Women who face menopause after a cancer diagnosis may be able to manage their symptoms without relying on estrogen-based therapies, although discussing this with a cancer team will help patients find what’s best for them.
Patients with cancer who experience early-onset menopause after treatment may manage their symptoms with lifestyle changes, including diet and exercise, and non-estrogen-based therapies, according to an expert at a recent conference.
In addition, although there are several ways to approach symptom relief with, it is important to be mindful of what route a patient takes, especially if it’s something not provided by a doctor.
“I know a lot of people don’t like to take medicine, so you can start with non-medical treatments,” said Dr. Deborah Kwolek, internal medicine physician, women’s health specialist and menopause specialist at Massachusetts General Hospital at Harvard Medical School in Boston, during a presentation at 13th Annual Joining Forces Against Hereditary Cancer Conference. “But be very cautious about anything you order online. If you’ve been told you can’t take hormones, again, beware because (something that you purchase yourself) may have some hormonal activity. So just be careful with that.”
Menopause, or the loss of regular ovarian function resulting in low estrogen levels, naturally occurs in all women due to age, though patients who have undergone surgeries or medical treatments affecting the ovaries may experience an early-onset menopause.
One of the most common menopausal symptoms are hot flashes, but women may also experience bone-density loss, increased cardiac risks, mood and sleep issues, weight gain, or genital and bladder issues. Many doctors treat these symptoms by addressing their root cause — the lack of naturally produced estrogen in the woman’s body — but many cancer survivors may not pursue hormone therapy due to their medical history or current medications.
While some systemic estrogen therapies may be safely used under the advisement of a physician, topical estrogen (hormones taken through cream on the skin instead of taking an oral medication) may pose a lower risk to cancer survivors.
Many general lifestyle changes may help manage menopausal symptoms without using estrogen treatments. Patients are encouraged to increase their exercise, eat a plant-based diet and limit alcohol consumption. Generally managing stress and seeking out time with friends and loved ones has also been shown to help mitigate symptoms of depression and troubled sleep without medical intervention.
To potentially lower the cardiac risks, patients are similarly advised to monitor diet and activity, but patients who have high blood pressure, cholesterol or diabetes should be especially careful about heart health. Smokers or those who have a family history of heart issues should also be cautious. Habitually taking aspirin or statins (cholesterol-lowering drugs) may also lower the risk for heart issues, although patients should discuss this with their health care providers.
Selective serotonin reuptake inhibitors (SSRIs) are medications traditionally designed to treat clinical depression and other mood disorders, which may be effective for managing depressive symptoms in patients going through menopause but have also helped women manage their hot flashes and night sweats, according to the presentation. Kwolek specifically recommended Effexor (venlafaxine) as an SSRI she often prescribes, as well as Lexapro (escitalopram) and Zoloft (sertraline).
“Sometimes if one medicine is a little too strong for you, some women complain and say, ‘It made me feel like a zombie,’” Kwolek said. “Chances are, you were on too high of a dose, or it could be that you were on too low of a dose and bumping it up a little bit more would have given you a really good effect. (If) you’re like a zombie, that usually is too high a dose.”
If one medication does not work for a patient, there may be other options, according to the presentation.
“If one of these medications doesn't work for you, often you can switch,” she explained. “These are all sorts of what we call brother drugs or sister drugs. They're very similar to each other but not exactly the same.”
Patients who were treated with Soltamox (tamoxifen), an estrogen modulator used in breast cancer treatments, should be cautious about which SSRIs they are prescribed, as the medications can negatively interact with each other.
Many women experience genitourinary issues in addition to menopausal symptoms. Topical estrogen is effective, Kwolek said, but keeping genitals lubricated and moisturized may help patients manage overall sexual health. Kwolek also suggests doing Kegels and other pelvic floor exercises to strengthen vaginal muscles and reduce symptoms.
While sexual health concerns include physical pain and incontinence, there are many psychological symptoms; cancer survivors routinely face post-traumatic stress disorder and body dysmorphia (body image) in relation to treatment and subsequent menopausal symptoms.
"I just want encourage you, make sure you have a doctor who's really knowledgeable, who could talk to you about these things and refer you for sex therapy if you need it,” Kwolek said. “This is really important, a really important part of your health. So please, don't let this go unaddressed.”
She also emphasized the importance of self-advocacy during this time in a patient’s life.
“Please make sure that you … are advocating for yourself, that you have the correct information and that all your providers are communicating with each other to find out what treatments you can take, and how to deal with all the symptoms that come along with menopause,” Kwolek said.
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