Hormonal therapies for breast cancer

  • Breast cancer

    Ovarian ablation and breast cancer

    Your doctor may talk to you about having ovarian ablation or ovarian suppression to stop your ovaries producing oestrogen.

Hormonal therapy reduces the chances of breast cancer coming back. It is used in women with oestrogen-receptor (ER) positive breast cancer. There are different types. They reduce the amount of oestrogen in the body or block its effects on the cancer cells.

You take hormonal therapy for a number of years. It is important not to stop taking it. Always talk to your cancer doctor or specialist nurse If you are having difficult side effects. Side effects can be similar to menopause effects, for example, hot flushes.

Tamoxifen is usually given to women who have not been through the menopause. But it can be given to some women after menopause.

Aromatase inhibitors (AIs) are given after menopause. AIs can cause joint pain and bone thinning. You have scans to check your bone health.

Goserelin (Zoladex®) is given as an injection to women who have not been through the menopause. It stops the ovaries making oestrogen and causes a temporary menopause. Some women have surgery to remove the ovaries. This causes the menopause and permanent infertility. You have these treatments alone or with another hormonal therapy drug.

Hormonal therapy

Hormones help control how cells grow and what they do in the body. The hormones oestrogen and progesterone, particularly oestrogen, can encourage some breast cancers to grow.

Hormonal therapies reduce the amount of oestrogen in the body or stop it attaching to the cancer cells. They only work for women with oestrogen-receptor (ER) positive cancers.

Your cancer doctor will advise you to take hormonal therapy to reduce the risk of the breast cancer coming back. It also helps reduce the risk of getting a new breast cancer in your other breast. Sometimes hormonal therapy drugs are given before surgery to shrink a cancer and avoid a mastectomy.

You usually take hormonal therapy drugs for a number of years. For some women, this could be up to 10 years. You usually start taking them after surgery or chemotherapy.

The type of hormonal therapy you have depends on:

  • whether you have been through the menopause or not
  • the risk of the cancer coming back
  • how the side effects are likely to affect you.

We have more information about individual hormonal therapy drugs.


Taking your hormonal therapy

Hormonal therapy drugs reduce the risk of breast cancer coming back. It is important to take it for as long as you have been prescribed it for. Try to make taking it part of your daily routine so it becomes a habit.

Most women cope well with the side effects of hormonal therapy. They may be more of a problem in the first few months, but usually get better over time. 

If the side effects do not improve or are difficult to cope with, talk to your specialist nurse or cancer doctor. They can prescribe drugs to help and suggest ways of coping. If you are still having problems after this, then your cancer doctor may suggest changing to a different type of hormonal therapy.


Types of hormonal therapy

Tamoxifen

Tamoxifen is an anti-oestrogen drug that stops oestrogen attaching to breast cancer cells and making them grow. It is usually given to women who have not been through the menopause. Some women take it for a few years and then go on to take an aromatase inhibitor.

Tamoxifen can also be given to women who have been through the menopause and have a low risk of the cancer coming back. Or it may be prescribed for post-menopausal women who have problems with their bones. 

Tamoxifen does not cause bone thinning in women who have been through the menopause. If you have bad side effects with aromatase inhibitor drugs, you may be given tamoxifen instead.

Tamoxifen is taken daily as a tablet.

The side effects are similar to the effects of the menopause and may include:

  • hot flushes and sweats
  • weight gain
  • tiredness.

Tamoxifen can slightly increase the risk of a blood clot. In post-menopausal women, it can slightly increase the risk of womb cancer. It is important to tell your cancer doctor if you have any vaginal bleeding. We have more detailed information about these side effects.

Your cancer doctor may advise you to take tamoxifen for 5 to 10 years. If you are close to menopause when you start taking it, your doctor may change you to an aromatase inhibitor after a few years of taking tamoxifen. They may do blood tests to check your hormone levels first.

There may be situations where continuing with tamoxifen may not be suitable. If any side effects of tamoxifen become a problem, you may need to take a different hormonal therapy.

Women who want to get pregnant must stop taking tamoxifen because it can harm an unborn baby. Talk to your cancer doctor or specialist nurse if you want a break from tamoxifen to try to get pregnant.

Aromatase inhibitors (AIs)

Aromatase inhibitors (AIs) are the main hormonal therapy used for women who have been through the menopause. They stop oestrogen being made in the fatty tissue. Your cancer doctor may prescribe an aromatase inhibitor such as anastrozole, letrozole or exemestane.

AIs may also be given to younger women with drugs to stop the ovaries working, or after the ovaries have been removed (see below).

These drugs are taken daily as a tablet. Side effects can include:

  • joint and muscle pain
  • hot flushes
  • tiredness.

Your bone health

If taken over a long period of time, AIs can cause bone thinning (osteoporosis). Before you start an AI, you have a scan called a DEXA (dual-energy x-ray absorptiometry) scan, to check your bone health (density).

If you are at risk of osteoporosis, your cancer doctor may prescribe drugs called bisphosphonates to protect your bones. Some women may already be taking bisphosphonates to reduce the risk of breast cancer coming back.

Your doctor may advise you to take calcium and vitamin D supplements to help strengthen your bones. There are things you can do to look after your bones including eating healthily and doing regular exercise such as walking.


Ovarian suppression or ablation

If you have not been through the menopause, your cancer doctor may advise having one of these treatments with another hormonal therapy:

  • Ovarian suppression, which stops the ovaries making oestrogen and causes a temporary menopause.
  • Ovarian ablation, which removes the ovaries and causes a permanent menopause.

These treatments lower oestrogen levels, which reduces the risk of breast cancer coming back. But they can also affect your bone health. Before treatment starts, you have a DEXA scan to check your bone health (density). Your doctor will advise you on how to look after your bones.

Drugs to stop the ovaries making oestrogen (ovarian suppression)

Goserelin (Zoladex®) is a drug that stops the ovaries making oestrogen and causes a temporary menopause. You may have goserelin on its own or with tamoxifen or an AI.

Goserelin stops the pituitary gland in the brain from sending messages to the ovaries to produce oestrogen. The side effects are similar to menopausal symptoms and include:

  • hot flushes and sweats
  • joint pain
  • low sex drive.

Your specialist nurse will give you goserelin as a monthly injection under the skin of the tummy (abdomen). When you finish treatment, your ovaries usually start to produce oestrogen again. This means your periods will come back. But this may not happen if you were close to your natural menopause when you started taking goserelin.

Removing the ovaries (ovarian ablation)

This may be an option for women who do not want to take goserelin injections. You will usually have tamoxifen or an AI as well as ovarian ablation.

Removing the ovaries involves a small operation. It can often be done during a short stay in hospital using keyhole surgery. The surgeon makes a small cut in the tummy area and inserts a thin tube with a tiny light and camera on the end (laparoscope). The surgeon removes the ovaries through the cut using the laparoscope, which has a small surgical instrument attached to it. Women usually recover quickly from this operation.

If you have this surgery, your periods will stop straight away and you will have your menopause. It also means you will no longer be able to have children. Becoming infertile because of cancer treatment can be hard to cope with, but there is support available.

Hormonal therapy before menopause

Your doctor may recommend one of the following:

  • tamoxifen, an anti-oestrogen drug
  • goserelin on its own or with tamoxifen or an AI
  • surgery to remove the ovaries on its own or with tamoxifen or an AI.

Hormonal therapy after menopause

Your doctor may prescribe one of the following drugs:

  • an aromatase inhibitor such as anastrozole, letrozole, exemestane
  • the anti-oestrogen drug tamoxifen and an aromatase inhibitor (one type is given after the other)
  • tamoxifen on its own.

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