Treatment-induced menopause

In this blog we take a look at medical menopause and how it can be managed.

Before menopause, a woman’s ovaries produce the hormones oestrogen and progesterone. These control a woman’s monthly cycle (periods). Menopause is the time in a woman’s life when her ovaries stop making oestrogen and most women start menopause naturally between 45 and 55 years of age. Some cancer treatments can affect the way the ovaries work, and this can cause an early menopause for some women. This is called treatment-induced menopause.

Treatment-induced menopause can be caused by:

  • Surgical removal of both ovaries
  • Chemotherapy
  • Radiotherapy to the pelvis
  • Hormonal therapy

If both ovaries are removed, a woman goes into treatment-induced menopause that is permanent and sudden.

Some chemotherapy drugs used in the treatment of leukaemia can cause permanent or temporary menopause. It is more often permanent in women who are within a few years of natural menopause; however, it may not be permanent in younger women.

The effect of radiotherapy on the ovaries may be temporary or permanent. This depends on the woman’s age and the dose of radiation.

Some hormone therapies for men and women with breast cancer can cause menopause symptoms as the drugs stop or reduce the production of oestrogen.

What are the symptoms of treatment-induced menopause?

Symptoms of treatment-induced menopause can vary in severity. Each woman experiences menopause differently. The symptoms of treatment-induced menopause are the same as natural menopause. They include:

  • Hot flushes
  • Night sweats
  • Irregular or no menstrual periods
  • Problems sleeping such as not being able to fall asleep, or insomnia
  • Vaginal dryness, itching, irritation or discharge
  • Loss of interest in sex
  • Painful intercourse
  • Bladder or vaginal infections
  • Mood swings or irritability
  • Dry skin
  • Aches and pains
  • Weight gain
  • Loss of confidence
  • Poor concentration
  • Depression

Most women have some of these symptoms and the symptoms can vary from mild to severe. For some women, they last for many years. These symptoms are sometimes worse if menopause has happened suddenly because of cancer treatments.

What is vaginal dryness?

Vaginal dryness can affect any woman; however, after the menopause it is very common. It’s important to understand that you are not alone in suffering from this common condition. You should speak to your GP or practice nurse and they can help you to find the right treatment for you to be able to regain your sexual confidence and quality of life.

Vaginal moisture

Natural lubrication produced by glands at the neck of the womb (the cervix) keeps the vagina supple and moist. The moisture moves slowly down through the vagina, keeping it clean and removing dead cells. The vaginal moisture is slightly acidic, and this helps to keep the area healthy, preventing infections such as thrush. It is perfectly normal for most women to notice a slight white vaginal discharge.

During sexual excitement, the Bartholin’s glands (two glands at the entrance of the vagina) produce extra moisture to aid sexual intercourse. However, a quarter of women aged 50-59 experience vaginal dryness problems during sex and 16% experience pain. Without the production of oestrogen, the skin and support tissues of the lips (vulva) and vagina become thinner and less elastic and the vagina can become dry.

In many cases vaginal dryness does not only cause pain during sex, but it can also make it uncomfortable to sit, stand, exercise, urinate or even work. Vaginal dryness can affect everyday life, whether women are sexually active or not. This can have a detrimental effect on quality of life. Many women also notice that having a cervical smear becomes more painful or difficult.

Recognising that vaginal dryness is normal and common is the first step to helping yourself. The next is to talk to your doctor or practice nurse, who can recommend a treatment to suit you.

Treatment

  • Local oestrogen – this is available in the form of small tablets inserted into the vagina with an applicator, a waxy pessary, vaginal gel, creams or a vaginal ring. The ring needs to be removed and replaced every three months. Vaginal dryness can respond well to local oestrogen treatments; they can also help greatly with discomfort and pain during sex, correct the vaginal pH and regulate bacteria. Unlike conventional forms of HRT, the effects are local and therefore the risks are minimal.
  • DHEA – a once daily pessary containing dehydroepiandrosterone
  • Ospemifene – a tablet treatment that has an oestrogen-like effect in the vagina, suitable for some women who are not candidates for vaginal oestrogen
  • Avoid perfumed soaps
  • Use creams to treat skin irritation
  • Lubricants and moisturisers can be useful, particularly for women who are not suited to oestrogen replacement
  • Take more time during sexual intercourse giving the Bartholin’s glands time to produce the maximum amount of lubrication.

What are hot flushes and night sweats?

Flushes can be accompanied by sweating and palpitations or sometimes shivering, and can cause embarrassment, anxiety, discomfort and sleep disruption.

What causes them?

Hot flushes occur when oestrogen levels are changing and adjusting to a lower level during the menopause transition. They tend to be more frequent when oestrogen reduces rapidly. Hormone levels affect our body temperature control mechanisms – it is as if a thermostat has a narrower range of temperature changes it can tolerate, so that our bodies try to ‘cool down’ by having a hot flush in response to small changes in our bodies and in our surroundings that previously would have gone unnoticed. The threshold for flushing also narrows if we are under stress so reducing stress and relaxation is an important part of managing hot flushes.

Relaxation and paced breathing can be used to calm down your body’s physical and emotional reactions. Paced breathing is slow, even breathing from your stomach. The diaphragm is located just below the lungs and forms a barrier between the lungs and the stomach. Breathing from the stomach or below the diaphragm increases lung capacity, so that we get more oxygen, and it also has a significant calming effect. If practiced regularly, paced or diaphragmatic breathing can help you to relax. You can practice by keeping the chest and shoulders still and pushing the stomach out as you breathe in, and taking slow, deeper breaths. Putting one hand on your chest and one hand on your stomach helps as you get used to this way of breathing. The hand on your chest should stay fairly still and the hand on your stomach should rise and fall as you breathe. It might be easier to practise this lying down at first. Once you get used to it you will be able to use this breathing for a few minutes during the day to reduce stress and to feel calm. Letting your shoulders relax and focussing on your breathing for a few minutes can give you time to pause and to think how you want to react in a stressful situation.

What can help to cool down?

Wear light layers so it is easy to remove layers if you have a hot flush. Try wearing loose fitting clothes made of natural, light fabrics such as cotton. Cotton sheets, with a lower thread count, will also help you to remain cool at night. Remove any heavy, thick down duvets from your bed; placing a towel in your bed can absorb some of the sweat, preventing your sheets from becoming drenched. Some women also use a Chillow Pillow, which remains cool throughout the night.

Hot flushes can be triggered by stimulants, such as coffee, hot drinks and some spicy foods, alcohol, stress, changes in temperature, or activities, e.g. rushing to work. If you keep a diary of hot flushes and note down what was happening just before the flush you might be able to identify your hot flush triggers, and then by making small practical changes you can gain some control over them.

Infertility and menopause

A permanent menopause means that you will not be able to have children naturally—this is called infertility. Infertility can be very difficult to deal with, especially if you wanted to get pregnant, and it can be particularly hard when you are already coping with a diagnosis of leukaemia. It is important to speak to your medical team before you start your treatment if you want to have children in the future. It is sometimes possible to preserve fertility, but as these techniques can take time, it may be that your treatment for leukaemia must start without delay.

Possible long-term effects of menopause

Osteoporosis

Menopause and particularly early menopause may increase the risk of bone thinning known as osteoporosis because oestrogen helps to maintain bone calcium levels and bone density. Tell your medical team if other people in your family have had osteoporosis as it does run in families. Do not forget, men can get osteoporosis too.

Regular weight bearing exercises and a healthy diet with plenty of calcium and vitamin D will help you to look after your bones. The NHS recommends:

“Calcium is important for maintaining strong bones. Adults need 700mg a day, which you should be able to get from your daily diet. Calcium rich foods include:

  • Leafy green vegetables
  • Dried fruit
  • Tofu
  • Yoghurt

“Vitamin D is important for healthy bones because it helps your body absorb calcium. All adults should consume 10 micrograms of vitamin D a day. Good dietary sources are:

  • Oily fish – such as salmon, sardines, herring and mackerel
  • Red meat
  • Liver
  • Egg yolks
  • Fortified food such as most fat spreads and some breakfast cereals

“However, it can be difficult to get enough vitamin D from foods alone. Ask your GP for a blood test to check your levels, if they are low, they can prescribe a supplement.”

Heart and circulatory disease

Oestrogen protects the arteries of a woman’s heart by reducing build-up of fatty plaque. Low oestrogen levels can increase your cholesterol levels which can further increase your risk of developing heart and circulatory disease. Menopause can cause palpitations (feeling your heart beating faster than usual) due to the changing hormone levels. This can sometimes happen during hot flushes. Palpitations are usually harmless, but it’s important to speak to your GP if you are concerned, especially if you have a family history of heart disease. Again, it is really important to maintain a healthy diet and exercise routine. A well-balanced diet should include at least five portions of fruit and veg a day. Many experts suggest this should be nearer to 10 potions per day. A portion is about a handful (80g), for example:

  • Four broccoli florets
  • One pear
  • Three heaped teaspoons of carrots
  • Seven-eight strawberries

Eating too much salt can increase the risk of developing high blood pressure and if you drink alcohol it’s important to stay within the recommended guidelines:

  • Men and women should not drink more than 14 units of alcohol each week
  • You should have several consecutive alcohol-free days each week

What is Hormone Replacement Therapy (HRT)?

HRT can be used to manage the symptoms of menopause at whichever age it occurs. This can be oestrogen on its own or combined with progesterone. HRT is the most effective treatment available to relieve symptoms and protect women from the long-term effects of menopause; however, HRT has had some bad press resulting in some women avoiding it. Two major studies were conducted in the 1990s and the published results suggested there were significant health risks associated with HRT. Since then, many international studies have discredited the results of these first trials. Women wishing to start HRT should carefully discuss the benefits and risks of treatment with their doctor to see what is right for them, taking into account their age, medical history, risk factors and personal preferences. For most women who use HRT for the short-term treatment of symptoms of the menopause, the benefits of treatment are considered to outweigh the risks. The lowest effective HRT dose should be taken, with duration of use depending on the clinical reasons for use. HRT remains licensed for osteoporosis prevention and can be considered the treatment of choice for women starting treatment below age 60 years, and especially for those with a premature menopause. Women on HRT should be re-assessed by their doctor at least annually. For some women, long-term use of HRT may be necessary for continued symptom relief and quality of life.

If your doctor does not recommend HRT for you or you do not want to take it, there are other ways to manage menopause symptoms.

Cognitive behaviour therapy (CBT)

This is a non-medical approach that can be helpful for a range of health problems, including anxiety and stress, depressed mood, hot flushes and night sweats, sleep problems and fatigue. CBT helps people to develop practical ways of managing problems and provides new coping skills and useful strategies. For this reason, it can be a helpful approach to try because the skills can be applied to different problems and can improve wellbeing in general.

CBT for hot flushes focuses on the links between physical symptoms, thoughts, feelings and behaviour. The way we think about symptoms in certain situations tends to affect the emotions we feel and what we do, and these reactions can in turn increase intensity of the hot flushes.

 

For example, when a woman feels the onset of a hot flush, she thinks that everyone is looking at her and that she cannot cope; this leads to feelings of embarrassment, loss of control and anxiety. These feelings might then lead to increased tension, palpitations and sweating, which intensify the hot flush experience. CBT can help you to find ways to reduce these negative reactions to hot flushes. Learning calmer more neutral responses will help you to feel more in control and more able to cope.

CBT can alleviate low mood and anxiety which may arise as a result of the menopause. North American Menopause Society (NAMS) recommends a CBT approach that combines relaxation techniques, sleep hygiene and learning to take a positive healthy attitude to a menopause challenge. A fact sheet (written by Professor Myra Hunter, Kings College London) on the Women’s Health Concern website provides guidance on cognitive behavioural therapy in a self-help format for women to access directly.

Herbal treatments

Guidelines recommend that you look for the THR logo standing for traditional herbal medicines. These products have been approved and you can be sure that the product has the correct dosage, is of high quality and has suitable product information. The NICE guidelines also recommend that many available herbal medicines have an unpredictable dose and purity, and some herbal medicines have significant drug interactions. It is imperative that you speak to your haematology team before taking any herbal treatments as they could interfere with the effectiveness of medication you already take.

Useful contacts:

National Osteoporosis Society (NOS) www.nos.org.uk Freephone helpline: 0808 800 0035 (Monday-Friday 9am-5pm – now open until 7pm on Tuesdays Email: nurses@nos.org.uk

Menopause Matters www.menopausematters.co.uk

British Acupuncture Council 63 Jeddo Road, London, W12 9HQ Tel: 020 8735 0400 Website: www.acupuncture.org.uk

British Reflexology Association Monks Orchard, Whitbourne, Worcester WR6 5RB Tel: 01886 821 207 Website: www.britreflex.co.uk

Complementary Medical Association Tel: 0845 129 8434 Website: www.the-cma.org.uk

International Federation of Professional Aromatherapists 82 Ashby Road, Hinckley Leicestershire, LE10 1SN Tel: 01455 637987 Website: www.ifparoma.org

National Institute of Medical Herbalists Clover House, James Court, South Street, Exeter, Devon EX1 1EE Tel: 01392 426022 Website: www.nimh.org.uk

Society of Homeopaths 11 Brookfield, Duncan Close, Moulton Park, Northampton NN3 6WL Tel: 01604 817890 Website: www.homeopathy-soh.org

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