This information is about menopausal symptoms that can occur because of breast cancer treatment. It gives suggestions about coping with these symptoms. Symptoms may not always be severe, but can cause a lot of discomfort.

Women naturally stop having regular periods, usually at some time between their mid-40s and mid-50s. The menopause, or change of life, happens because the ovaries stop producing the sex hormones oestrogen and progesterone. The change in hormone levels can cause a number of symptoms.

Symptoms can include:

• hot flushes and sweats
• vaginal dryness
• passing urine more often (frequency)
• lower sex drive
• tiredness
• sleeplessness
• dry skin
• aches and pains
• mood swings
• poor concentration
• loss of confidence and memory.

Women may have one or more of these symptoms, and symptoms can range from being very mild to more severe.

Menopause, particularly if it occurs early in life, may cause other effects on the body, such as thinning of the bones (osteoporosis) and heart disease. These effects develop at different rates in different people. Their tendency to develop is, at least partly, passed on from your parents (genetically determined).

The sex hormones oestrogen and progesterone can affect the growth of breast cancer cells. Treatments for breast cancer often involve hormonal therapy that blocks oestrogen from getting to breast cancer cells, or reduces the level of oestrogen in the body. These treatments may cause an early menopause or menopausal symptoms.

Surgery, radiotherapy, chemotherapy and hormonal therapy may be used alone or in combination to treat breast cancer. Some of these treatments can affect the function of the ovaries; you may begin your menopause earlier than expected, or have menopausal symptoms due to the treatment itself.

Women who develop breast cancer at a young age may be advised to have treatment to stop their ovaries producing oestrogen, as oestrogen could stimulate the growth of breast cancer cells. The ovaries can be permanently stopped from producing oestrogen, using surgery or radiotherapy. Chemotherapy or hormonal therapy may stop the ovaries working, either permanently or temporarily.

Surgery The ovaries can be removed in a minor operation, during a short stay in hospital. This will bring on a sudden and permanent menopause. Menopausal symptoms may start within a few days of the operation.

Radiotherapy A low dose of radiotherapy to the ovaries will stop them from working. As a low dose is used, there are rarely any side effects from radiotherapy other than menopausal symptoms. It will bring on the menopause, although it may take a few months before menopausal symptoms occur and your periods stop.

Chemotherapy Some chemotherapy drugs will stop the ovaries from working. This can be temporary, but the nearer you are to your natural menopausal age, the more likely it is to be permanent. If it is permanent, the treatment will bring on the menopause and you may develop some of the symptoms described earlier. Even if the treatment does not cause an immediate menopause, it may prompt the menopause start earlier than it would otherwise have done.

It is not possible to predict before your treatment whether the chemotherapy will affect you temporarily or permanently. Your periods could return to normal in time, so you could still get pregnant and should use contraception after your chemotherapy has ended.

Hormonal therapy Two main types of hormonal therapy can be used to treat breast cancer. These are:

• drugs that block oestrogen from attaching to the cancer cells
• drugs that stop oestrogen from being produced.

Hormonal therapy drugs that block the effects of oestrogen (such as tamoxifen), may cause side effects similar to the symptoms of the menopause. Periods may become irregular or stop. However, if the treatment is ended, the menopausal symptoms usually stop – although this can take a few months.

As with chemotherapy, the nearer you are to your natural menopausal age, the more likely it is that hormonal therapy will bring on an early menopause, and that your periods will not start again when treatment has ended. Women who have already had their menopause may have menopausal symptoms again when they begin hormonal therapy.

Hormonal therapies known as LHRH analogues, such as goserelin (Zoladex®), stop the ovaries from producing oestrogen altogether, but unlike surgery or radiotherapy, this is reversible. These drugs cause menopausal symptoms while you are taking them. However, usually your periods start again when treatment is stopped.

Women who are close to their natural menopause when they start treatment, may find that their periods do not begin again after treatment.

These are the most common menopausal symptoms, although the exact cause is unknown. Body temperature control seems to be affected by falling oestrogen levels. It is difficult to stop hot flushes and sweats, but their frequency or intensity can often be reduced.

There are a range of medicines that your doctor can prescribe, to try to reduce the severity and number of flushes and sweats.

• Research trials have shown that low-dose progestogens (megestrol acetate, norethisterone and medroxyprogesterone acetate) can help some women. However, they can take at least 3–4 weeks to reduce the number of hot flushes and sweats. Some women have an initial increase (or flare) in the number of the flushes that they have. Other side effects such as breast tenderness and a bloated feeling can also occur.
• Antidepressants such as venlafaxine (Efexor®) may also be helpful when given in low doses. Some women have found that they reduce the number and severity of hot flushes, although research trials have shown differing results. These drugs can take several weeks to work and can cause side effects, such as sickness (nausea), a dry mouth, and a decreased appetite. Your doctor or breast care nurse can discuss the possible side effects with you.
• Clonidine (Catapres®, Dixarit®) is a drug that is usually used to treat high blood pressure or migraines, and it is sometimes prescribed for hot flushes and sweats. However, it can take four weeks to work, and for a lot of women it may not work at all, or only work for a short while. Side effects include constipation, a dry mouth, and drowsiness.
• Tibolone (Livial®) is a type of hormone replacement therapy (HRT) that does not contain oestrogen and does not cause a monthly bleed. It can help to reduce flushes and sweats, and may also protect against bone thinning (osteoporosis). It may also help to reduce feelings of depression, and improve your sex drive. The use of tibolone by women who have had breast cancer is still being researched in trials, but if other medication has not been helpful your cancer specialist may recommend this drug. Possible side effects include weight gain, fluid retention, dizziness, irregular vaginal bleeding, headaches, increased growth of facial hair, joint pains, and skin rashes.
• Other types of HRT can be prescribed if the symptoms are severe and nothing else helps. However, taking HRT that contains oestrogen after you have had breast cancer, can increase the risk of the cancer coming back if your cancer is oestrogen-dependent. Your cancer specialist can discuss with you the possible benefits and risks of HRT in your situation. You may be offered HRT as part of a clinical trial.
• Progesterone cream, when applied to the skin, may help to reduce hot flushes. However, research trials have not shown that there is any benefit.

Helpful tips for reducing hot flushes and sweats

• Wear several layers of light clothing (preferably cotton) that you can easily take off or put back on depending on your body temperature.
• Cut down on alcohol and hot drinks that contain caffeine, such as coffee and tea. Sipping cold drinks may help.
• Avoid overly spicy foods.
• Lukewarm showers and baths are less likely to trigger sweats than hot ones.
• Flushes and sweats are often worse at night. Put a soft cotton towel on your bed that you can easily change if it gets wet during the night.
• Lowering the room temperature and making sure there is good air circulation, by opening a window or using a gentle fan, can sometimes help.
• A yoga breathing technique known as the 'cooling breath' or sheetali, can help to reduce your body temperature. Contact the British Wheel of Yoga (BWY) to find a registered yoga teacher.
• If you are taking tamoxifen, changing the brand, or having half the dose in the morning and half in the evening, can sometimes reduce hot flushes and sweats. Halving the daily dose may help some women.

A low level of oestrogen in the body causes vaginal dryness, and sometimes itching. Some creams can be helpful when applied directly to the vagina (topical treatment).

Some of the creams contain a small amount of the hormone oestrogen. The long-term risks of using creams containing oestrogen after breast cancer are unknown. There is a possibility that these products could increase the risk of the cancer coming back, although this is uncertain. Topical oestrogen treatments may also affect the cells that line the womb.

Your doctor can tell you which of the products below is most suitable for you. Your treatment should be regularly reviewed by your doctor, and you should tell them about any new symptoms.

Some of the creams may damage condoms and diaphragms, so care should be taken to avoid pregnancy.

• Replens MD® is a non-hormonal cream that you apply 2–3 times a week. The cream binds to the vaginal wall and helps to rehydrate cells. It boosts blood flow in the vagina.
• Vagifem® is a tablet that you insert into the vagina (a pessary). It is normally used daily for two weeks, and then dosage is reduced to just twice a week. A small research study has shown that Vagifem can increase the amount of oestrogen circulating in the body. Because of this risk, Vagifem may not be recommended for women who are taking aromatase inhibitors, such as anastrozole (Arimidex®), exemestane (Aromasin®), or letrozole (Femara®). Your specialist or breast care nurse can give you further advice and information about this.
• Ovestin® and Ortho-Gynest® are creams, or pessaries, that can reduce dryness and itching for a short time. They contain a small amount of oestrogen.
• Estring® is a vaginal ring that is worn for three months. It slowly releases a small amount of oestrogen and may help to reduce dryness.
• Water-based lubricants such as Senselle®, KY-Jelly®, Astroglide® and Sylk® can help to reduce discomfort from vaginal dryness during sex.

A little baby oil, or a few drops of bath oil in your bath, helps to moisturise the skin.

Some women have found taking one or more of zinc, vitamin B, and linseed oil supplements helpful.

You may experience sleeplessness, due to hot flushes and sweats or anxiety. The following suggestions may help you to relax and sleep well, and can help you to feel more in control during the day:

• Have a lukewarm bath to relax before bedtime
• A warm herbal, or milk, drink before bed can help you to relax
• Wear nightwear that is made of absorbent lightweight cotton.
• If you can't sleep, don't just lie in bed; get up and read, listen to the radio or audio-books on tape/CD, or watch TV until you feel sleepy.
• Your GP can prescribe sleeping tablets for a short period of time; these may help to re-establish a sleep pattern.
• Techniques such as listening to relaxation tapes/CDs, doing relaxation exercises, visualisation, massage or meditation can help to reduce anxiety and sleeplessness.

The psychological effects of menopausal symptoms can be hard to cope with when you already have to deal with the physical effects of cancer.

Some menopausal symptoms are very difficult to deal with. These include a lower sex drive, mood swings, poor confidence, and a loss of concentration and memory. You may feel very emotional or anxious without really knowing why. These symptoms may be quite distressing for you and for your partner, if you have one.

A number of organisations provide support to women going through the menopause. Helpful books are also listed later.

HRT is probably the only effective way of treating severe psychological menopausal symptoms. You will need to discuss whether or not HRT is appropriate for you with your cancer specialist.

Detailed information on dealing with menopausal symptoms is available in our health professionals section.

An early menopause can increase your risk of bone thinning (osteoporosis) and heart disease. There are ways of reducing these risks.

Osteoporosis

Oestrogen helps to maintain bone calcium levels and bone density. The risk of osteoporosis therefore increases after menopause. Regular weight-bearing exercises such as walking, dancing, hiking, and gentle weight-lifting help to maintain bone density. If you already have osteoporosis you should avoid exercises that put too much strain on your bones, such as jogging. Swimming is not so helpful, as your bones are not supporting your weight while you swim. A physiotherapist or your breast care nurse can give you further advice about exercise after breast cancer.

It is important to make sure that you get enough calcium and vitamin D in your diet. Dairy products are the best source of calcium but, if you prefer not to eat them, you can get calcium from eggs, green leafy vegetables, nuts, and whole fish such as whitebait, sardines, and pilchards. Vitamin D helps the body to use calcium effectively. A well-balanced diet will normally give you all the calcium and vitamin D you need, but calcium and vitamin D supplements may also be helpful. Be aware that smoking and drinking alcohol can reduce your calcium levels.

If other people in your family have had osteoporosis, you may wish to talk to your cancer specialist about using medicines such as bisphosphonates. These drugs can help to prevent osteoporosis and reduce bone weakening.

The drug tamoxifen, which is commonly used to treat breast cancer, helps to protect the bones in post-menopausal women. Another drug, raloxifene (Evista®), can also help to prevent osteoporosis. However, aromatase inhibitors such as anastrozole (Arimidex®), that are also commonly used to treat breast cancer, can increase the risk of developing osteoporosis. Women taking aromatase inhibitors may need to have their bone density monitored during their treatment.

If you already have osteoporosis, you can talk to your doctor about taking calcium and vitamin D supplements. Warm baths can help to relax stiff joints and regular exercise will keep you supple. Be aware of dangers or trip hazards that could lead to falls. The National Osteoporosis Society can give you more information about prevention of osteoporosis and can let you know about helpful treatments.

Heart disease

The risk of heart disease increases in women after menopause, so you need to follow the well-established advice on reducing your risks:

• Stop smoking if possible, or at least cut down the number of cigarettes smoked each day
• Eat less animal fat and dairy produce, and eat more fresh fruit and vegetables
• Take regular gentle exercise.
• If there is heart disease in your family, you may wish to talk to your cancer specialist or GP about using medicines to try to prevent it.

There are a variety of complementary therapies that may help you to control your menopausal symptoms. Some of these have been researched, but for others the evidence is only anecdotal (based on personal accounts rather than facts).

Some of these therapies may be available on the NHS, and your GP can give you further details. If you would like to find a complementary therapist, make sure that they are properly qualified and registered. The British Complementary Medical Association has lists of registered therapists throughout the UK.

It is a good idea to discuss the use of any complementary therapy with your doctor, as some therapies may interfere with your cancer treatment.

Acupuncture involves putting sterile needles through the skin, and into energy points, to help restore health and balance in the body. There is some evidence that acupuncture may help to reduce the number and severity of hot flushes.

Homeopathy aims to cure 'like with like' by using tiny amounts of substances that would normally produce the symptoms being treated. There is no scientific proof that this works, but some women find that it helps to improve their menopausal symptoms.

Different relaxation techniques, such as progressive muscle relaxation (slowly tensing then releasing each muscle group), audio tapes/CDs, or paced respiration (a technique using slow controlled breathing), may help to reduce hot flushes.

Some women find evening primrose oil helpful for relieving menopausal symptoms, although it is expensive and there is no scientific evidence that it works.

There is some evidence to suggest that hypnosis can help to reduce the length and severity of hot flushes. It is unlikely to be available on the NHS.

Plant oestrogens (phytoestrogens) can have a very weak oestrogen-like effect, and may help to improve menopausal symptoms. However, there is concern that they may also increase the risk of a recurrence of an oestrogen-dependent breast cancer, so it is wise to discuss their use with your doctor. The two most commonly used plant oestrogens are black cohosh and red clover. Black cohosh contains phytoestrogens and may help to improve flushes although the evidence is inconclusive. Side effects include sickness (nausea), vomiting, headaches, and possible liver disease. It should not be taken for more than six months at a time. Red clover contains chemicals called isoflavones, which are a type of phytoestrogen. There is conflicting evidence as to whether or not it can help to reduce menopausal symptoms. It may increase the risk of bleeding and should not be used by women taking medication to thin their blood (anticoagulants).

Vitamin E may help to reduce the frequency of hot flushes, and has very few side effects. Women with heart disease, diabetes, or high blood pressure should consult their doctor before taking vitamin E supplements.

Coping with menopausal symptoms after cancer treatment can often be very difficult. You may feel anxious, angry, or frustrated that you are now having to cope with more symptoms. These are all normal reactions.

An early menopause and infertility are often difficult to come to terms with, particularly for women who hoped to have children, or who would have liked to have more children. Many people find it helpful to talk through their feelings with their doctor or nurse, or with friends and family members.

Understanding the Menopause and HRT
A MacGreggor
Family Doctor Publications, 2005
ISBN 1-903474-11-6
Up-to-date, easy to read book containing useful information on the risks and benefits of HRT.

The Menopause and HRT
Kathy Abernethy
Bailliere Tindall, 2002
ISBN 0-702026-35-2
Gives information to women going through menopause, and has helpful information on ways of coping with the symptoms.

The Premature Menopause Book
Kathryn Petras
Avon Books, 1999
ISBN 0-380805-41-3
Discusses ways to cope with emotional and physical effects of early menopause.

This information has been compiled using information from a number of reliable sources, including:

• Oxford Textbook of Oncology (2nd edition). Eds Souhami et al. Oxford University Press, 2002.
• Cancer of the Breast (5th edition). Eds Donegan and Spratt. Saunders, 2002.
• Martindale: the Complete Drug Reference (35th edition). Eds Sweetman et al. Pharmaceutical Press, 2007.
• Improving Outcomes in Breast Cancer – The Research Evidence. National Institute of Clinical Excellence, 2002.

For further references, please see the general bibliography.