Treatment Induced Menopause
Choose a section for more information:
- The Role of Hormones
- Menopausal Symptoms
- Keeping Healthy
- Complementary/Alternative Therapies
- Further Reading
- Cessation of Menstruation/Fertility
- Hot Flashes/Flushes
- Skin Changes
- Urinary and Vaginal Changes
- Cardiovascular Disease
- Range of Emotions
- Hormone Replacement Therapy
- Who Should be Treated with Hormones?
Cessation of Menstruation/Fertility
A woman who has a natural menopause will experience a gradual diminishing and eventual stop of menstrual flow. Treatment induced menopause may cause menstrual periods to stop abruptly and in women who experience surgical menopause fertility ends immediately. With other types of induced menopause, fertility may end immediately, or gradually over several months. Occasionally, menstrual periods may resume after chemotherapy.
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As your body adjusts to the estrogen loss following your surgery, or treatment, you may experience hot flashes or flushes. Women describe them as a wave of heat that rises from the chest and over the face. The frequency and length of hot flashes will vary between women and may last anywhere from 30 seconds to 5 minutes. Hot flashes may be accompanied by a rapid heartbeat, sensation of pounding in the chest, or palpitations, and sweating. They may or may not be accompanied by skin reddening. Hot flashes that occur during sleep are sometimes called night sweats and involve profuse sweating. This may interfere with rest and sleep, and can result in extreme fatigue. Interrupted sleep can affect a woman’s concentration, memory, and performance.
Natural fibre clothing allows your skin to breathe, and is more absorbent. Many women find that cotton gowns are best at night, while layered clothing can be stripped down to a thin cotton shirt during daytime hot flashes. Participating in a good exercise program can be useful in controlling hot flashes. If you have several hot flashes daily, remember to replenish the fluids lost during perspiration. Sucking on an ice cube to cool off is said to be helpful. Some women keep a pitcher of cold water at the bedside for night time flashes. Many women report that spicy food, coffee, tea, cola, chocolate, alcohol, and smoking may trigger hot flashes. Stress may also affect the frequency and severity of hot flashes. Keeping a record of when your hot flashes occur will help you determine their triggers.
The most common skin changes during menopause are dryness and wrinkling. Women may also experience thinning scalp hair, increased facial hair, or changes in skin pigmentation. Smoking may accelerate these skin changes.
A good moisturizing cream, using a #15 sun screen (or greater), and limiting sun exposure during peak exposure time, may help to decrease the dryness and wrinkling.
Urinary and Vaginal Changes
Without the stimulation of ovarian hormones, the vaginal lining becomes thinner and drier. You may experience vaginal burning or itching. Sexual intercourse may cause pain or discomfort and bleeding. Small tears in the thin vaginal lining can lead to discharge and infection.
Regular sexual activity, once or twice per week, can help to keep the vagina moist. By resuming lovemaking slowly, and gently, regardless of the period of abstinence, vaginal pain during intercourse should decrease. Sexual pleasuring, with or without a partner, is as effective as intercourse in maintaining vaginal moisture. Choose the sexual pace and pleasure you feel comfortable with.
You may choose to use vaginal moisturizers and lubricants to improve vaginal health and decrease irritation. There are two different types of vaginal products available without prescription, to relieve vaginal dryness. Water-soluble lubricants like K-Y Jelly® or Gyne-moistrin® may be used to provide pain relief, whereas remoisturizers like Replens® must be used regularly to provide relief from vaginal dryness.
Estrogen loss contributes to changes in the tissues supporting the bladder and urethra. This may result in urinary stress incontinence, urgency, or frequency. You may notice this if you experience dribbling of urine or urine loss during coughing or sneezing. Kegel exercises can strengthen the muscles of the lower pelvis and can help improve some of these symptoms. If you are unsure how to perform Kegel exercises, ask your health care provider.
If lubricants, moisturizers, or sexual activity do not reduce vaginal irritation, replacing estrogen locally is an effective way to restore vaginal health. Estrogen vaginal creams may be absorbed into the bloodstream and may not be appropriate for some women with estrogen sensitive cancers. Other options include a vaginal tablet, Vagifem® or vaginal ring, Estring® that deliver estrogen to the vaginal area with minimal circulation throughout the body. You may want to discuss these options with your health care provider.
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Insomnia is a complex condition, usually with many contributing factors.
The initial difficulty with sleeping may arise from a simple event, such as headache, hot flashes, medical illness, or stress. Sometimes the anxiety over loss of sleep can lead to a vicious cycle of sleep loss and further anxiety. Although several factors may contribute to insomnia (difficulty falling asleep or difficulty staying asleep) continued interrupted sleep can progress to a chronic state.
Several medications are known to contribute to broken sleep, or making it difficult to fall asleep. Medications such as bronchodilators, steroids, some blood pressure medications, or antidepressants may cause insomnia. Stimulants such as caffeine or nicotine may also contribute to a broken sleep. Alcohol can cause rebound insomnia. It is important to speak to your physician/pharmacist regarding side effects from prescribed medications.
Although medications are available by prescription to assist with falling asleep, there are several non-pharmacologic treatments that will reduce the time needed to fall asleep, and also decrease early wakening.
1) Maintain a regular sleep schedule, and do not nap, especially close to bedtime.
2) Avoid sleeping in after a bad night’s sleep.
3) Avoid watching the clock, and do not lie awake in bed for long periods.
4) Restrict excessive liquid intake, or heavy evening meals.
5) Exercise regularly, but not within 3-4 hours of bedtime.
6) Minimize or avoid caffeine, alcohol, tobacco, and stimulant intake.
Go to bed only when sleepy, and maintain a regular schedule. Avoid naps, and only use the bedroom for sexual activity or sleep. When unable to sleep within 20 minutes, get out of bed and engage in a relaxing activity until drowsy, then return to bed.
Try keeping a sleep log, and determine your total average sleep time for a baseline period. Start staying in bed only as long as the total baseline sleep time, i.e., if your average total sleep time is 6 hours, do not go to bed prior to midnight. If you can maintain the 6 hours sleep for most nights of the week, then increase the time in bed by 15 minutes. Adjust every 5-7days.
Try progressive muscle relaxation. Alternate tensing and relaxing muscle groups will help you relax, and can help block anxiety –associated insomnia. Find a comfortable position in bed, then starting with your feet, tense and relax your muscles, then calves, and so on, working your way up to facial muscles.
Adapted from Primary Care Approach to Insomnia Management (2005) Winkelman, J.
Low bone mass is called osteoporosis. A low bone mass means the bones become weak, brittle, and prone to breakage. Wrist, spine, and hip fractures are most common. You reach your peak bone mass between 20 and 30 years of age. After this time period, bone mass decreases. The most rapid period of bone loss occurs when estrogen levels in your body decline; i.e. around menopause. If you have treatment induced menopause well before the age of natural menopause, you are at risk for developing osteoporosis earlier in life.
- family history of osteoporosis
- thinness (body fat contributes to the production of estrogen)
- Ethnic background (fair skinned women of Northern or Western European backgrounds, Oriental, and Caucasian women have a higher risk than African-American women.)
- poor dietary intake of vitamin D or calcium rich foods
- cigarette smoking
- excessive caffeine or alcohol consumption
- sedentary lifestyle
- overactive thyroid or parathyroid gland
- use of certain medications (e.g., corticosteroids, high dose thyroid medication, anti-convulsants, or aromatase inhibitors)
- daily weight-bearing exercises
- stop smoking
- limit alcohol to no more than 2 drinks per day
- decrease caffeine consumption to three servings or less per day (includes coffee, tea, or cola beverages)
- include adequate calcium and vitamin D in your diet
To reduce your fracture risk, women who experience treatment induced menopause before the age of 40 should consider estrogen replacement therapy. Non-hormonal prescription drugs are also available to prevent osteoporosis in those women unable to take estrogen. Special bone density X-rays are available to help identify those women at greatest risk.
Menopausal women on estrogen replacement therapy should consume 1200mg of calcium in their daily diet. Those women not taking estrogen replacement therapy should consume 1500 mg of calcium daily. Vitamin D is also important in maintaining bone health. The recommended daily allowance is at least 400IU.
Foods that contain about 300 mg. of calcium include:
1 cup whole, 2%, or skin milk (250ml.)
2 thin processed cheese slices
1.5 oz. hard cheese (50g.)
small container yogourt (175g.)
Foods that contain about 200-mg. calcium include:
1 cup baked beans
3 oz. canned salmon, with bones (90g.)
Women who do not like dairy products, or are unable to eat them due to an intolerance, may choose to take calcium supplements instead. There are many different calcium supplements available, containing different forms of calcium. Check the label for elemental calcium in the supplement you buy. Ask your pharmacist for assistance in finding which calcium supplement would be best for you, and when it should be taken.
The number one killer in older women is cardiovascular disease. Your risk of a heart attack or stroke significantly increases after menopause. Women who experience early menopause may be at an increased risk of cardiovascular disease as estrogen has been shown to have a positive effect on blood cholesterol levels.
Cholesterol is a substance that is associated with cardiovascular disease. It circulates in the bloodstream attached to molecules called lipoproteins. There are several types of lipoproteins. Low-density lipoproteins or LDLs, in combination with cholesterol, contribute to the narrowing and blocking of arteries. This condition can lead to high blood pressure, heart attack, or stroke. High-density lipoproteins, or HDLs, act like a cleaner to remove cholesterol deposits from arteries. Estrogen acts to raise the level of HDL (the good cholesterol) and decrease the level of LDL (bad cholesterol in the bloodstream.
- family history of early deaths from heart disease or stroke
- high blood pressure
- high blood cholesterol
- sedentary lifestyle (lack of exercise)
- Stop smoking. Smoking is a major risk factor for developing cardiovascular disease.
- Maintain normal cholesterol levels. Reducing the total amount of fat in your diet and avoiding foods high in cholesterol are good starts toward controlling cholesterol levels. Dietary fat can be visible, such as the skin on chicken, but it may also be hidden in processing and/or preparation. Consult your health care provider for advice if you have a family history of high cholesterol.
- Increase activity. You don’t need to become an Olympic athlete, but regular exercise helps to reduce total blood cholesterol and increase the HDL.
- Achieve and maintain a normal body weight through healthy eating and regular physical exercise.
- Reduce your stress. Learn and practice stress management. Stress raises the level of cholesterol in the blood. Too much stress can also contribute to heart attacks.
Range of Emotions
Perhaps the most significant influence in your adapting to treatment induced menopause is knowing who you are. What does it mean to you to be female?
Removal of your reproductive organs may cause a whole range of emotions. While the surgical procedure may signal a welcome relief to years of pain or heavy bleeding, it also signals the end of childbearing. You may experience depression and anxiety regarding these issues, the surgery or treatments, or the reaction of your partner. While most women are relieved to have no more menstrual periods, you may also experience a sense of loss that a natural process has ended. If you have never had children, treatment induced menopause may represent a sense of finality, and grief.
Some women have expressed loss of sexual desire, while others speak of feeling unattractive, or losing their femininity and self worth. A diagnosis of cancer may compound these feelings. It is important for women to know that is okay to experience these emotions, that it is normal.
Hormone Replacement Therapy
The management of treatment induced menopause consists of replacing your body with the hormones it naturally produced until the average age of menopause (age 51). Replacement therapy may refer to estrogen, progesterone, or androgen, alone or in combination. Estrogen is used to treat the signs and symptoms of menopause, and to prevent osteoporosis. Estrogens, however may cause the uterine lining to grow. Progesterone is added to estrogen therapy in women who still have a uterus to prevent the uterine lining from becoming too thick. Progesterone can also be used alone to treat hot flashes in women who cannot take estrogen. Testosterone is used primarily in women who have had their ovaries removed. This hormone may improve sexual interest and can contribute to an increased sense of well being. Very low doses may be used to increase libido, while higher doses may cause undesirable effects.
Your doctor may prescribe estrogen, progesterone, or testosterone or any combination of these medications, depending on your individual risks and benefits. If you are on therapy and it does not seem to be working for you, or you are having side effects or problems taking the medication, don’t give up. There are many different estrogens and progesterones available. They have different routes of administration (by mouth, through the skin or vagina, or by injection), and dosages. It is important to discuss your hormone replacement therapy options with your health care provider to ensure that your choice meets your needs.
When you have had your ovaries surgically removed, therapy is usually started within two days. Hot flashes may occur within hours after surgery, or treatment, but for many women, menopause symptoms may not occur until months later. Some women may have to wait until pathology reports are known before therapy is started.
Who Should be Treated with Hormones?
Despite its merits, hormone replacement therapy also has some drawbacks and is sometimes controversial. Women with undiagnosed vaginal bleeding, a hormone dependant cancer, known cardiac or liver disease, and those women with a personal or family history of blood clots may not be able to take estrogen. Estrogen should be used cautiously in women who have endometriosis, chronic migraine headaches, or gall bladder disease.
For all women, the severity of menopausal symptoms, the risk for developing cardiovascular disease or osteoporosis, must be weighed against the risks of hormone therapy. These medications are not for every woman. You must make an informed decision about what is right for you. Become a partner with your health care professionals. Review your choices and options regularly. Several non-hormonal options exist and may be considered alone, or in combination with hormone replacement therapy.