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Menopause Help for Breast Cancer Survivors

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Breast cancer treatment often comes with a host of unwelcome side effects. One you may not expect from the treatment that has saved your life is the sometimes sudden and often intense onset of menopausal symptoms, such as hot flashes, night sweats, brain fogginess and vaginal dryness. Some women experience such debilitating symptoms that they skip preventive “adjuvant” cancer therapies just to avoid them. More than half of women in one recent study did just that—a decision with potentially dire consequences down the road.

A better approach: After doing everything possible to prevent a recurrence of breast cancer, explore the many safe ways you can minimize menopausal symptoms.

HOW BREAST CANCER LEADS TO MENOPAUSAL SYMPTOMS

Breast cancer and its treatment doesn’t always bring on menopause or make symptoms worse. But it often does. The great majority of women in their 40s receiving chemotherapy for breast cancer, for example, will experience cessation of menstruation, which often is permanent.  Here are the main reasons…

  • Chemotherapy may have harmful effects on your ovaries. Chemo drugs attack cancer cells, but they can also damage your ovaries (and your eggs). The result can be a sudden drop in estrogen…and the immediate onset of menopausal symptoms. If you’re premenopausal, your periods may stop or become irregular and may not return after treatment.
  • Surgery to remove the ovaries triggers immediate menopause. Some women with breast cancer are also at a high risk of developing ovarian cancer, particularly those who have the BRCA gene. If your treatment included surgical removal of your ovaries, you’ll experience “surgical menopause,” which often causes more intense symptoms than natural menopause.
  • Hormonal therapy for some kinds of cancer can make menopause symptoms worse. Some types of breast cancer are hormone-receptor positive. Receptors—tiny gatelike proteins in the cancer cell—respond to hormones. One treatment for this kind of breast cancer are drugs called selective estrogen receptor modulators (SERMS). These drugs, such as tamoxifen and raloxifene, can lead to hot flashes, vaginal dryness or other menopausal symptoms. Other hormonal treatments called aromatase inhibitors are used to treat breast cancer in postmenopausal women. They can halt all estrogen production, which worsens menopause symptoms.

WHY HORMONE THERAPY ISN’T RECOMMENDED FOR BREAST CANCER SURVIVORS

Many women ease menopausal symptoms using systemic hormone therapy—a combination of estrogen and progestin (a synthetic progesterone) for women with a uterus…estrogen alone for women without a uterus—that enters the bloodstream. These include pills and skin patches. But that type of relief may be off the table for breast cancer survivors, especially those who are taking drugs to prevent their cancer from returning.

Another type of hormone therapy, vaginal rings, deliver hormones through the vagina. One type of ring, Femring, is not considered suitable for women with a history of breast cancer because it releases hormones into the bloodstream. But another low-dose ring (Estring) may be OK for some breast cancer survivors because it releases lower levels of hormones and isn’t considered systemic. More on these below.

In the 1990s, a major study looking at combined estrogen and progestin therapy for menopause symptoms was halted when breast cancer survivors suffered recurrences. Another study going on at the same time didn’t show that same increased risk, but researchers called it off anyway to be on the safe side. The US Food and Drug Administration required a “black box” warning on hormone therapy that included an increased risk for breast cancer, prompting women with a history of breast cancer to avoid it. Is it estrogen alone that may affect the safety of hormone therapy for breast cancer survivors, or is it estrogen combined with progestin? The jury remains out.

TREATING MENOPAUSE SYMPTOMS SAFELY

So what should women who have a history of breast cancer do about their bothersome menopause symptoms? Start by talking to your oncologist. Together you can create a treatment plan that works with, not against, your breast cancer treatment or prevention therapy.

For vaginal dryness and painful intercourse

  • Vaginal moisturizers are available over the counter. They help to restore moisture to the lining of the vagina. Many are formulated to maintain the vagina’s normal pH balance, which can help you avoid infection and irritation.
  • Lubricants ease discomfort during sexual intercourse. Several types are available—oil-based (which should not be used with latex condoms), silicone-based and water-based. You may need to try a variety of lubricants to find one that you and your partner are happy with. Some women use coconut oil as a lubricant. Keep in mind that while moisturizers are used on a regular basis (regardless of sexual activity), lubricants are used specifically with sexual activity.
  • If these nonhormonal approaches aren’t enough, you may want to consider low-dose estrogen therapy—in the form of vaginal creams, tablets, and, as mentioned above, one brand of vaginal ring (Estring). Because the estrogen is absorbed into vaginal tissues and little makes it into the bloodstream, it’s considered a safer option for women who have had breast cancer. Although some oncologists are comfortable with their breast cancer patients using low-dose vaginal estrogen therapy, be aware that the FDA states that even low-dose local vaginal estrogen therapy should not be used in women with a personal history of breast cancer. Talk to your doctor, especially if you take an aromatase inhibitor—because even a small increase in estrogen can be a concern. Women taking tamoxifen to prevent a breast cancer recurrence, on the other hand, may be better candidates for low-dose estrogen therapy. (Editor’s note: You may also want to ask your doctor about Intrarosa, FDA-approved DHEA suppositories, which create estrogen in vaginal tissues but not in circulation.)

For hot flashes…

  • Avoid spicy foods such as hot peppers. They have a thermogenic effect, which means they can actually raise your body temperature. Caffeine and alcohol may also trigger hot flashes.
  • Alternative therapies such as deep, paced breathing can lessen the frequency of hot flashes or help you get through them. Practical solutions such as dressing in layers you can peel off and keeping a fan nearby are also smart. (Editor’s note: See also the Bottom Line articles, “A Pollen That Banishes…Hot Flashes” and “Neroli Oil Soothes Menopausal Symptoms“—both are nonhormonal botanicals that you may wish to discuss with your doctor.)
  • A low dose of an antidepressant—either a selective serotonin reuptake inhibitor (SSRI) or a selective norepinephrine reuptake inhibitor (SNRI)—may work to treat hot flashes without affecting hormones. Paroxitene (Brisdelle) is one low-dose SSRI that is FDA-approved to treat menopause symptoms, including in breast cancer survivors.
  • Some medications have been shown to be effective nonhormonal treatments for hot flashes, but they are not FDA approved for this purpose. These include venlafaxine (an SNRI), the antiseizure medication gabapentin (Neurontin), and clonidine (Catapres), a blood pressure medication. These may be options to discuss with your doctor.
  • Keep in mind that these nonhormonal medications are not as effective as hormone therapy for treating hot flashes, and their side effects may be different from hormone therapy.

Bottom line: If you’re a breast cancer survivor and have menopause symptoms, you don’t have to suffer in silence—or forgo potentially life-saving posttreatment therapies. With the right information and support from your health-care team, you can find the right treatments for you to feel better both physically and emotionally without increasing your risk for a recurrence. To learn more ways to thrive after breast cancer, see the Bottom Line article, “Breast Cancer Rehab: Vital Therapies Survivors Need But Don’t Get.”

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Source: Andrew M. Kaunitz, MD, University of Florida Research Foundation Professor, associate chair of the department of obstetrics and gynecology, University of Florida College of Medicine, Jacksonville. He serves on the board of trustees of The North American Menopause Society and on the advisory board of Facing Our Risk of Cancer (FORCE), an organization for individuals with BRCA mutations, and has authored or coauthored more than 300 articles in leading journals, including The New England Journal of Medicine. Date: May 19, 2017 Publication: Bottom Line Health
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