Menopause is a 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.
The symptoms of menopause vary from one person to another.
Hot flushes
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:
Menopause also increases the risk of heart disease and may reduce bone density.
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
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.
Hormone- blocking treatments
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 pregnancy.
Surgery and radiotherapy
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.
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.
Avoiding some things can reduce the frequency and severity of hot flushes. Avoid things such as:
Venlafaxine, desvenlafaxine, oxybutinin, and most recently, fezolinetant, are some of the medications that can be used to manage hot flushes in women with breast cancer.
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.
Sexual feelings vary during and after treatment for breast cancer, 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. 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.
After menopause, many women will report uncomfortable vaginal dryness. There are some simple things you can do to improve this:
If there are ongoing symptoms, your oncologist may discuss low dose topical oestrogen as an option.
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 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 years after menopause, so that bone density can be monitored and strategies to maintain bone density are implemented.
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. 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.
Exercise
Engaging in weight bearing exercises such as walking, running, and strength training.
Calcium and vitamin D
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. 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.
Often, a dose of 1000 international units (IU) a day is recommended. 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 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.
Medications
There are many drug treatments for osteoporosis if it develops. Your doctor will talk to you about these if your bone density is low.
It is important that you let your medical team know if you are troubled by the symptoms of menopause because often there are 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.
| Organisation | Contact |
|---|---|
| Westmead Breast Cancer Institute | (02) 8890 6728 |
| Cancer Council Helpline | 13 11 20 |
| Breast Cancer Network Australia | 1800 500 258 |
| Cancer Australia |
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