This is Part 2 of a series on life after cancer treatment
There is a moment I see in almost every patient on long-term hormonal therapy. They sit down. Scans are stable. The intensity has eased. I ask how they are really doing.
Joint pain waking them at three in the morning. Sleep that has not been right in months. Sex that has quietly disappeared. A body that feels unfamiliar in ways they do not have words for. And no one on their care team has offered them anything except a refill.
This is what finishing active treatment actually looks like for a lot of people. It is less like stepping back onto solid ground and more like kite surfing. The initial pull of the wind gets you moving, sometimes fast, sometimes forcefully. From the outside, it can look controlled, even smooth. But underneath, you are constantly adjusting. Balancing. Reading conditions that shift without warning. And no one hands you a manual for how to do that part well.
Video of my husband enjoying everything that PNW has to offer, including year-round cold plunges to support immune function, vagal tone, and overall vitality.
Aromatase inhibitors. Tamoxifen. ADT. Long-term targeted therapy. Maintenance immunotherapy. These medications extend survival and reduce recurrence risk. They also reshape nearly every system in the body. The downstream effects deserve the same clinical attention as the treatment that came before them.
That is what this post is about.
Part One: Endocrine Therapy
The long game with aromatase inhibitors and tamoxifen
The evidence for aromatase inhibitors and tamoxifen in hormone receptor–positive breast cancer is strong. They meaningfully reduce recurrence risk. What is becoming more nuanced is the question of duration and who truly benefits.
The field is actively re-examining how long therapy should be continued. The ABCSG-16/SALSA trial found no advantage to five years of extended anastrozole over two years, with higher fracture risk in the longer arm. Similarly, the IDEAL trial showed no superiority of five years of extended letrozole compared to two and a half years. These trials challenge the assumption that longer is always better and open the door to more individualized decisions based on risk profile, tolerability, and patient goals.
I discuss this with patients not to discourage endocrine therapy, but to ensure duration decisions are guided by current evidence rather than inertia. I explore this in more detail in a previous article here.
What I actively manage during endocrine therapy
Bone health. Aromatase inhibitors accelerate bone loss, and tamoxifen in premenopausal women can reduce bone density as well. I get a baseline DEXA scan at the start of AI therapy and recheck at two years. Vitamin D should be optimized to 70 to 100 ng/mL, not just flagged as sufficient at 20. Calcium from food first, supplemented to 1000 to 1200 mg daily if dietary intake is low, more is not better. Weight-bearing and resistance exercise are part of the bone protection plan. If a patient crosses into the osteopenia territory, I want to start support right away.
Strontium citrate supports bone health through a dual mechanism that most supplements cannot claim: it both stimulates osteoblast activity and inhibits osteoclast-mediated resorption, acting on both sides of the remodeling cycle simultaneously. The important caveat is that strontium incorporates into bone mineral and artificially inflates DEXA readings, so apparent gains in bone density overestimate true structural improvement. This is not a reason to avoid it. It is a reason to interpret the DEXA correctly, which means applying a strontium correction factor and tracking trends with that in mind rather than reading the numbers at face value. My favorite product is this Bone Builder Pack.
Metabolic health. Tamoxifen carries specific risk of fatty liver, elevated triglycerides, and insulin resistance that is undermonitored in most practices. Insulin resistance develops well before fasting glucose or HbA1c begin to shift, which is why I check fasting insulin at baseline and every six to twelve months rather than waiting for the standard markers to flag a problem. A full lipid panel rounds out the picture. A Mediterranean-forward diet combined with consistent resistance training can offset many of these effects. For liver health specifically, I assess for fibrosis using FibroScan or FibroTouch in patients with ongoing tamoxifen use, particularly when liver enzymes are trending or fatty liver is suspected. Both use transient elastography to measure liver stiffness non-invasively. FibroScan is more widely available; FibroTouch is an alternative worth asking about if FibroScan is not accessible in your area. For hepatic support I regularly use Thorne SAT (Silymarin, Artichoke, and Turmeric) and Heron Botanicals Liver Support as part of a broader liver protection strategy. When insulin resistance is already present, a metformin conversation with the prescribing oncologist is worth initiating, given accumulating evidence for both metabolic protection and potential cancer-related benefit.
Joint pain. Aromatase inhibitor-related arthralgia is the most common reason patients stop endocrine therapy early, and it is undermanaged. Consistent exercise, specifically aerobic movement combined with strength training, has some of the strongest evidence for reducing AI-related joint pain and should be the first recommendation, not the last. I check omega-3 status and typically recommend two to three grams of EPA plus DHA daily, optimize vitamin D and magnesium, and assess inflammatory markers. Acupuncture has RCT support for this specific indication. When joint pain remains unmanageable, switching between non-steroidal and steroidal AI agents is sometimes effective.
Sleep and mood. Hot flashes and night sweats are a primary driver of mood dysregulation, cognitive fog, and relationship strain on endocrine therapy. I treat them as a clinical target, not a complaint to tolerate. Cognitive behavioral therapy for insomnia (CBT-I) is the gold standard for sleep and should come before sedative hypnotics. For hot flashes, venlafaxine, escitalopram, and gabapentin all have evidence as nonhormonal options and are underused. Melatonin and magnesium glycinate are low-risk starting points I use routinely. For an in-depth conversation about restoring sleep, read my earlier article.
Sexual health. Vaginal dryness, painful intercourse, loss of libido, and changes in body image are common on endocrine therapy and almost universally underaddressed. I raise it with every patient because most will not raise it themselves. Local vaginal estrogen has minimal systemic absorption and a growing evidence base supporting safety even in ER+ breast cancer, though it always warrants a direct conversation with your oncologist. Non-hormonal options like vaginal hyaluronic acid and Replens are useful adjuncts, but let's be honest about what they do: they add moisture and lubrication. They do not address the underlying tissue changes driving the problem. Pelvic floor physical therapy works at a deeper level and is significantly underutilized. Ospemifene is a non-estrogen oral option for painful intercourse that acts at the tissue level and is worth raising if other approaches are not enough.
Two areas that almost never come up
Dr. Corinne Menn’s recent deep dive into tamoxifen’s systemic effects covers territory worth flagging. The bone story is more paradoxical than most patients realize: tamoxifen is bone protective in postmenopausal women but causes meaningful bone loss in premenopausal women, an effect made significantly worse by adding ovarian suppression. Two monitoring areas get almost no airtime in standard oncology visits. Eye health: retinopathy occurs in up to 12% of patients on standard dosing beyond two years, which calls for a baseline ophthalmologic exam and OCT screening every six months after year two. Oral health: tamoxifen accelerates periodontal disease and alveolar bone resorption in ways most patients are never warned about. Tell your dentist what you are on. It matters.
Periodontal disease is highly influenced by the oral and gut microbiome, which is often disrupted during cancer treatment and endocrine therapy. Shifts toward a more inflammatory microbial profile can accelerate gum disease, bone loss, and systemic inflammation. From a naturopathic perspective, this is modifiable. I focus on mechanical care first: twice-daily brushing, flossing, water flossers, tongue scraping, oil pulling, and regular cleanings. I often use tools such as Simply O3 Pure Organic Ozonated Olive Oil, Simply O3 Ozone Pulling Solution, and Biocidin toothpaste as part of a broader oral care strategy. Then I layer in microbiome and tissue support: oral probiotics containing Lactobacillus reuteri, Lactobacillus brevis, Lactobacillus salivarius NK02 or/and Streptococcus salivarius, xylitol to reduce pathogenic biofilms, and antimicrobial botanicals when appropriate. Nutritionally, vitamin C, vitamin D, vitamin K2, magnesium, zinc, CoQ10, omega-3s, collagen support, and a polyphenol-rich, low-sugar diet all help support connective tissue integrity, microbial balance, and healthier periodontal outcomes over time.
Part Two: ADT
The metabolic cost of androgen deprivation therapy
Androgen deprivation therapy extends survival and also fundamentally alters the hormonal environment in nearly every organ system. I see metabolic syndrome develop quickly in men on ADT: rising fasting glucose, insulin resistance, central weight gain, lipid shifts. Bone density drops. Cardiovascular risk increases. Cognitive function changes in ways many men never connect back to treatment.
This warrants proactive management from the start, not reactive intervention after damage has accumulated. Structured resistance training has the strongest evidence base for counteracting these effects and should be in place by the first month of therapy. I pair that with metabolic monitoring every three to six months, a baseline DEXA followed by annual rechecks, vitamin D optimization, and cardiovascular risk assessment in collaboration with primary care or cardiology when indicated.
The psychological dimension deserves direct attention. Identity, sexuality, mood, and self-perception all shift during ADT, often in ways men are not warned about. Silence around it makes it harder to manage, not easier.
The estradiol piece most people miss
Most of ADT side effects are not from testosterone suppression itself but from the loss of estradiol that follows. Men produce estradiol by converting testosterone, and when testosterone is suppressed to castrate levels, estradiol disappears with it. Estradiol is the primary regulator of bone turnover in men and a key player in thermoregulation and metabolic signaling. Hot flashes, brain fog, bone loss, fatigue: these are largely estradiol-deprivation symptoms. ADT creates a dual hormone deprivation state, and recognizing this reframes these effects as predictable endocrine consequences rather than vague, unavoidable side effects. The evidence is strongest for vasomotor symptoms and skeletal health, with more mixed data for cognition and mood.
I really enjoyed Howard Wolinsky’s piece in The Active Surveillor, which interviews Dr. Paul Schellhammer (former AUA president and prostate cancer patient himself), makes the case for transdermal estradiol as an alternative ADT strategy. High-dose transdermal estradiol can suppress testosterone to castrate levels while simultaneously restoring the estradiol that standard LHRH agents eliminate. The UK PATCH trial demonstrated comparable testosterone suppression, markedly fewer hot flashes, preserved bone density, and more favorable metabolic parameters, at the cost of higher rates of gynecomastia. The historical cardiovascular concern with estrogen turned out to be delivery-route specific, not estrogen specific, and long-term outcomes appear comparable. Transdermal estradiol remains outside standard guidelines and is not FDA-approved for prostate cancer, which continues to limit adoption more than the underlying biology does. For men struggling with ADT side effects, it is worth raising with their oncologist.
Managing inflammation on ADT
Inflammation drives many ADT-related changes and is often under-monitored. I track hs-CRP, fasting insulin, HbA1c, and triglyceride-to-HDL ratio as a baseline cardiometabolic picture, adding d-dimer, fibrinogen, ferritin, and LDH when I need a broader view. When I need deeper resolution, cytokine panels including IL-6, TNF-alpha, and IL-1beta help characterize the pattern of immune activation. The foundation remains lifestyle: resistance training with aerobic movement, a Mediterranean-forward high-fiber diet with adequate protein, sleep optimization, and minimizing alcohol and ultra-processed foods. I most often supplement with omega-3s, curcumin, EGCG, magnesium, vitamin D, and targeted polyphenols. Quercetin, PEA, and boswellia are in regular rotation, individually or in combination formulas. Some of my most commonly used products are Xymogen Cytokine Balance, Cymbiotika Inflammatory Health, or Vital Nutrients BCQ.
In selected cases I discuss off-label options with the oncology team: metformin for insulin resistance, statins when lipid-driven inflammation is present, and low-dose naltrexone for immunomodulation. The goal is not perfection. It is to keep inflammatory signaling as low as possible while patients remain on therapy.
A note on adherence
The adherence data for endocrine therapy are sobering. Many patients stop early because side effects become intolerable. I do not see this as a compliance failure. I see it as a signal that the downstream effects of these medications are not being managed adequately.
A medication can only help if someone can stay on it. My role is to make that possible. And when it is not, I want to be the person helping patients have an informed conversation with their oncologist about dose adjustment, switching agents, or reconsidering duration based on their specific biology, risk profile, and goals.
What should be in place
If you are on an aromatase inhibitor or tamoxifen:
Baseline DEXA before starting, recheck at two years. If osteopenia is found, start bone support, supplements first if no improvement in 6 mo (yes, a good quality supplement can work that quickly!) pivot to the bisphosphonate or denosumab conversation before density declines further.
Vitamin D optimized to at least 70 ng/mL. Being told you are “normal” at 30 is not the same as being optimized.
Fasting insulin, HbA1c, and full lipid panel at baseline and every six to twelve months. Fasting insulin catches insulin resistance years before glucose or HbA1c shift.
Liver enzymes at baseline and every six to twelve months on tamoxifen. If they trend up, ask about FibroScan or FibroTouch.
On tamoxifen: baseline eye exam with OCT, then OCT every six months after year two.
A structured exercise plan from day one that includes resistance training. This is not optional.
A management plan for joint pain, hot flashes, and sleep disruption if any are affecting your daily life. These are treatable. Ask if you have not been offered anything.
A direct conversation about sexual health. If your provider has not raised it, you might need a new provider?
Tell your dentist you are on tamoxifen.
If you are on ADT:
Baseline DEXA, fasting insulin, HbA1c, lipid panel, CMP, testosterone, and estradiol before starting.
Structured resistance training in place by month one.
Metabolic monitoring every three to six months including inflammatory markers.
Annual DEXA recheck. If bone density is declining, address it before a fracture.
Vitamin D optimized to at least 70 ng/mL.
Cardiovascular risk actively co-managed with primary care, cardiology or integrative provider.
Hot flashes, sexual health, and mood addressed directly. These are hormonal consequences, not incidental complaints.
If side effects are significantly affecting quality of life, ask your oncologist about transdermal estradiol or an alternative ADT strategy (decreased dosing, pulsed dosing etc.)
Psychological support on the table from the start, not offered only when things fall apart.
This new terrain may be unfamiliar, but you do not have to navigate it alone.
Part 1 of this series covers the acute transition when active treatment ends. Part 3 addresses the long tail of uncertainty with modern immunotherapy and targeted therapies.
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Educational content only. Not medical advice. For individualized care, visit drkseniamalarkey.com
Great article!
This is a great article I am on anastrozole and have lots of side effects. I am in a support group where 70 percent of the members are not taking their aromatics inhibitors as prescribed The joint pain in brutal The thought of doing 2 to 2.5 years instead of 5 years gives me hope! Thanks for providing this info!