What is the menopause?

Although most women will go through their menopause naturally, certain treatments for cancer can trigger an early menopause.

Going through an early menopause, as a result of cancer treatment, can be distressing; you may feel isolated and confused about the changes.

The onset of an early menopause can be sudden and symptoms such as hot flushes, vaginal dryness and mood changes can be hard to cope with, alongside your cancer diagnosis and treatment.

That is why it is so important to be prepared for the occurrence of menopausal symptoms and to ask for support when you need it.

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

It covers what the menopause is, symptoms you may experience, advice on treatments and lifestyle changes, and where to turn to for further advice and support.

If you have not had cancer and have a close blood relative who has had cancer, such as breast or ovarian cancer, you may have been told that you cannot take HRT. This is often not the case, as many women with a family history of cancer can still take HRT safely. If your GP is unsure, then you should see a doctor who specialises in the menopause.

Menopause facts

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

Your menopause is when you stop having periods. It occurs when your ovaries stop producing eggs and, as a result, levels of hormones called estrogen and progesterone fall.

There are four key stages:

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

Perimenopause: when you experience menopausal symptoms due to hormone changes, but still have your period

Menopause: when you do not have a period for 12 consecutive months

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

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

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

However, certain cancer treatments can stop the ovaries from working properly and bring about an earlier menopause.

These include:

  • Surgery involving the ovaries, such as an oophorectomy, where one or both ovaries are removed. You may also have one or both of your ovaries removed during a hysterectomy (an operation where your uterus is removed)
  • Radiotherapy to the pelvic area
  • Certain types of chemotherapy drugs to treat cancer
  • Drugs that block the action of hormones working (e.g. used for some women with breast cancer) The average age of the menopause is 51, and symptoms of the perimenopause usually start at around 45 years of age.

If your menopause occurs between the ages of 40 and 45, it is known as an early menopause.

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

Will my menopause be temporary or permanent?

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

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

If you have an oophorectomy or a hysterectomy where both ovaries are removed, then you will have your menopause immediately, regardless of your age. If one of your ovaries is left intact after an oophorectomy (or both are intact after a hysterectomy), there’s a chance that you’ll experience the menopause within five years of having surgery.

The menopause after pelvic radiotherapy or chemotherapy could be temporary or permanent. This usually depends on how close you are to the age of your natural menopause, and the dose of radiation or type of drugs used.

What symptoms can I expect?

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

About three in four women will experience symptoms during their menopause; symptoms vary greatly between women, in terms of how severe they are and how long they go on for. If your menopause has been triggered by treatment for cancer, your symptoms will be similar to those of a natural menopause.

Common symptoms can include:

Changes to your period: You can experience a change in flow – maybe having heavier or lighter periods than normal – and your periods will become less frequent before stopping completely.

Hot flushes: This is the most common symptom of all, affecting three out of four women. Hot flushes can come on suddenly at any time of day, spreading throughout your face, chest and body. For some women they may last just a few moments, for others several minutes. Hot flushes can have associated symptoms such as sweating, dizziness or even heart palpitations.

Night sweats: Many women find they wake up drenched in sweat and have to change their pajamas or bedclothes. This can also be a disruptive symptom for partners too.

Mood changes: Some women who suffer from mood changes find they are very disruptive to work and home life. You may find mood changes more common if you have had premenstrual syndrome in the past.

Fatigue and poor sleep: Poor sleep can be related to night sweats, but you may find you are more tired during the day – even if your sleep is not affected.

Brain fog: This is a collective term for symptoms such as memory lapses, poor concentration, difficultly absorbing information and a feeling your brain is like ‘cotton wool’. It presents problems at work and can also affect the simplest of tasks like reading a book or listening to the radio.

Loss of interest in sex: Women also have the hormone testosterone – which can influence our sex-drive. During the perimenopause and menopause, declining levels of testosterone in a woman’s body can lead to a lack of interest in sex and lack of pleasure from it. Joint pains and muscle aches: Estrogen is very important in providing lubrication in your joints and preventing inflammation, so low levels can leave your joints sore and aching.

Hair and skin changes: Estrogen helps to build collagen – the protein that protects the structure of our skin. Lower levels of estrogen can lead to reduced elasticity, fine lines and dryness. Some women find their skin becomes itchier, or they develop acne. Changing hormones can also make your hair thinner and less glossy, and you may notice increased facial hair growth.

Worsening migraines: If you suffer from migraines, you may find they become more severe and closer together.

Vaginal and urinary symptoms: Vaginal dryness and recurrent urinary tract infections (UTIs) can be more common in women going through their menopause as a result of cancer treatment. It can be a particular problem for women who take tamoxifen – a hormonal therapy drug used to treat some women with breast cancer.

Low estrogen can cause the tissues around the vagina to become thinner, dry, itchy and inflamed – known as vaginal atrophy or atrophic vaginitis. Your vagina also expands less easily during sex, making sex uncomfortable or painful.

Low estrogen also thins the lining of the bladder, leading to the urge to urinate more frequently. Some women find they have recurrent UTIs.

Long-term health problems which can arise from your menopause

Did you know? Women lose up to 10% of their bonestrength in the first five years after menopause

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

Osteoporosis

Osteoporosis is a condition that weakens the bones and makes them more likely to break.

People with osteoporosis have an increased risk of fractures, even with little or no trauma – meaning that normal stresses on the bones from standing, coughing or even hugging can result in fractures.

Estrogen helps keep our bones strong and healthy but as estrogen reduces during the menopause this puts women at greater risk of developing osteoporosis than men. Women can lose up to 10% of their bone density in the first five years after the menopause.

Other factors that increase your chances of getting osteoporosis are a family history of osteoporosis, smoking and heavy drinking.

Cardiovascular disease

This refers to conditions affecting the heart and blood vessels, such as coronary heart disease, congenital heart disease, stroke and vascular dementia. Estrogen keeps our blood vessels healthy and helps control cholesterol, so fluctuating levels can leave you at greater risk of cardiovascular disease.

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

Will my fertility be affected?

This depends on your individual circumstances such as your age and the type of treatment you have. Menopause guidelines from the National Institute of Health and Care Excellence (NICE) clearly state that women who are likely to go through menopause as a result of medical or surgical treatment should be offered support.

You should also be given information about menopause before you have treatment and ideally should be referred to a healthcare professional with expertise in menopause.

You should expect to discuss:

  • Risk of early menopause
  • How your fertility might be affected
  • Common menopausal symptoms
  • Longer-term health implications of menopause
  • Advice about contraception

Treatments: Hormone Replacement Therapy (HRT)

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

There are a range of treatments available to help manage your menopause symptoms, and in many cases, vastly improve 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 informed decision about the potential benefits and risks. Don’t wait until symptoms become unmanageable before you seek advice.

What is HRT and how does it work?

HRT is a treatment that relieves symptoms by replacing the estrogen your body stops making after the menopause. The type of estrogen most commonly used these days is 17 beta-estradiol.

Available as a skin patch, gel applied to the skin or as a tablet, HRT remains the most effective treatment to relieve symptoms. Hot flushes and night sweats usually stop within a few weeks of starting HRT. Many of the vaginal and urinary symptoms usually resolve within three months, but it can take up to a year in some cases.

You should also find that symptoms such as mood changes, difficulty concentrating, aches and pains in your joints and the appearance of your skin will also improve.

HRT will also help protect against osteoporosis and cardiovascular disease, which is especially important in women who go through an early menopause.

Is HRT suitable for me?

If your cancer is not hormone-dependent (such as certain breast cancers) then you should be able to take HRT. Most women who have had cancers that are not breast cancers can still safely take HRT. Women who have had some types of endometrial cancer may be advised not to take HRT. You should speak to a health professional about your individual circumstances so you can make an informed decision.

Remember that you should be given information about the impact of an early menopause before cancer treatment begins; you should not have to wait until your menopause symptoms become unbearablebefore seeking help.

If you are taking HRT and feel like your symptoms aren’t improving within a few months, speak to a health professional. Going through your menopause at a younger age means your body’s requirement for hormones is greater compared to older women.

It may be that your HRT dose is too low – many young women actually need two or even three times more HRT than the average dose given to older women – so your dosage or delivery method may need adjusting. Some women may need the type of their HRT changing, for example from a patch to a gel and some women benefit from taking testosterone in addition to estrogen.

Testosterone

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

As well as regulating sex drive, testosterone also helps with your mood, memory and concentration. Not all women will need testosterone, but talk to your health professional if you are taking HRT and find HRT alone is not helping with these symptoms. Testosterone is given as a cream or gel, or sometimes as an implant.

Other treatments / ways of improving symptoms

There are some alternative prescription medications that can be prescribed for symptoms if you cannot take HRT or choose not to.

These include some types of antidepressants such as citalopram or venlafaxine which can improve hot flushes, but they can have side effects such as nausea. Other medications, e.g. clonidine and gabapentin, may sometimes be given and can help some women. However, their use is often limited by side effects (such as nausea, insomnia or worsening libido).

Some women consider taking complementary and/or alternative treatments to HRT for their menopause symptoms. However, herbal products do not necessarily mean safe products, and many herbal medicines have unpredictable doses and purity. The MHRA (Medicines and Healthcare Products Regulatory Agency) have developed a certification trademark

called Traditional Herbal Registration (THR), which means that these products are considered safe (when used as intended) and have a standardised dose (although effectiveness has not been assessed).

While there is little scientific evidence to support their use in alleviating menopausal symptoms, some women use acupuncture or magnet therapy (e.g. Lady Care) with some success. Others find drinking certain herbal teas, for example, can lead to a better night’s sleep and a feeling of wellbeing. The use of aromatherapy oils, like lavender, may help with poor sleep, promote relaxation and improve symptoms of anxiety or depression.

Although little is known about the effect of aromatherapy specifically on menopausal symptoms, any therapy which allows you to relax and focus on yourself as an individual is an investment in yourself and can help you cope better with menopause symptoms.

Treatments for vaginal dryness and urinary symptoms

Estrogen placed directly to the vaginal area, in the form of cream, vaginal tablet or ring inserted into the vagina can help ease symptoms. A new treatment called Intrarosa® is also available which is a pessary containing DHEA. This can be given as an alternative to local estrogen treatments.

Using estrogen in this way is not the same as taking HRT, so does not have the same associated risks. It can be used safely by most women on a regular basis for a long period of time, which is important as symptoms related to vaginal dryness can continue when you are postmenopausal and often return when you stop treatment. Women who have had breast cancer in the past are still able to use vaginal estrogen, safely.

Another option for dryness is vaginal moisturisers and lubricants during sex. These products can be bought over the counter and can be used either alongside vaginal estrogen treatments or on their own.

Your symptoms should improve within a few weeks of treatment. See a health professional if there is no improvement, as these symptoms can be due to other conditions.

Cognitive Behavioural Therapy (CBT)

CBT is a talking therapy recommended by NICE as a treatment for low mood associated with menopause. It focuses on changing the way you think and behave, with sessions either in groups or one-to-one with a therapist. You can be referred via your GP but many women find it is quicker to organise privately.

Lifestyle changes

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

Maintaining a healthy lifestyle is always important, but particularly during your menopause. There is evidence that healthy lifestyle improvements, e.g. smoking cessation, weight loss and undertaking regular exercise, can improve some symptoms of the menopause – for example, hot flushes and night sweats.

Wearing lighter-weight clothing, sleeping in a cooler room and reducing stress (e.g. through mindfulness, breathing exercises or yoga, for example) may reduce the number of hot flushes. Some women find that things such as spicy foods, caffeine (in tea, coffee, cola, and chocolate), smoking, and alcohol may trigger hot flushes. Avoiding these may help for some women.

You should be aiming to:

Eat a healthy, balanced diet: a diet rich in calcium 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 particular importance to maintain bone health.

Limit alcohol and cigarettes: alcohol can interrupt sleep and exacerbate hot flushes. If you smoke, try to cut down with the aim of quitting altogether.

Get enough vitamin D: vitamin D also plays a part in keeping your bones strong and healthy. You should get all the vitamin D you need from sunlight and the small amounts found in food, but you may also want to take a supplement.

Relax: Where possible take time out for yourself. Do something you enjoy that lifts your mood, such as yoga or just spending time with loved ones.

Where can I go to for more advice?

This may feel like a very isolating time, but there are a number of sources of advice for women coping with cancer and their menopause.

The Eve Appeal is a charity funding research into and raising awareness of womb, ovarian, cervical, vulval and vaginal cancers www.eveappeal.org.uk

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

Macmillan Cancer Support
www.macmillan.org.uk

Cancer Research UK
www.cancerresearchuk.org

My Menopause Doctor
www.menopausedoctor.co.uk

NICE information for women having treatment likely to cause menopause www.tinyurl.com/NICE-menopausetreatment

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