Guideline No. 422f: Menopause and Breast Cancer

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).