21 October 2019

What’s best for treating menopause after cancer?

Cancer Endocrinology Women

There is a broad group of women who experience menopause because of their cancer treatment and prevention therapies – but treatment of menopausal symptoms isn’t always straightforward.

About one in eight women in Australia has had breast cancer and, for many, the chemotherapy induces an early menopause, says Professor Martha Hickey, the director of the Women’s Gynaecology Research Centre at The University of Melbourne.

Endocrine therapy prevents hormone-sensitive cancers from returning by lowering the woman’s oestrogen and progesterone levels, but this commonly leads to menopausal symptoms, says Professor Hickey.

Around 20% of women discontinue endocrine therapy because of the troublesome menopausal symptoms, despite this risking cancer recurrence.

“In addition, women who are pre-menopausal when they’re diagnosed with a haematological cancer, or with some of the colorectal cancers or with most gynae cancer, will end up experiencing menopausal symptoms,” says Professor Hickey.

Speaking on a podcast following her presentation at the RANZCOG annual scientific meeting this month, Professor Hickey says there are specialised Menopausal Symptoms After Cancer clinics in Western Australia and Victoria that work on a multidisciplinary model of care.

“In other places where the GPs don’t have those clinics available, it’s important to first of all say to the woman that there are effective treatments,” she says.

“And secondly, that there are benefits in remaining on her endocrine therapy in terms of breast cancer outcomes.”

Some women with menopausal symptoms after cancer will be able to take HRT, but the therapy might be unsafe for some women with a personal history of hormone-driven cancer.

“Those conversations really need to be had in association with the oncologist,” says Professor Hickey.

There are non-pharmacological treatments and non-hormonal treatments, which can be used to improve menopausal symptoms after breast cancer, says Professor Hickey.

“In terms of nonpharmacological treatments, there’s a CBT which has been specifically developed for that population and that can be accessed through the internet. There’s also evidence that hypnosis is helpful for some.’’

For women who are willing to take a pharmacological therapy, there is strong evidence that escitalopram and citalopram help manage hot flushes and depression, she says.

If women are experiencing particularly bad symptoms at night, gabapentin at an initial dose of 100mg to 300mg often improves sleep and reduces night-time vasomotor symptoms.

“Some of the controversy about gabapentin has been around its use in much higher doses and as a street drug where it does have a significant adverse effects,” Professor Hickey says.

‘’But at these low doses – 100mg to 300mg at night, some women up to 600mg at night  – that is well tolerated and seems to be effective.”

And what of clonidine? “It’s still around and it’s actually the only drug that is licensed for [treating menopausal symptoms],” says Professor Hickey.

“Clonidine is probably not as effective as the other medications I’ve mentioned. It’s sometimes used, it does cause some side-effects and it’s probably not quite as well tolerated as the other medications that I’ve just discussed.”

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