Lifestyle advice

• CKS found no trial evidence on lifestyle modification for women experiencing menopausal symptoms whilst taking tamoxifen.
• It is uncertain whether lifestyle modifications such as exercise, healthy weight loss, and stopping smoking improve hot flushes in menopausal women who are not taking tamoxifen.
• Therefore, these recommendations are based on expert opinion found in a review of symptoms and treatment in cancer therapy-induced early menopause [Boekhout et al, 2006], a review on hormonal breast cancer treatments for the primary care provider [Lyon et al, 2006], and recommendations in the CKS topic on Menopause [Rees and Purdie, 2006; ICSI, 2008].

Treatment of atrophic vaginitis

• Symptoms of atrophic vaginitis are less likely to occur with tamoxifen than with aromatase inhibitors. An expert review suggests non-hormonal vaginal lubricants (such as Replens MD^®) are helpful for some women, but are not as effective as topical oestrogens [Hickey et al, 2008].
• Gels such as Replens MD^® rehydrate the tissues and are a more physiological way of replacing vaginal secretions than with lubricant vaginal gels such as K-Y Jelly^® [RCOG, 2006].
• Topical vaginal oestrogens are widely used for atrophic vaginitis in the general population, and are considered to be the most effective treatment for vaginal dryness. However, CKS does not recommend their use in women with breast cancer because their safety in this group is not established, although there is no evidence of harm [Hickey et al, 2008].

Specialist advice

• For severe menopausal symptoms likely to be due to tamoxifen, there may be a place for modifying, or in some cases stopping, endocrine treatment [Hickey et al, 2008].
• Feedback from expert reviewers suggests that this should only be done in secondary care, after lifestyle measures and drug treatments have been tried.
• Treatment options may include a temporary break from tamoxifen treatment, or a switch to an aromatase inhibitor (for post-menopausal women).