Margaret Forbes RN(EC) MN BScN CON(C) Nurse Practitioner Juravinski Cancer Centre October 22/15

Margaret Forbes RN(EC) MN BScN CON(C) Nurse Practitioner Juravinski Cancer Centre October 22/15

Menopause Definition Menopause Symptoms Hot Flash Management Discussion Q&A

Normal part of aging when fertility and menstruation cease The ovaries no longer function to produce estrogen Other methods of inducing menopause: Chemotherapy or ovarian suppression Surgery (removal of ovaries) Radiation to ovaries

Hot flashes Insomnia Mood swings Hair thinning / skin changes Vaginal symptoms Lack of/decreased libido Weight gain Urinary symptoms Bone changes Memory changes Body image Decreased sense of well being (Mayo Clinic 2012; MSKCC, 2012, On-line source)

Hot Flashes most frequently reported symptom of menopause Effects up to 93% of all post-menopausal women to varying degrees and duration Caused by decreased levels of circulating estrogen in body (Carpenter et. al. 1997; Stearns & Loprinzi, 2003; Pritchard et. al. CMAJ Guidelines, 2002)

A sudden sensation of intense warmth usually in the upper body Often accompanied by reddening of the skin and profuse sweating Cold chill may follow Photo Courtesy Dr. M. Lock

Wikipedia online source 2008

Hot flashes usually lessen within 1 yr but for some they persist longer Non-drug & drug choices must be carefully considered by women and their health care providers Hormone replacement therapy not recommended after breast cancer diagnosis (Rapkin, 2006; Stearns & Hayes, 2002; Pritchard, Khan, Levine, CMAJ Guidelines 2002)

Increased HF intensity noted with: Tamoxifen, Aromatase Inhibitors (Letrozole, Anastrozole, Exemestane) and ovarian suppression can increase the frequency and severity of hot flashes Premenopausal women who have chemoinduced menopause seem to experience menopausal symptoms more acutely Post-menopause women who were on HRT for many years (Boekhout et al., 2006)

Lowered sense of wellbeing Hot Flashes Low mood Poor sleep Fatigue

Life style changes Medications Hormone Replacement Therapy CAM therapies

Common Triggers caffeine, alcohol, smoking, chocolate, spicy food Tracking to identify other triggers Time Severity (0-4) Activity Length 7 a.m. 2 Getting up 5 min 10 a.m. 3 Coffee break 10 min 2 p.m. 1 Sitting desk 2 min 5:15 3 Driving 5 min Build strategies

Use of fans + reduce room temperatures More time to get ready Loose fitting cotton clothing in layers Cool water or ice chips Paced breathing with every hot flash

Keep a lid on stress Increase sense of well-being Exercise, yoga, tai chi, reiki Meditation, mindfulness Manage emotions Seek counseling (e.g. social worker) Exercise 30min 5x/week Try to get a good sleep

Hot flashes often affect sleep Inadequate restorative sleep leads to daytime sleepiness Consider the context:? sleeping patterns prior to diagnosis Manage symptoms (e.g. pain, heartburn, urinary issues) Breathing issues (e.g. sleep apnea, asthma)

Establish routine bedtime and awake time Turn off TV/computer 1 hour before bed Avoid daytime napping Avoid caffeine, alcohol, heavy food 4-6 hours before bed Incorporate exercise in daily routine

Venlafaxine (Effexor XR) Fluoxetine (Prozac) Paroxetine (Paxil) Citalopram (Celexa) Sertraline (Zoloft) Can reduce hot flashes up to ~50%

Anti-seizure medication can reduce hot flashes by 50-60% Pregabalin (Lyrica): newer derivative has shown to be as effective as Gabapentin with less toxicity not covered by ODB and can be expensive without a drug plan

Blood pressure med Has been used for many years Can reduce hot flashes by ~ 40%

Most of these medications well tolerated Side effects with every medication Hot flashes get better over time thus drugs not required long-term Periodic weaning required (do not stop drug abruptly!)

HRT not safe for use after diagnosis of breast cancer Vaginal estrogens for vaginal dryness only when: vaginal moisturizers and lubricants are ineffective then only for a short while and in low doses Testosterone typically used in combination with HRT therefore not usually recommended in women with breast cancer

Formulated based on a saliva sample Compounded by a pharmacist Contain estradiol - there is no safety data available about the use of estradiol Should be avoided in women with breast cancer (Mayo Clinic website, 2009; NAMS, 2009)

40% of adults (with the majority being women) > 40 yrs of age have used at least 1 CAM therapy in last 12 months Do you know how the CAM you re using works? Testimonials are often the basis for use

Behavioural Therapies deep breathing, meditation sense of wellbeing Efficacy is difficult to assess in clinical trials due to impossibility of using a placebo Hypnosis + self hypnosis Imagery

Acupuncture increases secretion of central β-endorphins which may stabilize thermoregulation, decreasing HF Very fine needles inserted in specific areas producing the de qi sensation Avoid use of Needles on arm same side as Breast cancer Is a safe, tolerable treatment (Deng et al., 2007; Walker et al., 2010; Lee et al., 2009)

Black Cohosh Soy Isoflavones and Phytoestrogens (e.g. flax, soy) Kava Red clover Don quai Ginseng Vitamin E Evening Primrose Oil Omega 3 fatty acids

Phyto-estrogens may mimic the action of estrogen in the body Women who have had breast cancer should avoid or use sparingly Still no definitive answer & overall safety needs to be clarified

Black Cohosh 5 clinical trials comparing Black Cohosh to no treatment or to placebo (Osmers et al., 2005) Controversy: phytoestrogen or not? Soy Isoflavones and Phytoestrogens (e.g. flax, soy, red clover) FSH + LH in premenopausal women slightly estradiol in postmenopausal women (Hooper et al., 2009) Not typically recommended in breast cancer Challenge for vegetarians, lactose intolerant women

Kava? helps HF Can damage liver over time anxiety Red Clover (Promensil)? Estrogenic (classified as a phytoestrogen) Not effective for HF vs. placebo (Nelson et al. 2006) Dong Quai not effective for HF Interacts with warfarin (Coumadin) Ginseng Not effective for HF sense of well-being, mood and sleep (NCCAM/MSKCC online source 2012)

Omega 3 fatty acids (Lucas et al. 2009) E-EPA 55% reduction of HF Placebo 25% reduction of HF May increase bleeding time with higher doses Vitamin E vs. placebo resulted in 1 less HF/day (Barton et al., 1998) taking Vitamin E ( 400 IU/day) could be dangerous (Miller et al., 2005) Evening Primrose Oil One study done; no difference in HF vs. placebo Not estrogenic but many manufacturers combine with phytoestrogens Caution with anti-coagulants/anti-platelet therapies; may bleeding ( www.mskcc.org ;online source)

Unable to assess no RCTs Ingredients non-hormonal non-phytoestrogenic Botanicals Hot Flash Eliminator (flower essences) Drops are stimulated with Reiki Not evaluated in RCT

Herbal does not = safe Research every product ingredient before using and to confirm with health care provider to ensure safety More studies about CAM therapies are needed to confirm efficacy and safety

Memorial Sloan Kettering Cancer Centre www.mskcc.org/aboutherbs National Centre for Complementary and Alternative Medicine www.nccam.com The Mayo Clinic www.mayoclinic.com Remember to look at information about menopause in the setting of breast cancer

Hot flashes are a commonly reported symptom in women with breast cancer A combination of strategies works the best and should be tailored for each person Speak to your health care provider Remind yourself: Hot Flashes Do Get Better Over Time!!

Thank-you!