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«Breast cancer and early menopause a guide for younger women Breast cancer and early menopause a guide for younger women Breast cancer and early ...»

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Regardless of whether menopause is temporary or permanent, you may experience menopausal symptoms during treatment. Some women who have already gone through menopause also experience menopausal symptoms with certain treatments. For example, drugs such as tamoxifen, and aromatase inhibitors – anastrozole (Arimidex®), letrozole (Femara®) and exemestane (Aromasin®) – can cause symptoms such as hot flushes. These symptoms usually stop once treatment finishes.

“I think perhaps knowing who to go to early on would have been helpful, because you do feel alone and frightened. It’s strange, you don’t know what’s going on at first you feel a bit like you are going mad. Getting information made me feel a bit more in control.”

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Surgical removal of the ovaries As part of breast cancer treatment, you may be offered surgery to remove your ovaries (oophorectomy). If you are pre-menopausal, removal of the ovaries will bring on permanent menopause and will cause a sudden and permanent drop in your hormone levels.

Radiotherapy to the ovaries You may be offered radiotherapy to your ovaries to stop your ovaries from working. This is different to having radiotherapy to the breast. Radiotherapy to the ovaries stops them from producing and releasing hormones and results in a permanent menopause.

Chemotherapy Many different chemotherapy drugs are used in the treatment of breast cancer. Not all chemotherapy drugs cause menopausal symptoms.

Chemotherapy treatments change all the time – and so too does the risk of early menopause.

Talk to your treating doctor or menopause specialist about whether the chemotherapy drugs recommended for you are likely to cause menopausal symptoms.

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The graph above shows the chances of menopause in the first year after diagnosis: without other treatment and with chemotherapy only.

Graph adapted from Goodwin P, Ennis M, Pritchard K, Trudeau M, Hood N. Risk of menopause during the first year after breast cancer diagnosis. J Clin Oncol 1999;17(8):2365-2370. The figures on this graph are average figures for all chemotherapies and provide a rough guide.

Hormonal therapies Hormonal therapies (also called endocrine therapies) may be given to women who have hormone receptors on their breast cancer cells.

Hormonal therapies work by blocking the action of oestrogen. Some hormonal therapies can cause menopausal symptoms in younger women.

Examples of hormonal therapies include:

goserelin (Zoladex®) tamoxifen aromatase inhibitors, including anastrozole (Arimidex®), letrozole (Femara®) and exemestane (Aromasin®)—aromatase inhibitors are only used for post-menopausal women.

If you are younger than 35 when you receive hormonal therapies, it is more likely that your normal menstrual cycle will return when treatment with hormonal therapies finishes.

Hormonal therapies can cause menopausal symptoms even in women whose periods stopped some years before they were diagnosed with breast cancer.

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However, blood tests are not always reliable and will not show whether treatment-induced menopause will be permanent or temporary.

Managing menopause is usually a matter of treating the symptoms rather than responding to test results.

How do I know if I am experiencing menopause?

If you’re experiencing menopause, your periods will stop. They may first become irregular. You may also experience other menopausal symptoms such as hot flushes. Some of the common symptoms of menopause are listed in Table 1. Symptoms of menopause vary considerably and not all women will experience all of the symptoms listed.

12 – Breast cancer and early menopause — a guide for younger women Table 1: Common menopausal symptoms Symptom Description Irregular Changes in the pattern of menstruation (less frequent, heavier, menstrual lighter or there may be breakthrough bleeding during the month).

periods For some women their periods may stop suddenly

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Vaginal Menopause can cause vaginal dryness. The vagina is normally a dryness moist environment and secretions increase during sexual arousal. A reduction in oestrogen levels can cause dryness and thinning of the vaginal wall. A dry vagina feels uncomfortable during intercourse and may cause discomfort at other times.

Sexuality Menopause can cause a loss of libido, and can decrease your desire and libido for sexual intimacy. Changes in libido may not only be the result of menopausal symptoms. Breast cancer and its treatment can influence a woman’s overall sense of femininity and sexuality. This can happen to any woman, whether or not she has a partner.

Bladder Bladder symptoms are common during menopause. They include symptoms frequency (needing to pass urine often), incontinence, urgency (not being able to ‘hold on’ when the bladder feels full) and urinary tract infections.

Sleep Sleeplessness or interrupted sleep is common during menopause.

disturbance You may wake up sweating from a hot flush. Getting to sleep can also be difficult.

Fatigue and Many women experience unexplained fatigue or tiredness. This may tiredness be related to sleep disturbance and/or fatigue from chemotherapy or radiotherapy.

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Talk to a member of your treatment team if your symptoms are affecting your quality of life.

“I was expecting the symptoms to be terrible…my mother had a terrible time with ‘the change’, but I was surprised, it was really only the vaginal dryness that worried me.” How long will menopausal symptoms last?

Most symptoms of menopause are temporary and will ease with time.

In women who have not been treated for breast cancer, menopausal symptoms last around 1–5 years but most improve over time. We don’t know whether the duration of menopause is the same for women who enter menopause early because of treatment for breast cancer. Some symptoms, such as vaginal dryness and pain during intercourse, can last after treatment has stopped.

For some women, the only symptom of menopause is that their monthly periods stop. If you have other symptoms, these can range in severity from very mild to severe.

Effects of breast cancer treatments on fertility Some treatments for breast cancer can affect your fertility (your ability to have children).

Once your cancer treatment has finished there is no reliable test to find out if you can still become pregnant. If your periods stop for a year or more, it’s likely that your menopause will be permanent. If your menopause is permanent, you will be unable to have children naturally.

If being able to have children is important for you, speak to your oncologist before starting treatment for breast cancer. Your oncologist may suggest that you see a fertility specialist to discuss your options.

14 – Breast cancer and early menopause — a guide for younger women Surgery or radiotherapy to the ovaries and fertility Surgery and radiotherapy to the ovaries causes permanent infertility.

If you have your ovaries removed by surgery, or if you have radiotherapy to the ovaries, you will no longer be able to have children naturally.

Chemotherapy and fertility Some chemotherapy drugs can cause a woman to become infertile.

Some women (usually women under 35 years) find that their periods return once chemotherapy finishes. However, this does not mean that you will be able to have children.

The effect of chemotherapy on your fertility will depend on a number of things, including your age and the type of drugs you receive. These effects can also vary between different women of the same age.

Talk to your oncologist or a fertility specialist about your individual situation before you start treatment.

Hormonal therapies and fertility Treatment with hormonal therapies (endocrine therapies) does not cause infertility. However, a woman’s fertility may fall naturally while taking hormonal therapies. Most hormonal therapies for breast cancer are given for 5 years. After 5 years, a woman’s fertility will have fallen naturally because she is older.

Although hormonal therapies for breast cancer can cause your periods to stop, this does not necessarily mean that you cannot become pregnant. If you are sexually active while you’re taking tamoxifen, it’s important to use an effective contraceptive if you do not wish to become pregnant during this time.

If you wish to become pregnant during the 5 years of hormonal therapy, it is important to discuss the risks and benefits of this with your oncologist.

Contraception after breast cancer treatment Treatments for breast cancer may reduce fertility temporarily or permanently.

However, this does not mean it is impossible to become pregnant during or after treatment.

Breast cancer and early menopause — a guide for younger women – 15 There is no evidence about whether or not it’s safe to take the oral contraceptive pill (‘the pill’) or use implants (Implanon®) during or after treatment for breast cancer. Therefore it’s recommended that you use nonhormonal forms of contraception, such as condoms, diaphragms, intrauterine contraceptive devices (IUDs) or male or female sterilisation. It’s still possible to catch sexually transmitted infections (STIs) after menopause. Condoms are the most effective way of protecting against STIs.

If you were pre-menopausal before breast cancer and you are sexually active, talk to a member of your health care team about suitable methods of contraception for you.

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I am planning a first or further pregnancy. Can I speak to a fertility specialist before starting treatment for breast cancer?

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You may like to write your own questions here:

16 – Breast cancer and early menopause — a guide for younger women Managing menopausal symptoms Summary The severity of menopausal symptoms varies for different women.

Symptoms may include mood changes, hot flushes, sleep disturbance, vaginal dryness, bladder problems, fatigue and bone and joint pains.

Menopause can also affect a woman’s libido or sexual desire.

There are a range of practical remedies and lifestyle changes that can help manage the symptoms of menopause.

Managing menopause Every woman’s experience of menopausal symptoms is different.

The severity of symptoms can vary between different women.

Symptoms of menopause may affect your everyday life. This section includes suggestions about changes to your lifestyle that can help reduce symptoms and make them easier to manage. These suggestions will not stop the symptoms completely. However, it’s worth noting that the lifestyle changes you put in place now may bring you other physical and mental benefits in the future.

Coping with stress and emotional worries Menopausal symptoms can be particularly distressing for younger women.

Most menopausal symptoms will resolve with time. However, for some women, the stress and emotional burden of menopause can be overwhelming.

Remember, it’s ok to ask for help. You may find it helpful to tell those close to you about what is happening and how your symptoms make you feel. Support and understanding from others can help you manage your symptoms.

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Mood changes Emotional responses to menopausal symptoms vary greatly between women.

Younger women may have particular concerns about loss of libido, loss of fertility or a feeling of growing old prematurely. Sleep deprivation associated with night sweats can also result in moodiness and irritability.

Managing mood changes can be more of a challenge for women who are working or caring for young children. Recognising these symptoms and allowing time for self-care (‘time out’) can help.

If you’re experiencing feelings that are overwhelming you or interfering with your daily activities, talk to your doctor or breast care nurse.

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18 – Breast cancer and early menopause — a guide for younger women Hot flushes and night sweats Hot flushes are a side effect of many hormonal treatments for breast cancer and are common during menopause.

Hot flushes may come and go and are not always severe. The duration of hot flushes also varies between women. Some women may experience hot flushes for many years.

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