Cancer Treatment and Menopause

As I approach the three year anniversary of my cancer diagnosis, I regularly reflect on the increasing depth of my understanding and insights into the cancer journey. Each year reveals a new level of awareness, a new appreciation for my journey, and mostly an admiration for the incredible women who are also walking their cancer road.

As a nurse, one of my greatest insights has been the awareness of seemingly endless opportunities to improve the cancer experience for younger women. Delving into and unpacking some of the lesser discussed ‘invisible’ cancer side-effects is a passion of mine. Cancer related menopause is a topic that I have wanted to address for some time.

Over the years of being immersed in the on-line cancer community, I have read numerous questions from women seeking advice about their menopausal symptoms. These women are from all over Australia, have different cancers and are at different stages of their journey. However their experience is similar, in that they have many unanswered questions about their menopause and a desire to improve their quality of life.

With my health professional hat on, for these women I can see that there are patient information and education gaps. Gaps prior to treatment, gaps immediately after treatment, and gaps longer term in the primary care setting. Of course cancer is stressful and treatment is often time-critical. We are human and important details may not be processed by the patient, or important details may be skimmed over by the medical team (at least from the patients perspective). At the time of diagnosis the priorities are being prioritised. That’s where good follow-up is essential and an unpacking of the patient’s priorities is vital! This is the difference that makes the difference in a patient’s quality of life.

What women say

“ I was just advised the treatment could likely tip me into menopause and nothing else was said. It has done that. I experienced weight gain, joint soreness, hot flashes and insomnia on top of all the chemo side effects. I guess it would helpful to know the total picture at the outset.”

 “Last week I wrote an email to my oncologist that it occurred to me that I may be in premenopause because of chemo. I expected to be feeling much better after completing chemo and prior to starting radiation but I don’t”.

“ Dealing with feelings around  little choice and sudden advice that you will be put into menopause 10 or more years earlier than you ever imagined. I’m my early 40s I honestly haven’t really given too much thought to menopause yet. But now I have no choice and will be in menopause indefinitely due to treatment induced menopause and the need to have a hysterectomy after chemo. I guess just some of the emotions around it. Most people think that going to menopause is a good thing if you’ve already had your kids as no more periods but for some reason I’m struggling with it emotionally. ”

“ My biggest issues are hot flushes and joint and bone pain. My doctor has prescribed medication for the hot flushes, but the joint pain is constant and painful. I am really struggling with them. Had been told pretty much to suck it up, it’s menopause. My bones ache, every joint in my body aches and I’m sick of sucking it up. Every day I’m in a state of fear thinking I now have bone cancer. I’m sick of being told that it is normal, for doctors these symptoms might be normal, but for me they bloody well are not. ”.

“ I certainly felt I was not really given much information at all- just told you may or may not get your period back after treatment and nothing at all about having any more babies – my doctor made a verbal assumption that those days were over for me!”.

“ I had no chat about what to expect . I never got my period back at all. I’m on the injection and a daily tablet. I had no discussion about my sex life, sex drive, the changes in the body nothing. I mean I knew about menopause but not about rapid menopause.”

“Very limited information provided prior to treatment. She even ‘joked’ saying I could thank her later, as I won’t get a period anymore. I didn’t think that was funny at the time, I was perfectly happy with my periods, would have them back in a heartbeat if it meant not having to deal with Menopause. I’m now on Clitogist tablets that cost me $50 per month & can’t cope without them.”

“ I got very little heads up and only because I asked about the impacts of the radiation on organs nearby. “It’ll fry your eggs & ovaries and most likely go into pre-menopause”. Nothing about it all happening immediately. I think they assume by your age (47) that it’s somehow not important. I certainly didn’t get advised anything about what may happen in my body or suggestions on how to handle it. Left to just deal with it on my own. After all the weight gain from chemo I’m left with a body and hormones that don’t work and I can’t shift the weight at all.”

“ I was 39 and menopause wasn’t even mentioned, it wasn’t until chemo and radiation finished and I saw my rheumatologist and she told me! ”

 “I have lots of questions.  I’m 41. Have been suffering with the paws since 32 and I’m over it. When does this end? I feel like I’ve suffered enough. Any info would be great”.

(Thank-you to my amazing cancer communities. All feedback shared with permission.)

To help address some of the reoccurring themes that women have shared, I have invited Dr Lironne Wein a Melbourne Medical Oncologist to share her expertise on the subject.

How does cancer/treatment cause menopause

Dr Lironne Wein, Medical Oncologist, Women’s Health Melbourne

There are several reasons why a woman with cancer may become menopausal.  These include:

  • Surgical removal of the ovaries (bilateral oophorectomy)
  • Ovarian function suppression (with an injection such as Zoladex)
  • Chemotherapy 
  • Pelvic radiotherapy 
  • Naturally going through menopause at the time of cancer treatment

Some women may also experience menopausal symptoms as a result of cancer treatment, without these treatments actually causing menopause per se.  Reasons for this include:

  • Endocrine therapy (tamoxifen and aromatase inhibitors)
  • Needing to stop menopausal hormone therapy which they were already on 

Sometimes becoming menopausal is an unwanted side effect of treatment (such as in the case of chemotherapy being toxic to the ovaries), and sometimes ovarian function suppression is used by doctors as a therapeutic measure (such as Zoladex injections for hormone receptor positive breast cancer).  

In some situations such as surgical removal of both ovaries, menopause is a definite outcome.  However, in other cases such as chemotherapy for early breast cancer, menopause may or may not occur.  In these cases if amenorrhoea (periods stopping) does occur it may be temporary or permanent.  Unfortunately, there is no reliable test to predict which women will become menopausal as a result of their treatment.  Risk will depend on factors including the age of the woman, type of chemotherapy and radiation dose.  

Cancer treatment/types that typically cause menopause

Breast cancer is one of the most common cancers among premenopausal women, and much of the medical research about menopause in cancer patients has been conducted in this patient population. Chemotherapy agents commonly used for breast cancer treatment including cyclophosphamide, anthracyclines and taxanes are known to be associated with chemotherapy induced amenorrhoea.  However, treatments for other cancers besides breast cancer can also be associated with loss of ovarian function, either due to ovarian toxicity from chemotherapy or radiotherapy, or surgical removal of the ovaries.  These cancers include, but are not limited to cervical, ovarian and endometrial cancers, colorectal cancers and haematological malignancies.  

Symptoms related to the female genital tract and sexuality are not limited to those women who go through menopause.  Cancer and cancer treatments can affect a women’s sexual function due to a whole range of factors, including fatigue, pain, altered anatomy and body image post treatment, changing relationships, stress and anxiety.

Symptoms 

Symptoms related to treatment induced menopause can come on more suddenly and are often more severe than those experienced by women going through natural menopause.  Vasomotor symptoms, which include hot flushes and night sweats, are amongst the most common symptoms.  The genitourinary syndrome of menopause (GSM) is a term used to encompass a range of symptoms, including genital symptoms such as vaginal dryness and itching, urinary symptoms such as urinary frequency, incontinence and recurrent urinary tract infections, as well as sexual symptoms such as loss of libido, lack of lubrication and painful intercourse.  It was previously known as vulvovaginal atrophy.  Other symptoms of menopause can include mood swings, poor memory and concentration, joint aches, sleep disturbance and fatigue. 

Importantly, menopause is not the only cause of these symptoms, and women should see their doctors to discuss whether there are other potential underlying medical issues that need to be investigated.  

Management 

It is important to understand that menopausal symptoms only really need to be treated if they are bothersome or impact on a woman’s ability to function.  Menopausal Hormone Therapy (MHT) (previously known as Hormone Replacement Therapy, HRT) is effective for treating menopausal symptoms, but is sometimes contraindicated in women with a history of cancer.  This means that these women are not allowed to use HRT, because they can be harmful in their particular circumstances.  This is not the case for all women who have had cancer and will depend on the particular characteristics of their tumours.  Some women who are not able to take systemic MHT may be able to use low dose vaginal oestrogen for relief of genitourinary symptoms.  Women should speak to their oncologists about whether MHT or low dose vaginal oestrogen may be appropriate for them.  

There are a range of other management options for women with menopausal symptoms.  The nature and severity of the symptoms, as well as personal preference and medical history will determine which options are appropriate for a particular woman.  Options include:

  • Lifestyle modifications (such as avoiding triggers for hot flushes and products which can irritate the vulva, stopping smoking, losing weight if obese) 
  • Non-hormonal medications such as certain antidepressants (citalopram, escitalopram, paroxetine, venlafaxine), pain medications (gabapentin) or blood pressure medications (clonidine)
  • Vaginal moisturisers and lubricants
  • Cognitive behavioural therapy (CBT)
  • Acupuncture 

There are many herbal therapies available over the counter, although evidence for these are limited.  If a woman wishes to try herbal therapies she should discuss this with her doctor, as there may be side effects and drug interactions.  Compounded bioidentical hormones should be avoided, as evidence is limited and safety may be a concern.  

Managing menopause after cancer is not only about symptom control.  Optimising bone health and cardiovascular health is important to ensuring the overall health and wellbeing of menopausal women.

Adequate calcium intake and vitamin D levels, as well as regular weight-bearing exercise should be encouraged.  Cardiovascular risk factors including high blood pressure, high cholesterol, diabetes, smoking and obesity should be monitored and managed as needed.  A doctor may recommend a bone density (DEXA) scan and a blood test. 

Menopause after cancer treatment is often best managed by a holistic and multidisciplinary team with expertise in this area.  This team can include doctors who specialise in menopause, breast care nurses, pelvic physiotherapists, psychologists and sexual counsellors.  In addition, young women with cancer should have access if desired to consultation with a fertility specialist both before and after treatment.  

Key messages 

Premature (before age 40 years) and early (before age 45 years) menopause can be a debilitating consequence of cancer treatment in young women.  Unfortunately, it can also sometimes be inadequately addressed by healthcare professionals and unexpected by patients.  Women who are suffering with menopausal symptoms as a result of cancer treatment should not hesitate to speak to their healthcare practitioners.  They should feel reassured that treatment options are available and that there are multidisciplinary specialist teams that have an interest in this area and are available to help.   

Where to find more information:

  • Cancer Council Victoria
  • Breast Cancer Network Australia
  • Australasian Menopause Society 

Dr Lironne Wein is a medical oncologist, specialising in breast cancer and has an interest in managing menopausal symptoms and wellbeing after cancer.  She consults at Women’s Health Melbourne, a specialist gynaecology and fertility practice which provides holistic care.

Contact  info@womenshealthmelbourne.com.au

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