How to Manage Menopause Symptoms after Breast Cancer

Menopause can be a trying time for women with breast cancer, especially since hormone replacement therapy — which relieves menopausal symptoms in some people — is usually not recommended.

“Three large, recent multicenter studies of women with a history of breast cancer showed an increased risk of metastases and second primary cancers when they underwent hormone therapy,” says Memorial Sloan Kettering medical oncologist Shari Goldfarb.    

Women who experience menopause as a side effect of cancer treatment often have more severe symptoms that last longer than for women who enter menopause naturally. That’s due to a rapid decline in estrogen levels over a short period of time, compared with a regular menopause transition that takes place over years. 

Here, Dr. Goldfarb outlines a variety of effective treatment options that can provide relief for women managing menopause symptoms after breast cancer.

Reducing Vaginal Dryness and Vaginal Atrophy

• Nonhormonal moisturizers. “We recommend nonhormonal vaginal moisturizers like Replens and Hyalo GYN to hydrate, increase comfort with sexual activity, and help restore elasticity of the vaginal tissue,” Dr. Goldfarb says. “They can also be used in combination with lubricants for intercourse. Some women — especially those who are taking aromatase inhibitors, which lower estrogen levels — may need to use vaginal moisturizers more often than the three times per week recommended on the package in order to get the most benefit.”

Along with Jeanne Carter, Director of MSK’s Female Sexual Medicine and Women’s Health Program, and medical oncologist Maura Dickler, Dr. Goldfarb is studying different ways of using these moisturizers and other intravaginal therapies to determine the optimal treatment and frequency of application in women with breast cancer. “We are also investigating whether the product helps reduce insertional pain experienced by some patients at the beginning of intercourse,” she says.  

• Physical and dilator therapy. Vaginal dilator therapy involves inserting dilators of varying sizes to gently stretch vaginal tissue and preserve elasticity. Dilators usually come in a set of increasing size and help to reduce anxiety about pain with intercourse. They should be used daily for ten minutes. Pelvic floor exercises, or Kegels, help to stretch and relax pelvic floor muscles, improving their control and strength and decreasing pain with intercourse or gynecologic exams. Both dilator therapy and physical therapy may promote better pelvic blood circulation and arousal response. MSK has a sexual health physiotherapist on staff who provides instruction about how to perform these exercises correctly to help patients learn how to relax their vaginal muscles.
• Low-dose local hormone treatment. MSK recently studied the use of low-dose estradiol tablets called Vagifem® in women with breast cancer. The low-dose estrogen tablets are inserted into the vagina to deliver very small amounts of the hormone directly to the vaginal tissue. This is a novel approach compared with higher-dose hormone treatment options that deliver estrogen to the whole body.
  
  “Every patient in the study reported improved sexual function and sexual satisfaction and felt better overall,” says Dr. Goldfarb. “We found only minimal elevations in estradiol levels in the blood and only a handful of patients with elevations outside a normal postmenopausal range.” A study planned for 2017 will assess the use of moisturizer combined with this type of intravaginal estrogen therapy versus moisturizer alone among menopausal breast cancer patients.

Easing Hot Flashes

• Nonhormonal drug options. Medications containing estrogen can relieve hot flashes for many women, but are not recommended for women with a history of breast cancer. Fortunately, there are alternatives. “Low doses of certain antidepressant medications such as venlafaxine, sertraline, and paroxetine are effective options for reducing the number and severity of hot flashes for some women,” Dr. Goldfarb says.

Addressing Emotional Issues

• Psychotherapy. Menopause related to cancer treatment can also take an emotional toll, producing feelings of anxiety, sadness, and loss, as well as decreased libido. MSK’s Female Sexual Medicine and Women’s Health Program, led by Dr. Carter, is staffed by a team of experts dedicated to helping women adjust to changes before and after cancer treatment.