ABSTRACT
Objective
Provide strategies for improving the care of perimenopausal and postmenopausal women
based on the most recent published evidence.
Target Population
Perimenopausal and postmenopausal women.
Benefits, Harms, and Costs
Target population will benefit from the most recent published scientific evidence
provided via the information from their health care provider. No harms or costs are
involved with this information since women will have the opportunity to choose among
the different therapeutic options for the management of the symptoms and morbidities
associated with menopause, including the option to choose no treatment.
Evidence
Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020,
and MeSH search terms were specific for each topic developed through the 7 chapters.
Validation Methods
The authors rated the quality of evidence and strength of recommendations using the
Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).
Intended Audience
physicians, including gynaecologists, obstetricians, family physicians, internists,
emergency medicine specialists; nurses, including registered nurses and nurse practitioners;
pharmacists; medical trainees, including medical students, residents, fellows; and
other providers of health care for the target population.
SUMMARY STATEMENTS
- 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).
RECOMMENDATIONS
- 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).
Keywords
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)To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Obstetrics and Gynaecology CanadaAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
REFERENCES
- Recommendations on screening for breast cancer in women aged 40-74 years who are not at increased risk for breast cancer.CMAJ. 2018; 190: E1441-E1E51
- Rating the risk factors for breast cancer.Ann Surg. 2003; 237: 474-482
- The Nams Hormone Therapy Position Statement Advisory Panel. The 2017 hormone therapy position statement of the north american menopause society.Menopause. 2017; 24: 728-753
- Managing menopause.J Obstet Gynaecol Can. 2014; 36: 830-833
- Risk of breast cancer after stopping menopausal hormone therapy in the e3n cohort.Breast Cancer Res Treat. 2014; 145: 535-543
- Collaborative Group on Hormonal Factors in Breast C. Type and timing of menopausal hormone therapy and breast cancer risk: Individual participant meta-analysis of the worldwide epidemiological evidence.Lancet. 2019; 394: 1159-1168
- Association of menopausal hormone therapy with breast cancer incidence and mortality during long-term follow-up of the women's health initiative randomized clinical trials.JAMA. 2020; 324: 369-380
- Use of hormone replacement therapy and risk of breast cancer: Nested case-control studies using the qresearch and cprd databases.BMJ. 2020; 371: m3873
- Levonorgestrel intrauterine system (lng-ius) with conjugated oral equine estrogen: A successful regimen for hrt in perimenopausal women.Hum Reprod. 2005; 20: 2653-2660
- Contemporary hormonal contraception and the risk of breast cancer.N Engl J Med. 2017; 377: 2228-2239
- Breast effects of bazedoxifene-conjugated estrogens: A randomized controlled trial.Obstet Gynecol. 2013; 121: 959-968
- Effect of a tissue selective estrogen complex on breast cancer: Role of unique properties of conjugated equine estrogen.Int J Cancer. 2018; 143: 1259-1268
- Hormone replacement therapy after breast cancer: 10 year follow up of the stockholm randomised trial.Eur J Cancer. 2013; 49: 52-59
- Habits (hormonal replacement therapy after breast cancer–is it safe?), a randomised comparison: Trial stopped.Lancet. 2004; 363: 453-455
- Tibolone increases bone mineral density but also relapse in breast cancer survivors: Liberate trial bone substudy.Breast Cancer Res. 2012; 14: R13
- Management of hot flashes in women with breast cancer receiving ovarian function suppression.Cancer Treat Rev. 2017; 52: 82-90
- Multicenter, randomized, cross-over clinical trial of venlafaxine versus gabapentin for the management of hot flashes in breast cancer survivors.J Clin Oncol. 2010; 28: 5147-5152
- Electroacupuncture versus gabapentin for hot flashes among breast cancer survivors: A randomized placebo-controlled trial.J Clin Oncol. 2015; 33: 3615-3620
- Comparative effectiveness of electro-acupuncture versus gabapentin for sleep disturbances in breast cancer survivors with hot flashes: A randomized trial.Menopause. 2017; 24: 517-523
- Paroxetine: A first for selective serotonin reuptake inhibitors - a new use: Approved for vasomotor symptoms in postmenopausal women.Womens Health (Lond). 2014; 10: 147-154
- Extended-release oxybutynin therapy for vasomotor symptoms in women: A randomized clinical trial.Menopause. 2016; 23: 1214-1221
- Oxybutynin vs placebo for hot flashes in women with or without breast cancer: A randomized, double-blind clinical trial (ACCRU SC-1603).JNCI Cancer Spectr. 2020; 4: pkz088
- Sexual dysfunction and aromatase inhibitor use in survivors of breast cancer.Clin Breast Cancer. 2009; 9: 219-224
- An efficient tool for the primary care management of menopause.Can Fam Physician. 2017; 63: 295-298
- Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer: Consensus recommendations from the north american menopause society and the international society for the study of women's sexual health.Menopause. 2018; 25: 596-608
- Efficacy of vaginal estradiol or vaginal moisturizer vs placebo for treating postmenopausal vulvovaginal symptoms: A randomized clinical trial.JAMA Intern Med. 2018; 178: 681-690
Serum estradiol levels in postmenopausal women with breast cancer receiving adjuvant aromatase inhibitors and vaginal estrogen. Clinicaltrials.Gov identifier: Nct00984399.
- Hormone replacement therapy after a diagnosis of breast cancer in relation to recurrence and mortality.J Natl Cancer Inst. 2001; 93: 754-762
- Tamoxifen, hormone receptors and hormone replacement therapy in women previously treated for breast cancer: A cohort study.Climacteric. 2002; 5: 151-155
- Local estrogen therapy and risk of breast cancer recurrence among hormone-treated patients: A nested case-control study.Breast Cancer Res Treat. 2012; 135: 603-609
- Evaluating the efficacy of vaginal dehydroepiandosterone for vaginal symptoms in postmenopausal cancer survivors: NCCTG N10C1 (alliance).Support Care Cancer. 2018; 26: 643-650
- Selective estrogen receptor modulators inhibit growth and progression of premalignant lesions in a mouse model of ductal carcinoma in situ.Breast Cancer Res. 2005; 7: R881-R889
- In vitro and in vivo biologic effects of ospemifene (FC-1271a) in breast cancer.J Steroid Biochem Mol Biol. 2001; 77: 271-279
- 366-Gynaecologic management of hereditary breast and ovarian cancer.J Obstet Gynaecol Can. 2018; 40: 1497-1510
- Effect of short-term hormone replacement therapy on breast cancer risk reduction after bilateral prophylactic oophorectomy in BRCA1 and BRCA2 mutation carriers: The prose study group.J Clin Oncol. 2005; 23: 7804-7810
- Hormone therapy and the risk of breast cancer in BRCA1 mutation carriers.J Natl Cancer Inst. 2008; 100: 1361-1367
- Hormone replacement therapy after oophorectomy and breast cancer risk among BRCA1 mutation carriers.JAMA Oncol. 2018; 4: 1059-1065
- Hormone replacement therapy after prophylactic risk-reducing salpingo-oophorectomy and breast cancer risk in BRCA1 and BRCA2 mutation carriers: A meta-analysis.Crit Rev Oncol Hematol. 2018; 132: 111-115
Article info
Publication history
Published online: November 16, 2021
No. 422f, December 2021 (Replaces No. 311, September 2014)Footnotes
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.
Identification
Copyright
© 2021 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
