Benefits, Harms, and Costs
- 1The association between breast cancer risk and menopausal hormone treatment is complex (moderate).
- 2Systemic menopausal hormone therapy is contraindicated in women with a personal history of any type of breast cancer (high).
- 3Non-hormonal options for systemic symptom management can be used in women who have had breast cancer (high).
- 4Menopausal hormone therapy does not significantly increase breast cancer risk in premenopausal BRCA carriers who have had risk-reducing salpingo-oophorectomy (moderate).
- 5Menopausal hormone therapy does not appear to increase breast cancer risk in unaffected BRCA1 or BRCA2 mutation carriers (moderate).
- 1When indicated, prescribe the menopausal hormone therapy regimen that confers the lowest possible breast cancer risk (conditional, moderate).
- 2Modifiable risk factors, such as weight, smoking, alcohol use, and exercise, should be optimized among menopausal patients considering treatment (strong, high).
- 3Non-pharmacotherapeutic options for the management of vasomotor symptoms in breast cancer patients include paced breathing, acupuncture, and cognitive behavioural therapy (strong, moderate).
- 4Venlafaxine is the first-line non-hormonal alternative for the management of vasomotor symptoms in breast cancer patients (conditional, moderate).
- 5Paroxetine, gabapentin, oxybutynin, and clonidine are non-hormonal options for refractory vasomotor symptoms. Paroxetine should be used with caution in patients receiving tamoxifen (conditional, moderate).
- 6Non-hormonal options for the management of genitourinary syndrome of menopause in breast cancer survivors include vaginal moisturizers, lubricants for intercourse, pelvic floor physiotherapy, and dilators or vibrators (strong, moderate).
- 7Local vaginal estrogens can be considered in breast cancer survivors. Clinical trials are ongoing to establish safety of vaginal hormonal products in breast cancer survivors taking aromatase inhibitors (conditional, moderate).
- 8Vaginal dehydroepiandrosterone and oral ospemifene are alternatives to local estrogen treatment for genitourinary syndrome of menopause; however, further studies are needed in breast cancer survivors (conditional, low).
- 9Menopausal hormone therapy regimens should be individualized and preference given to estrogen-alone therapy in any patient who has undergone hysterectomy (conditional, high).
ABBREVIATIONS:CE (conjugated estrogen), DHEA (dehydroepiandrosterone), ER (estrogen receptor), GSM (genitourinary syndrome of menopause), MHT (menopausal hormone therapy), MPA (medroxyprogesterone acetate), RRSO (risk-reducing salpingo-oophorectomy), SNRI (serotonin-norepinephrine uptake inhibitor), SSRI (selective serotonin reuptake inhibitor), VMS (vasomotor symptoms), WHI (Women's Health Initiative)
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This document reflects emerging clinical and scientific advances as of the publication date and is subject to change. The information is not meant to dictate an exclusive course of treatment or procedure. Institutions are free to amend the recommendations. The SOGC suggests, however, that they adequately document any such amendments.
Informed consent: Everyone has the right and responsibility to make informed decisions about their care together with their health care providers. In order to facilitate this, the SOGC recommends that health care providers provide patients with information and support that is evidence-based, culturally appropriate, and personalized.
Language and inclusivity: The SOGC recognizes the importance to be fully inclusive and when context is appropriate, gender-neutral language will be used. In other circumstances, we continue to use gendered language because of our mission to advance women's health. The SOGC recognizes and respects the rights of all people for whom the information in this document may apply, including but not limited to transgender, non-binary, and intersex people. The SOGC encourages health care providers to engage in respectful conversation with their patients about their gender identity and preferred gender pronouns and to apply these guidelines in a way that is sensitive to each person's needs.