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At some point in every woman's life, her hormone production drops below the level required to continue her periods. Some women welcome the end to monthly bleeding, bloating, and inconvenience. But others find that menopause affects:

	their sex life,
	triggers mood swings,
	causes debilitating hot flashes, (MORE on hot flashes)
	or even takes them down the road to bone and heart problems.

If menopause happens suddenly (caused by breast cancer treatment), leading to uncomfortable side effects and even dashed hopes of having a baby, it can feel like a disease even worse than breast cancer. It's these menopausal changes that may interfere most with day-to-day quality of life.

There are different kinds of menopause. If you have breast cancer, it is important to understand which kind of menopause you may be experiencing:

	natural menopause, a normal part of the aging process
	medical or surgical menopause that is the result of chemotherapy or ovary removal
	"cold turkey" menopause that is the result of being taken off menopausal hormone therapy after you were diagnosed with breast cancer.

But the good news is that there are ways to manage symptoms and live more comfortably with menopause.

You can do many things to help ease your way through menopause. Lifestyle modifications (diet, exercise, smoking cessation, attitude) may be just as important and effective as medications in helping you feel better and live longer.

Sex Life

Vaginal Dryness

With the significant drop in estrogen after menopause, the membranes of the vagina thin, lose elasticity, and decrease their production of lubricating fluids. Sexual intercourse may be uncomfortable or even painful. Pain with intercourse may be largely a result of soreness of the vulva, the area right outside your vagina. Try avoiding harsh soaps or using a barrier cream like Eucerin or Bag Balm.

Lubrication

Many women find that Replens or other lubricants help ease vaginal dryness. Replens is designed to moisturize the walls of the vagina, but it may not in fact be the best lubricant. It's expensive, and it tends to drip out of the vagina. If you need a lubricant, you may want to try Astroglide or Moist Again.

Yeast infections

You can also get yeast infections—a common side effect of antibiotics, steroids, and some chemotherapies—inside the folds of the vagina and vulva that cause discomfort, thick white discharge, and odor. Clean the area gently. You may need to use yeast-fighting creams or pills, sold over the counter or by prescription (Monistat, Terazol, Diflucan). Lotrisone, a combination anti-yeast and steroid medication, can ease the vulvar burning that can go along with a yeast infection.

Discharge

Troubling vaginal discharge can also occur with menopause. Of the women taking tamoxifen, 80% will have no change in vaginal symptoms, 10% will have vaginal dryness, and 10% will have vaginal discharge. Describing your symptoms clearly and accurately to your gynecologist will make it a lot easier for you to get help.

Vaginal estrogen preparations

If you've had no improvement with your vaginal discomfort despite the use of these various remedies, talk to your doctor about using a low-dose vaginal estrogen cream or Estring (a plastic ring filled with estrogen that is inserted into the vagina). A vaginal estrogen treatment can help thicken and lubricate the walls of the vagina, but with some absorption through the walls into the blood.

Estradiol is thought to be readily absorbed, estrone less readily absorbed, and estriol minimally absorbed. There is little information about this, however. Some studies suggest that estriol may have less potent effects on breast tissue than estradiol.

If you and your doctor decide it's okay for you to use a vaginal estrogen cream for vaginal dryness and pain, you may need only a very small amount. Your doctor might start you with a dose as low as 0.1 milligram of estrogen per day, applying just a small dab inside the vagina, for up to three to four weeks, and then cutting back to once or twice a week.

Mood Swings

Sadness, Depression and Fatigue

Your treatment for breast cancer may leave you feeling sad, tired, or depressed. These feelings are complex conditions, resulting from and affected by so many factors: your cancer diagnosis and treatment, aging, hormonal changes, your life experiences, your genetic constitution.

If you have been thrust into an abrupt menopause perhaps ten years earlier than you deserve to be there, with a rapid decline in hormone levels, you may be thrown into a depression not unlike postpartum depression. Natural menopause is not associated with a greater risk of depression.

Sadness is a natural part of your breast cancer experience, something you need to express and move through. If you don't allow yourself to feel sad and grieve, the unresolved grief gets in the way of feeling better and getting better. Fatigue, the most common side effect of cancer treatment, may have hit you hard, especially if hot flashes are stealing your rest. If your workday is also interrupted, you are likely to find yourself feeling overwhelmed, even debilitated.

How can you tell the difference between fatigue, sadness, and clinical depression? The symptoms of clinical depression include:

	an inability to cope
	an overwhelming feeling of helplessness and hopelessness
	inertia
	an inability to concentrate
	memory problems
	panic attacks
	loss of pleasure in what used to make you happy
	lack of interest in sex or food
	sleep problems.

If you think you're depressed, the first step is to get help. Talk to an accredited psychotherapist who can help you get better. Although another round of medication may worry you, antidepressants can be an important and sound approach to alleviating depression, sadness, and anxiety. But it's also important to obtain help by expressing what's bothering you and getting people-support for your problems.

Medication can take up to six weeks to begin to make a difference; in the meantime, continue to talk with the psychotherapist who is prescribing your medication. A support group is not sufficient at this point although later it can help keep you on an even keel.

A note about medication: Go to a specialist in antidepressant medications to get the best recommendation from the most highly skilled professional. Your oncologist is trained in cancer treatment, not treating depression. Seek help early to forestall serious trouble and long-term treatment. Sometimes just one visit to a psychotherapist can make a huge difference. Check the limits of your mental health insurance benefits; insist on your rights to coverage if you need it.

Depression is more than a side effect of treatment, or even a response to a serious disease. For mild depression, alternative therapies and behavioral therapies may be enough. Estrogen therapy may help the women without breast cancer who take it. But if you have serious depression, menopausal hormone therapy may not help—it may even make things worse.

Hot Flashes

All About Hot Flashes

If you've had one, there's no mistaking it: the sudden, intense, hot feeling on your face and upper body, perhaps preceded or accompanied by a rapid heartbeat and sweating, nausea, dizziness, anxiety, headache, weakness, or a feeling of suffocation. Some women experience an "aura," an uneasy feeling just before the hot flash, that lets them know what's coming. The flash is followed by a flush, leaving you reddened and perspiring. You can have a soaker or merely a moist upper lip. A chill can lead off the episode or be the finale.

What causes them

Hot flashes are mostly caused by the hormonal changes of menopause, but can also be affected by lifestyle and medications. A diminished level of estrogen has a direct effect on the hypothalamus, the part of the brain responsible for controlling your appetite, sleep cycles, sex hormones, and body temperature. Somehow (we don't know how), the drop in estrogen confuses the hypothalamus—which is sometimes referred to as the body's "thermostat"—and makes it read "too hot."

The brain responds to this report by broadcasting an all-out alert to the heart, blood vessels, and nervous system: "Get rid of the heat!" The message is transmitted by the nervous system's chemical messenger, epinephrine, and related compounds: norepinephrine, prostaglandin, serotonin. The message is delivered instantly. Your heart pumps faster, the blood vessels in your skin dilate to circulate more blood to radiate off the heat, and your sweat glands release sweat to cool you off even more.

This heat-releasing mechanism is how your body keeps you from overheating in the summer, but when the process is triggered instead by a drop in estrogen, your brain's confused response can make you very uncomfortable. Some women's skin temperature can rise six degrees Centigrade during a hot flash. Your body cools down when it shouldn't, and you are miserable: soaking wet in the middle of a board meeting or in the middle of a good night's sleep.

Who gets them

Eighty-five percent of the women in the United States experience hot flashes of some kind as they approach menopause and for the first year or two after their periods stop. Between 20 and 50% of women continue to have them for many more years. As time goes on, the intensity decreases.

If you have had breast cancer, your hot flashes can follow the same pattern as for women in general, or they can be more intense and last longer, particularly if menopause was premature, or if you are taking tamoxifen and your body hasn't adjusted to it. Rarely, women may not have hot flashes until they stop taking tamoxifen—an unpleasant surprise. In these women, tamoxifen develops an unusual estrogen-like ability to combat hot flashes.

There is considerable variation in time of onset, duration, frequency, and the nature of hot flashes, whether you've had breast cancer or not. An episode can last a few seconds or a few minutes, occasionally even an hour, but it can take another half hour for you to feel yourself again. The most common time of onset is between six and eight in the morning, and between six to ten at night.

How hot is hot?

Most women have mild to moderate hot flashes, but about 10–15% of women experience such severe hot flashes that they seek medical attention. For women who have had breast cancer, the number who suffer debilitating hot flashes is probably much higher. Randomized studies provide the most objective data: about 50–75% of women taking tamoxifen will report hot flashes, compared to 25–50% taking placebo.

The faster you go through the transition from regular periods to no periods—the peri-menopause or climacteric—the more significant your hot flashes will be. Hot flashes are severe after surgical menopause, and they can also be quite difficult after a chemotherapy-induced medical menopause. If you haven't been warned about hot flashes, a sudden severe episode can be frightening; you might even confuse the flash with a heart attack.

The intensity of hot flashes accompanying treatment with tamoxifen eventually improves for many women after the first three to six months. Because of the conversion of androstenedione from the adrenal glands into estrone by fat and muscle cells, heavy or muscular women experience less severe hot flashes than thin women. If you smoke, your blood vessels lose some of their ability to radiate heat, so you may suffer more severe hot flashes.

Beating the heat naturally

The best way to beat a hot flash is naturally. Hot flashes have a lot to do with the low levels of estrogen in your body, but other factors can cause your temperature control to go out of whack. Instead of estrogen therapy, look at less drastic measures first, partly because estrogen therapy is not known to be safe for women with a history of breast cancer—but also because you should always begin with the least aggressive approach to treating your menopausal symptoms.

Avoiding triggers

If you can identify the things that trigger your hot flashes, you've made the first step in getting the upper hand. Keep a record of when they occur and what you were eating or doing, or how you were feeling at the time. Many women find that stress tops the charts as a trigger. Was that hot flash in the boardroom a random hit, or were you feeling under pressure at the time? Was it a full day of pressure without a break?

Solution: Ease the pressure. Give yourself more time to plan your work, to rehearse your presentation, to deliver your assignments, to arrive where you're going. If you are doing a series of presentations, give yourself a chance to relax and cool off between sessions. And plan your schedule so you avoid meetings or decision making when you're most likely to be in a sweat.

Other hot flash triggers:

	alcohol
	caffeine
	diet pills
	spicy food

	hot food
	hot tubs
	saunas
	hot showers

	hot beds
	hot rooms
	hot weather
	smoking.

Hot flash survival tips

	Dress in layers, so you can peel off one layer after another as you get warmer.
	Don't wear wool, don't wear synthetics, and be wary of silk. That leaves cotton, linen, rayon, and more cotton. (Look at the bright side: You'll save on cleaning bills, and you can stop worrying about moths.)
	Avoid turtlenecks. Stick to open-neck shirts.
	Keep ice water at hand that you can sip to cool down your insides.
	Where possible, lower the thermostat. Maybe it's time for a decent air conditioner or a ceiling fan. Or maybe you'd prefer one of those little hand-held battery-operated fans or the foldable kind you flutter in front of your face. You can find perfectly adequate paper fans for about a dollar.
	Wear cotton pajamas or a nightgown. If you perspire a lot at night, your nightclothes are easier to change than the sheets.
	Use cotton sheets only, not synthetics.
	Get a bigger bed if you and your partner are on different heat planets but you still want to stay in close orbit.
	Take cool shower before bed.
	Try a mild medication like Tylenol
	Arrive at meetings early so that you can get the coolest seat.
	Use your freezer liberally. A number of women talked about opening the freezer at home (or in the supermarket) and sticking their head in when a hot flash hits.

Lifestyle changes to alleviate hot flashes

Exercise: Increasing your level of activity (for example, taking the stairs instead of the elevator) can reduce hot flashes and have a positive impact on just about every other symptom attributed to menopause and growing older, including:

	insomnia
	mood swings
	eroded self-image
	loss of libido

	fatigue
	elevated cholesterol levels
	heart, bone, and muscle health.

Exercise also increases endorphin levels, increasing your threshold for pain.

Relaxation and stress reduction: It isn't unusual to have trouble dealing with stress, especially if you've undergone treatment for breast cancer. You may find that one of the following techniques will help you minimize the devastating effects of stress on your body:

	relaxation exercises
	breathing exercises
	meditation
	visualization

	massage
	hypnosis
	yoga
	biofeedback techniques.

Changing your diet: Over time, a low-fat diet helps some women with hot flashes. Losing excess weight helps, but losing too much weight, or being too thin, can worsen symptoms. As you consider other food changes, keep in mind that natural doesn't mean harmless. Herbal remedies and soy preparations may work because of their plant estrogens, but you can't assume that just because an estrogen comes from a plant it's a safe remedy.

Chinese medicine: Chinese medicine has a long tradition of treating hot flashes. There are all kinds of hot flashes, and the Chinese have descriptions for all of them. Before treating you, a Chinese doctor takes a full history and performs a complete physical, with particular attention to your tongue and your pulse. He or she then determines whether you're suffering from a "hot" menopause or a "cold" menopause. If you have gone through a surgical or medical menopause, Chinese herbs are usually not considered strong enough to eliminate your menopausal hot flashes, but they can help.

Chinese medicine usually involves:

acupuncture, which moves your Xi (your inner wind, energy, or spirit). For every woman who's skeptical about this approach, there's a woman who's found acupuncture helpful for hot flashes.

herbology, in which many different herbs are cooked together to make a tea customized to your particular symptoms. Common to all Chinese herbal mixes is dong quai, thought to be a plant estrogen. More plant estrogens that women have found effective in treating hot flashes over the centuries can be found in ginseng, evening primrose oil, licorice root, red raspberry leaves, sarsaparilla, spearmint, damiana, motherwort, chasteberry (also known as Vitex), black cohosh, and wild yams. These herbal remedies, Chinese and other, may be effective at reducing hot flashes but, again, their relative safety in women who have had breast cancer is not known. Avoiding, or using plant estrogens with great caution, is best, and never try them without telling your doctor. Even leading Chinese medicine practitioners caution women not to self-treat with Chinese herbs.

Vitamins: Some women find that taking vitamin E every day (800 I.U., range 400–1000) helps. Actually, a placebo works almost as well. The National Cancer Institute's/National Surgical Adjuvant Breast and Bowel Project's Tamoxifen Breast Cancer Prevention Trial also recommends vitamin E, or one of the following: vitamin B6, 200–250 milligrams daily, and Peridin-C (containing antioxidants), two tablets taken three times daily. If vitamin E helps you, great, but if you have significant hot flashes, you will probably need something more effective.

Relieving hot flashes with medications

If you have tried these lifestyle, nutritional, and alternative medicine recommendations, and they have not helped, you may feel compelled to go on to stronger remedies, available only through your physician.

Blood pressure-lowering medication

Blood pressure-lowering medications such as clonidine (Catapres-TTS, 0.1–mg patch applied once weekly) and Aldomet (250 mg twice daily) can lessen the severity and frequency of hot flashes. They modify how the blood vessels respond to the brain's command to give off heat quickly. These drugs must be prescribed and adjusted carefully by your doctor.

Antidepressants

Low-dose antidepressant medication may help forestall a hot flash by rebalancing or intercepting the chemicals in the brain that transmit the hot flash alarm, epinephrine and serotonin.

Effexor (venlafaxine) can reduce hot flashes by about 50% in nearly 60% of women with breast cancer according to a study done by Dr. Charles Loprinzi at the Mayo Clinic. Improvement happened relatively quickly: 80% of the eventual decrease in hot flashes occurred within the first week of taking the medication. Side effects, when they were noted, were mild. The dose used was 12.5 milligrams taken twice daily.

A more recent study showed that some women may need a higher total dose of 75 milligrams daily to get significant relief. Extended-release preparations are available. Paxil (paroxetine) works in a similar way to Effexor and is a good alternative. Some women tolerate Paxil better. Its recommended dose is 10 mg once a day for the first week, then 20 mg once a day thereafter.

Mild sedatives

Bellergal-S simmers down overactive chemical activity in the brain. Taken occasionally, once or twice a day, it can be quite safe and effective—but not with alcohol. (It contains belladonna, phenobarbital, and an ergotamine.) Phenobarbital can cause drowsiness and, if you use it regularly, you can develop a dependency for it.

Progesterone-like products

Megace (megesterol acetate) can reduce hot flashes in approximately 80% of women who take it, and it is also considered a treatment for breast cancer when taken in high doses continuously. Megace is usually started at 40 milligrams daily, and it may take a few weeks to start to work. After a month the dose is adjusted up or down. The maximum dose is 80 milligrams per day. Those who reap its benefits and can tolerate its side effects (fluid retention and bloating) may do well on this medication.

Estrogen therapy

Menopausal hormone therapy, or estrogen therapy, is probably the most effective way to relieve hot flashes, but its use is highly controversial in women who have had breast cancer.

Most physicians would not recommend estrogen therapy to remedy severe tamoxifen-related hot flashes because estrogen is not known to be safe for women who have had breast cancer, and may reduce tamoxifen's effectiveness. Estrogen therapy may also add to the potential side effects from these combined drugs—such as blood clots forming and traveling to the lung, and increased risk of endometrial cancer.

However, if your hot flashes are severe and you have not had adequate relief from lifestyle modifications or non-hormonal remedies and medications, your doctor may suggest a limited course of low-dose menopausal hormone therapy to ease your transition into menopause.

The therapy should last only several months, depending on the degree of your symptoms, tapering off over the last month. Dr. John Eden of the Royal Hospital for Women in Paddington, Australia, studied simultaneous estrogen replacement and tamoxifen therapies in women beyond menopause. The study showed no short-term problem from combined side effects. The Eastern Cooperative Oncology Group (ECOG) is trying to launch a study that combines the two drugs. Share this information with your doctor, and decide together what you want to do.

Bone and Heart Problems

Long-Term Health Concerns After Menopause

More women fear breast cancer than fear heart disease or osteoporosis, but the statistics show that this fear may be misplaced:

	One out of eight or nine women gets breast cancer, and one out of two or three women gets heart disease.
	Thirty percent of all women die of heart disease (average age 75–80), 3 percent die from complications of osteoporosis (average age 80), and 3 percent die of breast cancer.
	Heart disease is the leading cause of death in women over 65, but one third of all cardiovascular deaths occur in women less than 65 years old.

Women who have had breast cancer have a greater chance of dying of breast cancer than women who have never had it, but they are at the same risk for heart disease as other women. Death caused by breast cancer occurs over a much greater age range, because women start getting breast cancer at much earlier ages than they do heart disease and osteoporosis: beginning in their 20s and on to over 100.

Managing Menopausal Symptoms