Today, we’re speaking to Dr Sophie McGrath, Consultant Medical Oncologist based at the Royal Marsden NHS Foundation Trust and at Kingston Hospital in London.

Title of paper: Management of menopausal symptoms following treatment for hormone receptor positive breast cancer

Available at: https://doi.org/10.3399/BJGP.2025.0264

This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.

Speaker A

00:00:00.800 - 00:01:11.660

Hello and welcome to BJJP Interviews. My name is Nada Khan and I'm one of the associate editors of the bjgp. Thanks for joining us today to listen to this podcast.

In today's episode, we're speaking to Dr. Sophie McGrath, who is a consultant medical oncologist based at the Royal Morrison NHS Trust and at Kingston Hospital in London.

We're here to talk about the recent analysis article that she and her colleagues have published here in the BJDP titled Management of Menopausal Symptoms Following Treatment for Hormone Receptor Positive Breast Cancer.

And just to point out that these colleagues included not just medical oncologists, but also GPs and patients, which I think has really shaped this article and is one of the reasons why we wanted to highlight it here in the podcast. So, hi Sophie, thanks for meeting me to talk about this article, which I think touches on a really important topic in practice.

But talk us through some of the initial side effects that you discuss in the introduction here. Just in terms of hormone positive breast cancer, what kind of symptoms do women experience generally as a result of endocrine therapy?

Speaker B

00:01:12.220 - 00:02:32.900

So, yeah, thanks very much for asking. And it's a bit of a broad answer that I would give.

I mean, I've focused on, or we have focused on three main symptoms within the article which relate to hot flushes or vasomotor symptoms, also to joint stiffness and pain and swelling, arthralgia, and also to vulvovaginal symptoms, otherwise known as genitourinary syndrome of menopause.

But I think what we've tried to include within the article as well is a table that certainly acknowledges that there are unfortunately many other symptoms that women can get as a result of these medications, essentially mimicking menopausal side effects.

And of course, you know, these might be symptoms that women having already gone through the menopause may have suffered or experienced at some point already.

But actually for a population of premenopausal women, these will be symptoms that they haven't had any experience of yet and can often be quite intense and develop quite suddenly. Whereas often our post menopausal women have had some sort of lead up to this, they've had some experience.

Speaker A

00:02:34.710 - 00:02:44.710

And you work as a medical oncologist. But just talk me through your own experience of working with women who are going through the sort of sudden menopause as you describe as well.

Speaker B

00:02:45.350 - 00:05:50.240

So obviously the focus of the article here is on menopausal side effects in general from the treatments that we use. And we've talked a lot about using our endocrine treatments such as tamoxifen, letrozole.

But actually many of our women also experience menopausal type side effect secondary to the chemotherapies we give them. So I think, you know, there's sort of two groups you often have, particularly premenopausal women who stop their periods whilst on chemotherapy.

That may happen several weeks into their chemotherapy treatment and it can be quite sudden.

You know, they're already dealing with the numerous side effects attributed to the chemotherapy itself, but then they're also having to tackle these hot flushes, insomnia, potentially arthralgia. Obviously the vaginal symptoms may be more medium to longer term impact.

So you've got that group of women who are sort of thrust into menopausal symptoms very quickly and then you have the other group who perhaps have already gone through their menopause.

So they're not necessarily getting those symptoms alongside chemotherapy, but, but then after that we are introducing letrozole, which by removing even that last little bit of oestrogen production in the system is giving them enhanced menopausal side effects yet again. So I think that's sort of psychologically a big thing for the patients to deal with as well.

Whether they're sort of having all of that thrust upon them in one go or whether it's more gradual and they're almost waiting for it to occur. So I think for us, us there's a lot we've got to get through in our consultations.

Obviously if it happens alongside chemotherapy, then we're seeing them regularly anyway. We've got our nurses to support them in the clinics too.

But I think the challenge arises more when our ladies are moving on to their endocrine therapy and moving away from regular consultations in our clinics and having more contact again with primary care. They're wanting to get on with their lives. They're wanting to not be coming up to the hospital quite so often.

And so that was a real focus of this article, wanting to reach out to primary care, but also perhaps non oncology based secondary or tertiary care practitioners.

So maybe gynecologists or people that work very closely within menopausal clinics, not necessarily just within primary care and try and work out how can we support these ladies with symptoms that may take several months to declare themselves and may even be once they've been discharged to our stratified follow up programs, but not necessarily seeing us regularly in, in the clinic.

Speaker A

00:05:51.120 - 00:06:13.110

And I think one thing that I'm always struck by, especially with Women going through the perimenopause and the menopause is that this is a busy time in women's lives. So they might be juggling younger children, a career, caring for, you know, older parents.

So there's a lot going on in these women's lives that things like arthralgia, vasomotor symptoms are going to have a big impact on. Really?

Speaker B

00:06:13.910 - 00:07:33.180

Absolutely. And I think it's really important that we let these ladies know that we're there to try and help and support them.

We're not going to have a one size fits all approach for everybody. But also we do try and not paint a doom and gloom picture from the outset.

Not all women suffer these symptoms to the same degree, of course, so it's sort of in making them aware that they could happen, but then arming all of those medical professionals that they may come into contact with, with the tools to work through and try and help and support. I think, you know, one, one thing that often vasomotor symptoms really impact, for instance, is sleep.

And so, you know, insomnia can be a really big problem for our ladies.

But actually, if you dig into it, you often find that it's because they're having their mainstay of their vasomotor symptoms in the night and they're being woken up by them and then they're struggling to get back to sleep.

So, you know, yes, I agree it's a really challenging time, both in terms of what we might be contributing to in terms of their symptoms, but also them wanting to get on with their lives after this diagnosis.

Speaker A

00:07:33.820 - 00:07:52.690

Yeah, fair enough. And you touch on the fact that systemic hormone replacement therapy is avoided in people with a history of breast cancer due to the increase in risk.

But I wonder if you could talk us through some of the alternative options here that you mentioned in the paper. And let's start with the vasomotor symptoms because you just touched on that as well.

Speaker B

00:07:53.170 - 00:12:56.770

So I suppose just to clarify, obviously the focus of this paper is in hormone receptor positive breast cancer because it is the majority subtype that we see in our women.

It's not a blanket rule, but we are less concerned usually about the use of hormone replacement therapy in our ladies with the hormone negative subtypes. Of course, the primary care practitioners always very happy for you to contact us oncologists if you want to clarify anything there.

But, you know, the focus of this article is about the hormone positive space.

And so certainly within those early years after a diagnosis, our mainstay is trying to minimize that Circulating level of oestrogen as much as possible.

Obviously that may be suppressing ovarian function with GnRH analogues but even on top of that, you know, if that were all that were required, then why do women, postmenopausal women develop hormone sensitive breast cancer? We know it's because of these, this production of estrogen elsewhere in the system.

So then you've got your aromatase inhibitor medications, they're trying to eradicate even those small amounts.

So it, it does, it's very counterintuitive for us to be able to support the use of even topical estrogen based treatments when we're in this sort of early stage after a diagnosis.

That said, of course, and it's sort of outside the scope of this discussion, but of course, you know, we will consider the particular risk of that individual patient. We'll have to consider, you know, their age, the quality of life etc.

So by no means is it a blanket rule but I think, you know, what we're hoping to gain from this article is to highlight what other possibilities are out there that we could look to try.

First of all, so in terms of the vasomotor symptoms, as you say, there are some of the sort of lifestyle changes which to be perfectly honest, I imagine most of our patients are well read.

You know, they will have already looked to methods that they can help themselves with such as portable fans, layered clothing, but it is important to bear those things in mind trying to use lighter fabrics where possible. There is some data to suggest that reducing or removing alcohol and caffeine can help with such symptoms.

And then there is, you know, the exercise in its own right, we know that's very helpful for the arthralgia but actually there is suggestion that that can help with the individual vasomotor symptoms as well.

But what we'll often then talk about with our ladies is say, right, well the next sort of group of potential strategies is around non pharmacological interventions but things that do have now a good database behind them. So actually there's qu a lot of growing evidence for cognitive behavioral therapy which I'm quite excited about.

You know we've had various trials including a major UK led trial, Menos 4 which really did show significant benefit for management of the vasomotor symptoms and many of the patients that I speak to are really open to this concept. The British Menopausal Society has great links.

Our local Maggie Centre, and I'm sure this is the case elsewhere around the country, is starting to offer on site or online CBT as well to try and help with such symptoms. But certainly there are self directed programs as well, which I would highly recommend patients to explore.

But the other thing from a non pharmacological perspective is acupuncture. And again we're fortunate where I work that we do have on site acupuncture services.

The wait is fairly long unfortunately, but at least we can offer that.

And many of our women have really noticed a significant improvement in the intensity and the frequency of their hot flushes from, from a course of acupuncture.

And sometimes ladies can be taught to self needle as well, which can be quite useful if they do find months down the line that they get a slight flare in the symptoms and then they can get that control back using the technique themselves. And then I suppose the final group is the pharmacological interventions.

Speaker A

00:12:57.250 - 00:13:00.690

And you mentioned tibalone in the paper as well, don't you? As well?

Speaker B

00:13:00.690 - 00:14:46.130

Yeah.

So in terms of data support supporting tibalone, I mean at the moment, just to clarify, I'm not recommending that within the paper as a well researched safe intervention within these patient group.

Unfortunately, you know, we know that it's got oestrogenic progestogenic properties, but unfortunately the main trial looking at this was actually stopped prematurely because there was a suggestion of increased recurrence rates of breast cancer. So at the moment that's certainly not something that we would advocate.

We weren't able to go into great amount of detail in the article, but I think a really interesting watch this space area is going to be these novel neurokinin 3 receptor antagonists.

So fezzalinitant is the one that probably most people will have heard of, but there are others and certainly in the non breast cancer space, I know that many women have gained significant improvement in menopausal symptoms from these medications, but we're just a little nervous reticent at the moment in the hormone positive breast cancer population, mainly because we just don't have the data in that group specifically.

But the trials are running at the moment and hopefully we'll have that data soon and have such medication available to our ladies if those other non pharmacological methods aren't working well for them.

Speaker A

00:14:46.210 - 00:15:02.050

And in terms of joint issues in arthralgia, you point out the lifestyle modifications that people can make, many of them quite similar to what you've described for the vasomotor symptoms alongside acupuncture as well, which you've mentioned. But you also touch on the use of duloxetine as well.

Speaker B

00:15:03.170 - 00:15:19.080

Yes. So it's there as an option. It has been looked at in trials.

There was some benefit noted, but I think it's a really tricky drug from a toxicity profile.

Speaker A

00:15:19.160 - 00:15:19.720

Yeah.

Speaker B

00:15:20.440 - 00:17:05.040

And also I think it's the same for the vasomotor symptoms.

When you start mentioning to patients about taking another medication to solve the side effects of the medication you're giving them, people do start getting a little bit nervous about that, that prospect. And duloxetine is one of those personally that I haven't seen a great deal of good benefit from in my own patient cohort.

That's not to say, of course, that it doesn't work for ladies out there.

Again, I was interested in producing this article that there was very little objective evidence supporting things like the omega 3 fish oils, glucosamine. Actually, in practice, many of my ladies are taking that not just for their joints, but for cardiovascular and brain health.

And they will say, look, actually when I'm not on it, I notice the difference. So I do find that generally in my ladies to be helpful and trying where possible, to keep regular movement and exercise. But it is a challenge.

And that is where, you know, by all means, sometimes we do end up having to change the endocrine therapy. It's much less prevalent, of course, with tamoxifen versus the aromatase inhibitors.

In practice, it can be less with exomestane versus some of the other aromatase inhibitors.

So I think it's really important that we try and work with our ladies as closely as possible and get these symptoms ironed out as much as we can in those early months.

Speaker A

00:17:05.840 - 00:17:40.750

Yeah, fair enough. And I think a common thing that we see a lot in practice and deal with as gps are the genitourinary symptoms of the menopause.

And I think there is some confusion about what kind of topical treatments we can use safely for this and whether oestrogen containing pessaries are safe in women with a history of a hormone receptor positive breast cancer. And I think I've even had, had, you know, conflicting advice given to me from colleagues or from hospital specialists as well.

Do you think gps are safe to start this in practice in this group of women?

Speaker B

00:17:41.790 - 00:22:01.630

So I suppose if we go to the guidelines now, whether that's UK based or American guidelines, they will mostly still say in the case of a hormone sensitive breast cancer patient that it is advisable to avoid even topical containing oestrogen containing products. There is a mixed data set from the trials as to whether there really is an increased rate of recurrence with the use of such medications.

But we do know that you definitely can detect increased rates of circulating oestrogen or estradiol in ladies that use such products. Whether that of course results in a recurrence is, you know, yet to be fully elucidated.

So I suppose, you know that judging by the guidelines that we have available to us, what we tend to say in the first instance is let's try and see if all non hormonal containing products have been utilized to the fore in the first instance. And I think what's often missed is the importance of saying with these non hormonal containing products.

So actually, you know, the lubricants are very useful around the time of intercourse, but it's actually the moisturizers that are going to provide the longer term benefit. And actually they need to be used regularly.

So the suggestion is at least two to three times per week applied and that on average, you know, it may take 30 plus days for a lady using that regular regime to really notice a significant difference. So I sort of say to my women, right, this becomes part of your skincare routine, okay?

It, you know, might not be what you would normally associate with your skincare routine, but you, you add this into, you know, your, your regular routine.

And by all means, if you have young sexually active ladies who are religiously applying these products, they've, they've done everything you've said and they are still really, really struggling. Even those women who, it may not be around intercourse, it may be recurrent urinary tract or just symptoms of itch or pain in the vaginal area.

If these methods have been tried and are not alleviating the symptoms, then I think we have to be open to the fact of looking at potentially short courses of using things like, I suppose, low dose estriol in the vaginal area.

What the article does talk about though is that it's thought that it's probably safer if you're going to use such products to combine those with tamoxifen based endocrine treatment rather than continuing with an aromatase inhibitor.

So I suppose what my quick answer