MANAGING MENOPAUSE AFTER BREAST CANCER

Breast cancer treatment can bring on menopause suddenly or make existing symptoms more severe, significantly affecting a woman’s quality of life. In this episode, we sit down with Dr Christina Jang to explore the challenges of managing menopause during and after breast cancer treatment.

Dr Jang discusses common symptoms, the treatment and management options available, the importance of balancing symptom relief with cancer care, and why a holistic approach to menopause can make a valuable difference to woman’s wellbeing.

“Women’s oestrogen is generally pretty stable up until they get through to the perimenopause. And at the perimenopausal stage the hormones fluctuate. They go up and down literally like a roller coaster. Then in the post-menopausal stage, their hormone levels are really low.”

“So, in women who undergo breast cancer treatment, some of the treatment they receive, such as their chemotherapy, their radiation, or even surgery, renders them menopausal. And instead of their hormones slowly declining, the issue is that they drop very suddenly, and their symptoms can be really severe and very dramatic, very quickly.”

What are the most common symptoms that you see in patients and how can they affect quality of life during and after treatment?

“Hot flushes are the main symptoms. They’re the cardinal symptoms that we all associate with menopause. And that’s still probably what most women present with, hot sweats and flushes. And then there’s also a lot of women who have urinary symptoms. What I mean by that is vaginal dryness, vaginal discomfort, they can get more urinary tract infections.”

“They don’t often share those symptoms unless we ask for them. More frequently though, we’re seeing women who are presenting with other symptoms such as brain fog, joint aches and pains. So, they’re the main ones that we would see. And obviously one of the biggest challenges is balancing symptom management with ongoing breast cancer treatment.”

How has our understanding of safe and effective menopausal management evolved in recent years?

“It’s been a big area of focus in the last few years. In terms of therapies traditionally for women who can’t use hormone therapy, we’ve had few medications that that are available to us, we’ve got anti-seizure medications, and we’ve had cardiac type medications that we traditionally use.

“These days, we have a newer class of medication called the Neurokinin 3 receptor antagonist become available, which works by target the mechanism behind the hot flushes, and they’re quite effective. They’re probably close to first line now for the treatment of hot flushes.”

“In general, the worldwide conversation is broader, there is more media attention about menopause, and women are seeking more information. And so, it makes us look at what other options are available, even if it’s not just those conventional medications that we’re using.”

There are often questions around hormonal therapy and other treatment options after a breast cancer diagnosis. What are some of the current approaches available and how do clinicians work with patients to find the right treatment management plan for them?

“It really depends on the patient, and on what symptoms she has. For example, the medication I mentioned before, Fezolinetant, treats hot flushes very well, but it doesn’t treat the other symptoms that I mentioned before.”

“It’s not very good for sleep, or for mood. So, if it’s those symptoms that are concerning her, we could think about other medications. There are medications such as the SSRIs and SNRIs, which are traditionally used for mood – they’re antidepressants. So, if mood is a predominant symptom, we may use those medications.”

“We go through and we discuss what the woman’s symptoms are, what medications are available and what is suitable for them. In some women we also talk about lifestyle, and cognitive behavioural therapy, which is effective as well.”

“The conversation may also turn to using hormones, if they feel that any non-hormonal medication I’m giving them isn’t effective. But it’s really important for me to discuss it with the oncologist as well.”

How important is it to take a holistic approach to care and who else should be involved in supporting women through these stages?

“I think it’s important first and foremost to have their GP involved. So, the GP can coordinate the approach to treatment. They may not be as confident in prescribing all the different therapies, but I think if they’re on board and can be the main support person, that’s important.”

“I always like to have a good relationship with the oncologist and whoever the woman is primarily seeing. I think exercise therapy is important as well. And one area which is not discussed a lot, as I said, are the genital or urinary symptoms.”

“I think a physiotherapist who has an interest in pelvic health, specifically a Women’s Health Physiotherapist, are very good and a very important part of the team. Especially if we can’t use any vaginal hormone therapies, which are often oestrogen based.”

“Other specialists, or other healthcare professionals including dietitians, exercise physiologists, and exercise therapists, are also important for these women as well.”

Looking ahead, where do you see the biggest opportunities for improving menopausal care for women affected by breast cancer, and are there any emerging areas of research?

“I think the taboo around this topic has been lifted, and it’s no longer just a blanket ‘no’ for use of hormones in women with a history of breast cancer. I think it’s a conversation that’s worth having. And it really depends on the type if disease they’ve got, and whether the oncologist feels comfortable using it.”

“And then it’s a matter of discussing with the patient whether she’s comfortable with using it or not. We talk through the benefits; we talk through some of the risks and then we trial it and see whether they feel well, and we ask them whether they want to use it or not.”

“The main message is that these symptoms can be really debilitating for women. Please listen to them, and please hear what they’re saying. There are lots of treatments and therapies, which are available. Please discuss it with your patients and refer them to someone who can help them.”