Understanding and Managing Hot Flashes During Endocrine Therapy for Breast Cancer
The advent of endocrine therapy marked a major breakthrough in the treatment of hormone receptor-positive breast cancer. For patients whose tumors express estrogen or progesterone receptors, estrogen-blocking medications can significantly reduce the risk of recurrence.
Common Endocrine Therapies
The most frequently prescribed estrogen blockers include:
Tamoxifen: Typically used in premenopausal women.
Anastrozole(Arimidex), Letrozole (Femara), and Exemestane (Aromasin) : Commonly used in postmenopausal women.
These treatments can reduce the risk of cancer recurrence, even though we still lack a treatment that can eliminate the risk entirely.
A Systemic Approach with Systemic Effects
Unlike chemotherapy, endocrine therapy is not considered cytotoxic, but it is a systemic treatment—it affects the whole body, not just breast tissue. The main challenge lies in managing the side effects that arise due to this systemic impact.
Common Side Effects
Tamoxifen: Hot flashes, increased risk of blood clots, vaginal dryness, joint pain, difficulty concentrating, and depression.
Aromatase Inhibitors (Anastrozole, Letrozole, Exemestane): Hot flashes, osteoporosis, vaginal dryness, joint pain, cognitive changes, and depression.
Because side effects vary and can be bothersome, I’ll cover them in more depth across a series of newsletters to make the information easier to digest.
Focus on Hot Flashes
Hot flashes are one of the most common and disruptive side effects. Hot flashes can be distressing but are usually temporary and tend to improve over time. Discontinuing therapy solely due to hot flashes is not recommended. There are several effective management options—both medical and non-medical.
Medications That Can Help
Venlafaxine (Effexor)
An antidepressant that has shown efficacy in reducing hot flashes without interfering with tamoxifen's effectiveness. It can also help with mood symptoms related to estrogen suppression.
Citalopram (Celexa)
Another antidepressant with minimal interaction with tamoxifen, effective in alleviating hot flashes.
Gabapentin (Neurontin)
Originally used for seizures and nerve pain, it also reduces hot flash frequency and severity. Side effects may include drowsiness and dizziness.
Clonidine
A blood pressure medication that may offer mild relief. Common side effects are dry mouth, sedation, and constipation.
Oxybutynin (Ditropan XL)
Typically used for overactive bladder, it has shown promise in hot flash management. Side effects include dry mouth and constipation.
Alternative & Complementary Therapies
1. Black Cohosh
Effectiveness: Some studies suggest it may help, but results are inconsistent.
Safety: There's concern about its potential estrogen-like activity, especially in hormone-sensitive cancers. It may also interfere with tamoxifen’s metabolism.
Bottom line: Use with caution and only under medical supervision.
2. Acupuncture
Some studies show it may help reduce hot flashes, but evidence is mixed. Still, it's generally safe and worth considering.
3. Cognitive Behavioral Therapy (CBT)
CBT has been proven to reduce the emotional distress associated with hot flashes and improve quality of life.
4. Breathing Exercises Simple, structured breathing techniques can help regulate the nervous system and reduce the frequency and intensity of hot flashes. The will calm your nervous system, improve body temperature regulation, and reduce anxiety.
Evidence-Based Breathing Techniques
Duration Paced Respiration
Slow, deep abdominal breathing (6–8 breaths per minute).Morning/evening or during hot flashes10–15 min
Diaphragmatic Breathing
Belly breathing with focus on nasal inhale and slow exhale. Daily + during symptoms10–15 min
Box Breathing (4-4-4-4)
Inhale → Hold → Exhale → Hold, each for 4 seconds. During stress or hot flashes1–2 min
Mindfulness Breathing (MBSR)Focused breath awareness and body scan. As part of CBT or relaxation routine10+ min
Conclusion
Hot flashes—while frustrating— can be managed with a range of options, including medications, breathing techniques, or integrative therapies like CBT or acupuncture. My goal is to help you stay on your endocrine therapy without compromising your quality of life.In future newsletters, I’ll address other common side effects of estrogen blockers so that you feel informed, empowered, and supported throughout your treatment journey.
References
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5.Szmyd M, Lloyd V, Hallman K, Aleck K, Mladenovik V, McKee C, Morse M, Bedgood T, Dinda S. The effects of black cohosh on the regulation of estrogen receptor (ERα) and progesterone receptor (PR) in breast cancer cells. Breast Cancer (Dove Med Press). 2018 Jan 18;10:1-11. doi: 10.2147/BCTT.S144865. PMID: 29403307; PMCID: PMC5779278.