Over nine million breast cancer survivors worldwide suffer compromised quality of life attributable to estrogen depletion related symptoms of menopause and side effects of cancer therapy. Hormone Replacement Therapy (HRT) is very effective in managing these symptoms in general population and in breast cancer survivors. However, the concern of breast cancer recurrence as a result of HRT use keeps many oncologists from using this approach in symptom management. Evidence from randomized trials, observational studies and met-analyses on the impact of HRT use on breast cancer recurrence and survival remains controversial. Climacteric symptoms in breast cancer survivors should be delineated for type and severity for methodical management. Lifestyle modifications are effective for mild symptoms, while non-hormonal pharmaceutical approaches can be used as second-line therapy for control of hot flashes, vulvo-vaginal atrophy, arthralgia, mood swings, sleep disturbance, and depression. Evidence does not conclusively render HRT, as a contraindicated approach for these patients; informed consent and shared-decision-making is a reasonable approach for HRT use in symptomatic breast cancer survivors.