Cancer: Managing Menopausal Symptoms
By Sean McConnell, MD
Menopause, or cessation of the monthly menstrual cycle, is a natural
part of a woman’s maturation. For most women this transition begins to
occur in the late forties and early fifties, but individual family
history influences this timeline as well. Menopause results from a drop
in hormone levels when the ovaries stop producing estrogen and
progesterone. For many women this drop in hormone production occurs
gradually, but for women undergoing surgical removal of the ovaries,
pelvic radiation, or chemotherapy, the onset of menopause can be much
The most common symptoms of menopause include hot flashes and night
sweats, vaginal dryness, itching, painful intercourse or loss of
interest, mood swings, memory lapses, fatigue, and difficulty sleeping.
The severity and duration of these symptoms are highly variable, though
studies have suggested the average length of symptoms may last about
four years, with hot flashes, for example, occurring about seven times a
day. For women with breast cancer finding a therapy which is safe and
effective can be challenging.
Safety considerations are paramount in approaching every woman’s
management of menopausal symptoms, and especially so for women with a
personal history of breast cancer. Replacement of the hormones lost has
long been known to significantly ease the symptoms of menopause;
however, recent studies have called into question the routine use of
these medications even though they are the most effective form of
therapy. Like any health care decision carefully made between a patient
and her physician, a discussion about whether or not a woman might
benefit from hormones should take into consideration her age and
severity of symptoms, personal and family history, and relative risks.
For breast cancer survivors, reducing the risk of cancer recurrence is
of primary consideration. Unfortunately, treatment of menopause symptoms
with estrogen and progestins unacceptably raises the risk of breast
cancer recurrence. One study demonstrated that breast cancer patients
experienced an increased risk of cancer recurrence from 10 percent up to
25 percent when placed on hormone treatment for menopausal symptoms. The
reason for this increased risk is related to how breast cancer tumors
respond to estrogen and progesterone hormones. Approximately
three-quarters of breast cancers contain receptors for estrogen or
progesterone, and exposure to these hormones triggers tumor growth.
Many current breast cancer treatment strategies take advantage of the
hormonal responsiveness of the tumor, and several classes of
anti-breast-cancer medications attempt to block hormonal stimulation of
the cancer cells. Aromatase inhibitors (like Arimidex ®) block the
low-level production of estrogen from the body’s fat sources. The
elimination of this relatively low hormone level, however, can worsen
hot flashes and accelerate the postmenopausal loss of bone density,
causing osteoporosis and raising the risk of fractures. Selective
estrogen receptor modulators (SERMs), such as Tamoxifen® and
Raloxifene®, also block estrogen’s effect on breast cancer cells and can
increase hot flashes, but these medications actually help strengthen the
Selective serotonin reuptake inhibitors (SSRIs) have also been shown to
have a role in the management of menopausal symptoms. Originally
formulated as antidepressants, these medications have long been used in
women with breast cancer to treat menopausal symptoms. They have been
shown to decrease the frequency of hot flashes when compared to placebo.
There is no contraindication to these medications in breast cancer
There are other nonhormonal options such as Gabapentin®, a medicine used
for seizures and chronic pain, and Clonidine®, an antihypertensive which
can also successfully decrease the symptoms of menopause.
Due to the recent recognition of the potential risks of hormone
treatment, it is no wonder than millions of women have turned to
alternative treatments for relief of menopausal symptoms. Plant-based
estrogens, called phytoestrogens, are commonly found in plant sources
like soy beans, flax seeds, and red clover. Although often marketed as
natural and safer alternatives, the mere aspect of their plant-based
derivation should not automatically vouch for the safety of these
products. Their structural similarity to estrogen is what allows
phytoestrogens to act on estrogen receptors, and by this same action
they may potentially stimulate breast cancer tumors.
Despite the breast cancer recurrence risk of systemic hormone therapy,
studies have suggested that much lower doses of estrogen are acceptable
for the local treatment of vaginal dryness or irritation. Low-dose
estrogen, in the form of vaginal cream or a plastic vaginal ring insert,
can effectively treat dryness and painful thin skin (atrophic vaginitis)
without raising circulating estrogen levels. Pain during intercourse may
also be treated with a water-based personal lubricant like Replens®,
Astroglide®, or KY Jelly®.
Non-medication strategies for managing menopausal symptoms center on the
adoption of a healthy lifestyle. Make it a priority to eat well by
choosing a diet low in saturated fats and including plenty of fruits,
vegetables, and high-fiber foods. Because women on breast cancer
treatments may be more at risk for osteoporosis, include calcium and
vitamin D supplements. Participate in weight-bearing and aerobic
exercise to keep bones strong and to maintain overall fitness. Exercise
can also help manage weight, lift mood, reduce anxiety, and improve
sleep. Limit caffeine, alcohol, and stress. To accommodate for hot
flashes, dress in layers and avoid stimulants such as hot weather and
saunas. Some women find that cutting back on alcohol, caffeine, sugar,
and spicy foods also helps. Research has shown that the gentle physical
stretching postures, breathing exercises, and meditation techniques of
yoga can also reduce symptoms. Breathing exercises can be useful to
reduce the duration of hot flashes. Take long, slow, deep breaths, seven
to eight breaths per minute if possible, when a hot flash is coming on,
and continue this for 15 minutes.
Symptoms of menopause often improve over time, but if symptoms are
bothersome, uncomfortable, or disruptive, it is important to seek help.
The risks and benefits of managing symptoms are different for each
woman, so before implementing any of these strategies, it is important
to discuss these issues with a physician.
This article is part of the Menopause and Youlibrary,
a web-based program sponsored by Women’s Health Source.
It is intended as an information resource providing guidelines for
women. As always, check with your own health care practitioner with your
specific concerns and questions.
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