INTRODUCTION

Menopause and cancer are associated due to the types of cancer treatment and hormone therapies. Cancer chemotherapy and radiation therapy are effective in stopping the activity of cancer cells and preventing tumour growth. However, chemotherapy and radiation therapy can also damage surrounding healthy tissue, including the ovaries. Hormone therapies, such as Tamoxifen and aromatase inhibitors used to treat breast cancer can also cause menopausal symptoms.

Injury to the ovaries has the same outcome as menopause due to the cessation of oestrogen activity. Some treatments such as pelvic radiation can also cause irritation and swelling or inflammation to the tissues of the vulva and vagina, again causing symptoms similar to those of menopause. In this group of women, topical or systemic hormonal treatments are usually contraindicated.

Symptoms: What can be Done?

Following cancer treatment, menopausal symptoms are common for many women and include hot flushes, night sweats, sleep disturbance, fatigue, decreased libido and extreme vaginal dryness. These symptoms can be distressing and last well beyond the cessation of cancer treatment. Often younger women are affected and experience these symptoms many years before they expected to. Older women, who may have already experienced menopause, may have their symptoms return all over again, years after they first subsided.

Management of these symptoms needs to be safe and effective in this special group of patients. Options include:

Studies indicate that a higher percentage of women with reduced oestrogen levels following cancer-related surgery or treatments will suffer from the typical menopause symptoms

Symptom Symptoms (%) Moderate – Severe (%)
Vaginal dryness 55 34
Sexual problems 60 45
Urinary problems 55 39
Hot flushes/sweats 85 63


Breast Cancer and Menopause

Breast cancer is one of the most common cancers in women.

  • In Australia, approximately 13000 women are diagnosed with breast cancer each year.
  • About 1500 of these women are younger than 50 at diagnosis.
  • Treatments such as chemotherapy, radiation therapy and hormonal therapies can have short or longer-term side effects.
  • Early menopause can be the unwanted side effect of some of these breast cancer treatments.
  • Approximately two-thirds of women under the age of 50 at the time of diagnosis will experience menopause as a result of their treatment.

Affected women are therefore often younger and require a different approach to treatment compared to women who enter menopause naturally. Symptoms not only affect a woman’s physical-self and body but also impact on her emotional well-being and personal, intimate relationships.

The discussion of the likelihood of immediate and induced menopause, can often be missed prior to commencement of cancer treatment. Often, patients are being offered life-saving treatments which are time sensitive, and unfortunately what to expect following treatment, the possibility of induced menopausal symptoms, the impact on psychological and emotional health, does not get the opportunity to be discussed. Women can also sometimes feel that their concerns are trivial compared to their cancer treatment or issues may be considered too sensitive to discuss. In addition to coping with a diagnosis of cancer and undergoing treatment, this can also impact on the severity of menopausal symptoms experienced and overall emotional well-being.

What is the link between breast Cancer treatment and Menopause?

Breast cancer is the most common cancer affecting females. It is reported that up to 25 percent of women are not yet in menopause when diagnosed with breast cancer. This means, menopause may be experienced sooner than what would have otherwise been anticipated. Women may also already be experiencing signs of menopause at diagnosis, symptoms can be accelerated further following treatment or hormone replacement therapy (HRT) may have to be ceased suddenly for treatment which can cause rebound symptoms.

Menopause following breast cancer treatment can be temporary or permanent. For women who have not yet reached menopause at the time of their diagnosis, they can often become menopausal as a result of treatment or an active decision, such as surgical removal of their ovaries to reduce their chance of breast cancer recurrence.

Women who have hormone receptor positive breast cancer can also be treated with medications such as Tamoxifen or an aromatase inhibitor that block oestrogen. Severe menopausal symptoms are more likely to occur as oestrogen action is being blocked throughout the body (Tamoxifen) or oestrogen production in the body is ceased (Aromatase Inhibitors).

Tamoxifen

Tamoxifen is a drug belonging to a group of medicines known as anti-oestrogens. It is widely used to treat hormone receptive (ER-positive) breast cancer, meaning a type of breast cancer which relies on the female sex hormone, oestrogen, to grow.

  • Tamoxifen works by blocking the actions of oestrogen.
  • Hormone-positive breast cancer cells have proteins called receptors, which sex hormones attach to.
  • When oestrogen comes into contact with the receptors, it fits into them and stimulates the cancer cells to divide so that the tumour grows.
  • Tamoxifen fits into the oestrogen receptor and blocks oestrogen from reaching the cancer cells.

This means the cancer either grows more slowly or stops growing altogether.

 

Side Effects of Tamoxifen

Each person’s reaction to any medicine is different. Some people have very few side effects, while others may experience more. Common side effects of Tamoxifen include:

  • Hot flushes and sweats
  • Nausea and indigestion
  • Weight gain
  • Change in periods – irregular or cessation
  • Increase in vaginal discharge
  • Vulval and vaginal itching

Women experiencing menopausal symptoms related to treatment of Breast Cancer or Tamoxifen cannot safely be prescribed Hormone Replacement Therapy (HRT) due to the risk of cancer progression or recurrence.

MonaLisa Touch treatment is a safe, non-hormonal and effective way of addressing resultant vulvo-vaginal and urinary symptoms. This in turn can provide relief from symptoms and improvement in quality of life.

Aromatase Inhibitors

Arimidex is a non-steroidal aromatase inhibitor, which reduces the amount of oestrogen produced by the body. It is used to treat breast cancer in women who no longer have their menstrual periods either naturally, due to their age or after surgery, radiotherapy or chemotherapy.

Side Effects of Aromatase Inhibitors

Possible side effects include:

  • Hot flushes
  • Fatigue and/or tiredness
  • Vaginal Dryness
  • Vaginal Bleeding
  • Thinning of hair
  • Mild skin rash
  • Nausea
  • Diarrhoea

Ovarian Cancer And Menopause

Treatment for ovarian cancer usually involves a combination of surgery (oophorectomy) and chemotherapy. Radiation therapy may be required, less commonly, depending on the type and stage of ovarian cancer.

For younger women, removal of their ovaries will result in sudden, induced menopause due to the loss of oestrogen production. If only one ovary is removed, adjuvant chemotherapy +/- radiotherapy will also likely cause damage to the remaining ovary and can also precipitate menopause.

Symptoms of menopause are the same as with natural menopause, but can be more severe, particularly in relation to vaginal dryness and painful intercourse as well as urinary tract changes.

Reference: Gupta P, et al. Climacteric 2006;9:49–58

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