Managing Bone Pain While Taking Hormone Therapy

Hormone therapy is prescribed by a medical oncologist for women and men diagnosed with hormone receptor-positive breast cancer. It is prescribed to slow or stop the growth of hormone-sensitive tumors by blocking the body’s ability to produce hormones or by interfering with hormone action. When taken by women and men with early-stage breast cancers, it helps reduce the risk of getting a recurrence of the original breast cancer or getting a new primary breast cancer.

Given the importance of hormone therapy, helping women and men manage the side effects of their hormone therapy is critical to remaining on it for the prescribed five years or more.

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Hormone Therapy Drugs

Tamoxifen is a drug used to treat ER-positive early-stage breast cancer in premenopausal and postmenopausal women as well as in men. Tamoxifen is approved by the FDA and has been in widespread use for over 30 years.

Aromatase Inhibitors (AIs) are a class of drugs used in the treatment of breast cancer in postmenopausal women and gynecomastia in men. They include Anastrozole (Arimidex), Letrozole (Femara), and Exemestane (Aromasin).

Tamoxifen and other aromatase inhibitors are the hormone therapy drugs most often prescribed for people with early-stage hormone receptor-positive breast cancer following the completion of their active treatment (surgery and chemotherapy/radiation).

Hormone Therapy and Recurrence Risk: Early and Late

The importance of using (and continuing) hormone therapy despite bone pain can't be overestimated in those who have had early stage breast cancer. These medications certainly reduce recurrence risk (by around half) early on, but what many people are less aware of is that they reduce the risk of late recurrence.

Unlike popular opinion that equates surviving five years with a "cure," we now know that the risk of recurrence in women who have had estrogen-receptor positive breast cancer does not drop off at 5 years. In fact, a person's risk of having the cancer return is constant from year 5 to year 20 following the diagnosis. Overall, an estrogen-receptor positive tumor is more likely to recur after 5 years than in the first 5 years.

Chemotherapy, while it reduces early recurrences significantly, does not appear to affect the risk of late recurrence. In contrast, hormone therapy can reduce the risk of these late recurrences, and the decreased risk lasts even after the medication has been discontinued.

Side Effects 

Some hormone therapy drugs have mild to moderate side effects, while others have side effects that impact on a survivor’s quality of life. Bone and joint pain, which is a major complaint of many taking a hormone therapy, is a side effect that definitely causes problems in everyday living.

Given that hormone therapy is usually prescribed for five years and possibly longer, finding ways of reducing the impact of bone and joint pain on mobility, work-related tasks, and routine activities of daily living is a major concern. When women and men on hormone therapy cannot get relief from their bone and joint pain, many consider quitting treatment, and some do. Tamoxifen and aromatase inhibitors are both known to share similar side effects including:

  • Hot flashes and night sweats
  • Loss of sex drive
  • Vaginal discharge
  • Vaginal dryness or itching
  • Weight gain
  • Sleep difficulties
  • Mood changes

Tamoxifen may increase the risk of blood clots and uncommonly, uterine cancer. Aromatase inhibitors can lead to bone loss (and people should consider having a bone density test done at the start of therapy). Since tamoxifen has anti-estrogen effects on breast cells but estrogen-like effects on bone, it doesn't lead to bone loss like aromatase inhibitors. Other very uncommon side effects may occur as well.

Is Tamoxifen or an Aromatase Inhibitor Such as Arimidex More Effective?

Several studies have compared various aromatase inhibitors to Tamoxifen.

The Arimidex, Tamoxifen, Alone or in Combination (ATAC) Trial compared the benefits and safety of Arimidex 1 mg with tamoxifen 20 mg given orally every day for five years, as adjuvant treatment for postmenopausal women with early-stage breast cancer.

Arimidex proved to be more effective than tamoxifen in a few different ways. Findings with Arimidex included:

  • Lengthening the time between the original diagnosis and recurrence in those experiencing a recurrence
  • Lowering the risk of cancer metastasizing to other areas of the body
  • Reducing the risk of developing new cancer in the contralateral (other) breast

However, bone and joint pain were reported more frequently on Arimidex than on Tamoxifen. Fractures also occurred more frequently in the first 2 years of taking Arimidex.

For many women, the daily occurrence of bone and joint pain is their biggest complaint. The severity of this pain and its impact on daily living causes some women on Arimidex to stop taking it.

Most women experiencing bone and joint pain reported having stiffness and pain upon awakening in their hands, hips, back, knees, feet, and shoulders that made it difficult to perform daily activities and work-related tasks. Joint pain often occurs in the knees, back, ankles, and feet as well as the hips. Carpal tunnel syndrome was a frequent diagnosed, as well.

Despite the pain, many were able to get pain relief from taking non-steroidal anti-inflammatory drugs.

Small studies have shown that women taking dietary supplements that include vitamins, glucosamine and chondroitin, vitamin D, and omega fish oils, on a regular basis experienced some relief from bone and joint pain. Acupuncture has also been demonstrated to help relieve bone pain. Women taking Arimidex or another aromatase inhibitor are encouraged to regularly participate in a weight-bearing exercise.

Given that aromatase inhibitors are known to cause muscle and joint pain, it is important to talk to your oncology team if you develop this side effect. Your team will want to evaluate the level of your pain, refer you for a bone density test if you haven't had one, and recommend exercises, activities, and possible use of medication to reduce your pain level.

The results of a small study indicate that survivors taking an aromatase inhibitor who participated regularly in a course of exercise for a year had about a 30 percent decrease in their worst pain. They also experienced a lessening in the severity of their pain. These reductions in pain resulted in an increased ability to perform routine activities of daily living. Women in the study who didn’t follow an exercise program for a year experienced a three percent increase in pain and in the severity of their pain.

Speaking from personal experience, the bone and joint pain of Arimidex, the aromatase inhibitor prescribed for me following my second bout with breast cancer, was more difficult to manage than that of Tamoxifen, which I took following my first diagnosis. The pain from Arimidex was almost exclusively in my feet, and usually constant, even waking me from sleep. It interfered with my favorite form of exercise, walking two miles a day.

The pain with Tamoxifen was more diffuse throughout my body and was more like an ache that came and went. Tamoxifen’s biggest physical challenge was muscle cramps in my calves.

I managed the pain from Arimidex and the cramps of tamoxifen by doing daily gentle exercises, swimming 3x a week, and trying to walk at least a mile each day. Sturdy shoes with arch support and a 1-1/2 inch heel made a big difference in my ability to walk with some degree of comfort. Not unlike the pain and stiffness of arthritis, the foot pain would eventually decrease as I continued to walk, and by the end of my walk, I was almost pain-free. Warm foot baths and the occasional foot and leg massage also helped.

A Word from Verywell

Hormone therapy works and it does reduce the incidence of recurrence. Arimidex is being prescribed more and more often than tamoxifen since it has proven to be more successful than tamoxifen in preventing a recurrence. If you are taking an aromatase inhibitor and are experiencing bone and joint pain, share what you are experiencing with your oncology team. You may be advised to participate in an organized exercise class in your community or join a walking group. Your medical oncologist can advise you about which pain relievers you can safely take, as even over the counter medications have side effects.

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Additional Reading
  • Cuzick J. Effect of anastrozole and tamoxifen as adjuvant treatment for early-stage breast cancer: 10-year analysis of the ATAC trial. The Lancet. Oncology. 2010;11(12):1135–41. http://www.ncbi.nlm.nih.gov/pubmed/21087898
  • Gaillard S, Stearns V. Aromatase inhibitor-associated bone and musculoskeletal effects: New evidence defining etiology and strategies for management. Breast cancer research: BCR. 2011;13(2). http://www.ncbi.nlm.nih.gov/pubmed/21457526