and S, Wren BG. A Case Controlled Study Of Combined Continuous EstrogenProgestin Replacement Therapy Among Women with A Personal History of Breast Cancer. Menopause
1995; 2 (2): 67-72.
Vassilopoulou-Sellin R, Asmar L, Hortobagyi GN et al. Estrogen Replacement Therapy After Localized Breast
Cancer: Clinical Outcome of 319 Women Followed Prospectively. J Clin Onco1 1999; 17 (5): 1482-87.
Brewster WR, DiSaia PJ, Grosen EA et al. An experience with Estrogen Replacement Therapy in Breast
Cancer Survivors. lnt J Fertil Womens Med 1999; 44 (4): 186-92.
Puthgraman K Natrajan MD, Soumilis K, Gambrell RD. Estrogen Replacement Therapy in Women with
Previous Breast Cancer. Am J Obstet Gynacol 1999; 181: 288-95.
O'Meara ES, Rossing MA, Daling JR et al. Hormone Replacement Therapy After A Diagnosis of Breast
Cancer In relation to Recurrence And Mortality. J Natl Cancer lnst 2001; 93 (10):754-62.
Marttunen MB, Hietanen P, Pyrohenen S et al. A Prospective Study On Women With a History of Breast
Cancer And With or Without Estrogen Replacement Therapy. Maturitas 2001; 39 (3): 217-25.
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Eden JA, Duma EM, Wren BG et al. HRT After Breast Cancer. The latest results from the Royal Hospital for
Women Breast Cancer Study. (Abstract) Scientific Program of the 5th Australasian Menopause Society
Congress 2001: 38.
Womens Health Initiative. Risks and Benefits of Estrogen plus Progestin in Healthy Post Menopausal
Women. JAMA July 17 2002; Vol.288; No.3.
Holmberg L and Anderson H. HABITS Hormonal replacement therapy after breast cancer - is it safe, a
randomised comparison: trial stopped. Lancet 2004; 363: 453-455.
The Womens Health Initiative Steering Committee. Effects of conjugated equine oestrogen in post
menopausal women with hysterectomy. The Womens Health Initiative randomised controlled trial. JAMA
2004; 291: 1701-1712.
Treatment of Menopause-associated vasomotor symptoms: position statement of the North American
Menopause Society. Menopause 2004; 11: 11-33.
The Million women study. Ongoing longitudinal study launched in 1997. Available at:
http://www.millionwomenstudy.org/index2.html
IMS Updated Recommendations on postmenopausal hormone therapy. Climacteric 2007; 10: 181-194.
Chlebowski RT, Anderson GL. Progestins and recurrence in breast cancer survivors. J Natl Cancer Inst
2005; 97: 471-472.
Conte P, Frassoldati A. Aromatase inhibitors in the adjuvant treatment of postmenopausal women with early
breast cancer: outing safety issues into perspective. The Breast Journal 2007; 13 (1): 28-35.
Hickey M, Saunders CM, Stuckey B. Management of menopausal symptoms in patients with breast cancer:
an evidence-based approach. Lancet Oncology 2005; 6: 687-695.
Greenspan SL, Bhattacharya RK, Sereika SM, Brufsky A, Vogel VG. Prevention of bone loss in survivors of
breast cancer: a randomised, double blind, placebo-controlled, clinical trial. J Clin Endocrinol Metab 2007;
92: 131-136.
Kennemans P, Bundred NJ, Foidart J et al for the Liberate study Group. Safety and efficacy of tibolone in
breast-cancer patients with vasomotor symptoms: a double-blind, randomised, non-inferiority trial. Lancet
Oncol 2009; 10: 135-46.
Holmberg L , Iversen OE , Rudenstam CM et al on behalf of the HABITS Study Group. Increased risk of
recurrence after hormone replacement therapy in breast cancer survivors. J Natl Cancer Inst 2008; 100:
475-82.
von Schoulz E and Rutqvist LE on behalf of the Stockholm Breast Cancer Study Group. Menopausal
hormone therapy after breast cancer: the Stockholm Randomized Trial. J Natl Cancer Inst 2005; 97: 53335.

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3.

Links to other related College Statements

(C-Gyn 09) Management of the menopause

http://www.ranzcog.edu.au/component/docman/doc_download/915-the-menopause-management-of-cgyn-09.html?Itemid=946
(C-Gen 02a) Consent and provision of information to patients in Australia regarding proposed treatment
http://www.ranzcog.edu.au/component/docman/doc_download/899-c-gen-02-guidelines-for-consentand-the-provision-of-information-regarding-proposed-treatment-.html
(C-Gen 02b) Consent and provision of information to patients in New Zealand regarding proposed
treatment
http://www.ranzcog.edu.au/doc/c-gen-02b-consent-and-provision-of-information-to-patients-in-newzealand-regarding-proposed-treatment.html
(C-Gen 15) Evidence-based Medicine, Obstetrics and Gynaecology
http://www.ranzcog.edu.au/component/docman/doc_download/894-c-gen-15-evidence-based-medicineobstetrics-and-gynaecology.html?Itemid=341

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4.

Other useful links

Australasian Menopause Society (AMS)

http://www.menopause.org.au/
Australasian Menopause Society (AMS): The risk of breast cancer with HRT use.
https://www.menopause.org.au/for-women/information-sheets/23-menopause-combined-hormonereplacement-therapy
Jean Hailes Foundation
http://www.jeanhailes.org.au/

5.

Patient information

RANZCOG Patient information pamphlet Menopause: A guide for women (released 2003). A range of
RANZCOG Patient Information Pamphlets can be ordered via:
http://www.ranzcog.edu.au/publication/womens-health-publications/patient-information pamphlets.html

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Appendices
Appendix A Womens Health Committee Membership

Name

Position on Committee

Associate Professor Stephen Robson

Dr James Harvey
Associate Professor Anusch Yazdani
Associate Professor Ian Pettigrew
Dr Ian Page
Professor Yee Leung
Professor Sue Walker
Dr Lisa Hui
Dr Joseph Sgroi
Dr Marilyn Clarke
Dr Donald Clark
Associate Professor Janet Vaughan
Dr Benjamin Bopp
Associate Professor Kirsten Black
Dr Jacqueline Boyle
Dr Martin Byrne
Ms Catherine Whitby
Ms Sherryn Elworthy
Dr Nicola Quirk

Chair and Board Member

Deputy Chair and Councillor
Member and Councillor
Member and Councillor
Member and Councillor
Member of EAC Committee
General Member
General Member
General Member
General Member
General Member
General Member
General Member
General Member
Chair of the ATSIWHC
GPOAC representative
Community representative
Midwifery representative
Trainee representative

Appendix B Overview of the development and review process for this statement
i.
Steps in developing and updating this statement
This statement was originally developed in March 1995 and was most recently reviewed in November
2014. The Womens Health Committee carried out the following steps in reviewing this statement:

ii.

Declarations of interest were sought from all members prior to reviewing this statement.

Structured clinical questions were developed and agreed upon.

An updated literature search to answer the clinical questions was undertaken.

At the November 2014 face-to-face committee meeting, the existing consensus-based

recommendations were reviewed and updated (where appropriate) based on the available
body of evidence and clinical expertise. Recommendations were graded as set out below in
Appendix B part iii)

Declaration of interest process and management

Declaring interests is essential in order to prevent any potential conflict between the private interests of
members, and their duties as part of the Womens Health Committee.
A declaration of interest form specific to guidelines and statements was developed by RANZCOG and
approved by the RANZCOG Board in September 2012. The Womens Health Committee members
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were required to declare their relevant interests in writing on this form prior to participating in the review
of this statement.
Members were required to update their information as soon as they become aware of any changes to
their interests and there was also a standing agenda item at each meeting where declarations of interest
were called for and recorded as part of the meeting minutes.
There were no significant real or perceived conflicts of interest that required management during the
process of updating this statement.
iii.

Grading of recommendations

Each recommendation in this College statement is given an overall grade as per the table below, based
on the National Health and Medical Research Council (NHMRC) Levels of Evidence and Grades of
Recommendations for Developers of Guidelines.17 Where no robust evidence was available but there
was sufficient consensus within the Womens Health Committee, consensus-based recommendations
were developed or existing ones updated and are identifiable as such. Consensus-based
recommendations were agreed to by the entire committee. Good Practice Notes are highlighted
throughout and provide practical guidance to facilitate implementation. These were also developed
through consensus of the entire committee.
Recommendation category

Description

Evidence-based

Body of evidence can be trusted to guide practice

Body of evidence can be trusted to guide practice in most

situations

Body of evidence provides some support for

recommendation(s) but care should be taken in its
application

The body of evidence is weak and the recommendation

must be applied with caution

Consensus-based

Recommendation based on clinical opinion and expertise as

insufficient evidence available

Good Practice Note

Practical advice and information based on clinical opinion

and expertise

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Appendix C Full Disclaimer

This information is intended to provide general advice to practitioners, and should not be relied on as a
substitute for proper assessment with respect to the particular circumstances of each case and the needs of
any patient.
This information has been prepared having regard to general circumstances. It is the responsibility of each
practitioner to have regard to the particular circumstances of each case. Clinical management should be
responsive to the needs of the individual patient and the particular circumstances of each case.
This information has been prepared having regard to the information available at the time of its preparation,
and each practitioner should have regard to relevant information, research or material which may have
been published or become available subsequently.
Whilst the College endeavours to ensure that information is accurate and current at the time of preparation,
it takes no responsibility for matters arising from changed circumstances or information or material that may
have become subsequently available.

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