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Lisa Vance with her daughter, Kayla.
At age 40, Lisa Vance viewed her first mammogram more as a right of passage than a cause for concern. Even when she was told a biopsy would be needed, the mother of two was reassured by her physician’s assertion that he would be “very surprised if it turned out to be anything at all.”
Despite this optimism, when Lisa had a biopsy following a suspicious finding on her mammogram, it revealed she had ductal carcinoma in situ. She was initially treated with lumpectomy, but subsequently had a right total mastectomy with immediate reconstruction.
Lisa’s cancer was initially designated as stage I, but lymph node metastasis detected during her mastectomy necessitated four rounds of chemotherapy with dexamethasone, docetaxel (Taxotere), and cyclophosphamide (Cytoxan).
During one of her chemotherapy treatments, Lisa had what she described as a “reaction,” feeling overheated and faint. The infusion was stopped, but Lisa was able to continue her treatment the same day, with the drugs infused at a slower pace. She also recalls feeling exhausted, especially after the later infusions; experiencing nausea and weight loss; and being extremely emotional.
Lisa’s estrogen-sensitive malignancy also required treatment with tamoxifen (Nolvadex) and goserelin (Zoladex), initiated approximately one month after completion of her chemotherapy. In addition to feeling achy and experiencing bone pain, Lisa also experienced medically induced menopause as the result of her tamoxifen treatment.
Lisa’s treatment was successful and she was declared “cancer-free” following a mammogram in July 2010. Subsequent mammograms, obtained twice annually, have continued to show no signs of cancer. Lisa’s goserelin was discontinued after two years; she will remain on tamoxifen indefinitely while being followed with semi-annual blood work.
In March 2012, Lisa underwent endometrial biopsy after reporting to her OB-GYN with bleeding, despite having experienced menopause some two years prior. While her biopsy was negative for malignancies, Lisa will undergo robotic-assisted total hysterectomy with bilateral oophorectomy on June 26. According to her OB-GYN, the bleeding is most likely related to her tamoxifen treatment, and the procedure is being undertaken to prevent the development of endometrial and ovarian malignancies.
As Lisa discovered, dealing with cancer is difficult enough without having to cope with the effects of treatment. And while most of those effects are temporary, menopause caused by medical or surgical interventions is a permanent reality.
While natural menopause typically occurs at about age 51, and after a gradual transition, medically or surgically induced menopause can occur at any age and is much more abrupt. When surgically induced (bilateral oophorectomy), menopause occurs immediately and the abrupt decline in estrogen, progesterone, and androgen can cause symptoms (eg, hot flashes, vaginal dryness, difficulty sleeping, mood swings) that are significantly more severe than those experienced with natural menopause. When menopause is caused by medical interventions (various chemotherapy agents and pelvic radiation that damages both ovaries), there may be a brief transition while the ovaries gradually cease production of hormones.
Indeed, women who experience induced menopause tend to require treatment for menopause-related symptoms more often—and sometimes for longer durations and at higher doses—than those who reach menopause spontaneously. Because cancer patients or surivors may be unable or unwilling to take hormonal medications, oncology clinicians need to be well-versed in the various nonhormonal treatments currently available for menopauserelated symptoms, or should consider referral to a practitioner with such expertise.
Additionally, early or premature menopause (before age 40) puts women at increased risk for a number of conditions, such as osteoporosis, that were once kept at bay by normal production of estrogen. As with menopause-related symptoms, medical professionals need to be well-informed about a br oad range of pharmaceutical agents and lifestyle choices with the potential to help prevent and treat these conditions.
Whether surgically or medically induced, early menopause forces women to deal with a host of emotional, physical, and practical issues—all in addition to the original diagnosis. While those who experience natural menopause often come to accept it as a new phase of life, the emotional consequences of early menopause can be quite different. Younger women like Lisa frequently express concerns about becoming “old before their time” or losing their femininity. For some of these women, the reality of being unable to bear children can be devastating.
Ensuring that women fully understand the risk of early menopause both prepares women emotionally for the life transition and allows those concerned about reproduction to explore fertility preservation options. Furthermore, referral to a trusted source of information and support, such as The North American Menopause Society (www.menopause.org), a world leader in menopause information and education, can be invaluable in helping patients cope effectively, and as a resource for clinicians who want to learn more.