All women become menopausal at some stage. Natural menopause is due to the ovaries gradually running out of egg cells and being unable to produce the usual cyclical production of oestrogen and progesterone. With changing balance of these hormones, the stimulation of the womb lining changes and so periods may become irregular and heavy. This changing phase, known as the perimenopause, can last for a few years until finally the ovarian hormone production is so low that the womb lining is not stimulated and periods stop, the time of the menopause. The resultant low level of oestrogen can produce a range of symptoms such as flushes, sweats, low mood, joint aches, disturbed sleep, and also some later consequences on vaginal, bladder, bone and heart health. The severity, duration and impact of symptoms and later health effects varies hugely between women, and hence the need for treatment is very individual.
Natural menopause usually takes place around the age of 51. However, for some women menopause can occur at a younger age and may be the result of treatment for another condition. When menopause occurs early after cancer treatment, it may seem like the last straw. Women may be unprepared for the onset of menopausal symptoms when they are also dealing with the devastating effects of diagnosis and treatment, and indeed may not initially realise what is happening.
The importance of provision of information before treatment which may lead to an early menopausewas recognised in the recent NICE guideline on diagnosis and management of the menopause which recommends that healthcare professionals should:
Offer women who are likely to go through menopause as a result of medical or surgical treatment (including women with cancer, at high risk of hormone sensitive cancer or having gynaecological surgery) support and:
- information about menopause and fertility before they have their treatment
- referral to a healthcare professional with expertise in menopause
For women who have had treatment for cervical cancer, the type of treatment will determine whether or not the treatment will lead to early menopause. A hysterectomy may be performed and the ovaries may be able to be conserved. The ovarian function may then continue until they naturally stop working, but of course having a hysterectomy stops any periods and so it may be difficult to know whether or not the ovaries are still working. In this situation it is important to know what signs and symptoms to look out for.
If the ovaries are removed at the time of surgery, or are exposed to radiotherapy or chemotherapy, then menopause can happen suddenly. This sudden drop in oestrogen can lead to rapid onset of menopausal symptoms for which earlier preparation with provision of information is essential.
Whether treatment for cervical cancer leads to an early menopause, or women subsequently experience menopause at the usual age, treatment options need to be considered. The main reason to consider treatments is for symptom control. Symptoms affect around 80% of women but in varying degrees and not all require treatment. Diet and lifestyle measures can be the first step, with losing weight, stopping smoking, and reducing alcohol and caffeine being helpful both for symptom control and for later health benefits.
The most effective treatment for the effects of oestrogen lack is to replace oestrogen in the form of Hormone Replacement Therapy (HRT). HRT is recommended for women with troublesome menopausal symptoms, but is also recommended in women who experience a premature, (before age of 40) or early, (before age of 45) menopause, even if they do experience symptoms since HRT offers long term heart and bone health benefits. In this situation, HRT should be continued at least until the average age of the menopause.
Many women have concerns about taking HRT after much publicity in recent years about risks, but the current view is that for most women, the benefits outweigh the small risks. Having had cervical cancer does not mean that HRT should be avoided, there being no known association between HRT use and risk of cervical cancer. The type of HRT taken will depend on the treatment, such as whether or not a hysterectomy has been performed. Particular attention should be given to vaginal health, particularly if radiotherapy has been required. In this situation, vaginal oestrogen may be required in addition to HRT to help maintain vaginal health and prevent dryness and thinning of the vaginal skin.
It is sincerely hoped that with better education and understanding, the unwanted additional effects of treatment for cervical cancer can be reduced by appropriate preparation and treatment.