Some types of breast cancer are affected by hormones, like estrogen and progesterone. The breast cancer cells have receptors (proteins) that attach to estrogen and progesterone, which helps them grow. Treatments that stop these hormones from attaching to these receptors are called hormone or endocrine therapy.
Hormone therapy can reach cancer cells almost anywhere in the body and not just in the breast. It's recommended for women with tumors that are hormone receptor-positive. It does not help women whose tumors don't have hormone receptors (these tumors are called hormone receptor-negative).
Hormone therapy is often used after surgery (as adjuvant therapy) to help reduce the risk of the cancer coming back. Sometimes it is started before surgery (as neoadjuvant therapy).
It is usually taken for at least 5 years. Treatment longer than 5 years might be offered to women whose cancers have a higher chance of coming back. A test called the Breast Cancer Index might be used to help decide if a woman will benefit from more than 5 years of hormone therapy.
Hormone therapy can also be used to treat cancer that has come back after treatment or that has spread to other parts of the body.
About 2 out of 3 breast cancers are hormone receptor-positive. Their cells have receptors (proteins) for estrogen (ER-positive cancers) and/or progesterone (PR-positive cancers) which help the cancer cells grow and spread.
There are several types of hormone therapy for breast cancer. Most types of hormone therapy either lower estrogen levels in the body or stop estrogen from helping breast cancer cells grow.
These drugs work by stopping estrogen from fueling breast cancer cells to grow.
These drugs block estrogen from connecting to the cancer cells and telling them to grow and divide. While they have anti-estrogen effects in breast cells, they act like an estrogen in other tissues, like the uterus and the bones.
These drugs are pills, taken by mouth.
Tamoxifen can be used to treat women with breast cancer who have or have not gone through menopause.
This drug can be used in several ways:
Toremifene is a SERM that works in a similar way, but it is used less often and is only approved to treat post-menopausal women with metastatic breast cancer. It is not likely to work if tamoxifen has already been used and has stopped working.
The most common side effects of tamoxifen and toremifene are:
When tamoxifen treatment starts, a small number of women with cancer that has spread to the bones might have a tumor flare (the tumor gets bigger for a short time) which can cause bone pain. This usually goes away quickly, but rarely a woman may also develop a high calcium level in the blood that is hard to control. If this happens, the treatment may need to be stopped for a time.
Rare, but more serious side effects are also possible:
Like SERMs, these drugs attach to estrogen receptors. But SERDs bind to the receptors more tightly and cause them to be broken down. These drugs have anti-estrogen effects throughout the body.
SERDs are used most often in women who are past menopause. When given to pre-menopausal women, they need to be combined with a luteinizing-hormone releasing hormone (LHRH) agonist to turn off the ovaries (see Ovarian suppression below).
Fulvestrant can be used:
It is given as 2 injections into the buttocks (bottom). For the first month, the 2 shots are given 2 weeks apart. After that, they are given once a month.
This drug can be used to treat advanced, ER-positive, HER2-negative breast cancer when the cancer cells have an ESR1 gene mutation, and the cancer has grown after at least one other type of hormone therapy.
Elacestrant is taken daily as pills.
Common short-term side effects of these drugs can include:
Elacestrant can also increase cholesterol and fat levels in the blood.
Because estrogen stimulates hormone receptor-positive breast cancers to grow, lowering the estrogen level can help slow the cancer’s growth or help prevent it from coming back.
Aromatase inhibitors (AIs) are drugs that stop most estrogen production in the body. Before menopause, most estrogen is made by the ovaries. But in women whose ovaries aren’t working, either because they have gone through menopause or because of certain treatments, estrogen is still made in body fat by an enzyme called aromatase. AIs work by preventing aromatase from making estrogen.
These drugs are useful for women who have gone through menopause, although they can also be used in pre-menopausal women when they are combined with ovarian suppression (see below).
These AIs are pills taken every day to treat breast cancer:
The most common side effects of AIs are:
AIs tend to have side effects different from tamoxifen. They don't cause uterine cancers and very rarely cause blood clots. They can, however, cause muscle pain and joint stiffness and/or pain. The joint pain may be similar to a feeling of having arthritis in many different joints at one time. Options for treating this side effect include, stopping the AI and then switching to a different AI, taking a medicine called duloxetine (Cymbalta), or routine exercise with nonsteroidal anti-inflammatory drugs (NSAIDs). But the muscle and joint pain has led some women to stop treatment. If this happens, most doctors recommend using tamoxifen to complete 5 to 10 years of hormone treatment.
Because AIs drastically lower the estrogen level in women after menopause, they can also cause bone thinning, sometimes leading to osteoporosis and even fractures. If you are taking an AI, your bone density may be tested regularly and you may also be given bisphosphonates (zoledronic acid [Zometa] for example) or denosumab (Xgeva, Prolia), to strengthen your bones.
For pre-menopausal women, removing or shutting down the ovaries (ovarian suppression), which are the main source of estrogen, is effectively making them post-menopausal. This may allow some other hormone therapies, such as AIs, to be used. Ovarian suppression along with tamoxifen or an AI might be recommended for women whose breast cancer is at high risk of coming back.
There are several ways to remove or shut down the ovaries to treat breast cancer:
All of these methods can cause symptoms of menopause, including hot flashes, night sweats, vaginal dryness, and mood swings.
After surgery, hormone therapy can be given to reduce the risk of the cancer coming back. Taking an AI, either alone or after tamoxifen, has been shown to work better than taking just tamoxifen for 5 years.
These hormone therapy schedules are known to be helpful for women who are post-menopausal when diagnosed:
For most post-menopausal women whose cancers are hormone receptor-positive, most doctors recommend taking an AI at some point during adjuvant (after surgery) therapy. Standard treatment is to take these drugs for about 5 years, or to take in sequence with tamoxifen for 5 to 10 years. For women at a higher risk of recurrence, hormone treatment for longer than 5 years may be recommended. Tamoxifen is an option for some women who cannot take an AI. Taking tamoxifen for 10 years is considered more effective than taking it for 5 years, but you and your doctor will decide the best schedule of treatment for you.
These therapy schedules are known to be helpful for women who are pre-menopausal when diagnosed:
If you have early-stage breast cancer and had not gone through menopause when you were first diagnosed, your doctor might recommend taking tamoxifen first, and then taking an AI later if you go through menopause during treatment. Another option is ovarian suppression by getting a drug called a luteinizing hormone-releasing hormone (LHRH) agonist, which turns off the ovaries, along with an AI. Pre-menopausal women should not take an AI alone for breast cancer treatment because it is unsafe and can increase hormone levels.
Tamoxifen, AIs, elacestrant, and fulvestrant can be used to treat more advanced hormone-positive breast cancers, especially in post-menopausal women. They are often continued for as long as they are helpful. Pre-menopausal women might be offered tamoxifen alone or an AI in combination with an LHRH agonist for advanced disease.
Some other types of hormone therapy that were used more often in the past, but are rarely given now include:
These might be options if other forms of hormone therapy are no longer working, but they can often cause side effects.
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Burstein HJ, Lacchetti C, Anderson H, Buchholz TA, Davidson NE, Gelmon KA et al. Adjuvant Endocrine Therapy for Women With Hormone Receptor-Positive Breast Cancer: ASCO Clinical Practice Guideline Focused Update. J Clin Oncol. 2019 Feb 10;37(5):423-438.
Burstein HJ, Lacchetti C, Anderson H, Buchholz TA, Davidson NE, Gelmon KA et al. Adjuvant Endocrine Therapy for Women With Hormone Receptor-Positive Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update on Ovarian Suppression. J Clin Oncol. 2016;34(14):1689-1701. doi:10.1200/JCO.2015.65.9573.
Conzen SD and Henry NL. Managing the side effects of tamoxifen and aromatase inhibitors. In Vora SR, ed. UpToDate. Waltham, Mass.: UpToDate, 2021. https://www.uptodate.com. Accessed August 11, 2021.
Davies C, Pan H, Godwin J, et al. Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial. Lancet. 2013;381:805-816. Erratum in: Lancet. 2013 Mar 9;381(9869):804.
Gray RG, Rea D, Handley K, et al. Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years in 6,953 women with early breast cancer. J Clin Oncol (Meeting Abstracts) June 2013 vol. 31 no. 18_suppl 5.
Henry NL, Shah PD, Haider I, Freer PE, Jagsi R, Sabel MS. Chapter 88: Cancer of the Breast. In: Niederhuber JE, Armitage JO, Doroshow JH, Kastan MB, Tepper JE, eds. Abeloff’s Clinical Oncology. 6th ed. Philadelphia, Pa: Elsevier; 2020.
Jagsi R, King TA, Lehman C, Morrow M, Harris JR, Burstein HJ. Chapter 79: Malignant Tumors of the Breast. In: DeVita VT, Lawrence TS, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology. 11th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2019.
Ma CX and Sparano JA. Treatment approach to metastatic hormone receptor-positive, HER2-negative breast cancer: Endocrine therapy and targeted agents. In Vora SR, ed. UpToDate. Waltham, Mass.: UpToDate, 2021. https://www.uptodate.com. Accessed August 11, 2021.
National Cancer Institute. Physician Data Query (PDQ). Breast Cancer Treatment – Health Professional Version. 2021. Accessed at https://www.cancer.gov/types/breast/hp/breast-treatment-pdq on August 11, 2021.
National Comprehensive Cancer Network (NCCN). Practice Guidelines in Oncology: Breast Cancer. Version 6.2021. Accessed at https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf on August 11, 2021.
Osborne CK. Chapter 53: Adjuvant Systemic Therapy Treatment Guidelines. In: Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Diseases of the Breast. 5th ed. Philadelphia: Wolters Kluwer Health; 2014.
Rimawi MF and Osborne CK. Chapter 43: Adjuvant Systemic Therapy: Endocrine Therapy. In: Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Diseases of the Breast. 5th ed. Philadelphia: Wolters Kluwer Health; 2014.
Rocca A, Maltoni R, Bravaccini S, Donati C, Andreis D. Clinical utility of fulvestrant in the treatment of breast cancer: a report on the emerging clinical evidence. Cancer Manag Res. 2018;10:3083–3099.
Stearns V and Davidson NE. Chapter 45: Adjuvant Chemo Endocrine Therapy. In: Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Diseases of the Breast. 5th ed. Philadelphia: Wolters Kluwer Health; 2014.
Last Revised: January 31, 2023