What are the treatment options for premenopausal (before menopause) women?

From the Guidelines

Premenopausal women with breast cancer should be treated with ovarian suppression or ablation in combination with hormone therapy, as this approach has been shown to achieve similar results to those in postmenopausal women 1. The treatment options for premenopausal women with breast cancer are focused on managing symptoms and preventing disease progression.

Treatment Options

• Ovarian suppression or ablation in combination with hormone therapy, such as tamoxifen or an aromatase inhibitor, is a recommended approach 1.
• The combination of an aromatase inhibitor and a GnRH agonist (or oophorectomy) confers a significant absolute benefit in terms of freedom from distant recurrence and should be the preferred option in higher-risk patients 1.
• Tamoxifen alone for 5 years is indicated for low-risk patients, while switching to an aromatase inhibitor after 5 years of tamoxifen should be considered for women who have become definitively postmenopausal 1.

Important Considerations

• Premenopausal women should be counseled about the risks, associated symptoms, and outcomes of treatment-related amenorrhea and premature menopause, and referred for special fertility counseling/consultation 1.
• Treatment should be individualized based on symptom severity, medical history, and personal preferences, with the lowest effective dose used for the shortest duration necessary to control symptoms.
• Lifestyle modifications, such as regular exercise, maintaining a healthy weight, avoiding triggers like alcohol and spicy foods, dressing in layers, and practicing stress reduction techniques, are also important for managing symptoms. Based on the most recent and highest quality study, the combination of an aromatase inhibitor and a GnRH agonist (or oophorectomy) is the preferred treatment option for premenopausal women with breast cancer, particularly those at higher risk of relapse 1.

From the FDA Drug Label

Kariva® (desogestrel/ethinyl estradiol and ethinyl estradiol tablets USP) is indicated for the prevention of pregnancy in women who elect to use this product as a method of contraception.

The treatment options for premenopausal women include oral contraceptives, such as Kariva, which is indicated for the prevention of pregnancy.

• Key benefits: Oral contraceptives are highly effective in preventing pregnancy.
• Important considerations: Women should be carefully monitored while taking oral contraceptives, especially those with a history of hypertension, diabetes, or other health conditions. 2

From the Research

Treatment Options for Premenopausal Women

The following treatment options are available for premenopausal women:

• Combined oral contraceptives (COCs) can help control menstrual irregularity, heavy menstrual bleeding, and vasomotor symptoms, and significantly reduce the risk of ovarian cancer, endometrial cancer, and colorectal cancer 3
• Levonorgestrel-releasing intrauterine system (LNG IUS) is an effective treatment for menorrhagia, and is more effective than COCP in reducing menstrual blood loss (MBL) 4, 5
• Oral progestogens can regulate menstrual cycles and reduce MBL 4, 6
• Tranexamic acid is approved by the U.S. Food and Drug Administration for the treatment of ovulatory bleeding, but is expensive 4
• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as mefenamic acid and naproxen may be used to reduce MBL, but there is insufficient evidence to determine their effectiveness compared to COCP 5
• Gonadotrophin-releasing hormone (GnRH) analogues such as goserelin can be used as pre-operative endometrial thinning agents before endometrial destruction for heavy menstrual bleeding, and may improve operating conditions and short-term postoperative outcomes 7
• Danazol can also be used as a pre-operative endometrial thinning agent, but may produce more side effects than GnRH analogues 7
• Contraceptive vaginal ring (CVR) may be used to reduce MBL, but there is limited evidence to determine its effectiveness compared to COCP or other medical options 5
• Endometrial ablation, polypectomy, fibroidectomy, uterine artery embolization, and hysterectomy may be considered when medical management is ineffective or when clear structural causes are identified 4, 7

Benefits and Risks of Treatment Options

The benefits and risks of each treatment option should be carefully considered, including:

• COCPs: may reduce MBL, regulate menstrual cycles, and reduce the risk of certain cancers, but may increase the risk of cardiovascular events and breast cancer in some women 3, 5
• LNG IUS: may be more effective than COCP in reducing MBL, but may cause side effects such as nausea and vomiting 5
• GnRH analogues: may improve operating conditions and short-term postoperative outcomes, but may produce side effects such as hot flushes and vaginal dryness 7
• Danazol: may produce more side effects than GnRH analogues, including menopausal symptoms and weight gain 7
• CVR: may have similar effects to COCP, but there is limited evidence to determine its effectiveness and safety 5