Menopausal Problems and Breast Cancer
Menopause and Breast Cancer
Menopause presents special problems for women who have had breast cancer. Firstly, it may have been induced rather abruptly by the treatment used for early breast cancer, such as chemotherapy. In addition, some women with hormone sensitive tumours (those that are positive for the estrogen receptor “ER” and/or progesterone receptor “PR”), may have undergone additional hormone therapy that may have abruptly ended menstruation, such as the monthly injection, Zoladex, or the surgical removal of the ovaries (“oophorectomy”). Finally, drugs like tamoxifen, which are important breast cancer treatments, may make some of the symptoms of menopause, like hot flashes, worse.
What happens at menopause?
Menopausal symptoms are mostly due to the withdrawal from the body of high levels of circulating estrogen, the female sex hormone, which normally peaks just before the middle of each menstrual cycle, helping to prepare the lining of the womb and the breasts for potential pregnancy. Prior to menopause, most estrogen is produced in the ovaries, while small amounts are produced both before and after the menopause by the adrenal glands, which sit just above the kidneys, and by the fat tissue of the body.
When the ovaries no longer produce estrogen, a sensing center in the brain tells the pituitary gland, at the base of the brain, to try to stimulate more estrogen production. The pituitary pours out Luteinizing Hormone (LH) and it seems to be this hormone that produces some of the problem side effects like hot flashes.
Common symptoms of menopause and how to manage them.
Hot flashes (sometimes called "hot flushes")
Hot flashes are a common symptom of menopause and they are commonly made worse by taking tamoxifen. Hormones released from the pituitary gland cause them by inducing dilatation of blood vessels in the skin of the face and upper body. This warms the surface of the skin sending signals to the brain that the body is overheating. In fact, body temperature is normal and hot flashes should not be confused with a fever, when the body temperature can be measured by thermometer to be above the normal upper limit of 37.4 degrees centigrade. Skin warming is accompanied by a hot prickly sensation that may begin as a tightness or warmth over the face and scalp, and that quickly migrates to involve the whole upper torso. At it’s peak the flash is accompanied by sweating which is sometimes profuse as the body attempts to cool itself. There is an overwhelming desire to stand in front of an air conditioner, or remove clothing! They are more common at night when they might disturb sleep. In some women they are severe enough to disturb the ability to work and they severely inhibit quality of life, particularly as they are unpredictable and may occur at the most inconvenient moments socially and professionally. Each flash may last up to 5 or 10 minutes and some women experience them up to ten times daily, although the majority have only one or two episodes daily. Flashes can occur independent of outside air temperature, but seem more difficult to manage in the summer months, for obvious reasons. They can last for months to years, but the severity generally decreases rather than increases with time.
Simple measures may help to ease hot flushes, including the wearing of several layers of light clothing which can be removed if necessary, and sleeping in an air-conditioned room, or one with a ceiling fan.
Health food stores and pharmacies heavily promote natural products containing plant oestrogens as being of benefit in easing hot flushes. These products include Promensil and Remifem (black cohosh). Remifemin is the only product which has shown any benefit in properly conducted clinical trials, but the benefit is slight, and is less than that shown with venlafaxine. These products are also quite expensive. Furthermore, none of the "natural" estrogens are of proven safety in women who have had breast cancer, and recently they have been shown to stimulate breast cancer growth in the laboratory, which is a concern to me.
Two drugs that have been shown to reduce the severity of hot flushes are venlafaxine ("Efexor") and medroxyprogesterone acetate ("Provera"), in a dose of between 10 and 50 mg daily, and venlafaxine, in a dose of between 37.5 and 75 mg in the morning. These drugs must only be used under the advice of your doctor. Whilst there is some evidence that the blood pressure tablet Clonidine may reduce hot flushes, I have never seen it work, and most of my colleagues are skeptical about its efficacy.
NOTE: Antidepressant medication like venlafaxine can interfere with the activation of tamoxifen in the liver. Patients on tamoxifen should avoid the "selective serotonin reuptake inhibitor " (SSRI) antidepressants like venlafaxine unless under specific medical advice.
Vaginal irritation, dryness and discharge.
Vaginal irritation and dryness may be relieved by the use of local estrogen-containing pessaries, vaginal moisturisers or lubricants. The best of these is probably oestriol ("Ovestin"). This should be used twice weekly at first, then weekly, under strict medical supervision. Other helpful products include Replens®, Sylk® or Astraglide®.
Headaches
Mood disturbance
Unexplained and quite dramatic mood disturbance is one of the most unpleasant aspects of early menopause. Typically mood may swing from day to day unpredictably and uncontrollably. One day may be "flat", the next characterized by intense impatience and irritation by routine events and the behaviour of close associates and colleagues. You may "lose it" for no apparent reason and your customary levels of sweet-natured tolerance are suddenly stripped from you and most people around you are intensely irritating and unspeakably boring. You yell at your secretary for not removing stick-on notes from your files. She looks astonished.
The next day you may feel full of remorse, tearful for no reason. You may weep inconsolably over the thought of your cat being out in the rain all day while you are at work, or over your recollection of a trivial domestic dispute with your daughter over her late arrival home. "I’m such a dragon to that poor girl, she must hate me!" your brain says. Consolatory and reassuring words from your partner are only annoying and seem patronizing, which, in turn, makes him feel impotent and useless and compounds the tension. The next day you are overcome with the desire to completely reorganize the house, moving furniture and throwing out vast amounts of junk. You have to climb over the family to do so. They are completely unimpressed with the urgency you alone seem to be able to see in the project and tensions arise because of their seeming lack of cooperation and apparently passive resistance to your innovative domestic transformations.
The next day you are overwhelmed by the desire for reassurance. Your partner is puzzled and confused by your desire to be reaffirmed in his love for you. "You’re not going out with another bird are you?" you ask. You need to be hugged and nurtured.
Sometimes these mood variations extend into true depression and may require professional assistance and perhaps antidepressant medication. Tell-tale signs of serious depression include:
Fatigue and Lack of Energy
Many women experience unexplained, and sometimes quite overwhelming, fatigue during early menopause. The causes are poorly understood but must relate to estrogen withdrawal because the problem responds promptly to HRT. The symptom can appear suddenly from one day to the next and may transform the sufferer into a "zombie"-like state with a constant strong desire to lie down, and an inability to keep the eyes propped open. Some liken it to a bad case of jet lag. Of course your doctor should always check out sustained fatigue in case it is a symptom of something more serious like anaemia. However, in the majority of cases, all tests are normal.
This is a tricky symptom to deal with and in the most severe cases it may be necessary to bite the bullet and use a gentle form of HRT, like tibolone ("Livial"), for a short period.
Some tips for managing fatigue include:
Insomnia
Estrogen withdrawal often exacerbates insomnia, partly due to the hot flashes, but partly by direct mechanisms. Click here for tips on managing insomnia.
Osteoporosis
After menopause it is common for there to be a gradual reduction in bone density due to slow leaching of calcium from the skeleton. Paradoxically, tamoxifen reduces this problem in women after menopause, but seems to exacerbate it in women who are still having periods. The best advice for all women on tamoxifen is that they have regular weight bearing exercise, a sensible daily intake of calcium (see below), and that every two years they have their bone density measured by their doctor. There is no need to take osteoporosis preventing medicines such as vitamin D and calcium supplements unless this is indicated by your doctor.
For further details on Osteoporosis and its prevention, click here.
Sexual Problems
Menopause is frequently associated with a drop in libido. In addition there may be physical difficulties with intercourse, especially vaginal dryness. Simple lubricants may help like KY Gel. Vaginal irritation and dryness may be relieved by the use of local estrogen containing pessaries. The best of these is probably oestriol ("Ovestin"). This should be used twice weekly at first, then weekly, always under strict medical supervision. Systemic absorption of oestriol is thought to be minimal making it safe to take in women with a history of hormone-sensitive breast cancer.
Weight Gain
Weight gain is a common event at the time of menopause due to changes in metabolic rate. It is critical that all women in mid-life watch carefully their caloric intake, and engage in regular weight bearing exercise. For more information regarding diet, click here.
Hormone Replacement Therapy (“HRT”) after Breast Cancer
In women who have no history of breast cancer and who are experiencing disabling menopausal symptoms, there is one sure fire way to reduce hot flashes and that is the use of HRT, using agents that have estrogen-like activity. This can be rapidly and extremely effective, eliminating uncomfortable hot flashes and stabilizing mood swings. However, I am personally loath to recommend this to women who have a history of breast cancer unless they have menopausal symptoms that are absolutely disabling.
A Warning from the “HABITS” Trial
Early in 2004 we received a serious warning about the use of HRT in women who had previously had breast cancer. The Trial, called the "HRT after breast cancer-is it safe?" (HABITS) Trial, and published in the esteemed medical journal, “The Lancet”, showed that during an average follow-up of two years, 26 of 650 women in the HRT group developed breast cancer, compared with only 7 of 650 women in the control group. Based on these findings, the investigators terminated the HABITS trial on December 17, 2003. Women in the HRT group were advised to discontinue such therapy. This is the most important finding so far that indicates that HRT is contraindicated in women who have had a previous breast cancer.
Tibolone ("Livial")
In women who had breast tumours that were not hormone receptor positive, some specialists feel relaxed about using HRT for short periods. The hormone agent tibolone (“Livial”) is weakly estrogenic, and might therefore be the best one to choose in the first instance, where other methods have failed. Again, I must stress that any such endeavour should be done under careful medical advice and with the full knowledge of your breast cancer specialist. Livial is not on the Australian Pharmaceutical Benefits Scheme and costs about $60.00 for one month’s supply. The dose is one 2.5 mg tablet each morning.
Do herbal preparations work?
There are a number of herbal preparations which are alleged to help menopausal symptoms like hot flashes. Probably the best of these is Remifemin.
Here’s what the Director of the Menopause Clinic at Westmead , Professor Peter Illingworth has to say about Remifemin:
"Of all these herbal things, Remifemin is the one with the most going for it in terms of "evidence" and accordingly I would not be at all hostile to its use in healthy women. However, it is still not the level of decent Randomised Clinical Trial evidence that would get it a listing as a prescribed drug.
In addition, it seems highly likely that the mechanism of effect in suppressing hot flashes is through an oestrogen-like action. The herbs probably contain plant oestrogens and that is how it works to relieve symptoms. In other words, it may be not much different from a low (and probably fairly unreliable and variable) dose of Hormone Replacement Therapy. Is this harmful?? I don’t know, and neither does anybody. The level of this effect on breast cancer recurrence is going to be so small that it would take a massive and sophisticated study to exclude a small risk. However, if I had breast cancer, I wouldn’t use it."
Menopause presents special problems for women who have had breast cancer. Firstly, it may have been induced rather abruptly by the treatment used for early breast cancer, such as chemotherapy. In addition, some women with hormone sensitive tumours (those that are positive for the estrogen receptor “ER” and/or progesterone receptor “PR”), may have undergone additional hormone therapy that may have abruptly ended menstruation, such as the monthly injection, Zoladex, or the surgical removal of the ovaries (“oophorectomy”). Finally, drugs like tamoxifen, which are important breast cancer treatments, may make some of the symptoms of menopause, like hot flashes, worse.
What happens at menopause?
Menopausal symptoms are mostly due to the withdrawal from the body of high levels of circulating estrogen, the female sex hormone, which normally peaks just before the middle of each menstrual cycle, helping to prepare the lining of the womb and the breasts for potential pregnancy. Prior to menopause, most estrogen is produced in the ovaries, while small amounts are produced both before and after the menopause by the adrenal glands, which sit just above the kidneys, and by the fat tissue of the body.
When the ovaries no longer produce estrogen, a sensing center in the brain tells the pituitary gland, at the base of the brain, to try to stimulate more estrogen production. The pituitary pours out Luteinizing Hormone (LH) and it seems to be this hormone that produces some of the problem side effects like hot flashes.
Common symptoms of menopause and how to manage them.
Hot flashes (sometimes called "hot flushes")
Hot flashes are a common symptom of menopause and they are commonly made worse by taking tamoxifen. Hormones released from the pituitary gland cause them by inducing dilatation of blood vessels in the skin of the face and upper body. This warms the surface of the skin sending signals to the brain that the body is overheating. In fact, body temperature is normal and hot flashes should not be confused with a fever, when the body temperature can be measured by thermometer to be above the normal upper limit of 37.4 degrees centigrade. Skin warming is accompanied by a hot prickly sensation that may begin as a tightness or warmth over the face and scalp, and that quickly migrates to involve the whole upper torso. At it’s peak the flash is accompanied by sweating which is sometimes profuse as the body attempts to cool itself. There is an overwhelming desire to stand in front of an air conditioner, or remove clothing! They are more common at night when they might disturb sleep. In some women they are severe enough to disturb the ability to work and they severely inhibit quality of life, particularly as they are unpredictable and may occur at the most inconvenient moments socially and professionally. Each flash may last up to 5 or 10 minutes and some women experience them up to ten times daily, although the majority have only one or two episodes daily. Flashes can occur independent of outside air temperature, but seem more difficult to manage in the summer months, for obvious reasons. They can last for months to years, but the severity generally decreases rather than increases with time.
Simple measures may help to ease hot flushes, including the wearing of several layers of light clothing which can be removed if necessary, and sleeping in an air-conditioned room, or one with a ceiling fan.
Health food stores and pharmacies heavily promote natural products containing plant oestrogens as being of benefit in easing hot flushes. These products include Promensil and Remifem (black cohosh). Remifemin is the only product which has shown any benefit in properly conducted clinical trials, but the benefit is slight, and is less than that shown with venlafaxine. These products are also quite expensive. Furthermore, none of the "natural" estrogens are of proven safety in women who have had breast cancer, and recently they have been shown to stimulate breast cancer growth in the laboratory, which is a concern to me.
Two drugs that have been shown to reduce the severity of hot flushes are venlafaxine ("Efexor") and medroxyprogesterone acetate ("Provera"), in a dose of between 10 and 50 mg daily, and venlafaxine, in a dose of between 37.5 and 75 mg in the morning. These drugs must only be used under the advice of your doctor. Whilst there is some evidence that the blood pressure tablet Clonidine may reduce hot flushes, I have never seen it work, and most of my colleagues are skeptical about its efficacy.
NOTE: Antidepressant medication like venlafaxine can interfere with the activation of tamoxifen in the liver. Patients on tamoxifen should avoid the "selective serotonin reuptake inhibitor " (SSRI) antidepressants like venlafaxine unless under specific medical advice.
Vaginal irritation, dryness and discharge.
Vaginal irritation and dryness may be relieved by the use of local estrogen-containing pessaries, vaginal moisturisers or lubricants. The best of these is probably oestriol ("Ovestin"). This should be used twice weekly at first, then weekly, under strict medical supervision. Other helpful products include Replens®, Sylk® or Astraglide®.
Headaches
Mood disturbance
Unexplained and quite dramatic mood disturbance is one of the most unpleasant aspects of early menopause. Typically mood may swing from day to day unpredictably and uncontrollably. One day may be "flat", the next characterized by intense impatience and irritation by routine events and the behaviour of close associates and colleagues. You may "lose it" for no apparent reason and your customary levels of sweet-natured tolerance are suddenly stripped from you and most people around you are intensely irritating and unspeakably boring. You yell at your secretary for not removing stick-on notes from your files. She looks astonished.
The next day you may feel full of remorse, tearful for no reason. You may weep inconsolably over the thought of your cat being out in the rain all day while you are at work, or over your recollection of a trivial domestic dispute with your daughter over her late arrival home. "I’m such a dragon to that poor girl, she must hate me!" your brain says. Consolatory and reassuring words from your partner are only annoying and seem patronizing, which, in turn, makes him feel impotent and useless and compounds the tension. The next day you are overcome with the desire to completely reorganize the house, moving furniture and throwing out vast amounts of junk. You have to climb over the family to do so. They are completely unimpressed with the urgency you alone seem to be able to see in the project and tensions arise because of their seeming lack of cooperation and apparently passive resistance to your innovative domestic transformations.
The next day you are overwhelmed by the desire for reassurance. Your partner is puzzled and confused by your desire to be reaffirmed in his love for you. "You’re not going out with another bird are you?" you ask. You need to be hugged and nurtured.
Sometimes these mood variations extend into true depression and may require professional assistance and perhaps antidepressant medication. Tell-tale signs of serious depression include:
- Preoccupation with thoughts of worthlessness
- A feeling that everything is hopeless
- Sleep disturbance – especially early waking
- Inability to experience joy in former areas of happiness such as children or grandchildren
- Loss of optimism
- Preoccupation with disease and death
- Planning and/or preparation for suicide
- Actual suicide attempt
Fatigue and Lack of Energy
Many women experience unexplained, and sometimes quite overwhelming, fatigue during early menopause. The causes are poorly understood but must relate to estrogen withdrawal because the problem responds promptly to HRT. The symptom can appear suddenly from one day to the next and may transform the sufferer into a "zombie"-like state with a constant strong desire to lie down, and an inability to keep the eyes propped open. Some liken it to a bad case of jet lag. Of course your doctor should always check out sustained fatigue in case it is a symptom of something more serious like anaemia. However, in the majority of cases, all tests are normal.
This is a tricky symptom to deal with and in the most severe cases it may be necessary to bite the bullet and use a gentle form of HRT, like tibolone ("Livial"), for a short period.
Some tips for managing fatigue include:
- Good sleep hygiene and a regular daily routine that avoids large variations in the time of rising and retiring.
- Exercise - This is probably the most important strategy.
- Good eating
- Removal of "energy sinks" from your life. Are you spending most of your waking hours fuming about the neighbour who thinks he’s Jimmy Hendricks, or the fact that your sister won’t lift a finger to help your ageing dad, or an ongoing dispute in the office over line management for the new clerical assistant, or the total lack of understanding your partner seems to have about your current problems? Is this stuff in your head when you hit the pillow and again when you awaken in the morning? You are wasting valuable and precious energy and you have to take active steps to put these issues back under your control. This may involve the help of a good clinical psychologist to work out a step-by-step strategy and monitor it with you. we work with some great Clinical Psychologists, Jemma Gilchrist and Rebecca Van Lloy, and would be delighted to refer you. It will cost you around $75.00 per visit and you will retrieve some of that from your health fund. It’s worth it.
Insomnia
Estrogen withdrawal often exacerbates insomnia, partly due to the hot flashes, but partly by direct mechanisms. Click here for tips on managing insomnia.
Osteoporosis
After menopause it is common for there to be a gradual reduction in bone density due to slow leaching of calcium from the skeleton. Paradoxically, tamoxifen reduces this problem in women after menopause, but seems to exacerbate it in women who are still having periods. The best advice for all women on tamoxifen is that they have regular weight bearing exercise, a sensible daily intake of calcium (see below), and that every two years they have their bone density measured by their doctor. There is no need to take osteoporosis preventing medicines such as vitamin D and calcium supplements unless this is indicated by your doctor.
For further details on Osteoporosis and its prevention, click here.
Sexual Problems
Menopause is frequently associated with a drop in libido. In addition there may be physical difficulties with intercourse, especially vaginal dryness. Simple lubricants may help like KY Gel. Vaginal irritation and dryness may be relieved by the use of local estrogen containing pessaries. The best of these is probably oestriol ("Ovestin"). This should be used twice weekly at first, then weekly, always under strict medical supervision. Systemic absorption of oestriol is thought to be minimal making it safe to take in women with a history of hormone-sensitive breast cancer.
Weight Gain
Weight gain is a common event at the time of menopause due to changes in metabolic rate. It is critical that all women in mid-life watch carefully their caloric intake, and engage in regular weight bearing exercise. For more information regarding diet, click here.
Hormone Replacement Therapy (“HRT”) after Breast Cancer
In women who have no history of breast cancer and who are experiencing disabling menopausal symptoms, there is one sure fire way to reduce hot flashes and that is the use of HRT, using agents that have estrogen-like activity. This can be rapidly and extremely effective, eliminating uncomfortable hot flashes and stabilizing mood swings. However, I am personally loath to recommend this to women who have a history of breast cancer unless they have menopausal symptoms that are absolutely disabling.
A Warning from the “HABITS” Trial
Early in 2004 we received a serious warning about the use of HRT in women who had previously had breast cancer. The Trial, called the "HRT after breast cancer-is it safe?" (HABITS) Trial, and published in the esteemed medical journal, “The Lancet”, showed that during an average follow-up of two years, 26 of 650 women in the HRT group developed breast cancer, compared with only 7 of 650 women in the control group. Based on these findings, the investigators terminated the HABITS trial on December 17, 2003. Women in the HRT group were advised to discontinue such therapy. This is the most important finding so far that indicates that HRT is contraindicated in women who have had a previous breast cancer.
Tibolone ("Livial")
In women who had breast tumours that were not hormone receptor positive, some specialists feel relaxed about using HRT for short periods. The hormone agent tibolone (“Livial”) is weakly estrogenic, and might therefore be the best one to choose in the first instance, where other methods have failed. Again, I must stress that any such endeavour should be done under careful medical advice and with the full knowledge of your breast cancer specialist. Livial is not on the Australian Pharmaceutical Benefits Scheme and costs about $60.00 for one month’s supply. The dose is one 2.5 mg tablet each morning.
Do herbal preparations work?
There are a number of herbal preparations which are alleged to help menopausal symptoms like hot flashes. Probably the best of these is Remifemin.
Here’s what the Director of the Menopause Clinic at Westmead , Professor Peter Illingworth has to say about Remifemin:
"Of all these herbal things, Remifemin is the one with the most going for it in terms of "evidence" and accordingly I would not be at all hostile to its use in healthy women. However, it is still not the level of decent Randomised Clinical Trial evidence that would get it a listing as a prescribed drug.
In addition, it seems highly likely that the mechanism of effect in suppressing hot flashes is through an oestrogen-like action. The herbs probably contain plant oestrogens and that is how it works to relieve symptoms. In other words, it may be not much different from a low (and probably fairly unreliable and variable) dose of Hormone Replacement Therapy. Is this harmful?? I don’t know, and neither does anybody. The level of this effect on breast cancer recurrence is going to be so small that it would take a massive and sophisticated study to exclude a small risk. However, if I had breast cancer, I wouldn’t use it."