Breast Cancer Survivorship: A Focus on Menopause Management, Intimacy, & Quality of Life

By on October 1, 2018

As great progress is being made every day in curing or significantly controlling many cancers, survivorship is becoming an increasingly important concept and consideration when treating cancer patients. Breast cancer is the most common female cancer with long-term survival. And, since medical oncologists are not typically well-versed in menopause and sexual issues, it falls to the gynecologist to make sure women understand them.

There are several categories of breast cancer survivors. There are the young, premenopausal women who experience menopausal symptoms caused by chemotherapy. There are post- and peri-menopausal women on hormone therapy who are forced to stop after their diagnosis. And then woman who barely suffer at all from menopausal symptoms whose cancer treatments (such as estrogen blockers or aromatase inhibitors) induce or worsen them. Symptoms such as hot flashes, night sweats, and vaginal dryness can begin quite abruptly in women in the first two categories above and usually occur in addition to multiple other stressors. 

It is only recently that the needs of breast cancer survivors have been regularly spoken about. In 2015, the authors “A manifesto on the preservation of sexual function in women and girls with cancer” highlighted that to this day, “female patients who are treated for cancer receive insufficient counseling, support, or treatment to preserve or regain sexual function after cancer treatment,” despite the fact that even most menopausal cancer patients who have a partner “are sexually active in the year before treatment”. In a survey of women, mean age 55, 7% had sought advice or medical help for problems related to sexuality, while over 40% were interested in receiving care to address sexual issues.

So, why aren’t more survivors complaining of treatment-related side effects? It has typically been found that women will take the mindset that they should “just be happy that they are a survivor” and quietly cope with their intimacy and sexual health issues. On the other hand, conflicts exist among caregivers on appropriate treatments. Estrogen therapies are mistrusted by most breast surgeons and oncologists, but they are often unfamiliar with alternative medications and their side effects. Even some gynecologists are unfamiliar with alternative menopausal therapies.

Alternative treatments for symptoms of menopause, or vasomotor symptoms, are important to distinguish as they come in many forms; from lifestyle interventions to over-the-counter remedies:

  1. Lifestyle Intervention: Simple lifestyle changes can help reduce the onset and reoccurrence of menopausal symptoms.  
  • Layer clothing
  • Keep room cool at night
  • Decrease smoking (smokers have more hot flashes)
  • Lose weight (heavier women have more hot flashes)
  • Avoid known triggers (such as wine)
  1. Complementary/Alternative Medicine
  • Soy and soy supplements containing isoflavones (check with oncologist; some oncologists might counsel patients to avoid soy)
  • Black Cohosh
    • Standardized brand: Remifemin one 20-mg tablet twice daily
  1. Vaginal Dryness OTC Remedies  

• Vaginal moisturizer 

  • Replens: An estrogen-free, long lasting vaginal moisturizer to alleviate dryness.

• Lubricant

  • Replens Silky Smooth: Premium silicone lubricant that moisturizes and lubricates to enhance the ease and comfort of intimacy.  
  1. Prescription Medications

• SSRls/SNRI antidepressants have shown to be effective for hot flashes

  • Venlafaxine, 37.5 g/75 g once daily
  • If not on tamoxifen:
    • Fluoxetine, 20 mg once daily
    • Paroxetine, 10-20 mg once daily
  • Side effects: potential weight gain, and decreased libido 

• Vaginal Estrogens

  • Vagifem tablets: vaginal tablets estradiol hemihydrate
    • 1 tablet vaginally daily for 2 weeks; then 1 twice weekly 10 µg of estradiol

• Estring: 2 mg release 7.5 micrograms/day of estradiol for 90 days

• Cream

  • Estrace (estradiol), 0.1 mg estradiol/gram
  • Premarin (conjugated estrogens), 0.625 mg/gram
  • Topically, insert 1 g vaginally daily as needed

If you or someone you know is a breast cancer survivor and are facing these major hindrances to your quality of life, talk to your gynecologist about the above solutions available to you. Find out what works best for you.  Avoiding these concerns does not make them disappear, so voice them! It is fortunate that women do have options for therapy that are both safe and effective. 

For more information and helpful resources on breast cancer survivorship and menopause, visit www.madameovary.com. 

 

Mary Jane Minkin, MD, is clinical professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the Yale University School of Medicine, and has been in private practice in New Haven (CT) for more than 35 years. Dr. Minkin is board-certified in obstetrics and gynecology, and she practices at Yale-New Haven Hospital. 

By Mary Jane Minkin, MD, Clinical Professor, Obstetrics, Gynecology and Reproductive Sciences at Yale School of Medicine—

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Breast Cancer Survivorship: A Focus on Menopause Management, Intimacy, & Quality of Life