MENOPAUSAL SYMPTOMS OCCUR when the level of oestrogen in your body drops. Hormonal therapy, ovarian suppression and chemotherapy all reduce the amount of oestrogen in your body, and they can also affect your future fertility.
Being thrown into a sudden menopause because of chemotherapy or hormonal manipulation is much harder to cope with than a natural menopause because it happens overnight, instead of a gradual build-up over several years. Trish had already gone through the menopause when she started treatment, but Liz hadn’t, and she found it very hard to deal with, on top of chemotherapy and a mastectomy. Above all, she hated feeling old before her time. We’re going to walk you through what the menopause is, and how to cope if it happens to you.
The menopause is when you stop having periods and can no longer have a baby, and normally starts in your early fifties. It happens because your ovaries slowly stop producing the hormones oestrogen and progesterone, and takes several years. Your body undergoes several changes because of the low oestrogen levels which can cause a wide variety of symptoms (explained here).
Chemotherapy, ovarian suppression and hormone therapy can cause an immediate early menopause if you are young or may worsen your symptoms if you are already menopausal. The symptoms are more intense if your menopause is immediate, unlike a natural menopause when your body has several years to adjust. It can be very hard to cope at first, especially if you are young and faced with a daily reminder that you’ve had breast cancer. The symptoms normally get better within a year or two. Going through the menopause can also affect your partner and your relationship. It’s important to talk to them and explain why you are getting menopausal symptoms so they know what it happening to you and why.
Trish was 56 and post-menopausal when she got breast cancer. She’d been taking hormone replacement therapy (HRT) to control her symptoms. When her breast cancer was diagnosed, she was advised to stop HRT. This brought back troublesome symptoms, especially hot flushes, which settled down after a few weeks. Her GP prescribed her some oestrogen pessaries to help with vaginal dryness.
Liz was 40 when she was diagnosed and was thrown into an instant menopause with chemotherapy, which continued on tamoxifen. Like most young women, she found it very hard to cope and thought things would never settle down. It took a good couple of years for her symptoms to improve, but they are slowly getting better now.
Your doctor can check this with a blood test to monitor the levels of two hormones:
1. Follicle-stimulating hormone (FSH) is made by the brain. It stimulates your ovaries to produce eggs. As the menopause approaches, the ovaries stop responding and the brain makes more FSH. Therefore, high levels of FSH (about 100 times higher than a pre-menopausal woman) indicate you are menopausal.
2. Estradiol (or oestrodiol) is the main form of oestrogen found in your blood. If you are pre-menopausal, you will have high levels, but after the menopause these levels will fall to less than one-tenth of their previous levels.
HORMONE REPLACEMENT THERAPY (HRT)
HRT is a treatment often given to women to help them cope with the menopause by replacing oestrogen and/or progesterone. If your cancer is sensitive to oestrogen, you will be strongly advised not to take HRT because it increases your oestrogen levels, which will increase your risk of recurrence and your risk of developing breast cancer in your other breast. If your symptoms are so severe that they are affecting your quality of life, it may be worth the risk of taking HRT while accepting that it might make your cancer come back. Only you can decide whether you want to take that chance.
If your cancer isn’t sensitive to oestrogen, your oncologist may say it’s okay to take a low dose of HRT for a short time to control the worst of the symptoms. There is a risk, however, that HRT will increase your chance of developing a second breast cancer that is sensitive to oestrogen.
These are the most common and (often) the most troublesome symptoms. They happen when the sluggish ovary releases a little burst of oestrogen. Most women get a couple of flushes every day but you can get them two to three times every hour, day and night. They range from a mild sensation of warmth in your face to a full body flush that leaves you dripping in sweat, then shivering as the sweat dries. They can be embarrassing and distressing, especially if they happen in public. They normally last for a few seconds, and can be triggered by spicy food, alcohol and caffeine.
Night sweats can mean you wake up on wet sheets. They can affect your sex life (as bodily contact can bring them on), and you may find yourself pushing your partner away. They can disturb your sleep, leaving you feeling tired and irritable, and you may forget things or find it harder to concentrate as a result. Your partner may also get less sleep as you wake them up when you fling your bedcovers on the floor.
Menopausal symptoms can sometimes be unexpected. When Liz first had a night sweat, she thought she had wet herself because she felt liquid trickling down her inner thigh.
Here are our tips to help you cope:
● Avoid triggers. Keep a diary to see if you can identify anything that brings them on.
● Clothing. Wear layers so you can easily strip off when you get a hot flush. At night, try wearing sports clothes that wick away sweat. Natural fibres (cotton and silk) might keep you cooler than man-made fibres (such as nylon and polyester). Mattress and pillow protectors will stop sheets getting stained. If you have a partner, try using two single duvets so they don’t get disturbed when you throw off the cover. You can then use a lighter weight duvet if you want.
● Accessories. Carry a small hand or battery-operated fan in your handbag and a water spray for your face. You can also buy gel pillows or ‘chillows’ that stay icy cold which are wonderful when you’re having a night sweat.
● Complementary therapies. Acupuncture, hypnotherapy, massage and reflexology have all been shown to help ease symptoms. Your breast care nurse or GP may be able to recommend a practitioner.
● Antidepressants. Low doses of antidepressants, like Citalopram and Venlafaxine, can reduce the number of flushes that you get and make them less intense. They take a couple of weeks to work, and they do have some side effects which your doctor will discuss with you.
● Other drugs. Gabapentin (normally given for chronic pain) and Clonidine (normally given for high blood pressure) can also reduce the number of flushes. They take several weeks to work and also have side effects.
The National Institute for Health and Care Excellence, which provides guidance for healthcare professionals in the UK, does not recommend taking herbal remedies (such as black cohosh, red clover, soy products, plant oestrogens or vitamin E). This is because there is very little evidence to show that they work.
Oestrogen is a natural vaginal lubricant. Without it, your vagina can become dry, itchy and uncomfortable, and this can make sex painful. There are several lubricants and vaginal moisturisers that can help (see here). If you need more than a lubricant, your oncologist may recommend a vaginal tablet (Vagifem, Ortho-Gynest) or cream (EstroGel, Ovestin). These contain a very low dose of oestrogen which is absorbed locally into the wall of the vagina. Because the amount you absorb is so small, these vaginal oestrogens are safe to use even if your cancer is sensitive to oestrogen.
Women may lose interest in sex after the menopause. This can be due to physical reasons (night sweats, vaginal dryness), hormonal reasons (oestrogen boosts your sex drive) and psychological reasons (feeling less attractive after treatment). Your low sex drive can have a knock-on effect on your partner and your relationship. (For advice and tips on how to cope, see Chapter 17.)
As your oestrogen levels drop, the lining of your bladder and urethra (the tube that connects your bladder to the outside world) thins and becomes more sensitive. This can lead to bladder inflammation (cystitis) where you pass urine more frequently, and urinary tract infections. You may also start to leak urine occasionally. Drinking lots of clear fluids will stop your urine from getting concentrated and dilute any bacteria. Pelvic floor exercises can also help if you start to leak urine (see here for some ideas).
You may feel tired, especially if your sleep is disrupted by night sweats. Severe fatigue (see here) is uncommon but can happen. Regular exercise, like a gentle half an hour walk every day, can help give you more energy.
It is common to gain weight around your tummy after the menopause because your metabolism slows down. This can make it even harder to lose any extra weight you may have gained during treatment. (For advice and tips on how to cope with this, see Chapter 15.)
Low oestrogen levels can make you irritable and find it hard to concentrate. This can lead to mood swings, which can be unpredictable and overwhelming. Rarely, this can lead to full-blown depression. Alternatively, you may feel stressed and develop anxiety and panic attacks (see Chapter 4 for advice and help).
Your hair can become dry and thin and your skin can feel thin, dry and itchy. Using hair conditioner and hypoallergenic soap, shower gels and moisturisers (such as baby brands) can all help. Eat a healthy, varied diet so you get enough vitamins and minerals, drink plenty of water, using a high-factor sunscreen and avoid hot showers and baths.
Every woman has to go through the menopause at some point in her life. Some women have disabling symptoms whereas others sail through, and the same can be said of treatment-induced menopause.
Women are born with thousands of eggs stored in their ovaries. If you are fertile, your ovaries release an egg each month. As you get older, the number of eggs you have left gets smaller and your egg quality gets worse – both reduce your fertility. You stop producing eggs a few years before your menopause, usually in your early fifties.
As a rule of thumb, chemotherapy adds 10 years to your reproductive age, so if you’re 30 when you start, you’ll have the fertility of a 40-year-old when you finish. The younger you are, the more likely your fertility will return after treatment. However, if you are over 35, there is a risk that you will be infertile once your treatment finishes.
Before you start chemotherapy or have your ovaries removed, you need to think about whether you would like children in the future. This is regardless of whether you are in a relationship with someone you want to have children with, in an early or casual relationship, or single.
Here are some questions you might want to ask:
● Am I fertile now?
● Will chemotherapy make me infertile?
● Can I preserve my eggs?
● Will fertility treatment delay my cancer treatment?
● Will delaying my cancer treatment to preserve my fertility make me more likely to have a recurrence or to die from my cancer?
● What do I do if I’m single?
● I already have children. Can I still preserve my eggs?
● Do I have to pay for fertility treatment?
● What are my chances of having a baby after treatment?
Liz didn’t have children when she was diagnosed with breast cancer. She needed chemotherapy first, and fertility hadn’t even crossed her mind. The first time it was mentioned was when she met her oncologist. Liz and her husband had to decide there and then that they were never going to have children. In hindsight, she wished she’d had the presence of mind to ask for a couple of minutes to have a private discussion with her husband instead of making a life-changing decision in front of her doctor.
‘Ovarian function suppression’ is the simplest option which shuts down your ovaries during chemotherapy with a monthly injection of a drug called Zoladex (see here). Your ovaries should start working again after chemotherapy, although do bear in mind that there’s no guarantee.
For a greater chance of having a baby after treatment, you need more intensive treatment at a specialist fertility clinic who will guide you through the options below. Fertility treatments for cancer patients should be free on the NHS. In reality though, depending on where you live, your age and whether you already have children, you may need to pay for some of the treatment. All of these treatments are done before you start chemotherapy or have your ovaries removed. We discuss the two most common options below.
This is the most effective way to preserve your fertility. Your ovaries are first stimulated with daily hormone injections to encourage them to produce more eggs. This increases the number of eggs that can be collected, and therefore increases the chance of a pregnancy in the future. If you are having chemotherapy before surgery, there is a risk that these additional hormones may stimulate your cancer to grow. If your cancer is triple negative, it is safe for you to have one or two cycles of IVF. If your cancer is ER-positive, you might be given tamoxifen or letrozole (see Chapter 13) to reduce the level of oestrogen in your body during stimulation. However, some fertility clinics may insist that you have surgery first because of the risk of cancer growth during fertility treatment.
Several eggs are then collected, fertilised outside your body with sperm from your partner or a sperm donor, and stored as embryos (fertilised eggs). They can be kept for up to 10 years before being implanted into your womb. If you are having IVF before chemotherapy, it will delay chemotherapy by a few weeks.
If you are in a relationship and don’t want to use your partner’s sperm, or if you are single and don’t want to use donor sperm, you can freeze your eggs after ovarian stimulation. These can also be stored for 10 years, before being thawed and fertilised with sperm. This gives you the option of fertilising your own eggs with the sperm of a new partner (perhaps someone you haven’t met yet), although the pregnancy success rate is not as high as with IVF.
If your cancer is not sensitive to oestrogen and you are having chemotherapy or Herceptin, you have to continue using contraception until six months after you have finished treatment. By that time, the drugs will have left your system and can no longer harm an unborn baby.
If your cancer is sensitive to oestrogen, you will need to take tamoxifen for at least five years. You need to stop taking tamoxifen in order to get pregnant, and this means stopping treatment to prevent your cancer coming back. Most doctors advise waiting at least two years before taking a treatment break to try and get pregnant. You also can’t breastfeed with tamoxifen, but you could bottle-feed if you wanted to restart sooner. In total, this could mean a two- to three-year gap from tamoxifen, which could increase the risk that your cancer might come back. You need to weigh up the pros of (hopefully) having a baby with the cons of stopping treatment to prevent your cancer back.
At the time of writing, there is currently a research trial called POSITIVE (Pregnancy Outcome and Safety of Interrupting Therapy for Women with Endocrine Responsive Breast Cancer) investigating the effect of this break in treatment on your overall survival from breast cancer. Early data from a previous trial suggested that having a baby after breast cancer treatment doesn’t increase the risk of your cancer coming back or the risk of you dying from your breast cancer.
OTHER OPTIONS TO HAVE CHILDREN
If you can’t have a baby naturally, there are other options available. These include using a donor egg (fertilised with your partner’s sperm or donor sperm), surrogacy (where another woman carries your baby for you), adoption and fostering. You can find out further information about surrogacy at the Human Fertilisation and Embryology Authority website or the Surrogacy UK website. For information about adoption and fostering visit the Adoption UK or British Adoption and Fostering Academy website. (See here for further details.)
Realising that having breast cancer means that you can never have children of your own can be devastating, especially when the decision was taken away from you because of your cancer treatment.
If you are finding it hard to cope, your specialist nurse or GP can refer you to a counsellor. There is also support available online from specialist organisations such as the Daisy Network for women facing an early menopause. Breast Cancer Care has a free service called ‘Someone Like Me’ that can put you in touch with other women in your situation. They run ‘Younger Women Together’ events for women under 45 who have been diagnosed in the last three years that provide information and support. (See here for further details.) Younger Breast Cancer Network (YBCN) is a private Facebook group set up by young women with breast cancer. If you want to join, you simply send a private message to the group.
Liz felt intense grief for the child she’d never have, and it took a good 12 months for those feelings to pass. There are other ways to welcome children into your life, such as volunteering at schools and after-school clubs, and you can also become the world’s greatest auntie/friend. It can be hard when people only talk about their children (as it is for any woman who is childless). It’s okay to speak up and ask your friends to change the topic every once in a while.