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Consequences and Management of Menopause in Women with Breast Cancer (pp. 51-77) $25.00
Authors:  C. Simmons (Internal Medicine Resident McMaster University), S. Verma and M. Clemons (Toronto-Sunnybrook Regional Cancer Centre, Toronto, Canada
Breast cancer is a common malignancy and remains a major health issue with significant morbitiy and mortality. Surveillance, Epidemiology and End Results (SEER) data shows that white women in the US have a 13.1% lifetime risk of developing breast cancer, while African American women have a 9.6% lifetime incidence. The lifetime risk of dying of breast cancer is 3.4% in both groups [1]. It has been known for over 100 years that breast tissue is sensitive to endogenous hormones. However, it has only become clear in recent decades that prolonged exposure to endogenous and exogenous sex steroids, particularly estrogens can lead to the development of breast cancer [2,3].
In view of the hormone dependent nature of breast cancers, issues around the management of cancer treatment related menopausal symptoms are particularly pertinent. The reasons that women with breast cancer are more prone to both the short and long term consequences of menopause are as follows:

• The average age of diagnosis with breast cancer in women is 62, making most women peri- or post-menopausal at the time of their diagnosis.
• At diagnosis, many women are taking an estrogen replacement which they are conventionally instructed to discontinue. This may result in an abrupt recurrence of menopause-associated symptoms.
• For post-menopausal women, therapeutic hormonal manipulation with agents such as tamoxifen and the aromatase inhibitors, leads to an adjustment of a woman’s endogenous estrogen state and consequently menopausal symptoms are a common consequence.
• For pre-menopausal women receiving either endocrine or chemotherapy premature and permanent menopause is common [2] Chemotherapy and endocrine therapy with aromatase inhibitors also have additional adverse effects on bone health.
• As a consequence of improved therapy and/or earlier detection more women are surviving breast cancer and living longer [3]. As a result patients are living longer with their menopausal symptoms.

Based on the above factors, the management of menopause and its complications in breast cancer survivors is becoming an increasingly concerning issue – both in the short and long term. While estrogens and hormone replacement therapy has been studied extensively for the treatment and prevention of post-menopausal symptoms, their use in breast cancer patients is questionable. Current guidelines state that the use of hormone replacement therapies in breast cancer patients is not recommended [4]. Alternatives to this therapy include several non-hormonal agents and lifestyle modifications which will be discussed further. These therapies and recommendations may help improve the general health and quality of life in post-menopausal women with breast cancer. 

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Consequences and Management of Menopause in Women with Breast Cancer (pp. 51-77)