Breast cancer and early menopause – a guide for younger women

Menopause occurs when a woman’s ovaries no longer produce eggs, which results in her periods stopping. The term ‘menopause’ technically refers to a woman’s final menstrual period; however we generally refer to life after menopause as ‘being in menopause’.

Before menopause, the ovaries release one mature egg each month while the lining of the womb (uterus) thickens to prepare for pregnancy. If a woman does not become pregnant before the egg dies, the lining of the womb breaks down leading to monthly menstruation (‘periods’). The ovaries produce three main hormones: estrogen, progesterone and testosterone which affect many normal body functions and feelings such as sexual desire.

Menopause can cause a number of different symptoms and can increase the risk of other health conditions such as osteoporosis (loss of bone strength). Some women find that menopausal symptoms have little or no impact. For others, menopausal symptoms can be more severe and can affect their quality of life.

Menopause usually occurs between the ages of 45 and 55, however breast cancer treatment often causes it to occur at an earlier age than normal (see below).

Menopause can be a challenge at any age for some women, but when it occurs earlier than expected, it can be particularly distressing. Menopause brought on by breast cancer treatment occurs more suddenly than natural menopause so there is less time for the body to adjust to the drop in hormone levels. It may be harder for younger women to deal with these changes when their friends are all still getting regular periods. But every woman reacts a little differently to an early menopause. While some women feel sad about the loss of ’young womanhood’, others feel that they have gotten a new lease on life. They may enjoy having no periods and may feel more care-free and confident as a result, particularly if their periods were painful or heavy.

Most symptoms of early menopause can be managed with appropriate care. The following details provide information and strategies about how to manage the symptoms of early menopause.

Some of the common symptoms of menopause are listed in Table 1. Symptoms of menopause vary considerably and not all women will experience all of the symptoms listed. For some women, the only symptom of menopause is that their monthly periods stop. Some women experience other symptoms, which can range in severity from very mild to severe.

Talk to a member of your treatment team if your symptoms are affecting your quality of life.

Most symptoms of menopause are temporary and will ease with time.

In women who have not been treated for breast cancer, menopausal symptoms last around 1–5 years but most improve over time. We don’t know whether the duration of menopausal symptoms is the same for women who enter menopause early because of treatment for breast cancer.

Treatments for breast cancer may reduce fertility temporarily or permanently. However, this does not mean it is impossible to become pregnant during or after treatment.

Non-hormonal forms of contraception, such as condoms, diaphragms, intrauterine contraceptive devices (IUDs) or male or female sterilisation are recommended. It’s still possible to catch sexually transmitted infections (STIs) after menopause. Condoms are the most effective way of protecting against STIs.

If you were pre-menopausal before breast cancer and you are sexually active, talk to a member of your health care team about suitable methods of contraception for you.

Hot flashes are a side effect of many hormonal treatments for breast cancer and are common during menopause.

Hot flashes may come and go and are not always severe, however they, and night sweats, may be more severe after breast cancer than during natural menopause. The duration of hot flashes also varies between women. Some women may experience hot flashes for many years.

What helps?

Although we don’t know how to stop hot flashes, there are some things you can do to help manage the symptoms:

• exercise
• wear natural fibres like cotton which absorb sweat
• dress in layers, so that it’s easy to take off an item of clothing when you experience a hot flash
• reduce your intake of caffeine, alcohol, spicy foods, sugar and other simple carbohydrates
• have an early supper, and no snacks after 8 pm
• keep a small fan in your work area and drink cold water to cool you down
• keep a note of when you experience hot flashes and what you’re doing when they occur; this may help you identify the ‘triggers’ that cause your flashes and help you find ways to avoid them
• consider meditation, yoga and other relaxation techniques
• some women have found they can relieve the symptoms if they switch to deep, slow abdominal breathing (controlled breathing) at the first sign of a hot flash

Staying cool in bed:

• keep cold water by your bed ready to drink at the first sign of a sweat
• use cotton sheets and cotton nightclothes, or sleep naked
• sleep under layers, so you can easily remove extra bed covers
• have a small fan running to keep the air moving while you sleep

Regular exercise may ease hot flashes and improve your sleep. You may like to keep a packet of pre-moistened tissues/towels, such as baby wipes, handy for when hot flashes occur.

Medication

If these ‘lifestyle’ changes are not adequately controlling hot flashes, there are some medications that may be helpful.

Gabapentin

Gabapentin is a drug used to treat chronic nerve pain and epileptic fits. It has been shown to be effective in reducing hot flashes. Many women find gabapentin acceptable to use. However, up to half of the women who use gabapentin experience side effects including sleepiness, light-headedness, and dizziness. These side effects may resolve with time or can be reduced by adjusting the dose.

Venlafaxine and other similar drugs

Many studies have shown that antidepressants like venlafaxine (Effexor®), paroxetine (Paxil®), fluoxetine (Prozac®), citalopram (Celexa®) or sertraline (Zoloft®) may reduce hot flashes. These drugs act quickly (within a week) but may not have a long-lasting effect.

Around a quarter of women experience side effects with antidepressants.

Some of these drugs, particularly fluoxetine and paroxetine, may interfere with the way that your body breaks down tamoxifen. This may interfere with the action of tamoxifen. Effexor is the antidepressant most commonly prescribed for women taking tamoxifen.

Menopause can reduce the body’s production of the hormone estrogen. Estrogen is important for maintaining the moisture and elasticity (stretch) of the vagina. When estrogen levels are lower, vaginal dryness and loss of vaginal elasticity can make sexual intercourse uncomfortable or painful. Unlike hot flashes, vaginal dryness does not improve over time, is progressive, and may be a long-term problem unless treated. Whether or not a woman is sexually active vaginal dryness can lead to chronic discomfort, itch, or bleeding.

What to do about vaginal dryness

The most effective solution for vaginal dryness is to use a product that will add moisture to the vaginal tissue. There are three types of vaginal moisturisers. All are applied directly into the vagina.

Non-hormonal vaginal moisturisers

Non-hormonal vaginal moisturisers provide relief from the symptoms of vaginal dryness. These products (eg. Replens®, repaGyn® or Gynotrof®) come in a semiliquid form and are usually applied twice a week. They are available from most pharmacies.

Vaginal gels and lubricants

Vaginal pH-balanced gels are used to prevent and treat vaginal dryness. With a pH similar to that of normal vaginal discharge, these gels have been found to improve vaginal dryness and vaginal pH in women after breast cancer.

Vaginal lubricants provide lubrication to enhance the comfort and ease of sexual intercourse. If you use a vaginal lubricant choose a water-based or silicon-based lubricant rather than oil-based lubricants which may increase the risk of getting yeast infections. These products (eg. Astroglide® or KY®Jelly) come as ‘semi-gel’ creams are available from pharmacies.

Applying a gel containing a local anaesthetic to the area around the vulva immediately before sexual intercourse may reduce pain and discomfort associated with penetration.

Vaginal estrogens

Vaginal oestrogens are creams, rings or tablets containing low doses of the hormone oestrogen that are inserted directly in the vagina. They are designed to help reduce symptoms associated with vaginal dryness and discomfort with sexual activity.

When vaginal estrogens are used, minimal amounts of estrogen may be absorbed into the body. Because of this, vaginal estrogens should only be prescribed by a medical practitioner who is aware of your history of breast cancer. It is important to check with your oncologist before using a vaginal estrogen as it may not be appropriate for some women with hormone-sensitive (ER+) breast cancer.

Other ways of managing vaginal dryness

• Avoid substances that can irritate or dry the vaginal region, such as soap, or products containing alcohol or perfume. Products containing petroleum jelly and baby oil can also cause irritation. Use a soap-free product to wash the vaginal area.
• Wear cotton underwear and avoid nylon underwear, tight underwear, or tight clothing.
• If you’re sexually active, discuss your concerns with your partner. If your partner is aware of how you feel, he or she is more likely to help you explore alternatives.
• Simple strategies, such as changing the position for intercourse, can relieve discomfort. Pain during sex can make you tense, and that tension can cause more pain. Try exploring alternative ways to be intimate so you and your partner can maintain a pleasurable and satisfying sexual relationship.

Menopause can cause a loss of libido, and can decrease your desire for sexual intimacy.

Managing these symptoms may require some effort – and open communication between you and your partner.

Some women say it takes longer to become aroused and experience orgasm during and after menopause. The loss of desire and libido may be directly related to lower levels of the hormones estrogen, progesterone, or testosterone. Vaginal dryness and pain may further increase the problem.

Changes in libido may not only be the result of your menopausal symptoms. Breast cancer and its treatment can influence your overall sense of femininity and sexuality. This can happen to any woman, whether or not she has a partner.

What helps?

There is a range of practical and lifestyle remedies that can help manage some of the effects of early menopause on sexuality and libido, including managing vaginal dryness.

• Be open with your partner; explain what is happening and what might be helpful for you.
• Relaxation techniques may help to reduce your stress levels and help you refocus on your relationship.
• Treat vaginal dryness if it is causing discomfort (see previous section for details).
• Downplay the importance of sexual intercourse and orgasm, at least for a while. Instead, focus on the pleasure of touching, kissing, and imagery. Women need foreplay to become properly aroused, so don’t hurry this aspect of your relationship, and let your partner know what helps.

You and your partner may find it helpful to talk to a health professional – you can do this together or separately. You may want to ask for advice from a trained specialist such as a relationship counsellor or sex therapist.

Bladder problems – such as incontinence, passing urine more frequently at night and urinary tract infections – can become more frequent during menopause.

If you experience a burning pain when passing urine, or if you feel the need to go to the toilet frequently yet pass only small amounts of urine, see your general practitioner. You may have a bladder infection that requires treatment with antibiotics.

What can help avoid bladder infections?

• Drink sufficient fluids – especially early in the day.
• Go to the toilet promptly when your bladder is full.
• Drinking cranberry juice may help avoid infections.
• Pass urine directly after intercourse.
• Wipe from front to back after using the toilet.

What can help avoid incontinence?

• Try pelvic floor exercises to reduce urine leakage and improve bladder control. Exercise brochures are available from most general practitioners and pharmacists. You may find it helpful to seek advice from a physiotherapist - ask your doctor or breast care nurse for a referral.
• Avoid food and drinks containing high levels of caffeine as this can irritate the bladder and can increase incontinence.
• If these measures don’t help ask your doctor for referral to a urologist or uro-gynecologist.

Many women experience disturbed sleep during menopause.

You may wake up sweating from a hot flash. Other common problems include repeated awakenings, difficulty getting back to sleep and difficulty falling asleep. Disrupted sleep can cause fatigue and tiredness.

If this is causing tiredness during the day, or if you’re regularly waking up feeling anxious and worried, talk to a member of your health care team. Techniques and treatments are available that can help.

What can help?

There are a number of things that may help you sleep better.

• Before bed, avoid caffeine-based drinks, alcohol, and other stimulants like cigarettes and TV. If you’re used to having a bedtime drink, try a non-stimulating herbal tea, like chamomile.
• Use the bedroom for sleep only – no TV or written work (sex is fine!).
• Establish a regular bedtime and waking routine – try to avoid taking naps during the day.
• Keep your bedroom cool.
• Increase your physical activity during the day – such as walking, cardio exercises, yoga or swimming.
• Try controlled breathing – deep slow abdominal breathing.
• Make a regular daily habit of relaxation or meditation.
• Consider asking your general practitioner for a short-term mild sedative.

Painful joints can be a problem associated with menopause and can also be a side effect of drugs used to treat breast cancer, such as aromatase inhibitors. Sometimes joints can feel stiff and sore.

What can help?

Exercise can help to maintain a range of movement and maintain a healthy weight (excess weight puts a strain on the hips and knees). You may wish to talk to a dietitian and ask about vitamin supplements.

If you have bone or joint pain, tell your general practitioner to check that you don’t have other joint changes, such as arthritis. It may also be possible to switch you to a drug that causes less joint pain.

Weight gain is common during both cancer treatment and menopause.

Maintaining a healthy weight is an important aspect of long-term health for cancer survivors, particularly because significant weight gain (10% or more of one’s pre-treatment weight) increases the risk of breast cancer recurrence and death as well as the risk of new breast cancers.

There are many ways to avoid weight gain and to lose additional weight if you put it on. Talk to your doctor or breast care nurse, or ask to speak to a dietitian for advice.

What can help?

• Eat a healthy diet, including lots of fresh fruit and vegetables.
• Reduce your intake of fats, especially saturated fats. Replace fatty meat with skinless chicken or turkey breast, lean fish, lentils, beans and soy as protein sources. Choose low-fat dairy products.
• Drink more water and avoid sugary liquids like soft drink and fruit juice. Even artificially sweetened drinks can lead to weight gain for reasons that are not well understood.
• Participate in regular physical activity, aiming for at least 30 minutes of moderate-intensity activity every day, and limiting sedentary habits (the time you spend sitting or lying down).
• If you choose to drink alcohol, limit your intake.
• Eat supper early and do not snack after dinner. Often what feels like hunger is really just thirst or fatigue
• You can get detailed advice on your particular needs from an accredited, practising dietitian.

Emotional responses to menopausal symptoms vary greatly between women.

Younger women may have particular concerns about loss of libido, loss of fertility or a feeling of growing old prematurely. Sleep deprivation associated with night sweats can also result in moodiness and irritability.

Managing mood changes can be more of a challenge for women who are working or caring for young children. Recognising these symptoms and allowing time for self-care (‘time out’) can help.

If you’re experiencing feelings that are overwhelming you or interfering with your daily activities, talk to your doctor or nurse. They may suggest referral to a psychologist or psychiatrist. There are many effective treatments for depression.

Menopause does not cause you to lose your memory.

However, changes in sleep pattern, tiredness, depression and anxiety can cause you to become forgetful and may impair your mental functioning.

What can help?

• Make lists of things that are important to remember.
• Stay mentally active—try a crossword, Sudoku or quizzes.
• Keep a brief diary of appointments and things to do and check it regularly.
• Regular exercise can help improve your sleep patterns and your mood.
• Explain to your family and friends what is happening to you so they can help and give you support.

Complementary therapies are a range of approaches to care aimed at enhancing quality of life and improving wellbeing. They may be used alongside conventional treatments. You may also hear people talk about ‘alternative therapies’. These are therapies that are taken instead of conventional approaches to treatment.

Most ’complementary’, ’natural’ or ‘alternative’ therapies have not been fully tested for their effectiveness or safety in treating menopausal symptoms. It is important to talk to your doctor before taking any complementary or ‘natural’ preparations as they may interact with other cancer therapies.

Some herbal preparations may contain estrogen-like compounds. This can be a concern for women who have had a diagnosis of breast cancer.

Relaxation therapy

Relaxation can help reduce anxiety and stress. In women who have had breast cancer, relaxation therapy may improve sleep. There are meditation and Visualization/Relaxation groups, led by professional program leaders, available in Canada through the Wellspring organization.

Yoga and physical activity

Physical activity is very important both during and after cancer treatment Yoga and/or aerobic (“cardio”) exercise may improve hot flashes.

Mindfulness Based Stress Reduction (MBSR)

Mindfulness Based Stress reduction is a technique where one focuses on the present, gradually letting go of thoughts about the past or the future. It can support sleep and general well-being after breast cancer. Mindfulness-Based Cancer Recovery: A Step-by-Step MBSR Approach to Help You Cope with Treatment and Reclaim Your Life, by Linda Carlson et al is a helpful book about MBSR.

Acupuncture

Early studies on the effectiveness of acupuncture in treating hot flashes look promising.

If you have had breast cancer with surgery or radiotherapy to the axilla (armpit), you should avoid having acupuncture on the affected arm and ensure sterile needles are used to help prevent lymphedema.

Premature or early menopause may increase the risk of heart disease. This means that exercise, weight control, treatment for high blood pressure, a balanced diet, stopping smoking and reducing alcohol intake are likely to be very important in women experiencing early menopause.

Loss of estrogen at menopause may increase the risk of osteoporosis (thinning or weakening of the bones). The risk of osteoporosis can be increased further by some breast cancer drugs such as aromatase inhibitors.

Women with a family history of osteoporosis, who smoke, are underweight, have hyperthyroidism, have taken steroids, or are taking aromatase inhibitors are at particular risk of osteoporosis.

Hormonal therapy for breast cancer may also affect bone health. In women under age 50, ovarian suppression and aromatase inhibitors decrease bone strength and increase fracture risk. Tamoxifen reduces bone density to a lesser extent. Your doctor may measure your bone density if you’re at increased risk of osteoporosis before prescribing a hormonal therapy for you. If you’re already at increased risk of osteoporosis, your doctor will consider this when recommending which hormonal therapy is suitable for you. Your doctor may also prescribe a drug like zoledronic acid that helps prevent bone loss. If you are concerned about your bone health you can discuss this with your oncologist when you start hormonal therapy.

How can I reduce my risk of osteoporosis?

There are a number of effective strategies for avoiding osteoporosis including:

• eating a balanced diet that contains enough calcium (1,200 mg/day) — a glass of milk or small tub of yogurt has about 250mg of calcium
• getting adequate Vitamin D, by taking 1000 units daily of a Vitamin D supplement. Since vitamin D requires a bit of fat for it to be absorbed, in pill form it should be taken with food. If it comes as a liquid in a bottle, each drop has a bit of fat so you can take it any time
• not smoking
• limiting alcohol intake
• doing regular weight-bearing exercise, for example walking, playing tennis or dancing, for at least 30 minutes, 2–3 times a week
• resistance training, such as exercise with weights