Managing Hormone Therapy in Breast Cancer
Rehab Tools to Manage the Side-effects of Hormone Therapy
You are here reading this because you’re wanting to explore how one can use their body’s ability to make things just a bit better. After the cancer treatments have slowed down, often the last thing that those with breast cancer desire is more medication. Often after an exhaustive treatment period there is little energy left for all that remains. Coupled with pressure to return to work, or navigate disability funding, it can be a lot to bear.
Symptoms during treatment can be plentiful, at times just as burdening post-treatment. One can use the analogy of 'long haul cancer syndrome', akin to long haul covid. Symptoms related to long haul cancer are under discussed, under-funded and often poorly treated.
With hormone positive breast cancers, hormone therapy is often the final step.
After starting hormone therapy, some have few side effects while others may find it difficult to come to terms with the ‘new normal’. If you are finding yourself burdened with symptoms of nausea, hot flashes, malaise, joint or muscle pain and/or flat-lined like feelings, this blog is rich with tools that work.
Cancer Physiotherapy offers Personalized Rehab Plans for Symptoms such as Pain, 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: AIMS, arthragia/myalgia, hot flashes and nausea
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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) founds in cruciferous vegetables (broccoli, kale etc.)
Reishi mushroom (estrogen receptor inhibitor)
Hormone Therapy and Reoccurrence Reduction
Treatment involving hormone therapy will inevitably impact your estrogen and/or progesterone 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. 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 tend to greatly tapper off. At times symptoms can be unmanageable after 3 months or dangerous such as uncontrolled vaginal bleeding. In these scenarios, contact your medical oncologist right away. At times, there are options to trial a different brand or type which may be more tolerated.
Common Symptoms of Hormone Therapy
Cancer treatment may lead to treatment related conditions such as cancer related fatigue and de-conditioning; at times the de-conditioning is diagnosed as cancer related cachexia (muscle loss). Together, these conditions can make exercise and the recovery from it a challenge. In addition, we know 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, this can compound any pre-existing fatigue and exercise intolerance.
Hormone therapy can lead to fatigue.
Estrogen has many roles but the ones that relate to exercise tolerance are its role 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.
As hormone therapy suppresses estrogen levels; and estrogen availability can impact exercise stamina, the first 3 months of hormone therapy can be the most challenging. 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. But as the cycle continues, estrogen levels rise again and stamina returns; this can be comparable to after 3 months of hormone therapy when your body has turned to other hormones 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 the loss os estrogen. Hormones released through exercise such as catecholamines improve energy, reduce pain rand reduce inflammation.
Hormone therapy may impact exercise tolerance but in the long run exercise can substitute for the loss of estrogen.
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 or estrogen-progestogen, hence in hormone sensitive cancers estrogen treatments aren’t an option.
Estrogen has many roles:
Anti-inflammatory
Metabolic Accelerator
Bone Builder
and more…
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. Often it is worse in the morning and worse after long periods of immobility.
The most common symptom associated with hormone therapy is pain/stiffness.
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 misdiganosed as osteoarthritis. More accurately, it 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.
Cancer treatment often leads to general de-conditioning, pain and fatigue; in other terms changes in dopamine utilization occur (abnormalities in dopaminergic neurotransmission). Pain and stiffness can compound these other symptoms leading to less ease with movement and less ability to simply ‘feel good’.
Patients going through treatment often have less dopamine release compared to pre-diagnosis, 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 frequent increased musculoskeletal pain. Therefor while undergoing hormone therapy decreased levels of dopamine and estrogen have been associated with higher levels of musculoskeletal pain.
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 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 movement prescription. This blog will eloborate on tools that work with the body’s capacity to produce endogenous opioids and catecholamines; impacting pain perception and inflammation.
Pain is a bio-psycho-social symptom. It’s complex; it needs to be treated with more than just pain medication.
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 taking place.
We know that nausea is heavily impacted by dopamine receptors, this chemoreceptor trigger zone in the medulla oblongata of the brain stem contains ‘type D2 receptors’. This offers some 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. This opens the door to exploring the idea that increasing dopamine, endogenous opioids and catecholamines in general may actually lead to a decrease in nausea.
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. In addition, these 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.
Tools That Work: Managing Symptoms of Hormone Therapy
#1) Rehab Tool: Cool your Body; Palms, Feet and Forehead.
Our common response when we are feeling nauseous or having a hot flash is to unbutton our blouse, 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.
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 the soles of your feet, palms of your hands and forehead are portals to quickly change your body’s core temperature and cool you down.
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 a ‘cold sensation’ as we don’t want vasoconstriction to occur. The temperature should be evidently cooler but comfortable. These easy tools work, they lower your core temperature and reduce sweating, therefor allowing you to feel more comfortable.
#2) Rehab Tool: Cold Exposure
Here we are talking about deliberate cold submersion; this involves a lot more than just the glabrous tissue mentioned above; in this case we are aiming to be submerged from the neck down, exposing our body to a cold experience.
For the sake of accessibility, we are going to define cold exposure to include a cold bath, cold shower, submersing into a cold body of water in nature or the use of cryotherapy equipment. At times patients may opt to use wet suit gloves, booties or a thin wet suit to start. Although some methods are more effective such as full emersion in comparison to a cool shower, regardless of the type of exposure, physiologically blood is shunting out of the periphery and into the core.
Try a cold shower, bath or getting into a cold body of water
How to Get Started Safely with Cold Exposure:
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 and practice your breathing.
The cold is always 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 running out. Starting slowly can involve starting with cool temperatures as opposed to cold and staying exposed longer. In addition, try decreasing the temperature over a 3 weeks time span. Another strategy would be to be to gradually enter into the cold water, over a 2-3 min time period.
The goal is to focus on your breathing rate, aim to slow it down and breath diaphragmatically 5.5 seconds in and out. Trust the process, in time the panic and 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. This may take time to achieve; the point is don’t rush in and out in panic.
On a more personal note, I have been emerging into the discomfort of cold since 2019 and it has helped me innumerably.
The Cold Exposure Protocol Should Include:
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 some calm)
3) A temperature that is uncomfortably cold such that you’d like to escape it. (Can decrease temperature over time as stated above.)
We understand thus far that repeated cold exposure over long periods of time may have an anti-inflammatory impact effecting levels of interleukin-6 a pro-inflammatory cytokine that contributes to reducing chronic inflammation and pain. In addition, cold exposure supports a large 200-300% increase in dopamine release which helps mental well-being and simply feeling good.
Dopamine is a catecholamine; the brain has many distinct dopamine pathways which play a major role in the motivational component of reward-motivated behaviour. Dopamine is termed a ‘motivational salience’ hormone, which means that it helps to propel behaviour towards a desired outcome resulting in feeling really good. Hence 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 exposure may be of great value to many experiencing side effects with hormone therapy.
#3) Rehab Tool: Get Moving
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Exercise intolerance post cancer treatment can be a result of treatment related conditions such as chording, radiation fibrosis syndrome, cancer related fatigue and hormone therapy as mentioned above. The above can make returning to exercise frustrating, painful and lead to push crash cycling.
Try Cold Exposure to Improve Exercise Tolerance.
Lactic acid remains in the system after high intensity or strength training and can often result in delayed onset muscle soreness “DOMS”. Recovering from cancer means controlling inflammation and promoting recovery is important. I have made reference before in a social media post 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, nausea and fatigue can make light exercise challenging and recovering even more so.
Returning to exercise for those on hormone therapy looks different for every patient depending on age, cancer type, treatment phase, health history, symptom burden and baseline fitness prior to diagnosis. My detailed blog on Exercise as medicine elaborates on the most common questions asked around cancer and exercise, and how it needs to be personalized to the patient.
Here at the cancer physio, we aim to support patients being active all throughout all 5 phases, by prescribing a personalized rehab plan taking into account the safe exercise guidelines. Personalized exercise can help manage pain, improve well-being, build stamina and increase bone density.
Consistent exercise as medicine, cooling your body and using cold exposure together are very effective tools for managing the symptoms of hormone therapy within breast cancer. My hope is these simple tools in addition to a personalized cancer rehab plan 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 Blogger:
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 and 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. All of my patients have been told a lot of ‘no and don’t’ statement through-out their journey; at times mitigating risk is important but one must always ask at what cost.
I have worked with many patients with breast cancer that were told to never do a push-up, never plank again, or those with lymphedema that were told to never exercise at higher intensities, or never exercise without a compression sleeve. Every phase of treatment, every intervention and there for every new tool used is a very personal decision. Informed decision making and a graded approach with room to observe can lessen risk and open up a lot of possibility. My ask is simple, I ask that you ask good questions too, as much as possible and keep them coming. Understand that not all of them will have answers, but in the unknown try to remain curious, hopeful and even optimistic. If your sense of self and psychology benefit immensely from exploring your capacity as a human being, then I challenge you to explore the boundaries a bit; you might just be little surprised.
