Practice Lesson of the Week

Amenorrhoea, menopause, and endocrine therapy for breast cancer

BMJ 2009; 339 doi: (Published 03 December 2009) Cite this as: BMJ 2009;339:b4261
  1. Eitan Amir, medical oncology fellow,
  2. Bostjan Seruga, medical oncology fellow,
  3. Orit Freedman, medical oncology fellow,
  4. Mark Clemons, medical oncologist
  1. 1Department of Medical Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada M5G 2M9
  1. Correspondence to: M Clemons mclemons{at}
  • Accepted 3 April 2009

Prolonged amenorrhoea is not necessarily indicative of menopause

Almost a third of the 1.3 million women diagnosed with breast cancer each year are premenopausal or perimenopausal, and about three quarters have endocrine sensitive disease.1 2 3 Many of these women are treated with cytotoxic chemotherapy. This treatment significantly improves survival outcomes,4 5 but it is also associated with an increased risk of temporary or permanent amenorrhoea. In recent years, aromatase inhibitor therapy has become a global standard of care for postmenopausal women with receptor positive disease.6 However, an increasing number of women who are premenopausal or perimenopausal at the time of diagnosis and whose menses stop with adjuvant chemotherapy are also being given aromatase inhibitors as monotherapy (that is, without concomitant ovarian suppression or ablation), even though their use as single agents is absolutely contraindicated in premenopausal or perimenopausal women. Therefore, accurate determination of menopausal status is vital in the effective endocrine management of women with breast cancer. We present a case of incorrect assessment of menopausal status and discuss its effects.

Case report

A 47 year old woman was diagnosed with a lymph node positive, invasive ductal carcinoma. The tumour was oestrogen receptor and progesterone receptor positive and HER-2/neu receptor negative on immunohistochemistry. At the time of diagnosis, she had not had a menstrual period for six months. She received primary chemotherapy consisting of 5-fluorouracil (500 mg/m2), epirubicin (100 mg/m2), and cyclophosphamide (500 mg/m2) (FEC), followed by docetaxel (75 mg/m2) over 24 weeks. After chemotherapy she was started on 20 mg tamoxifen daily as adjuvant endocrine treatment. Tamoxifen was discontinued after 10 months because of intolerable hot flushes. By this time, she had not had a period for almost 18 months. …

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