Many treatments for breast cancer can suppress the production of oestrogen and interfere with the function of the ovaries. Oestrogen are one type of female hormone and a lack of them causes symptoms similar to those of the menopause. It is not possible to predict how each individual will be affected and some women suffer more than others. This may be permanent or temporary. In women with breast cancer this also may be recommended as a therapeutic maneuver either using a drug called Zoladex or removing the ovaries surgically or now less often irradiating them. The risk and benefits of this should have been discussed before the start of therapy. The three main causes of damage to a woman's ovarian function are Chemotherapy, radiotherapy and hormone therapy:

[1] Chemotherapy may make your menstrual cycle irregular and your period may stop. In some women this may be permanent. If your periods stop you could still become pregnant and you should take contraceptive precautions during chemotherapy. The extent of damage to the ovaries depends on the type of Chemotherapy drug

What is menopause?
The menopause describes events taking place in a woman which brings about the end of her childbearing days. This is because a woman:

• no longer produces eggs
• no longer produces sex hormones, importantly oestrogen
• stops menstruating

Will I experience any symptoms?
The symptoms experienced by women varies. Some symptoms to be expected are: absence of periods, hot flushes, night sweats, tiredness, disturbed sleep, vaginal discomfort, urinary problems and mood swings. However, the better your health at the time of the menopause, the fewer symptoms you are likely to suffer. However, if your symptoms are sever, there are treatments available from your doctor, such as HRT.

How will I change?
The process of menopause tends to be gradual and as will be any of the physical changes which take place:

• your skin and breasts may become less supple and less firm
• your bones tend to become more brittle (osteoporosis)
• your vagina will shrink slightly and the lining will becomes drier, thinner, less resilient and more prone to infection. You may find that a lubricant such as KY jelly helps. Any vagina infection should be dealt with by your doctor
• your urinary passages will also become more prone to infection
• your periods may change to become lighter or heavier, shorter or longer and may become more erratic
• spotting may occur after intercourse
• you may experience hot flushes and night sweats (sever hot flushes). During a hot flush your heart will beat faster and your skin will feel warmer and sweaty. Hot flushes and night sweats will cease once your hormones have settled down, but in the meantime try to avoid alcohol and coffee as these aggravate the situation.

When is it likely to occur?
The menopause usually happens between the ages of 45 and 55, and happens gradually. However, if the menopause is brought on through chemotherapy and radiotherapy, the change will be more sudden.

Osteoporosis Reduced oestrogen means your bones may become brittle, making it easier to break your bones. This can be reduced through regular exercise and a increased calcium intake.

Weight Gain This can be a distressing result of lowered oestrogen levels. A well balanced, low fat diet can help to reduce weight and the nursing or medical staff can advise you. Try not to fell guilty about your weight gain. You may gave had a lot to cope with and your general fitness is the most important thing.
Although this is not as a direct result of the menopause, it often coincides with it. It is important to take regular exercise to prevent heart attacks and high blood pressure. You should consult your doctor before undertaking strenuous exercise or radical dietary changes.

Hot flushes A lack of oestrogen can cause irregularities in the body's cooling system. Hot flushes: a sudden unpleasant sensation of burning heat spreading across the face, neck and chest, can occur. Some women experience one or two flushes a week, whilst others can have ten or more a day but generally, the number of hot flushes will decrease over time.

Night sweats These sudden sweats are often linked to hot flushes and tend to happen at night, although they can also happen during the day. Women sometimes find that their sleep patterns are disturbed because of these sweats.

Vaginal changes 

Altered periods - If you were having periods before your treatment you may experience a change in your menstrual cycle. Periods may be heavier, irregular, scanty or they may stop altogether. If you experience new vaginal bleeding after a lapse of several months you should mention this to your oncology doctor or your GP.

Vaginal dryness - Can be caused by a reduction in oestrogen. Vaginal lubricants such as 'Senselle' and 'Replens' and K.Y. jelly are available from good chemists and may help. There are other vaginal lubrications available and discussion with your oncology team might be useful.

Reduction in sex drive In some cases testosterone (the hormone responsible for controlling the sex drive) can be effective in restoring libido. Testosterone is given every six months as an implant under the skin of your buttock or abdomen. Reduction in sex drive, may result from low oestrogen levels, because you are stressed, or because of any of the symptoms described in this leaflet. If this causes problems in your relationship it may help to talk about it with the nurse or your oncology doctor. Using lubricants for vaginal dryness or by altering lovemaking positions can help. Some useful over the counter products are available.  

Irritability and tiredness You  may notice that you are less tolerant, more anxious or that you are having mood swings. It will help to have a regular sleep pattern and to pace yourself through the day. The odd treat for yourself, time out and learning how to relax will help you cope better and boost your morale. There are ways to aid relaxation, such as relaxation tapes, and the nursing staff can advise you on how to acquire these. You may find that resting during the day (if you are able) will make up for some of the sleep lost at night.
Talking about your feelings can be helpful. Many patients find it worthwhile to attend a support group to spend time with other women who are going through a similar experience.
It is important to remember that it is entirely natural to experience strong feelings as a result of a diagnosis of breast cancer, and in reaction to some of the less acceptable treatment side effects.
If you find that you are unable to cope with mood swings or if you are feeling "down" for  prolonged periods, try talking to your GP or nurse. S/he may be able to refer to a professional counselor or therapist who can help.

Headaches These can simply be due to anxiety or lack of sleep but please report frequent headaches to  the medical staff. Taking your usual pain killers can help.

Other symptoms Contact your doctor if you experience any of the following symptoms

1. Any lumps you find in your breasts.
2. Any discharge or bleeding from a nipple, or any tendency for it to turn inwards.
3. Any unexpected bleeding from the vagina, even if it is slight.
4. Any vaginal discharge.
5. Any persistent pain in your abdomen.

Hot flushes

1. wear cotton clothing rather than polyester or other man made fibres, as cotton absorbs moisture and still provides warmth after a flush is over

2. nighties made from a special microfibre cotton material that allows your skin to breathe are available from:-
   Dream Care Night Wear
   Pond Park Avenue
   Lisburn, Co. Antrim,Northern Ireland, BT 2833L

3. 'Andy Cooler' scarves wrapped around the neck or head can help to keep you cool. If you are interested a cheque for £3.00 payable to: 'The Nottingham Breast Cancer Support Group' can be sent to:
   'The Nottingham Breast Cancer Support Group'
   c/o The Breast Care Nurses
   The City Hospital Trust
   Hucknall Road, Nottingham NG5 1PB

4. try wearing layers of clothing that can be taken off or put on as your body temperature changes

5. use several layers of bedclothes (natural fabrics are better) which you can remove as required

6. try using sprays or moist wipes to help lower your skin temperature (you could add pleasant smelling oils to the spray, such as peppermint which has cooling properties or lavender which has a relaxing effect.

7. use an electric fan placed on a desk or table to help lower your skin temperature

8. if you are not sleeping well because of flushes, try to find time to have a rest during the day

9. try to avoid warm, stuffy rooms as they can make flushes worse.

10. take plenty of cool baths and showers

Diet

Phyto-oestrogens are chemicals which are found in plant foods (phyto means 'plant'). They are similar in structure to the female sex hormone oestrogen. There are different types of Phyto-oestrogens. Some are found in soya bean products. Others are found in the fibre of whole grains, fruit, vegetables and flax seed. Milk may also contain Phyto-oestrogens, but this depends on what the cows have been eating! Some early research has suggested that women whose diets are high in Phyto-oestrogens have a lower risk of breast cancer and do not suffer hot flushes. In some studies eating Phyto-oestrogens (soya flour and linseed supplements) regularly over several weeks reduced oestrogen levels. The HRT cake has been designed to carry ingredients with high phyto-oestrogen levels and is therefore good for hot flushes. Some over the counter products are useful sources of phyto-oestrogens.  

Alcohol Some patient report that menopausal symptoms can be made worse by alcohol, particularly wine (particularly Chianti) and cherry brandy.

Smoking Ladies who smoke tend to suffer greater from hot flushes.

Fluids Hot drinks can bring on a hot flush. Drink plenty of fluids, particularly if you are sweating a lot

Spicy foods Avoid hot, spicy foods, especially at night.

Hormone replacement therapy ( HRT)

HRT replaces hormones that you body is unable to make itself and will help stop the symptoms of menopause, especially hot flushes, night sweats and possibly emotion swings. The risks involved in taking HRT are minimal and is used by millions of women around the world. HRT can be administered in several ways:

• As a tablet taken every day
• As a cream applied to the skin or vagina
• As a tiny implant under the skin of the abdomen
• As a patch applied to the skin, twice weekly.

If you have an intact womb, oestrogen must be given with a progesterone several days each month to simulate the normal monthly cycle. This causes the return of monthly ‘periods’ although these are usually much lighter than they were but this does not mean that you are fertile once again, but you should remember that the low doses used in HRT are not enough to guarantee contraceptive cover. You must take other precautions until you are quite sure you will not have a final, late fertile cycle.

HRT and cancer
There is no evidence of an increased risk breast cancer from HRT but should not be used by those who have had breast or uterine cancer.

HRT and blood pressure?
Blood pressure is not usually affected by HRT

Other side effects
These can include:

• headaches and a feeling of sickness during the first weeks of treatment
• tender breasts
• leg cramps

These symptoms usually disappear after the first few weeks of treatment. Consult your doctor if you are concerned about them.

In general, regular exercise and a healthy life style will make menopausal symptoms easier to deal with. The symptoms should improve over time and you will learn to manage them.

If any of the above symptoms make you feel low, anxious or depressed please remember that your oncology specialist and the nursing staff are there to help and there are often things we can do to make your symptoms easier to live with.

For how long will I need HRT?
This mainly depends on what symptoms are being treated. Women who are likely to suffer severe bone loss may benefit from taking HRT for many years. Other symptoms may only need to be treated for up to two years.

Support Groups:
If you write to them please enclose a stamped addressed envelope for their reply. 

Further general information Your doctors and specialist nurses are in an ideal position to give you relevant information on your disease and treatment as they know your individual circumstances. Cancerbackup has a help line (0808 800 1234) and a prize winning video available in English, Italian, Urdu, Bengali, Gujarati & Hindi explaining Radiotherapy & Chemotherapy. Cancernet.co.uk has over 500 pages describing cancer, its management, practical tips and tool which patients, their carers and their doctors have found helpful during the cancer journey.