Breast cancer is one of the most common cancers among women worldwide, but it is not the end of life for many.
Life after breast cancer can come with many challenges, e.g. fatigue, loss of body image, emotional distress, sexual difficulties, and for many women, abrupt and early menopause.
The latter can be particularly difficult for breast cancer survivors as menopausal symptoms can have great impact on daily life and relationships.
The good news is that with proper assessment and individualised treatment, many of these symptoms can be managed.
Treatment after-effects
Breast cancer treatment can be surgery, chemotherapy, radiotherapy, endocrine therapy, or a combination of these treatments.
While these techniques can save lives, they can also leave long-lasting scars in the body and mind.
Surgery can change the shape or appearance of the breast.
Some women experience scarring and/or altered sensation, or lymphoedema after lymph node surgery.
Chemotherapy can cause fatigue, hair loss, weight loss and changes in reproductive function.
Radiotherapy can cause skin changes and discomfort.
The emotional impact is just as important.
Many survivors are still worried about recurrence even after treatment has been successful.
Some describe feeling that they are always on the clock for the next scan or medical appointment.
Body image and sexuality can be affected, impacting confidence and intimate relationships.
These are not signs of weakness; they are part of the delicate process of adapting to life after cancer.
A good survivorship plan should therefore look beyond cancer surveillance.
Physical health, emotional well-being, sexual health, bone health, cardiovascular (heart) health, lifestyle and menopausal symptoms should all be considered as well.
When menopause arrives early
While menopause is sometimes presented as just being at the end of menstrual periods, it is actually a transition that shapes health in many ways.
Natural menopause typically occurs between the mid-40s and mid-50s.
Breast cancer treatment can lead to menopause much earlier.
Women can also experience sudden changes in hormone levels after chemotherapy or treatments designed to suppress ovarian function.
Some breast cancer survivors are also prescribed endocrine therapies that block or reduce the effects of oestrogen.
The resulting symptoms can be substantial.
Hot flushes and night sweats can disturb sleep.
Poor sleep can then contribute to daytime fatigue, irritability and difficulty concentrating.
Painful vaginal tissue loss and decreased libido can make sex painful for some women.
Cognitive complaints (e.g. forgetfulness or difficulty concentrating) have also been reported by women during menopause and by cancer patients recovering from treatment.
For a breast cancer survivor, these changes may take place at the same time as ongoing cancer treatment or concerns about recurrence.
This can create a very difficult situation.
A woman may be told that her cancer treatment is working well, yet she may feel far from well because of persistent menopausal symptoms.
This is why quality of life should be part of survivorship care.
Managing menopausal symptoms
Lifestyle measures can provide an important foundation to helping manage menopause.
Regular physical activity (including resistance exercise), a balanced diet, maintaining a healthy body weight, adequate protein intake, good sleep habits and stress management can support general health and help women cope with some menopausal symptoms.
Psychological support can also be valuable.
Counselling, psychotherapy, and cancer survivor support groups can help women process anxiety, changes in identity, and concerns about relationships and sexuality.
For vaginal and sexual symptoms, non-hormonal vaginal moisturisers and lubricants may be useful.
Other treatments can sometimes be considered, but women with a history of breast cancer should discuss hormonal options with their cancer and menopause care teams.
One of these is transdermal testosterone therapy.
Testosterone is commonly associated with men, but women naturally produce testosterone as well.
It contributes to sexual desire, muscle and bone health, and aspects of general well-being.
Transdermal testosterone delivers testosterone through the skin – usually as a gel, cream or patch.
It avoids the first-pass effect through the liver associated with oral administration and can provide relatively steady absorption when appropriately prescribed.
In menopause medicine, testosterone has attracted particular interest for women experiencing persistent low sexual desire.
Some women also report improvements in energy, well-being and sexual function, although the evidence for benefits beyond sexual function is more limited.
For breast cancer survivors, however, the situation is considerably more complicated.
Why caution matters
A history of breast cancer does not automatically mean that every hormone treatment is prohibited.
But it does mean that hormone therapy needs to be considered carefully and individually.
The type of breast cancer is particularly important.
Many breast cancers are hormone-receptor positive, meaning that their growth can be influenced by hormones such as oestrogen.
Survivors of these cancers may be receiving endocrine therapy specifically to reduce hormonal stimulation of any remaining cancer cells.
Testosterone also interacts with the body’s hormone pathways.
Some testosterone can be converted into oestrogen through an enzyme called aromatase.
This is one reason why the use of testosterone in women with a history of breast cancer requires careful consideration.
Importantly, evidence regarding the long-term safety of testosterone therapy in breast cancer survivors remains limited.
Therefore, transdermal testosterone should not be presented as a routine or automatically safe treatment for breast cancer survivors.
A personalised approach
Before considering testosterone, a woman should have a comprehensive assessment.
Her doctor should review:
- The original breast cancer diagnosis and stage
- Oestrogen and progesterone receptor status
- HER2 (human epidermal growth factor receptor 2) status where relevant
- Previous surgery, chemotherapy and radiotherapy
- Current endocrine or anti-cancer treatment
- Menopausal symptoms
- Sexual health and libido
- Cardiovascular and metabolic health
- Bone health
- Current medications and other medical conditions.
The reason for considering testosterone should also be clearly established.
For example, persistent low sexual desire that causes personal distress is different from non-specific fatigue.
Testosterone should not simply be prescribed because a blood test shows that testosterone is “low”.
In women, testosterone levels do not always correlate neatly with symptoms, and treatment decisions should be based on the clinical picture as a whole.
If testosterone is prescribed, professional supervision and monitoring are important.
Treatment should be carried out at the lowest effective dose, avoiding high levels of the hormone, and reviewed regularly.
Women should also be warned about potential adverse effects, e.g. acne, increased facial or body hair, scalp hair thinning and changes in cholesterol or other metabolic parameters.
The goal is not to prescribe a hormone.
What is important is to find out why the symptoms are so severe and what are the safest strategies to take.
Living well
Breast cancer survivorship is about more than cancer.
It is also about building women’s self-esteem, health, relationships and quality of life.
Menopause can be part of that conversation.
Women should not feel embarrassed to talk about hot flushes, vaginal dryness, painful sex, loss of libido, sleep problems or mood changes – these are real health conditions.
Hormonal treatment decisions are also important for breast cancer survivors.
Transdermal testosterone may be useful in certain cases, but it should be weighed against the uncertainty and risk in women with hormone-sensitive breast cancer.
The most important message is that women do not have to suffer in silence.
A thoughtful survivorship programme can take lifestyle medicine, menopause care, sexual health, psychological support and preventive healthcare into account.
Every survivor has a different cancer history, different symptoms and different priorities.
The right approach is therefore not a “one-size-fits-all” treatment, but a personalised plan developed through informed discussion between the woman and her healthcare team.
Surviving breast cancer is a big victory.
The next chapter of this story needs to be more than surveillance; it should also be able to help women feel healthy and confident, and live their lives to the fullest.
Datuk Dr Nor Ashikin Mokhtar is a consultant obstetrician and gynaecologist, and a functional medicine practitioner. For further information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
