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1 Late effects of breast cancer treatment menopausal symptoms 1 Late effects of breast cancer treatment menopausal symptoms This information is from the booklet Managing the late effects of breast cancer treatment. You may find the full booklet helpful. We can send you a free copy see page 6. Contents Managing menopausal symptoms Hot flushes and sweats Vaginal dryness Urinary problems Psychological effects More information and support Managing menopausal symptoms Some treatments for breast cancer can affect the way the ovaries work. As a result, you may start your menopause earlier than expected, or have menopausal symptoms due to the treatment itself. The menopause happens because the ovaries stop producing the hormones oestrogen and progesterone. This usually happens sometime between the mid-40s and mid-50s. Women who have had chemotherapy (anti-cancer drugs to destroy cancer cells) close to the age of natural menopause (around 50) may go into the menopause quickly. Younger women in their 30s may find that their periods stop for a while and then come back again. However, they may have an earlier menopause than usual. Hormonal therapy drugs, such as tamoxifen, anastrozole, letrozole and exemestane, may have side effects that are similar to menopausal symptoms. Hormonal therapy drugs work by altering the production or activity of particular hormones in the body. Occasionally, breast cancer treatment may involve an operation to remove the ovaries. This will cause a permanent menopause.

2 Late effects of breast cancer treatment menopausal symptoms 2 Coping with an early menopause or menopausal symptoms when you re already dealing with cancer can be very difficult. But there are several things that may help to reduce the symptoms. Choosing which ones are right for you will depend on: your personal preferences the possible risks and benefits of each approach the type and severity of your symptoms what other treatments you are taking. We have more detailed information about breast cancer and menopausal symptoms that we can send you. Hot flushes and sweats This is the most common menopausal symptom. Hot flushes can vary from a mild feeling of warmth in the face to a drenching night sweat. Flushes and night sweats can be particularly disruptive to your sleep pattern. It s difficult to stop hot flushes and sweats, but their frequency or intensity can often be reduced. Using a combination of approaches is often more effective. Here are some suggestions for ways to manage hot flushes: Keep a record of when you have flushes to find out which things trigger them, so you can try to avoid them. Wear natural fabrics, such as cotton. Dress in layers, so you can remove clothes if and when you need to. Use cotton sheets or cooling fabrics and pillows that are designed to keep you cool in bed. Have layers of bedding that you can easily take off during the night. Keep the room temperature cool or use a fan. Have cold drinks rather than hot ones. Cut down on the amount of alcohol you drink. If you smoke, cut down or stop. Losing weight can help to reduce flushing. Try complementary therapies, such as controlled breathing or yoga.

3 Late effects of breast cancer treatment menopausal symptoms 3 Medicines for hot flushes There are different medicines that your doctor can prescribe to help reduce the severity and frequency of your hot flushes and sweats. Low doses of some antidepressants may reduce the number and severity of hot flushes in some women. However, some of them aren t recommended for women taking tamoxifen as they may interfere with how well it works. Your doctor or specialist nurse can give you more information. An anti-epilepsy drug called gabapentin and a medicine used to treat high blood pressure or migraines called clonidine are also used. Both have been shown to be effective at reducing the severity and frequency of hot flushes. Megestrol acetate is also effective in treating hot flushes. But some doctors have concerns about using it because it is similar to the female hormone progesterone. Hormone replacement therapy (HRT) HRT is not usually recommended after breast cancer because it increases the risk of the cancer coming back. Tibolone, a different type of HRT, should also be avoided. Although it doesn t contain oestrogen, it increases the risk of breast cancer coming back. Some doctors may prescribe HRT if a woman s symptoms are very severe and nothing else helps. It s important to talk this through with your cancer specialist to make sure that you are clear about the possible risks and benefits. Complementary therapies for hot flushes Some women find that complementary therapies help to reduce hot flushes. There are different types that may be used. Acupuncture is the practice of putting sterile needles through the skin at specific points in the body. There s some research evidence that it may help to reduce the number and severity of hot flushes. The needles should not be used on the arm of the affected side. Hypnosis may help to reduce the length and severity of hot flushes, but it s unlikely to be available on the NHS. Controlled breathing techniques, such as paced breathing or a yoga technique called Sheetali can be an effective way of managing flushes. Evening primrose oil may be helpful, although it is expensive. A few small research studies have shown a benefit, but the current view is that there is no good quality evidence that it works. Homeopathy uses tiny amounts of substances that would normally produce the symptoms being treated. Although it may be used by some women, there s no scientific proof that it works. Plant oestrogens (phytoestrogens), such as black cohosh and red clover, can have a weak oestrogen-like effect, so doctors don t recommend them for women who have had breast cancer.

4 Late effects of breast cancer treatment menopausal symptoms 4 Vaginal dryness Lower oestrogen levels can cause changes in the lining of the vagina, making it drier, less stretchy and more fragile. This can cause vaginal discomfort or pain in some women. Vaginal creams or lubricants can help to rehydrate the walls of the vagina and reduce discomfort from vaginal dryness, especially during sex. Not all products are the same and some may cause a skin irritation. You may need to try more than one product to find which works best for you. They are sold in chemists and on the internet. Your doctor or breast care nurse can give you more information. There are also treatments that release a small amount of oestrogen into the vagina. This helps to restore some lubrication and stretchiness (elasticity). The long-term risks of using products containing oestrogen after breast cancer aren t fully known. Many breast specialists think that very little of the oestrogen is absorbed by the body. However, hormone-based vaginal treatments are not recommended for women taking an aromatase inhibitor, such as anastrozole, exemestane or letrozole. It s important to talk to your specialist or breast care nurse before you use any products containing oestrogen. If they re prescribed for you, they should be used in the lowest possible dose and for short periods of time. The hormonal therapy drug tamoxifen can cause vaginal discharge. Let your doctor or specialist nurse know if this happens. Urinary problems Oestrogen helps to maintain the health of the tube that drains urine from the bladder (urethra) and the pelvic floor muscles (that surround the base of the bladder and the urethra). When there is less oestrogen in the body the urethra may become less elastic and the pelvic floor muscles may become weak. This can lead to urinary problems, so you may: pass urine more often have some urine leakage (incontinence) be more prone to urinary infections. It s important to drink enough fluid (at least pints/1.5 litres) each day to keep your bladder healthy. If you don t drink enough, your urine will become concentrated and irritate the bladder. You will also be more likely to develop urinary infections. Speak to your doctor if you develop symptoms of a urinary infection such as: pain or discomfort when passing urine cloudy-looking urine urine that smells bad.

5 Late effects of breast cancer treatment menopausal symptoms 5 Talk to your doctor or specialist nurse if you have any incontinence as they may be able to help you. Sometimes pelvic floor exercises (also called Kegel exercises) can help. These exercises strengthen the muscles that hold urine in the bladder. Your nurse or doctor can explain to you how to do these exercises or you can order an instruction leaflet from the Bladder and Bowel Foundation visit bladderandbowelfoundation.org There are lots of different pads or panty liners you can use. Try to avoid those with a scent because they can irritate the skin and make symptoms worse. Vaginal treatments containing low doses of oestrogen can improve urinary problems and reduce urinary infections. Psychological effects The psychological effects of menopausal symptoms can be hard to cope with when you already have to deal with the physical effects of cancer. Psychological effects can include: a lower sex drive mood swings lack of confidence a loss of concentration and memory You may feel emotional or anxious without really knowing why. A number of organisations, including The Daisy Network, provide support to women going through the menopause. To find out what support you could get from The Daisy Network, visit daisynetwork.org.uk Many women find it helpful to talk through their feelings with their doctor or nurse, or with family and friends. You may also find it helps to speak to a professional counsellor.

6 Late effects of breast cancer treatment menopausal symptoms 6 More information and support More than one in three of us will get cancer. For most of us it will be the toughest fight we ever face. And the feelings of isolation and loneliness that so many people experience make it even harder. But you don t have to go through it alone. The Macmillan team is with you every step of the way. Visit macmillan.org.uk or call us on , Monday to Friday, 9am to 8pm. You can order a copy of Managing the late effects of breast cancer treatment, or any other cancer information, from be.macmillan.org. uk or by calling us. Hard of hearing? Use textphone , or Text Relay. Speak another language? We have telephone interpreters. We provide information in a range of languages and formats. Visit macmillan.org.uk/otherformats or call us. We make every effort to ensure that the information we provide is accurate and up to date but it should not be relied upon as a substitute for specialist professional advice tailored to your situation. So far as is permitted by law, Macmillan does not accept liability in relation to the use of any information contained in this publication, or third-party information or websites included or referred to in it. Macmillan Cancer Support Registered charity in England and Wales (261017), Scotland (SC039907) and the Isle of Man (604). Registered office 89 Albert Embankment, London, SE1 7UQ Revised in March, Next planned review in 2018.

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