Lifestyle modification, rather than hormone therapy, should form the basis for managing estrogen-depletion symptoms and associated clinical problems in breast cancer survivors, according to a review of available evidence.

The review, conducted by the writing group for the Endocrine Society’s guidelines on management of menopausal symptoms, was prompted by the paucity of both randomized controlled trials in breast cancer survivors with estrogen deficiency issues and guidelines that sufficiently focus on treatment of this subgroup of women.

The problem is significant given that the number of survivors is increasing and has reached 9.3 million worldwide, and that the prevalence of estrogen-deficiency symptoms after breast cancer ranges from 79% to 95%, Richard J. Santen, MD, of the University of Virginia, Charlottesville, and his colleagues reported.

“A large proportion of women experience menopausal symptoms or clinical manifestations of estrogen deficiency during treatment of their breast cancer or after completion of therapy. The specific symptoms and clinical challenges differ based on menopausal status prior to initiation of cancer treatment and therapeutic agents used,” the researchers wrote in a report published in the Journal of Clinical Endocrinology & Metabolism (2017 Aug 2. doi: 10.1210/jc.2017-01138 ).

For instance, among premenopausal women treated with chemotherapy, ovarian insufficiency, severe menopausal symptoms, and infertility can result. Postmenopasual women treated with aromatase inhibitors may experience arthralgia, accelerated bone loss, and osteoporotic fractures, as well as severe vulvovaginal atrophy, they explained, noting that both premenopausal and postmenopausal survivors can experience moderate-to-severe vasomotor symptoms and sleep disturbance with related fatigue, depressive symptoms, and mood changes.

“Less common problems include weight gain, symptomatic osteoarthritis and intervertebral disk degeneration, degenerative skin changes, radiation and chemotherapy-related cardiovascular disease, and reduced quality of life,” the researchers wrote.

Based on a review of randomized controlled clinical trials, observational studies, evidence-based guidelines, and expert opinion from professional societies, the writing group concluded that individualized lifestyle modifications and nonpharmacologic therapies are recommended for the treatment of these symptoms.

Specifically, the writing group recommended smoking cessation, weight loss when indicated, limited alcohol intake, maintenance of adequate vitamin D and calcium levels, a healthy diet, and regular physical activity for all women with prior breast cancer.

They also recommended nonpharmacologic therapies for vasomotor symptoms, and noted that cognitive behavioral therapy, hypnosis, and acupuncture are among the approaches that may be helpful.

Vaginal lubricants and moisturizers can also be helpful for mild vulvovaginal atrophy, they wrote. For women with more severe symptoms or signs of estrogen deficiency, pharmacologic agents are available to relieve vasomotor symptoms and vulvovaginal atrophy, and to prevent and treat fractures, they wrote, adding that “therapy must be individualized based on each woman’s needs and goals for therapy.”

Among emerging approaches to treatment of symptoms are selective estrogen receptor modulators (SERMs), tissue selective estrogen complex (TSEC) therapy, estetrol, and neurokinin B inhibitors, which show promise for expanding options for symptom relief with less breast cancer risk. However, these have not yet been tested in women with prior breast cancer, the researchers noted.

Dr. Santen reported receiving research funding from Panterhei Bioscience. Other authors received research funding from Therapeutics MD and Lawley Pharmaceuticals, and honoraria from Abbott, Besins Health Care, and Pfizer.