Telling women that cancer or medical treatment may cause early menopause

Once people have education about the premature menopause they’re often more comfortable themselves and it’s not just me, and “Oh, I feel funny, I’m not less loveable.” All that sort of stuff.

So it depends on the person very much how they cope with it. If it’s cancer related there’s a normally a large group of counsellors available if they’ve had a premature menopause or they’re in one of those genetic groups that’s got a predisposition to cancer and they decide to have their ovaries removed. So that’s a very different kettle of fish and we would be looking at combined treatment with a number of practitioners in that sort of situation.

I see women who’ve had menopause as a result of a number of different issues. Usually it’s because they’ve actually experienced terrible endometriosis or terrible premenstrual depression and have decided that they just want a surgical solution. And, unfortunately the surgical solution is quite a sudden removal of ovaries and uterus, but with often no replacement of hormones. And, in that context, I’ve seen women with sudden menopause have quite significant mental state issues particularly florid depression.

Some of the things that are a bit surprising is when a woman does have a surgical menopause, for example, and there isn’t replacement of the gonadal hormones that then, of course, the depression hits – to our thinking, this is not a surprise. But, out there, the knowledge isn’t commonplace. And so, again, the reaching for a standard antidepressant treatment, an SSRI or SNRI, antidepressant medication is a first line and it doesn’t actually have the same impact that using hormone replacement treatments or hormone adjuncts can actually have.

Sometimes when they are given the pathology results, they don’t really quite understand what the pathology results mean. And they don’t always understand what the doctors are saying about the treatments that they’ll need.

What you were saying about being told that “You are just taking a tablet for the endocrine therapy,” and that sometimes not conveying the full impact of what that will do. Do you think there’s things the doctors could be saying to make that clearer with women?

The doctors will talk to them in more detail once they prescribe the tablet, but they don’t go into detail earlier on. I think that’s because they feel that the patient has got enough to cope with, with the surgery. As with anything, I think, if you know all the side effects that might happen it can be really scary and it’s getting your head round the fact that you are not necessarily going to get all those side effects but that you may get some.

One step at a time and you can get people through. If you throw too much information at them too soon then you just confuse them.

I personally, and I think a lot of people do, is use a multidisciplinary approach rather than just have one person, myself, have to do the whole lot and the reason for that is that you can’t be an expert in every area so from the point of view of the initial presentation when they come to see us, there are issues around diet that we deal with to try to minimise the concept that they could put on a significant amount of weight when they have treatment, when they go into early menopause.

The second issue is that we use, I use an exercise physiologist who allows them to stay as mobile as possible. It’s been show that the more exercise you do, you can lessen some of the symptoms of menopause and certainly there are some studies to show that if you do moderate exercise regularly you reduce hot flushing and some of those other things and you certainly reduce your cardiovascular risk and some of the other risks and obviously diabetic risk and related to weight gain and all of those things.

So we’d normally use those. In most women we would get them to see one of our psycho- oncologists and it may just be a single discussion around the concept of how they deal with some of the stress related to what techniques they do or they may be total basket cases and need to see someone every week for six months type thing so once again there’s a wide range of things that we do.

We have breast care nurses that help educate the women and so they will talk to them and give them resources around what potentially they can do to improve things. There are a hell of a lot of quasi treatments for premature menopause and a lot of them cost a lot of money and a lot of naturopaths sell them and things like that, I don’t really adhere to any of those being effective.

A lot of women would go and use some sort of natural therapies of one type or another to potentially work. There’s the old saying that there’s only one type of medicine and it’s not alternative medicine it’s actually just medicine. So we deal with that a lot, dealing with a lot of the questions that they ask about a lot of that area.

Care nurses are really good in dealing with those things and then we have the surgeons and the radiation oncologists and the other people so there’s significant network of people in the longer term normally look at making sure that their cardiovascular health is managed and also their bone health. And if they have evidence of bone loss we’d use an endocrinologist to look after that or any other issues related to endocrine therapy.

I would sit down and speak about – and I’m speaking from breast cancer perspective – the diagnosis and what that might mean, the possible treatment pathways that they may be embarking upon and what that might mean for them so I would initially start talking about because it is about providing as much information as you can to prepare that individual for the future. I would start talking with them about the possibility that they may certainly be required to, or offered treatments that may affect their menopausal status and what that might mean and the side effects that they might experience or may not too.

Sometimes when women start on for example endocrine therapy, we can sit down very early on in the piece and speak about ways in which they can manage the potential side effects and so forth and also I’d certainly encourage their partners to come along as well because one of the most important things is a aspects of a woman that is affected obviously if they enter early menopause is the sexuality side of things.

I think that’s really important and I think it’s important to speak to women and their partner about that because it’s something they essentially have to work out together. And given the effects of early menopause it’s quite often building that intimacy in a relationship is something that really needs to be started from the very beginning if you like and built up again. And that’s something that doesn’t happen overnight as well and it takes a lot of work to get things back to normal.

Or a new normal I should say and that’s another thing to just reiterating to patients that this whole experience be it, regardless of how it affects you medically, emotionally and spiritually it can affect you and change you for the rest of your life, quite often in a good way and learning to deal with that because quite often individuals will learn new things and new coping mechanisms that they never knew existed, have a new outlook on life, new priorities or a new perspective.

So, and helping them to digest that and reflect on their experience and recognise how that will essentially change them.

We will negotiate with their oncologist for enough time. The thing is, you can do stuff even if you haven’t got time. If you’ve got a big lesion in your chest, and you’ve got Hodgkin’s Disease, and your doctor wants to start your chemotherapy in two days, then we can take ovarian tissue. That only takes one day. We can take ovarian tissue, and then we can also start you on some medicines to try and protect your ovaries during the chemo.

There’s lots of things that we can do – but, really, the oncologists are so well-trained now, that in all honesty – like – they’ll give you time, if they can. In the old days, they’d be “Oh, we’ve just got to save the life,” but now, actually, it’s much better than that. Now, the oncologist will say, “Actually, yeah, you can have this two to three weeks,” or they’ll say “Look, this patient’s got terrible respiratory compromise, I’m sorry.” So, we have very good faith that the oncologists are all geared up now for optimising fertility preservation, they really are. If we think they’re not, we’ll negotiate with them on the patient’s behalf, but we’re not going to do anything silly.

I find that a surprisingly easy conversation. You know, these patients are great patients, and they really understand, and they know we’re going all out, and they know that we will help – we will advocate on their behalf, but that also, we won’t let them go to be at risk by what we’re doing.

ZOLADEX [goserelin] will cause menopause, and that’s desired in some women for example with endometriosis, as an extreme sort of measure. So I probably wouldn’t call it menopause, because there’s a finality about menopause, it’s the last period, and the cessation forever really of ovarian function.

So I’d probably call that a temporary inhibition of ovarian function, or a blockade of ovarian function, which is again medically created. But if that treatment were had and then they didn’t regain ovarian function after it, then by definition it would be menopause yes.

It will depend on whether they’re 40 or under, or 45 or under, and once they’re 45 plus, it’s normal to have menopause. And again some women don’t understand that, and have extreme sorrow that menopause was meant to be at 50 or 51, and some of my ladies have said oh, I’ve been robbed of five years of my life, that’s how they feel it. And again there’s – it depends on the individual, their psychology, and their experiences otherwise – but some have an extreme grief about – and understandably, early or premature menopause.

But some even around 45 think that that is early, and unexpected, and they didn’t know about it. They weren’t expecting it, as none of these women were, unless they were medically treated and counselled, well this is going to lead to this.

I think they’ve got competing, quite different agendas. You know, the BRCA carriers are almost sort of euphoric, they’re cured, so they’re much more tolerant probably of their menopausal symptoms and they’re quite well, they’ve had quite a long lag time. Many of them have been discussing having their ovaries out for the preceding decade. Whereas the people who have got breast cancer, it’s been thrust upon them. They get the breast cancer, they have surgery, then chemotherapy and then you know, are rendered menopausal. So, they don’t have that preceding education period to anticipate what might happen and so perhaps less well discussed.