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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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Although hormone replacement therapy (HRT) is a very effective treatment for menopausal symptoms, it is generally not recommended after breast cancer.

The safety of other treatments such as tibolone or testosterone for women who have had breast cancer is not yet known.

Few non-hormonal treatments have been shown to be effective in the management of menopausal symptoms.

Most of the ‘alternative’, ’complementary’ or ’natural’ therapies have not been fully tested for their effectiveness or safety in treating menopausal symptoms and some may interact with other breast cancer treatments.

Talk to your oncologist about your options for menopausal treatments before making a decision. You may find it helpful to talk to a menopause specialist.

Treatments for menopausal symptoms Relatively few studies have looked at how menopausal symptoms can be treated safely after breast cancer. This section provides an overview of the common medical treatments used in managing menopausal symptoms, and discusses what is known about their use in women after breast cancer.

For some women, menopausal symptoms can be severe and can have a significant impact on their lifestyle. Your decision about whether to use a treatment for menopausal symptoms will depend on the severity of your symptoms and the potential effect of treatment on your risk of breast cancer coming back.

28 – Breast cancer and early menopause — a guide for younger women Talk to your oncologist about your options before making a decision.

You may find it helpful to talk to a menopause specialist – ask your oncologist for more information.

Hormonal treatments for menopausal symptoms Hormone replacement therapy Although hormone replacement therapy (HRT) is a very effective treatment for menopausal symptoms, it is generally not recommended after breast cancer.

Studies of HRT after breast cancer have shown mixed results. We don’t know whether HRT is definitely safe in women who have had breast cancer. The most common forms of HRT are ‘combined HRT’ which contains the hormones oestrogen and progestogen. Some treatments only use progestogen. These treatments are not as effective as those containing oestrogen. We don’t yet know whether it is safe to take progestogen after breast cancer.

Talk to your oncologist or general practitioner about your options.

Tibolone treatment We don’t know whether it is safe to take tibolone after breast cancer.

Tibolone (Livial®) is an alternative to HRT for treating menopausal symptoms.

The drug acts in a similar way to HRT but does not contain oestrogen or progestogen. Tibolone may help to improve libido for some women.

Talk to your oncologist or general practitioner about your options.

Testosterone treatment We don’t know whether it is safe to use testosterone after breast cancer.

Testosterone is produced by women as well as men. Testosterone levels fall gradually with increasing age and may be reduced by some breast cancer treatments. For some women, reduced levels of testosterone may lead to lower libido and lower energy levels. Hormonal treatments are available to increase testosterone levels.

Talk to your oncologist or general practitioner about your options.

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Clonidine Clonidine is a drug used to treat high blood pressure. It can be used to reduce menopause-associated hot flushes after breast cancer. Side effects of clonidine include a dry mouth and blurred vision.

Gabapentin Gabapentin is a drug used to treat chronic pain and epileptic fits. It has been shown to be effective in reducing hot flushes. Many women find gabapentin acceptable to use. However, up to half of the women who use gabapentin experience side effects including sleepiness, light-headedness, and dizziness.

These side effects may resolve with time or can be reduced by adjusting the dose.

Venlafaxine and other similar drugs Many studies have shown that antidepressants like venlafaxine (Efexor®), paroxetine (Paxil®), fluoxetine (Prozac®), citalopram (Celexa®) or sertraline (Zoloft®) may reduce hot flushes. These drugs act quickly (within a week) but may not have a long-lasting effect.

Around a quarter of women experience side effects with antidepressants.

Some of these drugs, particularly fluoxetine and paroxetine, may interfere with the way that your body breaks down tamoxifen. This may interfere with the action of tamoxifen. Ask your oncologist for more information.

30 – Breast cancer and early menopause — a guide for younger women Complementary and ‘herbal’ treatments Complementary therapies are a range of approaches to care aimed at enhancing quality of life and improving wellbeing. They may be used alongside conventional treatments. You may also hear people talk about ‘alternative therapies’. These are therapies that are taken instead of conventional approaches to treatment.

Herbal or complementary remedies should only be prescribed by a naturopath who is appropriately trained in their use.

Most ’complementary’, ’natural’ or ‘alternative’ therapies have not been fully tested for their effectiveness or safety in treating menopausal symptoms.





It is important to talk to your doctor before taking any complementary or ‘natural’ preparations as they may interact with other cancer therapies.

Some herbal preparations may contain oestrogen-like compounds. This can be a concern for women who have had a diagnosis of breast cancer.

Black cohosh The evidence about the effectiveness of black cohosh in managing menopause symptoms is inconsistent. Side effects of black cohosh include gastro-intestinal upsets and skin rash. There are also concerns about its safety after reports of liver damage.

Phyto-oestrogens and soy Phyto-estrogens (eg soy products and isoflavones) are not effective in treating hot flushes in menopausal women who have not had breast cancer.

They have not been tested following breast cancer but phyto-oestrogens and soy are unlikely to be effective. Their safety after breast cancer is not known.

Acupuncture Early studies on the effectiveness of acupuncture in treating hot flushes look promising.

If you have had breast cancer with surgery or radiotherapy to the axilla (armpit), you should avoid having acupuncture on the affected arm and ensure sterile needles are used to help prevent lymphoedema.

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Vitamin E Vitamin E given at a high dose (800 IU per day [usual dosage is 400-800 iu per day]) may be mildly effective in some women in reducing hot flushes.

Vitamin E is thought to be safe after breast cancer.

Other complementary or ‘over-the-counter’ remedies There is a wide range of ‘over-the-counter’ medications or herbal remedies available for the management of menopausal symptoms. There is very little evidence about the effectiveness or safety of over-the-counter menopausal remedies in women who have not had breast cancer and very little is known about their effects in women who have had breast cancer.

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32 – Breast cancer and early menopause — a guide for younger women ‘Bio-identical’ hormones ‘Bio-identical therapy’ generally refers to hormonal preparations that are individually prepared for the treatment of menopausal symptoms or other hormonal complaints. Bio-identical hormonal mixtures are compounded in troches (placed in the mouth) or creams (rubbed on the body). Bio-identical hormone preparations require a doctor’s prescription and are made up by chemists called compounding pharmacists. Bio-identical hormones have not been shown to be effective for the treatment of menopausal symptoms and their safety after breast cancer is not known. They may carry the same risks as HRT.

The Jean Hailes Foundation for Women’s Health offers further information on bio-identical hormones at www.jeanhailes.org.au Questions to ask your doctor about menopausal symptoms Listed below are some questions you might want to ask about options for treatment of menopause.

What treatments are available if I have severe menopausal symptoms?

What is known about the effectiveness of the treatment you are recommending?

Will the treatment you are recommending affect my risk of breast cancer coming back?

Questions to ask a complementary health practitioner Before you decide on any course of complementary therapy or activity, it is important to be well informed. You should also feel confident about the training of any complementary health practitioner. Questions you may want

to ask include:

What is your training?

Exactly what is the therapy you’re proposing?

What do you hope it will do?

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It is also important to ask the doctor(s) who are providing your conventional treatment whether the complementary therapies you’re considering could interact with the conventional treatments you’re receiving.

You may like to write your own questions here:

34 – Breast cancer and early menopause — a guide for younger women Effects of early menopause on long-term health Summary The effects of early menopause on long-term health are not yet fully understood.

Early menopause may increase the risk of heart disease and osteoporosis (thinning of the bones).

Long term effects of early menopause For women in their 50’s, menopause is a normal event. Most women adjust to the physical changes with little if any impact on their quality of life, or activities. Most symptoms associated with menopause are resolved within a year or two.

Only a few studies have looked at the effects of premature or early menopause on long-term health. This section provides a brief guide to the findings to date.

Heart disease Premature or early menopause may increase the risk of heart disease. This means that exercise, weight control, treatment for high blood pressure, a balanced diet, stopping smoking and reducing alcohol intake are likely to be very important in women experiencing early menopause.

Osteoporosis Loss of oestrogen at menopause may increase the risk of osteoporosis (thinning or weakening of the bones). The risk of osteoporosis can be increased further by some breast cancer drugs such as aromatase inhibitors (used for women who are post-menopausal). Weakening of the bone may be avoided if you are taking tamoxifen.

Breast cancer and early menopause — a guide for younger women – 35 Women with a family history of osteoporosis, who smoke, are underweight, have hyperthyroidism, have taken steroids, or are taking aromatase inhibitors are at particular risk of osteoporosis.

Your doctor may measure your bone density if you’re at increased risk of osteoporosis before prescribing a hormonal therapy for you. If you’re already at increased risk of osteoporosis, your doctor will consider this when recommending which hormonal therapy is suitable for you.

How can I reduce my risk of osteoporosis?

There are a number of effective strategies for avoiding osteoporosis

including:

a balanced diet that contains enough calcium (1,200 mg/day) — a glass of milk or small tub of yogurt has about 250mg of calcium adequate Vitamin D, this means taking Vitamin D supplements or being in direct sunlight for 5–15 minutes 4– 6 times a week, this may vary depending on where you live and what time of year it is.

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doing regular weight-bearing exercise, for example walking, playing tennis or dancing, for at least 30 minutes, 2–3 times a week* resistance training, such as exercise with weights*.

*Talk to a health professional before starting any new activity after treatment for breast cancer and build activities slowly.

Treatments are available that can improve bone strength. Talk to your doctor about how to reduce the risk of fractures and maintain bone strength.



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