Episode 60 Shownotes - Mired in Menopause?!?
You are listening to Best Life After Cancer, episode number 60! Today we are talking Mired in Menopause, which is one of the less talked about side effects of treatment of cancer, and becoming more important as we have more young cancer survivors!
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Hey, friends! When this episode airs, I will be doing a 5 day hiking trip in the White Mountains in New Hampshire. We are doing hut to hut hiking along a part of the Appalachian trail. The huts are spaced from 5 to 10 miles apart. If you do the whole chain, it is 45.6 miles. We are only doing a part of this, but even so, it is quite strenuous, with a lot of elevation. The good news is that because there are huts to stay in, you don’t have to carry a tent. They also have family style meals, so you don’t have to carry food. The lighter packs will be helpful. I am hiking this with my husband and 4 teen boys, who basically run up mountains. I am a slow hiker, and I am pretty sure I am about to get my butt handed to me! If this is my last ever podcast, well, you know I was giving it my all! I’m just kidding – the nice thing is that each hut, you can bail, hike down to the road, take a shuttle in to town and stay. But my goal is to make it through the whole thing with my men, even if it takes me twice as long as it does them. At the end, we have 2 nights in a cute nearby town with hot showers, comfy beds and restaurants for me to lick my wounds at the end. I got smart this vacation. This podcast and next week’s are already finished and lined up to go so that I am not having to come home and crank one out on Sunday like I did when we got back from Maine a few weeks ago – I know, really not great planning, right?? So, two weeks from now, I will update you on how it went. I think this is one of the most challenging things I have attempted in the last 10 years, but I am going to do my best to get it done!
- You are here to hear about what suggestions I have to make menopause less painful. It is interesting. I think after cancer treatment, this causes so much discomfort to so many people, but it really gets glossed over at appointments. Although I think many people know this, let me start by explaining what menopause is. Menopause is when the ovaries completely stop producing reproductive hormones and there is no menstrual cycle for 12 consecutive months. So, a woman is not in menopause until 12 months after their last period. The years leading up to this point, when women have changes in their cycles, hot flashes and other symptoms is called the menopausal transition, or perimenopause. The menopausal transition most often begins between 45 and 55 years old. It usually is about 7 years, but can last as long as 14 years. During the menopausal transition, the production of estrogen and progesterone by the ovaries varies greatly. During this time, there can be many changes in our bodies. Really, what women struggle with is not menopause, it is the menopausal transition when our hormones fluctuate up and down.
Menopause can be triggered suddenly by removal of the ovaries, either as part of a total hysterectomy, or removing the ovaries alone, a common surgery in women who have a BRACA mutation that increases the risk of ovarian cancer. Chemotherapy can also cause the ovaries to cease functioning and suddenly thrust a person into menopause. This is a sudden and abrupt transformation into menopause and can often come with heightened symptoms.
If you have symptoms that you think might be related to menopause, doctors can do bloodwork to see where you are in the process. They will often check FSH or follicle-stimulating hormone and E2, or estradiol levels, and can tell you where you are in the process.
During the menopausal transition, or perimenopause, women may have many new symptoms. These can include irregular or spotty periods, hot flashes, weight gain, depression or heightened emotions, vaginal dryness, discomfort with sex, and more. We will talk about all of these during the remainder of this podcast. One of the things many women don’t know about the perimenopausal time is that pregnancy is still possible. So if you don’t want a change of life baby, it is recommended that you continue with some form of birth control until the periods have been gone for a full, consecutive 12 months. After menopause, women become more vulnerable to osteoporosis and heart disease.
Where to start? For many people, hot flashes are the most challenging part of the perimenopausal period. These medically are known as vasomotor symptoms. They usually last for 3-5 years, and are worst in the first year after someone’s period stops. They can be anything from mild and feeling “warm” to burning up, where you are dripping sweat and surprised you aren’t catching things around you on fire. When I first started getting hot flashes, I remember one day, we were eating breakfast and I got one. It was winter, and there was snow on the back porch. I was still in my pajamas, so must have been a weekend. I got up from breakfast, and went out on the porch, and stood in the snow in my bare feet. I was convinced that the snow would melt to steam in a 5 foot circle around me, like something you would see in the old road runner cartoons when the bomb would blow up a perfect 5 foot circle around the cayote. Was that reference too obscure? I can’t be the only one who remembers the road runner cartoons. Same thing happened on the Itchy and Scratchy cartoons that were part of the Simpsons, for all you younger folks. Anyway, what I am telling you is that the severity of hot flashes varies greatly, from none, to thermonuclear detonation. These can make sleeping an issue, can interfere with work and other parts of life. People can also experience heart palpitations, anxiety or a sense of dread when they are coming on. I have also had patients with atypical hot flashes that described whole body itching or a sense that their skin was crawling, which over the years, I have come to understand is also a type of hot flashes without a clear sensation of heat. What can be done about them? If you have not had a breast, uterine or other hormonally active cancer, the most effective treatment is hormone replacement therapy in pill form. However, this does increase your risk of breast cancer, and has fallen more out of favor in recent years. So what other options are there? I am going to go through medical options, supplements as options and then other things that help.
From a medical standpoint, if you can’t, or understandably don’t want to, take hormonal therapy, the next most effective group of medications to help is antidepressants, which have a side effect of decreasing hot flashes. I don’t know why this is, and have not seen any really convincing explanations in the literature either. There is only one antidepressant that is FDA approved for hot flashes, and that is Brisdelle, which is a low dose paroxetine. Also used off label are Effexor XR, Paxil, Celexa and Lexapro. Other prescription meds that have been used include a group of medications used commonly for neuropathy post chemo, including gabapentin, or Neurontin, and Lyrica. If you have hot flashes, and some neuropathy, this might be a great first option. Oxybutynin, a medication for overactive bladder, has been used with some success for hot flashes as well, so if urgency or stress urinary incontinence is an issue, this might be the right one to try. Finally, clonidine or catapress, a med for hypertension, has been used by some, and found to be helpful. If you need a med for blood pressure and have hot flashes, this might knock out two problems with one pill.
There are some medical techniques with possible efficacy as well. A nerve block of the stellate ganglia is under investigation to help moderate to severe hot flashes and helps reduce neck pain.
What about supplements or alternative medical techniques? Dietary supplements including plant estrogens/soy may help, but need to be approved by your primary team if you have a cancer that is affected by hormones. Black cohosh may be helpful, but rarely is linked to severe liver toxicity, so should be used with caution. Vitamin E has been shown in some studies to have an effect on decreasing mild hot flashes. Interestingly, acupuncture has NOT been shown to help in randomized trials. Meditation, however, may help.
What lifestyle changes can help? First, dress in layers, so that you can easily add and take off based on your current temperature. Keeping a journal of what you eat and drink and the number of hot flashes may help. Many people find that alcohol increases their hot flashes, especially red wine. Losing weight may help. People with a lower BMI seem to have less hot flashes. Smoking is also linked to more hot flashes, so eliminating the cigarettes might help (I must say, though, the hot flashes are the least of the improvements with stopping smoking – reduced risk of cancer, stroke, heart disease and more also come with smoking cessation).
Finally, as I mentioned, hot flashes have really been a challenge for me, and have clearly disrupted my sleep. I have tried two typed of bed coolers. These install on top of your mattress and cool underneath of you to help regulate your body temperature. We first tried the sleep number cooling system, which blew cool air. We found that this worked great in the beginning, but then got smashed down by your body weight and over several months became much less effective. The second one we tried is called an Ooler. It uses a pad under your sheet with cool water pumped through it. I have found this very effective in helping keep me more comfortable as I sleep, and has decreased the number of times I wake up fully during the night. By the way, neither company knows I am mentioning them, and I have no affiliation with either. I just think the Ooler is worth the money if you are awake multiple times a night due to the hot flashes.
Another problem women clearly face, but is discussed infrequently, is vaginal changes. During this time, the vagina becomes less well lubricated, less stretchy, and the tissues become thinner. The vagina is actually shown to become shorter, and narrower. All of these changes can cause sex to become less pleasurable and often, downright painful. The medical term for painful sex is dyspareunia. The first thing I need to tell you – studies show that 65% of women use a personal lubricant for vaginal dryness. So, if you aren’t, and you are having pain with sex, you need to join the ranks of women who do. So, in terms of vaginal lubricants, there are water based, and there are others. Who needs what? Well, before menopause, a light bit of moisture is often enough. This would be a water based one. It’s like watering a lawn when the grass is a bit dry and a little brown. A bit of water perks things right up. But during perimenopause, things turn a bit more like the desert. Watering the desert with a hose – the water soaks right into the ground and is gone in an instant. Same thing with our lady parts as we age. In my clinic, I suggest a silicone based lubricant for my women. It does not absorb in, stays around, and really stays slick. It doesn’t get sticky like some water based ones do. I give out samples of uberlube to patients. The company is doing a lot of work educating cancer patients, their product is good quality, and you can get it delivered from amazon, without having to check out with it at the drugstore. Lubricants are for making sex more comfortable. If you have a sense that your vagina or vulva are dry and uncomfortable just normally, a vaginal moisturizer is the best option. A common one over the counter is Replens. Interestingly, while I didn’t find data to support this, there are many clinics that recommend coconut oil as a vulvar and vaginal moisturizer. It is naturally antibacterial, and is available also as vaginal suppositories. It has no additives that might be irritating to sensitive tissues. But a caution here – it is an oil, and so will break down latex in condoms! In terms of prescription options, there are 3. One is vaginal estrogen. This has only mild systemic absorption, and some medical oncologists will approve short term use even in hormonally positive breast cancers. I have offered that in the past, but now there are 2 new medications and a new procedure to help with vaginal dryness that are NOT hormonal, so I would likely start with them. One medication, called ospemifene, or Oshpena, is an oral medication for severe vaginal dryness and pain with sex. Prasterone, or Intrarosa, is a non-hormonal vaginal insert available by prescription only. These may be more effective than over the counter options. Finally, there is a vaginal laser treatment. This uses a laser, placed in the vagina, usually by a gynecologist. The diVa laser delivers two types of energy to aid in resurfacing the vaginal skin, while also stimulating the re-growth of new collagen, blood vessels, and nerve endings below the surface of the vaginal walls. The deeper layer of the vaginal skin is responsible for the elastic nature of the vagina, the lubrication of the vaginal skin, and the sensitivity of the vaginal canal. Restoring this deeper vaginal layer, creates significant long-term changes to dry, lax and painful tissue. Usually this is approximately 3 treatments, with no down time after. I’m planning a full podcast on the laser treatments with a great gynecologist in the next few months, so stay tuned if you want more information about this.
Another problem many women experience, that I think is underreported and underappreciated, is changes to the tissues around the female urethra. As our tissues lose elasticity, women become more prone to urinary urgency and stress urinary incontinence. This is when you leak when you cough, sneeze, laugh hard or jump around. This is reported in the literature in 30% of women aged 50-64, and is more common in women who have had vaginal births. If you are having stress urinary incontinence, the very first thing to do is start doing Kegel exercises. Google it and you will get instructions how to do these. I tell patients to do them during the commercials when they are watching TV. The diva laser treatments can target that area and help as well. Finally, if neither of these help, it is time to make an appointment at the local urologist’s office to discuss the procedures they have that can help improve continence.
Many women also notice hair thinning, dry skin and nail changes during the menopausal transition. I don’t really have much in the way of good advice for these, but if the hair loss is sudden and significant, seeing both your dermatologist and endocrinologist is a good idea to rule out causes other than menopause.
Finally, many, many women experience weight gain during menopause. They also notice a difference in where they deposit their fat. If weight gain is an issue, I have many other podcasts addressing this. But really, you should consider joining us in my September Weight Loss Coaching group. This will be a great group of cancer survivors, learning about how to lose weight and deal with the brain drama that is causing you to overeat, overdrink and more. I’d love to see you in the group. Interested? You can sign up for my upcoming weight loss FREE webinar on my website, www.bestlifeaftercancer.com.
I hope this episode was helpful, and I hope I survive the hiking to talk with you again soon!
