Managing Hormone Therapy in Breast Cancer
Tools to Manage the Side-effects of Hormone Therapy
Hopefully, you are here reading this because you’re wanting to make things just a bit better. Often after treatment there is little energy left for all that remains. After treatments have slowed down, the last thing desired is more medication; hormone therapy is often the last step. Coupled with pressure to return to work, or navigate disability funding, the final lag can often be overwhelming.
Symptoms post-treatment can be a lot to bear. One can use the analogy of 'long haul cancer syndrome', akin to long haul covid. Symptoms related to long haul cancer can be pain, fatigue or feeling flatlined amongst other breast cancer related conditions and often remain unsupported.
With hormone positive breast cancers, hormone therapy is often the final step.
After starting hormone therapy, some patients have few side effects while others are more burdened. If you are finding yourself overwhelmed with symptoms of hormone therapy such as nausea, hot flashes, malaise and/or pain, this blog is for you.
Cancer Physiotherapy offers: Personalized Rehab Plans + Tools for Pain, Fatigue, Hot Flashes and more…
Types of Hormone Therapy
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Function: block estrogen receptors or production and reduce estrogen conversion
Population prescribed: often post-menopausal and estrogen positive cancers
Examples: Anastrozole/Arimedex, Aromasin/Exemestane, Letrozole/Femara, Vorozole, and Testolactone
Common side effects: Arthralgia/myalgia, hot flashes, poor bone health, nausea, and significant reduction in estrogen
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Other similar types: Selective Estrogen Receptor Modulator (SERMS) Cycling-Dependent Kinase (CDK)
Function: blocks estrogen receptors, binds to estrogen and reduces ovarian estrogen
Population prescribed: pre-menopausal and estrogen +ve cancer
Examples: Tamoxifen/Nolvadex, Faslodex, Nolvadex and Soltamox and Ibrance/Palbociclib
Common side effects: hot flashes, joint pain, sleep disturbances and nausea
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Calcium D-glucarate and Diindolylmethane (DIM) found in cruciferous vegetables (broccoli, cabbage, kale, cauliflower etc.)
Omega 3 fatty acids (fatty fish, flax seeds)
Catechins (Green Tea)
Estrogen receptor inhibitor (Reishi mushroom)
*Always consult with your physician prior to taking any supplements
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Although a young area of science, this study used bio-identical hormone combinations in post-menopausal women to help reduce cancer risk while lessening the symptom burden that often comes from AI's.
As AI's have known negative impacts on the bone and cardiovascular system, there is need for an alternative with less symptom burden.
Hormone Therapy and Risk Reduction
Treatment involving hormone therapy will inevitably impact your estrogen levels. Fortunately, hormone therapies have good efficacy increasing survivorship rates, at times up to 50%. Ask your oncologist about the risk reduction rate that is specific to your cancer type and hormone therapy type.
Knowing the risk reduction rate can help you decide whether hormone therapy, given its potential side effects is right for you.
At times patients will trial a brand of hormone therapy and find the symptom burden too great. Symptoms are often worse for the first 3 months, and then tend to greatly tapper off. At times symptoms can be unmanageable after 3 months or alarming such as uncontrolled vaginal bleeding. In these cases, contact your medical oncologist right away. At times, there are options to trial a different type which may be more tolerated.
Common Symptoms/Side Effects of Hormone Therapy
Cancer treatment may lead to cancer related conditions such as cancer related fatigue and de-conditioning; (cancer related cachexia/muscle loss). Together, these conditions can make the tool of exercise and its recovery a challenge. We know that exercise can have a cardio-protective effect and an increase in Vo2 Max is strongly related to a decrease is all cause mortality. Hence there is immense value of exercising when diagnosed with cancer.
The challenge is that estrogen plays an important role in promoting glucose use by particular muscle fibres, therefor estrogen availability greatly impacts stamina as well. As hormone therapy suppresses estrogen levels, hormone therapy may compound any pre-existing fatigue and exercise intolerance making exercising even harder.
Decreased Estrogen May Lead to Fatigue Making Exercise Hard
#1) Hormone Therapy may Lead to FATIGUE.
Estrogen has many roles, it impacts exercise tolerance as an anti-inflammatory, metabolic accelerator and bone builder. There for, decreased levels of estrogen have been associated with malaise, fatigue and poor exercise stamina. Pool therapy may be a good way to start with light intensity aerobic exercise if fatigue is too limiting.
Hormone therapy suppresses estrogen levels; and as noted above this can impact exercise stamina. Many female athletes will tell you that day ~12-18 of the menstrual cycle when estrogen is at its lowest can lead to poor exercise stamina.
The first 3 months of hormone therapy can be the most challenging. After 3 months of hormone therapy data shows that symptoms tend to lessen, this may be your body fine tuning endogenous adaptations that can lead to improved energy.
This is where exercise is a double edged sword; being so fatigued it can be hard to get started, and if you do too much you might feel worse. But if you can take a graded approach starting slow with pool therapy, walking or light resistance training, the hormones released with exercise can have similar impacts as estrogen, making up for its loss. Hormones released through exercise such as catecholamines improve energy, reduce pain rand reduce inflammation.
A recent blog on exercising with cancer answers all questions on getting started safely and effectively. Tools of cold exposure may also help combat fatigue.
Exercise Related Hormones can Substitute for the Loss of Estrogen.
2) Hormone Therapy may Lead to Increased HOT FLASHES.
Although one might think hot flashes are simply an onset of ‘feeling hot’; anyone who has had one can testify that it is much more than that! A hot flash can involve a sudden onset of profuse sweating, a rapid increase in heart rate and an increase in body temperature; therefor creating a feeling of overwhelm. The typical treatment for menopausal women is systemic estrogen therapy, hence in hormone sensitive breast cancers estrogen treatments aren’t an option. I will elaborate on a specific way of cooling down your body as a primary tool to combat hot flashes.
Estrogen is:
an Anti-inflammatory
a Metabolic Accelerator
a Bone Builder
a Brain Booster
3) Hormone Therapy may Lead to Joint and Muscle PAIN.
Within the first 3 months of hormone therapy, some patients report increased stiffness in their hands, knees, back and other areas of their musculoskeletal (MSK) system. We can differentiate this pain from other causes such as osteoporosis or osteoarthritis because it typically presents in both sides of the body and in multiple joints in the first 3 months of hormone therapy.
At times the stiffness and pain can become intolerable; in some cases it can be misdiagnosed by clinicians outside of oncology. The increase in joint pain/stiffness can be classified as arthralgia/myalgia or at times even misdiagnosed as osteoarthritis. Often it is worse in the morning and worse after long periods of immobility.
The most common symptoms of hormone therapy are pain and stiffness.
Pain in the joints is known as the cancer related condition of Aromatase Inhibitor Induced Musculoskeletal Syndrome (AIIMS). Decreased estrogen levels can impact joint/tissue inflammation, in turn decreasing elastin and collagen production. Together this may cause a loss of tensile strength in tendons and therefor increase muscle and joint pain through out the body.
Cancer treatment often leads to general de-conditioning, pain and fatigue. Therefor less ease with movement and less ability to simply ‘feel good’ through movement can be compounded through the addition of hormone therapy. Increasing dopamine through cold exposure is one of the tool mentioned below to help battle these symptoms, along with graded exercise.
4) Hormone Therapy can Lead to Less Dopamine Release; Making it Hard to ‘Feel Good’.
Dopamine changes are particularly evident in cases where cancer related depression and cancer related fatigue are present. Decreased activity throughout the treatment period coupled with less dopamine release together may cause increased musculoskeletal pain. Therefor while undergoing hormone therapy decreased levels of dopamine and estrogen have been associated with higher levels of musculoskeletal pain.
This blog highlights tools that work with the body’s ability to produce endogenous opioids and catecholamines; impacting pain perception and reducing inflammation.
literature shows that short acting opioid use for acute pain can be helpful but opioid and pain medication for persistent pain often leads to hyperalgesia or ‘hypersensitivity’. We have come to understand in pain science that pain is protection, not detection. Certain medications such as hormone therapy and chemotherapies can sensitize our systems, reducing the threshold for pain. Think of cancer treatment as reigniting the reactive child like alarm system within all of us, it makes the system more sensitive, more likely to react and protect.
Pain is best treated with a multimodal approach, not just a prescription, as it is impacted by many psychosocial and biological factors. Pain is best treated through the incorporation of cognitive behaviour therapy, pain education, lifestyle support (sleep, nutrition) and especially a personalized rehab plan.
Pain is a Biopsychosocial Symptom. It’s Complex; It Needs to be Treated With More Than Just Medication.
5) Hormone Therapy may Lead to NAUSEA.
Often changes in hormones are paired with nausea, hence the first trimester for women expecting is often nausea laden. When I personally started oral hormone therapy as part of an IVF prep, the first 3 months were rampant with nausea likely attributing to changes in estrogen.
We know that nausea is heavily impacted by dopamine receptors, this chemoreceptor trigger zone is in the medulla oblongata of the brain. This poses curiosity surrounding the relationship between dopamine and nausea. If cancer treatment can impact dopamine as noted above; perhaps this is also related to how hormone therapy may cause nausea. Therefor, changing estrogen levels and a decrease in dopamine release may be associated with the onset of nausea in hormone therapy treatment. It’s safe to say that exploring increasing dopamine, endogenous opioids and catecholamines through exercise and cold exposure in general may actually lead to a decrease in nausea.
The First 3 Months of Therapy cause Changes in Estrogen Levels which May Lead to Nausea
6) Hormone therapy may lead to decreased BONE DENSITY.
Often Hormone therapies in addition to radiation and/or chemotherapy can impact bone density, making patients with breast cancer more at risk for osteoporosis. Aromatase inhibitors are known to negatively impact bone health. There are medications to help combat this risk, in addition to routine resistance training.
In addition, changes to bone density can impact the otoconia in your otolith organs of the vestibular system, making patients more susceptible to BPPV (benign paroxysmal positional vertigo) and other vestibular changes. If you are experiencing dizziness, unsteadiness, vertigo or sensitivity to head movements, consider a vestibular assessment here at the cancer physio.
Now for what you’ve been waiting for…
Tools That Work: Managing Symptoms of Hormone Therapy
A common response when we are feeling nauseous or feeling hot is to fan our face or hydrate. Research has confirmed that our most efficient form of heat exchange lays in venous arterial anastomoses in the palms of our hands, soles of our feet and forehead. In other words, these are web like areas rich in blood vessels. The skin there has little hair and a high concentration of direct transition from arteries to veins leading to efficient heat transfer.
#1) Rehab Tool: COOL YOUR BODY’S GLABROUS TISSUE
Glabrous Tissue is Found on your Palms, Soles of your Feet and Forehead
The skin of our hands, feet and forehead is known as glabrous tissues and it is an effective portal into the body’s core temperature. When having a hot flash, or feeling nauseous cooling the soles of your feet, palms of your hands and forehead are portals to quickly cooling your body’s core temperature.
Your Hands, Feet and Forehead are Portals to Cooling your Body’s Core Temperature
Say you’re feeling nauseous or a hot flash onsets, try placing your bare feet in cool water or on an icepack layered with a thin towel. Better yet, lay a cool wet towel on your forehead or grab a natural ice cube in a ziplock bag and squeeze it within the palm of your hand. If you have a water bottle, fill it with water and ice and gently wrap your hands around it.
Note that we are aiming for a ‘cool sensation’ here not an ‘extremely cold sensation’ as we don’t want vasoconstriction to occur. The temperature should be evidently cooler but comfortable. This tool lowers your core temperature and reduces sweating, helping to manage hot flashes.
#2) Rehab Tool: COLD PLUNGE
Here we are talking about deliberate cold submersion; this involves a lot more than just cooling glabrous tissue. With cold exposure, we are aiming to be submerged from the neck down, exposing our body to a cold experience.
Within this blog, we are going to define cold exposure to include a cold bath, cold shower, submersing into a cold body of water or using cryotherapy equipment. At times patients may opt to use wet suit gloves or booties to start. Although some methods of cold exposure are more effective (referenced in current literature); with cold experiences physiologically blood is always shunting out of the periphery and into the core. We want to keep cold exposure accessible to all, so we will include all possible types and not get picky!
Cold Exposure may Help Manage Pain, Fatigue and Mental Well-being
How to Get Started with Cold Plunging Safely
One should start slowly, building into colder temperatures over time. Jumping off of a dock and racing out in panic isn’t recommended or effective. It’s best to slowly adapt your body to the cold shock, practicing your breathing right from the start.
The cold is often uncomfortable; that is how we know it’s working. Starting slowly allows you to train yourself to focus on your breath as oppose to holding your breath, or panicking. Begin with cool temperatures as opposed to cold and staying in longer. In addition, try decreasing the temperature over a 3 week time span. Another strategy would be to be to gradually enter into the cold water; increasing your depth over a 2-3 min time period.
Slow Down your Breathing Rate
+ … D
on’t Hold your Breath …
Focus on slowing down your breathing rate, breathing deep and diaphragmatically. Ideally the rate should be slow such as James Nestor referenced coherent breathing method of ~5.5 seconds in and out. Conversely, try just focusing on your exhale being a bit longer than your inhale and not holding your breath. There are a few breathing methods available, Wim Hof branded Tummo as an example, that can also help generate heat but for the sake of this blog, we’ll keep the focus on simply slowing down your breathing rate.
Trust the process, in time the discomfort will pass, and your body will settle into the cold, this can take up to 3 minutes or more at times. It’s beneficial to leave the water feeling somewhat calm, promoting vagal stimulation as oppose to a state of panic.
On a more personal note, I have been emerging into the discomfort of cold since 2019 and it has helped me immensely, particularly with leg swelling and motivation.
Cold Plunge Protocol
1) When possible, cold exposure from the neck down
2) 11 minutes total/wk (each exposure should be at least ~3 min in length leaving in a state of “calm” not panick)
3) A temperature that is uncomfortably cold such that you’d like to escape it. (Can decrease temperature over time as stated above.)
Repeated cold plunging over long periods of time may have an anti-inflammatory impact effecting levels of interleukin-6 a pro-inflammatory cytokine. This contributes to reducing chronic inflammation and pain. In addition, cold plunging supports a 200-300% increase in dopamine release which helps mental well-being and motivation.
Dopamine is a catecholamine; playing a major role in the motivational component of reward-motivated behaviour. Dopamine is termed a ‘motivational salient’ hormone, which means that it helps to propel behaviour towards a desired outcome resulting in feeling good.
Dopamine is important when feeling flat-lined from estrogen deprivation. We know that nausea, fatigue and pain may be linked to lower levels of dopamine as noted prior; hence cold plunging may be of great value to many experiencing side effects of hormone therapy.
#3) Rehab Tool: Get MOVING
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Recovering from cancer involves an energy toll, with less of your body’s resources available to recover from the optimal stress of exercise. I have made reference before that battling cancer is similar to being an astronaut. There are added barriers that come from cancer treatment akin to the barriers of being in space. Poor recovery capacity, nausea and fatigue can make even light exercise challenging. Returning to exercise can be frustrating and at times result in push crash cycling.
Returning to exercise for those on hormone therapy looks different for every patient.
Returning to Exercise Should be Gradual yet Consistent
On rest days, focus on tools for improved recovery such as good sleep hygiene, nutrition and cold exposure. My detailed blog on Exercise as medicine answers the most common questions on cancer and exercise. Answers surrounding a gradual approach, intensity, duration and type can be found there.
Here at the cancer physio, we aim to support patients through all 5 phases of a cancer journey. Personalized rehab planning while taking into account the safe exercise guidelines allows for optimal rehab. Personalized rehab can help manage the symptoms associated with hormone therapy such as pain, nausea, depression and poor bone density amongst others.
Consistent exercise as medicine, cooling your body and using cold exposure, together are very effective tools for managing the symptoms of hormone therapy. My hope is these simple tools in addition to the support of a personalized cancer rehab plan together will help you feel just a bit more like yourself again.
Thank you for your interest in science and rehab.
Kindly, The Cancer Physio
A Note from The Cancer Physio:
With an aims to curate the latest science, and provide evidence rich tools, I think it is important to understand that not all questions can be answered and good science seeks to provide more questioning over time. I urge you to shy away from sweeping statements and soap box leaders with strong claims. Often new science is just around the corner.
Often patients have been told a lot of ‘no and don’t’ statements through-out their journey; at times mitigating risk is important but one must always ask at what cost.
I have worked with patients with breast cancer that were told to never do a push-up or those with lymphedema that were told to never exercise at higher intensities, or never exercise without a compression sleeve. I have worked with patients who fear hormone therapy will destroy their well being. I have worked with patients who opted not to have radiation due to fear of cardiac arrest.
Every phase of treatment, every intervention and there for every new tool used is a very personal decision.
Informed decision making and with room to observe can lessen risk and open up a lot of possibility.
My ask is that you ask good questions too, as much as possible and keep them coming. One person’s story may have a lot of impact but probabilities are important too.
Unfortunately, there will not always be an obvious answer, but…
In the unknown try to remain curious, hopeful and even optimistic.
If your sense of self is pushing you to explore your capacity as a human being, then I challenge you to keep the boundaries open a bit; you might just be a little surprised.
