Menopause after cancer


Having menopause and cancer at the same time can be very distressing. Managing your health, your illness and menopause all at the same time is difficult, given that your treatment options for menopause are often limited. However, there are many things you can do that can help you.

woman being treated for cancerMenopause and cancer are associated for several reasons:

  • Cancer treatment (chemotherapy and/or radiotherapy) can cause ovaries to fail, causing you to experience menopausal symptoms
  • Surgery for pelvic cancers, such as uterine, ovarian or cervical, can result in the removal of the ovaries, causing menopause
  • Hormone therapies (such as tamoxifen and aromatase inhibitors) used to treat breast cancer after surgery, radiotherapy and/or chemotherapy can cause menopausal symptoms.

Studies show 25% of women who develop breast cancer are not postmenopausal. This means that cancer treatment may cause them to experience menopause sooner than they otherwise would have done.

It is also possible that:

  • you may be in the perimenopause when diagnosed with cancer
  • stopping menopause hormone therapy, or MHT (formerly called hormone replacement therapy, or HRT) when your cancer diagnosis is made can bring on menopausal symptoms that otherwise may have been treated by MHT.

Breast cancer is the most common cancer affecting women, so much of the information and research about cancer and menopause relates to breast cancer. But treatment for other cancers (including childhood cancers, non-hormonal cancers and hormonal cancers) can also result in menopause.

Not all cancer treatments will cause menopause. For some women menopausal symptoms are temporary; for others, menopause is permanent. Sometimes periods will stop straight away, and sometimes menopausal symptoms will start immediately, or build up over time. There is no way of predicting how menopause will affect each woman. Whether permanent menopause occurs depends on age, the type and dosage of chemotherapy and how long it is used for.

Symptoms

It is sometimes difficult to distinguish between which are 'normal' menopausal symptoms and which symptoms are made worse because of the cancer.

Menopause symptoms experienced by menopausal women with breast cancer

Research suggests young menopausal women with breast cancer may experience the following:

Hot flushes & night sweats

  • Up to 80% of women with breast cancer seem to experience more severe and frequent hot flushes, compared to women with breast cancer [1]
  • Night sweats and hot flushes tend to vary with the type of treatment and can contribute to insomnia in women with breast cancer.

Urogenital symptoms

Of women with breast cancer, especially those taking aromatase inhibitors, 50-75% report one or more symptoms; for example, vaginal dryness, itching, painful sex or urinary tract infections.

Emotional/mental health

Increased depression and anxiety can be related to being diagnosed with a major illness. They are also affected by:

  • age
  • the stage of the cancer
  • how well treatment is going
  • how well you can cope with what is happening
  • the support you have.

Early menopause

Younger women with breast cancer can experience more physical symptoms, psychological distress and poorer sexual functioning compared to other (older) women with breast cancer.

Hormone therapy

Medications such as tamoxifen and aromatase inhibitors (AIs) are given to women who have oestrogen-dependent cancers. These medications are oestrogen suppressors (they lower oestrogen levels in the body) and can cause menopausal symptoms such as hot flushes, vaginal dryness and, with AIs, changes to bone density. Up to 20% of women with breast cancer consider stopping or stop hormone therapy because of their menopausal symptoms. If you are taking these medications and menopausal symptoms are really troubling you, please discuss this with your doctors.

Management & treatment of symptoms

Managing menopause in women with cancer involves a number of options:

  • lifestyle changes to help reduce depression, anxiety, cardiovascular and osteoporosis risks
  • complementary therapies:
    • herbal remedies (evidence on their effectiveness is limited)
    • cognitive behavioural therapy
    • hypnotherapy
  • psychological support
  • medication.

Healthy living

Having a healthy diet containing a variety of fresh foods can help you cope with menopausal symptoms. The increased tiredness and moodiness of menopause, along with having cancer, can often make it difficult to eat a healthy diet. It can take time to organise healthier food choices and you might not always feel like making the effort.

Physical activity of 30 minutes per day can help reduce stress, improve mood and increase your ability to cope with daily life, and this can help you cope better with menopausal symptoms. Depending on where you are up to in your treatment for cancer, gentle exercise and fresh air can help you through the day.

More information about ways to have a healthy diet and physical activity is in our Healthy living webpages.

Complementary therapies

Because women with hormone-dependent cancers usually are not able to use MHT, and they are suffering severe symptoms, it is valuable to know which alternative treatments are safe.

There is inconsistent research on herbal therapies specifically for women with breast cancer and menopause. Some herb and plant therapies can have side effects and interact with medications. If you are using herbal therapies or thinking about using them, please let your doctor know so you can explore any possible risks.

Cognitive behaviour therapy & hypnotherapy

Cognitive behaviour therapy (CBT) helps with how you think about the things happening to you, and also trains you to watch and change how you behave when you are worried or upset. CBT has been found to help reduce the severity and number of hot flushes in menopausal women with breast cancer.[1] It reduces bothersome vasomotor (the dilation and contraction of blood vessels) symptoms by up to 80%. CBT can improve mood and reduce anxiety. If you would like more information on CBT, please go to the toolkit on anxiety.jeanhailes.org.au and/or a self-management CBT program for vasomotor symptoms.

Hypnotherapy is a method of creating a state of deep relaxation to treat disorders of a mainly psychological or emotional origin, but it has also been shown to reduce some physical symptoms as well. Hypnotherapy has been shown to reduce the number and severity of hot flushes. One study showed significant reduction after five weekly sessions, with ongoing home practice.

Other complementary therapies

The following therapies have many benefits for improving wellbeing, but have not been shown to reduce hot flushes and sweats:

  • mindfulness: this involves paying attention, in the present moment, to bodily sensations and thoughts, and helps you learn to not get so caught up in your thinking. By becoming aware of the different sensations in your body and bringing attention to your thinking and feelings through mindfulness training, it has been shown that in women with breast cancer, stress is reduced and overall quality of life improves.[2] Some studies of mindfulness did show some reduction in hot flushes; however, overall the severity of symptoms has not been reduced significantly
  • relaxation
  • yoga
  • paced respiration (deep, controlled breathing)
  • exercise.

Menopause hormone therapy (MHT)

Menopause after cancer can present either immediately or within months or years of treatment. A small number of women who have cancers earlier in life, such as childhood cancer, may be at risk of early menopause. These women may be suitable for MHT.

Women with oestrogen-dependent cancers, including breast and high-risk endometrial cancer, generally do not use MHT.

Whether or not to use MHT is a decision to be made in consultation with your oncologist and other treating doctors.

For further information, see 'Menopause hormone therapy (MHT)' and 'Premature and early menopause'.

Tibolone & breast cancer

Tibolone (sold as Livial™/Xyvion ™) is a synthetic hormone, and its actions are similar to oestrogen, progesterone and testosterone.

Tibolone is not associated with an increased risk of breast cancer in women without breast cancer, but the multinational study of women with menopausal symptoms and breast cancer showed that tibolone increased the risk of recurrence compared to placebo.[3]

It should be noted that tibolone may interfere with the effectiveness of breast cancer therapies, and it is therefore not recommended for women with breast cancer.[4]

Conjugated oestrogens & Bazodoxifene and breast cancer

This is sold as Duavive™, a new therapy with conjugated oestrogens and a SERM (selective estrogen receptor modulator) for menopausal symptoms. There are no studies available of its use in women with breast cancer, so it is not recommended for use.

Non-hormonal medications for menopausal symptoms

For women not able to use hormone-based treatments for menopausal symptoms, a group of antidepressants called SSRIs/SNRIs (selective serotonin or serotonin-norepinephrine reuptake inhibitors) are sometimes used as they have been found to be helpful in reducing hot flushes. Some antidepressants (paroxetine and fluoxetine) can interfere with the effectiveness of tamoxifen in breast cancer treatment, leading to a possible increase in the risk of recurrence.

Your doctor can work out whether an antidepressant is suitable for you. These medications may also help you cope, so please ask your doctor about them.

Other options include gabapentin (an epilepsy and chronic pain medication) and clonidine (a blood pressure medication).

Studies have shown that all of these treatments can be useful to control hot flushes and sweats, and usually work within four weeks of starting the recommended dose. Their effects will differ from one woman to another, and your doctor is the best person to advise you about which option might be right for you.

What can you do to manage menopausal symptoms?

To help you manage menopausal symptoms, keep a record of the symptoms troubling you the most and list:

  • their frequency
  • their severity
  • the effect they have on your daily life.

Use this information to see what changes you can consider to reduce the impact of these troubling symptoms.

Seek advice from your doctors.

Seek information from a trusted source, such as the Breast Cancer Network Australia's 'My journey kit'.

Visit a psychologist who specialises in emotions in chronic illness. Medicare rebates are available for up to 10 visits per year to a psychologist, as a 'mental healthcare plan'. Discuss this with your doctor.

Mental & emotional health

The combination of coping with a cancer diagnosis and undergoing treatment, as well as the impact of managing menopausal symptoms, can be an overwhelming experience. Managing and maintaining your emotional health is an important aspect of your overall wellbeing.

Fertility & chemotherapy  

Before chemotherapy and/or radiotherapy, you should investigate your options for trying to preserve your fertility. There are a number of options, including:

  • embryo freezing
  • egg freezing
  • ovarian preservation
  • ovarian biopsy and freezing.

For more information download the booklet 'Fertility and Cancer' from the Cancer Council.

References

  1. Schover LR. Premature ovarian failure and its consequences: vasomotor symptoms, sexuality and fertility. J Clin Oncol. 2008 Feb10;26(5):753–8.

  2. Mann E, Smith MJ, Hellier J, Balabanovic JA, Hamed H, Grunfeld EA et al. Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment: a RCT. Lancet Oncol. Pub online Feb 15, 2012 DOI:10.1016/S1470–2045(11)70364–3 1.

  3. Carmody JF, Crawford S, Salmoirago-Blotcher E, Leung K, Churchill L, Olendzki N. Mindfulness training for coping with hot flashes: results of a randomized trial. Menopause. 2011 June;18(6):611–20.doi: 10.1097/gme.0b013e318204a05c.

  4. Henderson VP, Clemow L, Massion AO, Hurley TG, Druker S, Hébert JR. The effects of mindfulness-based stress reduction on psychosocial outcomes and quality of life in early-stage breast cancer patients: a randomised trial. Breast Cancer Res Treat. 2012 Jan;131(1):99–109. doi: 10.1007/s10549–011–1738–1. Epub 2011 Sep 8.

  5. Kenemans P, Bundred NJ, Foidart JM, Kubista E, von Schoultz B, Sismondi P et al. A double-blind, randomised non-inferiority trial. Safety and efficacy of tibolone in breast-cancer patients with vasomotor symptoms: a double-blind, randomised, non-inferiority, trial. Lancet Oncol 2009;10(2);135–46 Ebup 2009 Jan 23. www.ncbi.nlm.nih.gov/pubmed/19167925.

  6. Cummings SR, Ettinger B, Delmas PD, Kenemans P, Stathopoulos V, Verweij P et al. for the LIFT Trial investigators. The effects of tibolone in older postmenopausal women. N Engl J Med 2008;359:697–708 (http://content.nejm.org/cgi/content/abstract/359/7/697)

  7. Mintziori G, Lambrinoudaki I, Goulis DG, Ceausu I, Depypere H, Erel CT et al. EMAS position statement: Non-hormonal management of menopausal vasomotor symptoms. Maturitas. 2015 Jul;81(3):410–3. doi: 10.1016/j.maturitas.2015.04.009. Review.

  8. Vincent AJ. Management of menopause in women with breast cancer. Climacteric. 2015 Oct;18(5):690–701. doi: 10.3109/13697137.2014.996749. Review.

  9. Self-management Cognitive behaviour program for vasomotor symtpoms: www.womens-health-concern.org/help-&-advice/factsheets/cognitive-behaviour-therapy-cbt-menopausal-symptoms

Last updated 18 August 2018 — Last reviewed 17 December 2017

This web page is designed to be informative and educational. It is not intended to provide specific medical advice or replace advice from your health practitioner. The information above is based on current medical knowledge, evidence and practice as at December 2017.

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