Managing side effects of Hormonal Therapy

Vasomotor symptoms +

Vasomotor symptoms include hot flushes and/or sweats which can be disruptive during the day or night, potentially contributing to poor sleep, fatigue, poor concentration and focus. Oestrogen plays a role in temperature regulation. This is not well understood, but reduced oestrogen levels seem to interfere with the body’s internal thermostat in the brain.

The following may assist with preventing or managing vasomotor symptoms:

• Reduce potential precipitating dietary factors (smoking, alcohol, spicy foods)
• Optimise sleep conditions (see sleep hygiene) – consider bedside fans, cooling pads, gel toppers, choosing breathable fabrics
• Dress in layers and wear clothing made of natural fibres that breathe
• Try to and achieve an ideal body weight – weight loss can reduce the frequency of hot flushes
• Consider pharmacotherapy eg. SNRIs (venlafaxine/desvenlafaxine), SSRIs (escitalopram), gabapentin/pregabalin or oxybutynin.
• Consider cognitive behavioural therapy (CBT)
• Consider acupuncture

Musculoskeletal symptoms +

Common side effect of endocrine therapy include joint stiffness, joint pain, muscle pain and sometimes carpal tunnel syndrome. The reasons why endocrine therapy (especially aromatase inhibitors) cause joint symptoms is poorly understood. One theory is that oestrogen has pain-modifying properties, and therefore the depletion of oestrogen will lead to pain being felt in the joints, even the absence of objective damage to them. The following may assist with managing musculoskeletal symptoms:

• Regular exercise – studies examining the benefits of resistance training (two sessions per week) and aerobic training (150 minutes of moderate intensity per week) have demonstrated improvement in musculoskeletal symptoms
• Simple analgesia eg paracetamol and/or NSAIDs (eg ibuprofen)
• Supplement with vitamin D – there is some evidence that those with a higher vitamin D level may experience less joint pain with endocrine therapy
• Consider duloxetine (a medication which has been demonstrated to reduce the musculoskeletal symptoms associated with endocrine therapy)
• Consider switching endocrine therapy – studies have shown that between 30 and 40% of patients who switch from one aromatase inhibitor to an alternate aromatase inhibitors are able to tolerate the alternate one successfully. Tamoxifen is associated with less joint symptoms than aromatase inhibitors, so this may be another alternative.

Sexual dysfunction +

Unfortunately, reducing oestrogen levels in the body has many side effects including problems with sexual function. The most common of these are loss of libido, vaginal dryness and pain during intercourse.

For vaginal dryness, the main treatments are lubricants and moisturisers.

• Moisturisers such as Replens or Vagisil Pro Hydrate are available over the counter. These are designed to be used consistently, and often take around six weeks for maximum benefit to be reached.
• Lubricants such as Sylk or Astroglide can be used with intercourse
• Using soap-free washes (eg QV wash or Cetaphil)
• Vaginal oestrogens may be considered if other measures fail, although their use in breast cancer is controversial and this should be discussed with your doctor.
• Laser vaginal rejuvenation (e.g. MonaLisa Touch) may be an option as an alternative to, or addition to these treatments

Pelvic floor physiotherapists can assist with treatments which may reduce discomfort associated with intercourse. Speak to your doctor about recommending someone with expertise in this area.

Loss of libido can be a complicated issue, with many contributing factors including low oestrogen, pain, altered body image, fatigue to name just a few. Communication with your treating medical team is important so they can help address these concerns. Referral to a counsellor, psychologist or sex therapist may be helpful for some patients to explore issues affecting sexual wellbeing.

Bone health +

Reduced oestrogen levels can result in accelerated loss of bone density, leading to osteopenia or osteoporosis. Women usually reach peak bone mass in their 20s and usually there is minimal change in this until menopause. After menopause, bone mass falls because of reduced oestrogen.

Endocrine therapy which reduces oestrogen levels further can accelerate the loss of bone mass. This is especially true of aromatase inhibitors (particularly if combined with ovarian suppression). Tamoxifen tends to have less impact on bone mass in postmenopausal women, although it can contribute to bone loss in premenopausal women.

Measures to assist with maintaining optimal bone health include:

Exercise

• Osteogenic (bone strengthening) exercises are important to incorporate into your regular routine for bone health.
• Highly osteogenic exercises include basketball, netball, impact aerobics, gymnastics, tennis and skipping.
• Running, hill walking, stair climbing, and resistance training are moderately osteogenic.
• Whilst walking is low osteogenic, and swimming and cycling are non-osteogenic, these exercises do offer other health benefits so may be helpful to incorporate into your routine for other reasons.

Read more about exercises for bone health.

Vitamin D supplementation

• Vitamin D assists the body absorb calcium which is important for bone health. It may have other functions including reducing inflammation and helping the immune system.
• The best source of vitamin D is sunlight (5-10 minutes of sun exposure in the summer, 15 to 20 minutes in winter).
• Dietary sources of vitamin D include egg yolks, oily fish (eg sardines, mackerel), liver.
• One study has demonstrated an association between vitamin D levels and the risk of breast cancer recurrence. Those with a levels >80 nmol/L had a lower risk of recurrence than those with levels <42nmol data-preserve-html-node="true"/L. Whilst vitamin D levels in studies such as these may be a ‘surrogate marker’ of general well-being, aiming for higher levels is considered prudent given that the risks of vitamin D supplementation are minimal.
• A vitamin D supplement may be recommended, especially if your serum levels are insufficient.

Calcium supplementation

• Calcium is essential for bone health, so optimising dietary intake of calcium is advisable
• Dietary sources of calcium include dairy foods such as milk, yoghurt and cheese, as well as bony fish (eg sardines, tinned salmon), firm tofu, kidney beans, almonds, sesame seeds, dark green leafy vegetables (eg broccoli, spinach, kale).
• Optimal intake for adults 50 or less is 1000mg, although this increases to 1300mg for postmenopausal women.
• A calcium supplement may be recommended, especially if your dietary intake is insufficient.
• Supplemental calcium may be in the form of calcium carbonate or calcium citrate.
• Calcium carbonate is usually more readily available, but calcium citrate is recommended if you regularly take an acid suppressing medication such as pantoprazole, esomeprazole or rabeprazole.