If you have metastatic breast cancer (also called advanced breast cancer), it means the cancer has spread from your breast to other places in your body. It’s still considered breast cancer because the metastases have the same type of cancer cells. Your treatment options depend on the levels of hormone receptors in the tumor. Other factors include your health, the treatment you have received, and how long it took the cancer to recur. Treatment also depends on how widespread the cancer is, and whether you have gone through menopause.

Here are some questions to ask your doctor about advanced breast cancer before and after menopause.

What is usually the first treatment for hormone receptor-positive metastatic breast cancers?

Hormonal therapy, or endocrine therapy, is usually the most important component of treatment for women with HR-positive metastatic breast cancer. It’s sometimes called anti-hormone treatment because it acts as the opposite of hormone replacement therapy (HRT). The goal is to lower the levels of estrogen and progesterone in the body, or to block these hormones from getting to cancer cells and getting the estrogen they need to grow.

Hormonal therapy can be used to interrupt the influence of hormones on the cells’ growth and overall functioning. If the hormones are blocked or removed, the cancer cells are less likely to survive. Hormonal therapy also stops healthy breast cells from receiving hormones that could stimulate cancerous cells to regrow within the breast, or elsewhere.

How is metastatic breast cancer treated in premenopausal women?

Hormone inhibitors are not used in premenopausal women. Metastatic breast cancer treatment almost always begins with ovarian suppression. This procedure lowers hormone levels in the body to deprive the tumor of the estrogen it needs to grow.

Ovarian suppression can be achieved in one of two ways:

  • drugs that stop the ovaries from making estrogen, causing menopause for up to three months
  • a surgical procedure called oophorectomy that removes the ovaries and stops estrogen production permanently

Tamoxifen is also commonly used to treat metastatic breast cancer in premenopausal women. It can prevent the cancer from returning or spreading elsewhere. Tamoxifen may not be an option for women whose cancer progressed during prior tamoxifen treatment. Combining ovarian suppression and tamoxifen has been found to improve survival compared to either treatment alone.

What is the prescribed treatment for postmenopausal women?

Ovarian suppression is not necessary for postmenopausal women. Their ovaries have already stopped making large amounts of estrogen. They only make a small amount in their fat tissue and adrenal glands.

Postmenopausal hormone therapy usually includes an aromatase inhibitor, such as tamoxifen (Nolvadex), anastrozole (Arimidex), exemestane (Aromasin), and letrozole (Femara). These drugs reduce the amount of estrogen in a woman’s body by stopping tissues and organs besides the ovaries from making estrogen.

Common side effects of using these aromatase inhibitors include hot flashes, nausea, vomiting, and painful bones or joints. Serious side effects include thinning bones and an increase in cholesterol.

Postmenopausal women are usually prescribed tamoxifen for two to five years. If the drug is given for less than five years, an aromatase inhibitor often is given to complete the five-year span.

Ribociclib (Kisqali) is the first hormonal-based therapy available for women with HR+ or HER2 metastatic breast cancer. It’s a first-line, targeted treatment used in combination with hormone therapy.

When is chemotherapy used to treat metastatic breast cancers?

Chemotherapy is used for three different types of metastatic breast cancer:

  • hormone receptor-negative
  • hormone receptor-positive, but no longer responding to hormone therapy
  • HER2-positive, in combination with anti-HER2 treatments

If the first chemotherapy drug, or combination of drugs, stops working and the cancer spreads, a second or third drug can be used.

Finding the right treatment may take some trial and error. What’s right for someone else won't necessarily be right for you. Communicate openly with your doctor, follow your treatment plan, and keep an open mind. You may have difficult days ahead, but to fight this disease you must stay positive and be aware of all your treatment options.