News this month
Premature menopause side effect of breast cancer treatment

Breast cancer strikes nearly 200,000 women each year in the United States. About a quarter of these women will be relatively young and will have not yet gone through menopause. Premenopausal women with breast cancer commonly undergo surgery to remove the cancer, followed by chemotherapy and/or hormone therapy as a part of their cancer treatment.

These additional therapies, called adjuvant therapy, have been lauded because they increase survival. Their effectiveness, however, has a price in the form of a variety of side effects they cause. Some effects, such as fatigue and hair loss, are temporary. More permanent effects include damage to the ovaries, which can lead to what is called “therapy-induced premature menopause.” Not much has been written about therapy-induced menopause—until now.

How women cope with the diagnosis of breast cancer followed by the physical and emotional aspects of early menopause was the question posed by Yale researcher Tish Knobf, RN, PhD. In a recent study, she examined the experience of 27 pre-menopausal women with early breast cancer who also had adjuvant chemotherapy. The study findings have been reported in Cancer Nursing (June 2001) and Nursing Research (January/February 2002).

Chemotherapy-induced menopause occurs in 10 to 50 percent of women younger than 40 and in 50 to 94 percent of women over 40. This is an added burden to the difficulties of living with cancer.

The majority of women in the Yale study were married, well educated and employed. The mean age was 41. Thirty-seven percent received tamoxifen as adjuvant therapy following chemotherapy. The hormone has shown great benefit in preventing breast cancer recurrence.

Data was gathered through indepth personal interviews and discussions with oncology care providers. Amenorrhea, or lack of menstruation, was reported in 25 of the 27 women, two women reported irregular menses and one had a return of normal menses.

A review of past studies showed that women commonly experienced the following symptoms:

• 44 - 68 percent had trouble sleeping
• 55 - 65 percent experienced hot flashes
• 36 - 48 percent suffered from vaginal dryness
• 62 - 77 percent had joint pain
• 53 - 54 percent felt irritable or short-tempered

Women moved through this difficult time by, as Knobf named the process, "carrying on." She has identified four unique stages of "carrying on," which include:

• Being focused: During the stage, which occurs after diagnosis and while on adjuvant therapy, women discounted their menopausal symptoms and focused instead on getting through chemotherapy treatment and any immediate side effects.
• Facing uncertainty: Women in the study may not have been given adequate information about menopause or may have been reluctant to discuss menopausal symptoms and, as a result, were not sure how to interpret the symptoms they were experiencing. Women who received the least information experienced the greatest uncertainty.
• Becoming menopausal: In this phase, which took place some time after treatment ended, women became aware that menopause was more than just the end of their menstrual cycles. As symptoms such as hair loss or fatigue from treatment were resolving, they were faced with the reality of persistent menopausal symptoms.
• Balancing: This stage occurred generally 12 or more months after treatment ended. Women adapted healthy lifestyle behaviors and were generally cautious about anything they put into their bodies, whether it was food, medications or herbs.

Key factors that helped the women successfully make this transition included:

• Communication with health care providers
• Informational preparation about menopause
• Incidence, severity and distress of menopausal symptoms

It's easy to get caught up in the fight against breast cancer and not notice what else is going on in a woman's life. Traditionally, that's what happened with breast cancer patients who were suddenly thrown into menopause following chemotherapy or other treatments.

If menopause was noticed at all, it was given little attention. But hopefully that will change as doctors, nurses and the patients themselves learn more. By doing so, we can help women learn what to expect and enable them to better cope with the physical and emotional changes of menopause and breast cancer.

My study looked at how women coped with a diagnosis of breast cancer and treatment, combined with the additional challenge of premature menopause. Menopause has its own laundry list of symptoms that vary widely from person to person. These include hot flashes, irritability, trouble sleeping, vaginal dryness and emotional issues. The goal was to see which symptoms women experienced and what strategies were most effective in helping them cope.

Why menopause occurs
Chemotherapy can damage both ovaries, making them unable to produce enough estrogen. The result is menopause. Following chemotherapy, a woman may experience months or even years of irregular ovarian function. Depending on a woman's age and the type of chemotherapy used, normal ovarian function may return.

Menopause is more likely to be permanent if certain chemotherapy drugs are used, if chemotherapy drugs are used in combination or when the woman is closer in age to natural menopause.

Menopause is neglected
During chemotherapy, women traditionally discount menopausal symptoms. What doesn't help is that many oncologists are not very knowledgeable about managing menopausal symptoms and do not fully inform the woman what to expect weeks and months after treatment ends.

During treatment, a patient is busy going from treatment to treatment and she has little chance to reflect on what she's lived through. When therapy is over, a woman may allow herself to confront her fears for the first time and wonder about the future.

Many physical symptoms experienced during treatment persist after therapy with a gradual improvement over time. Menopause symptoms, however, may continue for a couple of years. Some, like hot flashes, may decrease after one to two years and gradually improve, while others, such as vaginal dryness, may not improve. It can be challenging for women who are distressed by menopausal symptoms to find the best methods of relief.

“Carrying On”
Vulnerability was identified as a basic social problem for these women. The four stages of "Carrying On" that we identified showed how women progressed from minimizing their initial menopause symptoms to developing an awareness that allowed them to balance menopause and cancer. The keys to making this transition successfully were communication with health care providers and information about what to expect.

Education needed
Health care providers need to educate premenopausal women about to undergo chemotherapy as to what they should expect during menopause—the hot flashes, the emotional changes. If these symptoms occur, patients should be encouraged to talk to their nurse or doctor about all their symptoms and decide which are bothering them the most. Then, acceptable interventions can be identified. For example, nonestrogen drugs are available to help control hot flashes and self care measures, such as avoiding stimulants like coffee and red wine, may be useful.

Women need information and support on how to live a healthy lifestyle, including the importance of diet and exercise. By doing so, we help the cancer survivor regain some control over her health…and that is so very important.

Tish Knobf, PhD, is an oncology clinical nurse specialist working in outpatient oncology at Yale-New Haven Hospital and American Cancer Society Professor of Oncology Nursing at Yale University School of Nursing.