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Menopause and cancer

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This booklet has been written by Dr Louise Newson, GP, menopause specialist and founder of the

Newson Health and Wellbeing Centre in Stratford-upon-Avon, England.

For more information on Dr Newson visit www.menopausedoctor.co.uk

Contents

What is the menopause? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

What sort of symptoms can I expect? . . . . . . . . . . . . . . . . . . . . . . . . 5

Long-term health problems that

can arise from your menopause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Treatments: hormone replacement therapy (HRT) . . . . . . . . . . . . 7-8

Other treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-9

Lifestyle changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

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What is the menopause?

Although most women will go throughtheir menopause naturally, certaintreatments for cancer can trigger an earlymenopause.

Going through an early menopause, as aresult of cancer treatment, can bedistressing; you may feel isolated andconfused about the changes.

The onset of an early menopause can besudden and symptoms such as hot flushes,vaginal dryness and mood changes can behard to cope with, alongside your cancerdiagnosis and treatment.

That is why it is so important to beprepared for the occurrence ofmenopausal symptoms and to ask forsupport when you need it.

This booklet has been created for womenwho may experience an early menopause,as a result of cancer treatment.

It covers what the menopause is,symptoms you may experience, advice ontreatments and lifestyle changes, andwhere to turn to for further advice andsupport.

If you have not had cancer and have aclose blood relative who has had cancer,such as breast or ovarian cancer, you mayhave been told that you cannot take HRT.This is often not the case, as many womenwith a family history of cancer can still takeHRT safely. If your GP is unsure, then youshould see a doctor who specialises in themenopause.

Your menopause is when you stop havingperiods. It occurs when your ovaries stopproducing eggs and, as a result, levels ofhormones called estrogen andprogesterone fall.

There are four key stages:

Pre-menopause: the time in your lifebefore any menopausal symptoms occur

Perimenopause: when you experiencemenopausal symptoms due to hormonechanges, but still have your period

Menopause: when you do not have aperiod for 12 consecutive months

Postmenopause: the time in your life afteryou have not had a period for 12consecutive months.

Menopause facts

Did you know? The term ‘meno’ refers to your menstrual cycle and ‘pause’ literally means to stop

Did you know? Menopause due to treatment for cancer can be temporaryor permanent, depending on your age and type of treatment

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Why can my cancer treatment affect when I go through the menopause?

Will my menopause be temporary or permanent?

Did you know? Menopause between the age of 40 and 45is known as an ‘early’ menopause

The average age of the menopause is 51,and symptoms of the perimenopauseusually start at around 45 years of age.

However, certain cancer treatments canstop the ovaries from working properlyand bring about an earlier menopause.

These include:

• Surgery involving the ovaries, such as anoophorectomy, where one or bothovaries are removed. You may also haveone or both of your ovaries removedduring a hysterectomy (an operationwhere your uterus is removed)

• Radiotherapy to the pelvic area

• Certain types of chemotherapy drugsto treat cancer

• Drugs that block the action ofhormones working (e.g. used for somewomen with breast cancer)The averageage of the menopause is 51, andsymptoms of the perimenopause usuallystart at around 45 years of age.

If your menopause occurs between theages of 40 and 45, it is known as an earlymenopause.

If it occurs before the age of 40, it isknown as premature ovarian insufficiency(POI).

This is dependent on a number of factors,including your age and the type of cancertreatment you are having.

If you have an oophorectomy or ahysterectomy where both ovaries areremoved, then you will have yourmenopause immediately, regardless ofyour age. If one of your ovaries is leftintact after an oophorectomy (or both areintact after a hysterectomy), there's a

chance that you'll experience themenopause within five years of havingsurgery.

The menopause after pelvic radiotherapyor chemotherapy could be temporary orpermanent. This usually depends on howclose you are to the age of your naturalmenopause, and the dose of radiation ortype of drugs used.

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What symptoms can I expect?

About three in four women will experiencesymptoms during their menopause; symptomsvary greatly between women, in terms of howsevere they are and how long they go on for.If your menopause has been triggered bytreatment for cancer, your symptoms will besimilar to those of a natural menopause.

Common symptoms can include:

Changes to your period: You can experiencea change in flow – maybe having heavier orlighter periods than normal - and your periodswill become less frequent before stoppingcompletely.Hot flushes: This is the most commonsymptom of all, affecting three out of fourwomen. Hot flushes can come on suddenly atany time of day, spreading throughout yourface, chest and body. For some women theymay last just a few moments, for othersseveral minutes. Hot flushes can haveassociated symptoms such as sweating,dizziness or even heart palpitations. Night sweats: Many women find they wakeup drenched in sweat and have to changetheir pyjamas or bed clothes. This can also bea disruptive symptom for partners too. Mood changes: Some women who sufferfrom mood changes find they are verydisruptive to work and home life. You may findmood changes more common if you have hadpremenstrual syndrome in the past.Fatigue and poor sleep: Poor sleep can berelated to night sweats, but you may find youare more tired during the day - even if yoursleep is not affected. Brain fog: This is a collective term forsymptoms such as memory lapses, poorconcentration, difficultly absorbing informationand a feeling your brain is like ‘cotton wool’. Itpresents problems at work and can also affectthe simplest of tasks like reading a book orlistening to the radio.

Loss of interest in sex: Women also have thehormone testosterone - which can influenceour sex-drive. During the perimenopause andmenopause, declining levels of testosterone ina woman’s body can lead to a lack of interestin sex and lack of pleasure from it. Joint pains and muscle aches: Estrogen is veryimportant in providing lubrication in yourjoints and preventing inflammation, so lowlevels can leave your joints sore and aching. Hair and skin changes: Estrogen helps tobuild collagen - the protein that protects thestructure of our skin. Lower levels of estrogencan lead to reduced elasticity, fine lines anddryness. Some women find their skinbecomes itchier, or they develop acne.Changing hormones can also make your hairthinner and less glossy, and you may noticeincreased facial hair growth.Worsening migraines: If you suffer frommigraines, you may find they become moresevere and closer together. Vaginal and urinary symptoms: Vaginaldryness and recurrent urinary tract infections(UTIs) can be more common in womengoing through their menopause as a result ofcancer treatment. It can be a particularproblem for women who take tamoxifen - ahormonal therapy drug used to treat somewomen with breast cancer.Low estrogen can cause the tissues aroundthe vagina to become thinner, dry, itchy andinflamed - known as vaginal atrophy oratrophic vaginitis. Your vagina also expands lesseasily during sex, making sex uncomfortableor painful. Low estrogen also thins the lining of thebladder, leading to the urge to urinate morefrequently. Some women find they haverecurrent UTIs. These vaginal and urinary symptoms canpresent long after your menopause ends.

Did you know? Hot flushes are the most common menopause symptom

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Cardiovascular disease

This refers to conditions affecting theheart and blood vessels, such as coronaryheart disease, congenital heart disease,stroke and vascular dementia. Estrogenkeeps our blood vessels healthy and helps control cholesterol, so fluctuatinglevels can leave you at greater risk of

cardiovascular disease.

Other risk factors of cardiovasculardisease include high blood pressure,smoking, being overweight and a familyhistory of cardiovascular disease.

Will my fertility be affected?

This depends on your individualcircumstances such as your age and thetype of treatment you have.

Menopause guidelines from the NationalInstitute of Health and Care Excellence(NICE) clearly state that women who arelikely to go through menopause as a resultof medical or surgical treatment should beoffered support.

You should also be given informationabout menopause before you havetreatment and ideally should be referred

to a healthcare professional withexpertise in menopause.

You should expect to discuss:

• Risk of early menopause

• How your fertility might be affected

• Common menopausal symptoms

• Longer-term health implications ofmenopause

• Advice about contraception

Long-term health problems which can arise from your menopause

An early menopause can put you at risk of the following health conditions at an earlier age

Osteoporosis

Osteoporosis is a condition that weakensthe bones and makes them more likely tobreak.

People with osteoporosis have anincreased risk of fractures, even with littleor no trauma – meaning that normalstresses on the bones from standing,coughing or even hugging can result infractures.

Estrogen helps keep our bones strong and

healthy but as estrogen reduces duringthe menopause this puts women atgreater risk of developing osteoporosisthan men. Women can lose up to 10% oftheir bone density in the first five yearsafter the menopause.

Other factors that increase your chancesof getting osteoporosis are a family historyof osteoporosis, smoking and heavydrinking.

Did you know? Women lose up to 10% of their bone-strength in thefirst five years after menopause

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Treatments: Hormone Replacement Therapy (HRT)

There are a range of treatments availableto help manage your menopausesymptoms, and in many cases, vastlyimprove your quality of life.

Your first step should be talking to a health

professional about the options available to you, so you can make an informeddecision about the potential benefits andrisks. Don’t wait until symptoms becomeunmanageable before you seek advice.

What is HRT and how does it work?

HRT is a treatment that relievessymptoms by replacing the estrogen yourbody stops making after the menopause.The type of estrogen most commonlyused these days is 17 beta-estradiol.

Available as a skin patch, gel applied to theskin or as a tablet, HRT remains the mosteffective treatment to relieve symptoms.Hot flushes and night sweats usually stopwithin a few weeks of starting HRT. Manyof the vaginal and urinary symptomsusually resolve within three months, but it

can take up to a year in some cases.

You should also find that symptoms suchas mood changes, difficulty concentrating,aches and pains in your joints and theappearance of your skin will also improve.

HRT will also help protect againstosteoporosis and cardiovascular disease,which is especially important in womenwho go through an early menopause.

Is HRT suitable for me?

If your cancer is not hormone-dependant(such as certain breast cancers) then youshould be able to take HRT. Most womenwho have had cancers that are not breastcancers can still safely take HRT. Womenwho have had some types of endometrialcancer may be advised not to take HRT.You should speak to a health professionalabout your individual circumstances soyou can make an informed decision.

Remember that you should be giveninformation about the impact of an earlymenopause before cancer treatmentbegins; you should not have to wait untilyour menopause symptoms becomeunbearable before seeking help.

If you are taking HRT and feel like yoursymptoms aren’t improving within a fewmonths, speak to a health professional.Going through your menopause at ayounger age means your body’srequirement for hormones is greatercompared to older women.

It may be that your HRT dose is too low- many young women actually need twoor even three times more HRT than theaverage dose given to older women – soyour dosage or delivery method mayneed adjusting. Some women may needthe type of their HRT changing, forexample from a patch to a gel and somewomen benefit from taking testosteronein addition to estrogen.

Did you know? HRT works by replacing the hormones your bodystops making after the menopause

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Testosterone

As well as regulating sex drive, testosteronealso helps with your mood, memory andconcentration. Not all women will needtestosterone, but talk to your health

professional if you are taking HRT and findHRT alone is not helping with thesesymptoms. Testosterone is given as a creamor gel, or sometimes as an implant.

Other treatments / ways of improving symptoms

There are some alternative prescriptionmedications that can be prescribed forsymptoms if you cannot take HRT orchoose not to.

These include some types ofantidepressants such as citalopram orvenlafaxine which can improve hot flushes,but they can have side effects such asnausea.

Other medications, eg clonidine andgabapentin, may sometimes be given andcan help some women. However, their useis often limited by side effects (such asnausea, insomnia or worsening libido).

Some women consider takingcomplementary and/or alternativetreatments to HRT for their menopausesymptoms. However, herbal products donot necessarily mean safe products, andmany herbal medicines have unpredictabledoses and purity. The MHRA (Medicinesand Healthcare Products RegulatoryAgency) have developed a certificationtrademark called Traditional Herbal

Registration (THR), which means thatthese products are considered safe (whenused as intended) and have a standardiseddose (although effectiveness has not beenassessed).

While there is little scientific evidence to support their use in alleviatingmenopausal symptoms, some women useacupuncture or magnet therapy (e.g.LadyCare) with some success. Others finddrinking certain herbal teas, for example,can lead to a better night’s sleep and a feeling of wellbeing. The use ofaromatherapy oils, like lavender, may helpwith poor sleep, promote relaxation andimprove symptoms of anxiety ordepression.

Although little is known about the effectof aromatherapy specifically onmenopausal symptoms, any therapy whichallows you to relax and focus on yourselfas an individual is an investment in yourselfand can help you cope better withmenopause symptoms.

Did you know? Women produce three times as much testosteronethan estrogen before the menopause

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Treatments for vaginal dryness and urinary symptoms

Estrogen placed directly to the vaginalarea, in the form of cream, vaginal tabletor ring inserted into the vagina can helpease symptoms. A new treatment calledIntrarosa® is also available which is apessary containing DHEA. This can begiven as an alternative to local estrogentreatments.

Using estrogen in this way is not the sameas taking HRT, so does not have the sameassociated risks. It can be used safely bymost women on a regular basis for a longperiod of time, which is important assymptoms related to vaginal dryness cancontinue when you are postmenopausaland often return when you stop

treatment. Women who have had breastcancer in the past are still able to usevaginal estrogen, safely.

Another option for dryness is vaginalmoisturisers and lubricants during sex.These products can be bought over thecounter and can be used either alongsidevaginal estrogen treatments or on theirown.

Your symptoms should improve within afew weeks of treatment. See a healthprofessional if there is no improvement, asthese symptoms can be due to otherconditions.

Cognitive Behavioural Therapy (CBT)

CBT is a talking therapy recommended byNICE as a treatment for low moodassociated with menopause. It focuses onchanging the way you think and behave,

with sessions either in groups or one-to-one with a therapist. You can bereferred via your GP but many womenfind it is quicker to organise privately.

Lifestyle changes

Maintaining a healthy lifestyle is alwaysimportant, but particularly during yourmenopause. There is evidence that healthylifestyle improvements, e.g. smokingcessation, weight loss and undertakingregular exercise, can improve somesymptoms of the menopause – forexample, hot flushes and night sweats.

Wearing lighter-weight clothing, sleepingin a cooler room and reducing stress (e.g.through mindfulness, breathing exercisesor yoga, for example) may reduce thenumber of hot flushes. Some women findthat things such as spicy foods, caffeine (intea, coffee, cola, chocolate), smoking, andalcohol may trigger hot flushes. Avoidingthese may help for some women.

You should be aiming to:

Eat a healthy, balanced diet: a diet rich incalcium helps protect your bones and

reduce the risk of osteoporosis.

Exercise regularly if you are able: Weight-bearing exercise (e.g. running, strength-training, dance, tennis) is of particularimportance to maintain bone health.

Limit alcohol and cigarettes: alcohol caninterrupt sleep and exacerbate hotflushes. If you smoke, try to cut down withthe aim of quitting altogether.

Get enough vitamin D: vitamin D alsoplays a part in keeping your bones strongand healthy. You should get all the vitaminD you need from sunlight and the smallamounts found in food, but you may alsowant to take a supplement.

Relax: Where possible take time out foryourself. Do something you enjoy that liftsyour mood, such as yoga or just spendingtime with loved ones.

This may feel like a very isolating time, butthere are a number of sources of advicefor women coping with cancer and theirmenopause.

The Eve Appeal is a charity fundingresearch into and raising awareness ofwomb, ovarian, cervical, vulval and vaginalcancers www.eveappeal.org.uk

Daisy Network is a charity for womenaffected by POI www.daisynetwork.org.uk

Macmillan Cancer Supportwww.macmillan.org.uk

Cancer Research UKwww.cancerresearchuk.org

My Menopause Doctorwww.menopausedoctor.co.uk

NICE information for women havingtreatment likely to cause menopausewww.tinyurl.com/NICE-menopause-treatment

Did you know? Alcohol, caffeine and spicy foods can alltrigger hot flushes

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Where can I go to for more advice?

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Dr Louise Newson is a GP and menopause specialist in Stratford-upon-Avon, UK.She has written and developed the website www.menopausedoctor.co.uk and is

the founder of the ‘balance’ menopause app.

The website and app contain evidence-based, non-biased information about theperimenopause and the menopause. She created both platforms to empowerwomen with information about their perimenopause and menopause and to

inform them about the treatments available.

Her aim is for women to acquire more knowledge and confidence to approachtheir own GP to ask for help and advice.

The team at Newson Health are passionate about improving awareness of safeprescribing of HRT to ladies at all stages of the perimenopause and menopause

and also offering holistic treatments for the perimenopause and menopause.

Louise is also the director of the not-for-profit company Newson Health Research and Education.

Winton House, Church Street, Stratford-upon-Avon, CV37 6HB

Enquiries: 01789 595004 | Email: info@newsonhealth.co.uk | Web: www.newsonhealth.co.uk

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