Cancer and the menopause: how nurses can support, educate and advocate for patients
How nurses can best support patients experiencing cancer and the menopause
Ten ways nurses can best support patients experiencing cancer and the menopause
- Many types of cancer can be diagnosed during menopause
- Nurses must dispel the fear, listen and talk to their patients
- Know local referral pathways offering specialised support
We talk to health professionals about how cancer nurses can best support their patients
1. Know who is most likely to be affected by cancer and the menopause
What is menopause?
Menopause is when a woman stops having periods as she reaches the end of her natural reproductive life. Oestrogen depletion associated with menopause causes irregular periods and has many other effects on the body
Some cancer treatments can cause an early menopause, which can be temporary or permanent.
Women who have ovaries removed to treat or prevent cancer will have a permanent menopause, and those whose ovaries are subjected to radiation are at high risk. There is an 81% chance of an early menopause after radiotherapy to the ovaries.
Chemotherapy can trigger the menopause, which is more likely to be permanent for women who are close to the age when they would have their natural menopause. In younger women it can sometimes cause a temporary menopause, with periods later returning. Some forms of chemotherapy carry higher risks of causing the menopause than others.
Women can be diagnosed with many types of cancer while they are experiencing the menopause.
2. Be ready to talk about the menopause
Nurses throughout cancer care, including those in the chemo suite or in outpatients, need to be able to talk to patients about the menopause, says Tracie Miles, gynaecological cancer nurse specialist at charity the Eve Appeal.
‘We shouldn’t be fearful – we need to be able to talk about it to our patients. Talk about it, normalise it and listen to what patients are saying,’ Dr Miles says. ‘An early menopause that comes crashing in can be very difficult, but there are things that can be done about it.’
The British Menopause Society offers different levels of accredited training for nurses wishing to find out more, she says.
3. Think about the long-term effects on health
Prolonged lack of oestrogen affects the bones and cardiovascular system, and postmenopausal women are at increased risk of a number of long-term conditions such as osteoporosis, says the National Institute for Health and Care Excellence (NICE).
Expert nurses say women, particularly those going through early menopause, need to be aware of these risks and have sufficient advice on options such as hormone replacement therapy (HRT).
The British Menopause Society says HRT has been shown to reduce the risk of fracture and can be used to prevent or treat osteoporosis in women under the age of 60 who have no contraindications.
Macmillan Cancer Support advises women to do regular weight-bearing exercises such as walking, dancing, hiking and gentle weightlifting to maintain bone density, and also ensure they have sufficient calcium and vitamin D in their diets.
Smoking and drinking alcohol can reduce calcium levels, so patients are advised to stick to sensible drinking guidelines and not to smoke.
When it comes to heart disease, risk can be reduced by not smoking, having a diet low in animal fat and high in fruit and vegetables, and taking regular exercise. Macmillan says if a patient has a family history of heart disease they should ask a cancer specialist or GP if they need medication.
4. Some treatments can cause menopausal symptoms without causing menopause
Some treatments will not cause an early menopause but may cause the symptoms associated with it. Menopausal symptoms can be triggered in women taking a hormone therapy for breast cancer such as tamoxifen, anastrozole (Arimidex), letrozole (Femara) and exemestane (Aromasin).
Another cohort who can start to experience symptoms are women who are diagnosed with breast cancer when on HRT. If they stop HRT on the advice of their healthcare team it can make menopausal symptoms return, Breast Cancer Care says.
5. Be aware that many women will suffer in silence
Many women undergoing cancer treatment may blame the treatment for symptoms they are experiencing, but they could actually be due to the menopause.
This means they are less likely to mention problems such as brain fog and joint pains as they may assume these are side effects of chemotherapy or other treatments. Hot flushes may be caused by tamoxifen or other hormone treatments.
Debby Holloway, nurse consultant in gynaecology at Guy’s and St Thomas’ NHS Foundation Trust and chair of the RCN women’s health forum committee, urges nurses to ask questions directly about symptoms to help unpick the true cause.
‘It can be difficult, because the symptoms of menopause and the side effects of treatment can often overlap,’ she says.
‘Also, women who have completed their treatment may not want to bring up menopausal symptoms as they think they shouldn’t complain after surviving cancer. So nurses need to ask patients directly about their symptoms, and bear the menopause in mind. Ask a patient if they have vaginal dryness and hot flushes and how it is affecting them to see if they could benefit from more help.’
6. Know where to refer women who need more support
Expert nurses urge all nurses in cancer care to know local referral pathways for women who need more specialised support in dealing with the menopause.
This could be a specialist menopause clinic, a member of the oncology team or a gynaecologist with a particular interest in the menopause.
The National Institute for Health and Care Excellence (NICE) says in its 2017 quality standards that women who are likely to go through menopause as a result of medical or surgical treatment should be given information beforehand about menopause and fertility.
But if this needs to come from a specialist, it is not always easy to find local services.
‘Some women don’t need to be managed by a menopause specialist, but those who have hormone-dependent cancer probably do,’ says Ms Holloway.
‘Those who need specialist care should get it, but there just aren’t enough services.
‘Most of the time cancer nurses are happy to manage things if they have a clear plan from the hospital. But there aren’t enough specialist menopause nurses.
‘It’s about finding out what is locally available. If nurses working in cancer spot gaps in their local service, it would be fantastic if they would consider getting training on the menopause.’
7. Be aware of available treatment options to manage symptoms
Around 1 million women in the UK have treatment for their menopausal symptoms, according to NICE. But the use of HRT remains mired in confusion which can deter women from using it.
The most common symptoms are hot flushes and night sweats. Other symptoms include mood changes, memory and concentration loss, vaginal dryness, lack of interest in sex, headaches, and joint and muscle stiffness. Quality of life may be severely affected.
The main guidance for treatment for premature ovarian insufficiency – menopause in women under 40 – is set out by NICE in its 2015 guidance. This says that women going through an early menopause should be offered a choice of HRT or a combined hormonal contraceptive, unless it is contraindicated, such as for women who have hormone-sensitive breast cancer.
It states the importance of having HRT until the age at which they would have naturally had the menopause should be explained to women, due to the long-term health benefits.
NICE says women should be told that the risk of diseases such as breast cancer and cardiovascular disease increases with age, but is low in women under 40.
‘Without HRT there can be lots of problems in the future’
Debby Holloway, nurse consultant in gynaecology
Those who cannot have HRT due to a hormone-sensitive cancer should be given advice, including on bone and cardiovascular health, and symptom management, NICE says.
‘Most of the gynaecological cancers don’t have contraindications for HRT,’ says Ms Holloway. ‘If someone is going through the menopause in their thirties then they must take something to protect their bones and heart. HRT will manage the symptoms they are experiencing and help protect their long-term health. Without HRT there can be lots of problems in the future.’
There are other options to be considered by women who have contraindications for HRT.
8. What to say about alternative and complementary therapies
Many women want to try alternatives to HRT. After looking into different approaches, NICE states that herbal remedies and bio-identical hormones not regulated by a medicines authority should not be considered safe, as there is so much variety in their effectiveness and potency, and there may be significant side effects.
NICE stresses that women with a history of breast cancer or at high risk of it should be aware that there is uncertainty about St John’s wort, and that it can cause potentially serious interactions with other drugs including tamoxifen, anticoagulants and anticonvulsants.
NICE backs the use of cognitive behavioural therapy, which can alleviate low mood or anxiety, and according to the BMS, can also reduce hot flushes and night sweats.
9. Don’t forget contraception advice
Even if women stop having periods they can still be fertile and could become pregnant. Breast Cancer Care advises women to assume they could still become pregnant unless they are under 40 and haven’t had a period for two years since treatment, or over 40 and haven’t had a period for at least a year since treatment. But this can vary, the charity says.
NICE says women who have gone through an early menopause should be warned that HRT does not have a contraceptive effect.
10. Consider the effect on a patient’s fertility
Some cancer treatments for younger women can have grave implications for fertility. Kathy Abernethy, a menopause specialist nurse and former chair of the British Menopause Society, says oncology teams are well prepared to discuss these issues with affected women soon after diagnosis.
‘Oncology teams are much better at identifying women before starting treatment, but it does depend on the urgency of the treatment,’ Ms Abernethy says. ‘This will be discussed with women though, who will then be referred to a fertility clinic.’
Cancer Research UK says loss of fertility can have a devastating effect and can be hard to cope with regardless of whether a woman wanted to have children or to add to her family. It says the woman and her partner may want to talk to a counsellor about the loss of fertility.
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