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What is menopause?
Menopause is the time when menstrual periods stop. At menopause, the ovaries stop releasing eggs and producing oestrogen (female hormone). This reduction in oestrogen causes many changes in the body. For some women, the changes are minor and do not cause any problems, but for other women, the changes are much more noticeable.
Most women go through menopause between the ages of 45 and 55. Symptoms related to menopause usually develop naturally over a number of years. A woman is said to have gone through menopause when she has not had a period for 12 months. Breast cancer treatment can bring about a sudden menopause in some women, and this may mean that the symptoms are more severe than if they occur during a ‘natural’ menopause
How will menopause affect me?
The symptoms of menopause vary from one person to another.
Hot flushes are common and may be mild, moderate or severe. Most women experience mild hot flushes at the time of menopause, and these become less frequent and less intense with time. A minority of women experience severe hot flushes and these can be distressing.A severe hot flush is an intense feeling of heat all over the body and it may be associated with sweating, palpitations and nausea. For some women, this happens frequently at night and interferes with sleeping. However, even the most severe flushes will diminish in the months and years after menopause. Sometimes short-term treatment is needed to try and ease the flushes when they are most intense.
Other symptoms of menopause
The extent and severity of other symptoms varies from person to person and effects may be seen in both natural menopause and menopause brought on by breast cancer treatments. There are also many other causes for these symptoms. Other symptoms of menopause include:
- mood changes such as anxiety, depression and irritability
- poor memory and poor concentration
- muscle and joint aches
- difficulty sleeping
- vaginal dryness
- reduced interest in sex
Menopause also increases the risk of heart disease, osteopenia (thin bones) and osteoporosis (very thin bones that may be at risk of breaking).
Positive feelings at menopause
For some women, menopause is a time of positive change. Feelings of relief at not having to deal with periods, premenstrual symptoms and contraception are common. Often children are growing up and leaving home and this may provide more time for women to spend with their partners and increased opportunities for intimacy.
Menopause and breast cancer treatment
The symptoms associated with menopause in women who have had breast cancer are the same as they are for any other woman. However, some of the treatments for breast cancer can make these symptoms worse.
Chemotherapy is the main breast cancer treatment that can bring on an early menopause. For some women, periods can stop temporarily during chemotherapy and in others they stop permanently. It is sometimes difficult to know if your periods will start again, and you may not know for 6 to 12 months. If you have no periods for 12 months it is extremely unlikely that they will start again. There is a lower chance of your periods coming back if you are over 40 at the time of treatment than there is if you are under 30. The likelihood of your periods coming back is also related to the type of chemotherapy you have and the doses used.
Tamoxifen and aromatase inhibitors are hormone-blocking treatments for breast cancer. They may have side effects similar to menopausal symptoms, for example, they can cause hot flushes. These medications often suppress periods even though the ovaries may still produce eggs. This means that pregnancy can still occur and in some cases fertility can temporarily increase while taking these tablets. Women who are still having periods before breast cancer treatment should therefore use contraception to avoid unwanted pregnancy.
Surgery and radiotherapy to the breast do not cause menopause. However, sometimes surgery to remove the ovaries or medication to ‘turn off’ the ovaries are part of breast cancer treatment, and these can cause menopause symptoms which may be sudden and severe.
How can I manage my menopause?
Some women have mild menopausal symptoms that don’t need any special treatment. Others experience more severe symptoms that interfere with their everyday life. Some suggestions to help manage these are given here.
Avoid things that worsen flushes.
Avoiding some things can reduce the frequency and severity of hot flushes. There is also evidence that regular exercise reduces hot flushes. Avoid things such as:
- hot drinks (tea and coffee)
- alcohol (particularly red wine)
- hot weather
- spicy foods
Venlafaxine (Efexor) is an antidepressant that reduces hot flushes in many women. It is usually given in a dose of 37.5 mg daily for two weeks, increasing to 75 mg daily. It is common to have some side effects such as headache, trouble sleeping, nausea and mild anxiety in the first two weeks, but these usually settle quickly. It is important that you tell your doctor about any other medication you are on, including herbal treatments, because this medication can interact with some others.There are other medications similar to venlafaxine, and some of these may also reduce hot flushes. However, some may also interfere with the action of tamoxifen. If you are taking tamoxifen for breast cancer treatment, it is important that you speak to your oncology team before you take any antidepressants.
Gabapentin is a prescription medication often used for the treatment of epilepsy and other neurological conditions. It is also very effective in reducing hot flushes, and it can have some side effects like dizziness and drowsiness.
Clonidine is another prescription medication sometimes used for hot flushes. Some trials have shown it helps reduce hot flushes, but in other trials, the drugs have not made a difference.
This is a hormonal treatment that can reduce hot flushes. It is a female hormone like oestrogen, but has been linked to an increased risk of breast cancer when used with oestrogen as hormone replacement therapy (HRT) after menopause. Experience shows that short-term Provera to be safe and effective in controlling hot flushes. In the past, Provera was used to treat advanced breast cancer and so it is sometimes used to treat hot flushes for women wanting to avoid oestrogen. Provera in a dose of 20 to 50 mg has been shown to reduce flushing in two out of three women. Some women (about one in eight) develop side effects similar to premenstrual syndrome, which may include bloating and irritability. If this happens, the medication may need to be changed. Primolut N, 5 to 10 mg daily is an alternative.
Hormone replacement therapy
HRT is a treatment that uses oestrogen and progestogen to reduce hot flushes. It should be avoided after breast cancer, as studies show it can increase the risk of cancer returning. More information about this is given later in this brochure.
Herbal therapies and soy products
There has been interest in using herbal therapies to treat menopausal symptoms. Vitamin E is one of these. At a dose of 800 IU per day, it can reduce hot flushes in some women, and is thought to be safe in women who have had breast cancer.
Soy products (phytoestrogens) contain natural chemicals similar to oestrogen. It is thought by some that using these products may reduce the number and the severity of hot flushes. Soy products, when included in a normal healthy diet, appear to be safe, but the use of high-dose phytoestrogen supplements is not recommended following breast cancer treatment.
Some women find that their hot flushes are so severe they would like to try some of these products even though their safety in women who have had breast cancer treatment isn’t proven.
- red clover extract (Promensil)
- black cohosh extract (Remifemin)
- soy products
- dong quai
Black cohosh is one of the few natural therapies shown to reduce hot flushes in research studies. It reduces hot flushes in women who have not had breast cancer, but this effect has not been proven in women who have had breast cancer.
Herbal products may take longer to have an effect than prescription medication, so if you decide to try these you should continue them for at least two to three months. There have been some reports of hepatitis (liver inflammation) in people using black cohosh. This is an extremely rare complication, but it is recommended that women who have liver
problems avoid using it.
Reduced interest in sex
Sexual feelings vary during and after treatment for breast cancer. Some women find they feel closer than ever to their partners. More commonly however, women find that their sexual interest declines because of physical and emotional stress.
Treatments for breast cancer can cause physical changes that can make sex difficult or painful. Changes in your body that make sex difficult usually settle after treatment. Treatments can also be tiring and emotionally draining. A diagnosis of breast cancer can put a strain on any relationship, and the physical changes can make things more difficult. It is rare for any physical changes to be permanent.
It is important that you discuss any issues related to sexuality with your doctor or nurse, because there are often things they can do to help.
Testosterone is a hormone medication that is sometimes used to increase libido in women. It is not known if it is safe to use after treatment for breast cancer.
After menopause, about half of women will report uncomfortable vaginal dryness. There are some simple things you can do to improve this:
- avoid washing your vaginal area with soap; this can dry your skin and cause irritation
- use a soap substitute to wash your vaginal area
- apply regular moisturisers such as sorbolene or vitamin E cream to your vulva and vagina
- use simple water-based lubricants such as ‘Sylk’ or ‘K-Y Gel’ to make your vagina more comfortable during intercourse.
- ask your doctor about a vaginal oestrogen treatment; this can help with vaginal dryness and bladder symptoms.
One of the long-term problems with menopause is thinning of the bones (osteopenia and osteoporosis). Bone density builds up during your teenage years and usually peaks between the age of 20 to 30. It will stay stable until menopause. After menopause, bone density falls by 1–3% a year. If your bone density drops too much there is a risk that your bones will break easily.
Crush fractures of the bones of the spine (vertebrae) can be very painful and difficult to treat in later life. People at increased risk of osteoporosis are those with a family history of osteoporosis, very thin people, those of Asian descent and people who smoke.
Osteopenia and osteoporosis can be diagnosed with a bone mineral density test. This is a simple test that takes around 15 minutes. It is recommended that all women have a bone density test every two to three years after menopause, so that osteoporosis can be found before it causes breaks in the bones (fractures). If treatment is started for osteoporosis, monitoring should occur every one to two years.
In addition to the normal fall in bone density that happens after menopause, some breast cancer treatments can reduce bone density. This happens most often with aromatase inhibitors such as letrozole, anastrozole or exemestane. If you are taking one of these medications your doctor may recommend that you have bone density tests more often. There is increasing research showing that vitamin D is important for bone health, especially after breast cancer. Your doctor may recommend a blood test to check your vitamin D level. If it is low and it is not possible to safely increase your sun exposure, you may be prescribed a vitamin D supplement
How can I protect against osteoporosis?
Maintain a generally healthy lifestyle.
Exercise regularly (at least 30 minutes of exercise most days is recommended). This should be weight-bearing exercise such as walking, running or dancing rather than non-weight-bearing exercise like swimming or cycling.
It is essential to make sure you are getting enough calcium and vitamin D for bone health, especially during and after menopause as bone loss is more rapid. At least 1000 mg of calcium per day is recommended if you have reached menopause or 1300 mg per day if you are over 70. This can be obtained from either the food you eat or by taking calcium supplements.
Calcium requirements can be achieved by eating three to four serves of foods high in calcium each day. These foods include milk, cheese and yoghurt, canned sardines and salmon with bones, and tofu. Calcium-fortified foods such as calcium-fortified orange juice and soy milk are also a good source of calcium. Calcium is also found in lower quantities in green leafy vegetables, broccoli, dried beans and peas, dried apricots and nuts such as almonds, hazelnuts and cashews; however the amounts are quite small and not enough to make a serve. If you are unable to meet your calcium requirements from your diet a supplement is recommended.
You should also ensure you have adequate vitamin D to enable calcium absorption. Vitamin D also has numerous other benefits for menopausal women such as maintaining muscle strength, and may be involved in prevention of other chronic diseases such as cardiovascular disease and cancer. Although the requirement for vitamin D to maintain bone health is 400 international units (IU) per day, to gain some of the possible benefits of chronic disease prevention, many health professionals recommend an intake of 1000-2000 IU vitamin D per day.
Vitamin D can be obtained from exposing the skin directly to the sun, as well as from food and supplements. Sun exposure early or late in the day in summer or during the day in winter (when the UV index is below 3) may be adequate to produce enough vitamin D. However this varies considerably between individuals, as vitamin D production depends on many factors such as skin pigmentation, age, body weight, season and latitude of where you live, so for some individuals it may not be possible to safely obtain sufficient vitamin D from the sun. For some individuals, such as those at increased risk of skin cancer or who use certain medications sun exposure is not recommended. Other ways to meet vitamin D requirements are by intake of a combination of foods and supplements. Oily fish such as salmon and sardines are good sources of vitamin D, while vitamin D-fortified foods such as some brands of milk and cheese, as well as meat and eggs also contain small amounts.Vitamin D supplements typically contain 1000 IU vitamin D per capsule, whereas calcium supplementsgenerally contain around 400 IU vitamin D and multivitamins around 50 IU.
There are many drug treatments for osteoporosis if it develops. Your doctor will talk to you about these if your bone density is low.
Hormone replacement therapy
HRT is the most effective treatment for menopausal symptoms. However, it has been shown to increase the risk of cancer returning in women who have been treated for breast cancer. It is therefore not recommended for routine use, particularly if your breast cancer is hormone sensitive (ER-positive). It should only be used as a last resort, in a very small group of women who have severe menopausal symptoms that make life miserable. It should only be used after careful discussion with your breast cancer specialist.
Tibolone (Livial) is a different form of HRT, but evidence shows that it increases the risk of cancer returning in much the same way as other types of HRT, particularly for women with ER-positive breast tumours.
Vaginal oestrogen is hormone therapy given in the form of vaginal cream or vaginal tablets. It is extremely effective for treating vaginal symptoms such as dryness and irritability, and for treating bladder symptoms. These treatments work only on the vagina and the bladder and are not absorbed in significant amounts into the blood, so they are thought to be safe to use in women who have had breast cancer. There are two products that may be suitable: Vagifem is a vaginal tablet that is used twice a week, and Ovestin is a vaginal cream that is used three or four times a week. Your doctor can talk to you in more detail about these medications.
Who can help?
Sometimes it is difficult to discuss the symptoms of menopause. Still, it is important that you let your medical team (doctors or nurses) know if you are troubled by these symptoms, because there are many effective treatments that can help. There are also many myths about menopause, and it is important that you get accurate information that is relevant to your personal situation.
Remember, the effects of menopause are common, and your treatment team has experience in helping women deal with them. Your GP is also an important person to talk to about these issues.
[This information guide is also available in PDF format to download.]