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Case History

image A 56-year-old woman comes complaining of hot flushes and vaginal dryness. She had a lumpectomy, radiotherapy and tamoxifen for an oestrogen receptor–positive invasive breast tumour six years ago and has not had a period for five years.

What are the issues?

What non-oestrogen based therapies can she use to control her flushes?

What can she use for vaginal dryness?


What are the issues?

image Breast cancer is a common condition and 212 920 women were expected to develop the disease in the United States in 2006.1 Standard advice is to avoid systemic oestrogen (hormone replacement therapy [HRT]), especially in women with oestrogen receptor– positive tumours. Most clinical studies of patients with breast cancer who have been prescribed systemic oestrogens have not shown an adverse effect on survival; however, these studies involved small numbers of patients with short-term follow-up. The situation has become confused with the contradictory results of two randomized trials in Scandinavia (HABITS and Stockholm studies).2,3 The HABITS study found an increased risk for women exposed to HRT but the Stockholm study did not. The increased risk of recurrence of breast cancer reported in HABITS has been suggested to be explained by the fact that most women randomized to HRT did not use concurrent tamoxifen and most used continuous combined HRT, whereas in the Stockholm study most women took tamoxifen and had long-cycle combined HRT. Thus, currently, the effect of HRT in women with breast cancer is uncertain.

What non-oestrogen based therapies can she use to control her flushes?

Pharmacological alternatives for hot flushes


Clonidine is a centrally acting α-adrenoceptor agonist that was developed originally for the treatment of hypertension. An oral dose of 50–75 μg twice daily has been used to treat vasomotor symptoms (Table 15.1). However, despite its popularity, evidence of efficacy in randomized controlled trials is poor.4

Table 15.1Pharmacological and non-pharmacological options for treating menopausal symptoms in women with breast cancer

β-blockers have been postulated as a possible option for treating vasomotor symptoms, but results from the small trials which have been conducted have been disappointing.

Selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs)

Fluoxetine, paroxetine, citalopram and venlafaxine have been found to be effective in several studies. However most are short-lasting and effective only for a few weeks.4 A nine-month placebo-controlled study of citalopram and ...

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