ENDOCRINE DILEMMA Managing menopausal symptoms after breast cancer John Eden Barbara Gross Research Unit, Royal Hospital for Women and University of NSW, Locked bag 2000, Randwick, New South Wales 2031, Australia Correspondence should be addressed to J Eden Email j.eden@unsw.edu.au Abstract Managing the symptoms of menopause after a diagnosis of breast cancer offers some unique clinical challenges. For some women, vasomotor symptoms can be severe and debilitating, and hormone therapy is at least relatively contraindicated. Non-oestrogen therapies for hot flushes include SSRIs, clonidine, gabapentin and perhaps black cohosh extracts. Vulvovaginal atrophy can usually be alleviated by simple moisturizers, although some may need specialized physiotherapy such as vaginal dilators. In a small number, topical oestrogens may be the only treatment that works. The CO 2 laser may be a novel, non-oestrogen therapy to alleviate this unpleasant symptom. Bone loss can be accelerated in some patients on AIs or those who had early menopause induced by chemotherapy. European Journal of Endocrinology (2016) 174, R71–R77 Introduction For many menopausal women, symptoms such as hot flushes, insomnia, mood swings and vaginal dryness are problematic. Hormone replacement therapy (HRT) and topical oestrogens are highly effective and safe when used for the short-term. However, for those with a personal history of breast cancer HRT, even topical oestrogens are considered at least relatively contra-indicated. Not only that, chemotherapy can induce premature menopause, pro- voking severe hot flushes. Many of the endocrine therapies used to treat ERC breast cancer (tamoxifen and aromatase inhibitors (AIs)) can aggravate or induce hot flushes. Thus many breast cancer survivors will have poor quality of life and painful, unpleasant intercourse, if not treated. Also, menopause per se, has long been associated with osteoporosis. Early menopause, induced by chemother- apy, and the AIs can accelerate this potentially devastating bone problem. Fortunately, there are many non-contro- versial options, such as the bisphosphonates, available to help these women (Table 1). The management of menopausal symptoms after a diagnosis of breast cancer is much more controversial and difficult. Health professionals working with breast cancer survi- vors are very aware of the quality of life issues after breast cancer. Over the last two decades, there has been much research and many clinical trials aimed at finding effective non-oestrogen therapies to help such menopausal women. Invited Author’s profile Dr J Eden (MB BS, MD, FRANZCOG, FRCOG, CREI) is a certificated reproductive endocrinologist and gynaecologist. He is a Conjoint Associate Professor at The University of New South Wales in Sydney. He is a visiting medical officer at the Royal Hospital for Women, Sydney, Australia where he is Director of the Sydney Menopause Centre and the Barbara Gross Research Unit. He also works at the Moree Aboriginal Health Service. John is a Director of the Women’s Health and Research Institute of Australia (WHRIA). His research interests include managing menopause after breast cancer, early menopause, polycystic ovary syndrome (PCOS), osteoporosis, biofilms, hormone replacement therapy as well as herbal medicine. European Journal of Endocrinology Review J Eden Menopause after breast cancer 174 :3 R71–R77 www.eje-online.org Ñ 2016 European Society of Endocrinology DOI: 10.1530/EJE-15-0814 Printed in Great Britain Published by Bioscientifica Ltd.