March 2002: Managing Menopausal Symptoms

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How common are extreme symptoms?

Question from Leeann: I've read that a percentage of women go through menopause without experiencing the more notorious symptoms, even without HRT. Is this also true for some women who are thrown into menopause because of breast cancer treatment?

Answer —Charles Loprinzi, M.D.: About 80 percent of women who go through menopause do get hot flashes. Therefore, about 20 percent of women do not, as suggested by the question. There are some women with breast cancer who also never have trouble with hot flashes. It's probably a lower percentage, however, because we give some of these women tamoxifen and that causes hot flashes, and sometimes chemotherapy puts women into premature menopause and that increases the risk of hot flashes. There are not a lot of data to tell exactly how many women with breast cancer, however, don't get hot flashes.

Tips for night sweats, hot flashes, chills?

Question from L: After 5 years on HRT therapy, I was diagnosed with a very small (<3 mm) invasive ductal tumor, which was hormone-receptor-positive. I have had radiation and have been on tamoxifen for 6 months. Any suggestions for the night sweats and hot flashes will greatly be appreciated. I am also curious as to what causes the chills, something I don't remember having when I went through menopause 6 years ago.

Answers —Debra Barton, Ph.D: For moderate to severe hot flashes that interrupt sleep, such as night sweats, one of the best non-hormonal alternatives that we have studied is called Effexor, which is one of the newer antidepressants. We use doses that are lower than what is used for depression. We start with 37.5 mg of extended release Effexor. Women take that for a week. If they are satisfied with their hot flash control, many women stay at that dose. If they aren't satisfied with their hot flash control, we can increase their dose to 75 mg once a day. We have found that reduces hot flashes, including night sweats, by about 60 percent.

Charles Loprinzi, M.D.: I think that the night sweats are just, in my mind, the nighttime equivalent of hot flashes. With regards to the chills, it is a common complaint that some women call "cold flashes." It's hard to sort everything out, except that it's a temperature-regulatory problem. Sometimes hot, sometimes cold, sometimes sweaty.

Jennifer Griggs, M.D., M.P.H.: There are some lifestyle things that you can try, before going on another medication. Those include exercise (which would have other benefits, of course), reduction in alcohol intake, reducing your caffeine intake, and avoiding spicy foods. At breastcancer.org, you can read a review of Dr. Barton and Dr. Loprinzi's Effexor study in the March Research News.

Debra Barton, Ph.D: Research has shown that before a hot flash, core body temperature rises, so things to keep body temperature down may very well prevent some hot flashes. There is some science behind common sense things we do but don't realize. For instance, drinking cool drinks, wearing cotton layered clothing that breathes, and having some sort of air circulation is very important and may be helpful. The other thing that research has found from lifestyle is that deep breathing can reduce hot flashes by about 40 percent. So deep, slow breaths, practiced twice a day, has been found in controlled studies to be helpful.

Jennifer Griggs, M.D., M.P.H.: It sounds as if you're describing a form of biofeedback or meditation.

Debra Barton, Ph.D:  It does get back to the whole idea of stress reduction control.

Effexor vs. tamoxifen for hot flashes?

Question from JC: I am 30 and upon finishing treatment in July I went on tamoxifen. Hot flashes were unbearable. I thought about Effexor, but then the doc decided to increase the Celexa to 30 mg. I was taking 20 mg for low-grade anxiety/depression. It has helped the hot flashes somewhat but I am wondering if Effexor would do a better job. I have to be able to control the hot flashes.

Answers —Charles Loprinzi, M.D.: Venlafaxine (Effexor) happens to be the first of the newer antidepressants that was well studied for treating hot flashes. It turns out that a number of people are looking at others of the newer antidepressants, including Celexa, and the preliminary studies (and these are preliminary only) suggest that a variety of the other newer antidepressants, such as Celexa, do reduce hot flashes similar to how venlafaxine works. At this time, there are not good comparative studies and there is not good information about whether one antidepressant will work when another one does not. Those are questions that are hopefully going to be addressed in the near future.

Jennifer Griggs, M.D., M.P.H.: It might be worth giving the increased Celexa dose a little longer before making a switch, since you've noticed some improvement.

Charles Loprinzi, M.D.: What we have found so far is that usually within a week or two, we'll get the hot flash reactions to the antidepressants as opposed to having to wait for a period of a month or longer to get the antidepressant effects of these medications.

Effexor affects sex drive, sexual response?

Question from Chat: Effexor may help some women with hot flashes, but doesn't it make sexual response more difficult?

Answers —Debra Barton, Ph.D: That's a very important question. In our first Effexor study, we looked at sex drive. We found over the four weeks of this study that women on all the doses of Effexor actually had increased sex drive. Now we haven't studied that specifically longer term, but I continue to follow many women on this medication and ask them consistently about any changes in their sex drives, and few women feel that it has decreased as a result of the medication. In the medical books, Effexor is associated with changes in the ability to have orgasm, either delayed or completely not being able to achieve an orgasm. However, incidence from placebo controlled trials is right around 2-3 percent, so even though that is some risk, it is fairly low.

Jennifer Griggs, M.D., M.P.H.: Treating depression and hot flashes effectively may make intimacy more possible and more enjoyable. Interested people could refer to last month's Ask-the-Expert Online Conference on sexuality after breast cancer.

Is joint pain normal?

Question from Victoria: Is joint pain normal?

Answers —Charles Loprinzi, M.D.: Joint pain is a common complaint in many women and men as we reach middle age. Joint pain itself is rarely caused by recurrent breast cancer. There is a particular syndrome or phenomenon where patients, a month or two following completion of chemotherapy, can get quite a bit of trouble with pain in their hips and knees and morning stiffness-type troubles. This has been termed "post-chemotherapy rheumatism" and is something that generally goes away in a matter of months.

Jennifer Griggs, M.D., M.P.H.: If you're uncertain about any pain you're having, of course, you should contact your cancer care provider(s).

Things to do when hot flash coming on?

Question from Ewe: Is there anything you can do to head off a hot flash when you think it's coming on?

Answer —Debra Barton, Ph.D: When you feel a hot flash coming on, your instinct is to uncover to decrease your body temperature. That is the time to try the deep breathing that could be very helpful, and air circulation as well.

Does progesterone work for hot flashes?

Question from Toni: Would taking progesterone work for hot flashes?

Answers —Charles Loprinzi, M.D.: We have previously studied megestrol acetate (brand name: Megace) in low doses with patients with breast cancer. This medication decreased hot flashes by approximately 80 percent from baseline. This result is similar to what would be expected from the use of estrogen. So from this, progesterone treatment is an effective means of alleviating hot flashes. However, there are some physicians and patients who are nervous about giving any hormone, including progesterone, to patients with breast cancer. Thus, nonhormonal means are often times utilized first.

Jennifer Griggs, M.D., M.P.H.: Would you comment, then, on the use of Megace in the treatment of metastatic breast cancer?

Charles Loprinzi, M.D.: It is true that Megace in relatively large doses, such as 160 mg per day, is used at times to treat patients with recurrent breast cancer. Why then do people worry about using it for hot flashes and causing recurrence of breast cancer? The answer is that the doses used for hot flash management are much lower than the doses for breast cancer treatment, and this causes concern among some doctors. In a similar manner, in the olden days (15-20 years ago) our best hormonal treatment for patients with breast cancer was actually DES. That is an estrogen therapy that was used in high doses where it seemed to shrink breast cancer, and in small doses, there's concern about making breast cancer grow. The whole question about the effect of these different hormonal treatments in breast cancer survivors continues to be one that is debated and studied.

HRT safe for breast cancer survivors?

Question from Dudie B: I am a 48-year-old 8-year survivor (DCIS). After a recent hysterectomy my ob/gyn wanted to put me on Estratest but my breast surgeon said it was too risky. Is it ever safe for survivors to take HRT?

Answers —Charles Loprinzi, M.D.: The pendulum seems to swing back and forth on the question of estrogen replacement therapy in women who've had breast cancer. Over the past decade or longer, there's been concern about giving these therapies to patients with a history of breast cancer. Interestingly, there are a number of new studies suggesting that estrogen therapy is not the big bad wolf that people thought it was. While the final answer on this is clearly not in, and while most physicians for quite some time are likely to be reluctant to give estrogen to breast cancer survivors, bits of new information suggest again that it's not so bad. Definitive studies—randomized placebo controlled trials—are in progress.

Jennifer Griggs, M.D., M.P.H.: There are alternatives to hormone replacement therapy for most of the concerns that make physicians want to put somebody on hormone replacement therapy. For example, women at risk for osteoporosis have other alternatives that can be discussed with their medical providers.

Charles Loprinzi, M.D.: I agree that it's not clear-cut that estrogen needs to be started. The reason for starting estrogen might be for hot flashes, but other things could be tried.

Lack of side effects normal with tamoxifen?

Question from Ms Jeepers: I am a 40-year-old and was recently diagnosed with invasive cancer at age 39. I had a lumpectomy followed by radiation treatment. I have been on tamoxifen for 4 months. I haven't experienced any significant side effects from it. Are there specific tests (i.e. blood work, etc.) I should be getting regularly?

Answer —Charles Loprinzi, M.D.: The lack of side effects from tamoxifen is not surprising. There will be many women who do not have side effects. In fact, regarding hot flashes caused by tamoxifen, which might affect 50 percent of women or so, it can be predicted who will get this among postmenopausal women. Those women who had hot flashes during menopause or who are taking estrogen therapy are many times more likely to get hot flashes once tamoxifen is started. With regard to tests, there are no specific tests for follow-up of tamoxifen, looking for side effects. In fact, the recommended tests for following a patient diagnosed with breast cancer, appropriately treated with radiation and surgery and now on tamoxifen, is to follow that patient with an intermittent history and physical exam by their doctor and a yearly mammogram. No other tests are recommended if the patient doesn't have any symptoms. These are the conclusions of an expert group of members of the American Society of Clinical Oncology (ASCO).

Periods still come back after tamoxifen?

Question from Kath: My periods ceased during chemo. Since taking tamoxifen, they have come back, 2-4 times a year. Should I be concerned or is that normal?

Answers —Charles Loprinzi, M.D.: In women who are close to the time of menopause, i.e. 50 years old, chemotherapy generally will put them into menopause, and usually this is permanent cessation of menses. If women are younger, i.e. in their 30s, chemotherapy may not have any effect on their menstrual cycling or may only temporarily cease their menstrual cycling. The effect of tamoxifen is variable on menstrual cycling, especially in young women. I assume that you are young, and thus the intermittent menses would not concern me. However, if a patient was older or postmenopausal and starts tamoxifen and develops vaginal bleeding, then the first concern that comes to mind of physicians is that this could be a sign of uterine cancer which is slightly increased by tamoxifen use, but which is still relatively rare. So in summary, if you are younger than age 40-45, then I would not be concerned.

Jennifer Griggs, M.D., M.P.H.: Intermittent vaginal bleeding on tamoxifen is very common and keeping track of your menstrual bleeding would be helpful to you and your doctor to see if there's a pattern to the bleeding or no pattern. That can be helpful to figure out if an evaluation needs to be done.

Charles Loprinzi, M.D.: Even postmenopausal women on tamoxifen get menstrual bleeding. The vast majority of the time, they do not have uterine cancer. Nonetheless, it deserves evaluation in postmenopausal women just to be certain.

Jennifer Griggs, M.D., M.P.H.: A lot of people think that tamoxifen causes menopause, but it actually does not lower estrogen, which is a definition of menopause.

Debra Barton, Ph.D: It's a funny thing that a drug that causes hot flashes is not causing menopause but just the symptoms of menopause. This probably is what gives rise to the confusion.

Soy products okay for hot flashes?

Question from Bonnie: I was told to stay away from soy products since my breast cancer, and some advise to take it for hot flashes. What is safe?

Answers —Debra Barton, Ph.D: There have been about 5 major placebo controlled studies looking at soy for hot flashes using anywhere from 50 mg of isoflavones to 150 mg of isoflavones. Most of the research has had women taking this from 4 weeks to 6 months, and most of the research shows that soy does not help hot flashes any more than a placebo does. In fact, the two positive studies had very mixed results. So the actual consensus from the North American Menopause Society is that there is not enough data at this time to support the use of soy for hot flashes.

Charles Loprinzi, M.D.: The pendulum has been swinging back and forth as to the safety vs. the harmfulness of soy in women with breast cancer. There are estrogen-type products in soy (called phytoestrogens). Soy has been on the list of agents that are thought to potentially prevent breast cancer and it has been recommended that it be studied for this situation. However, there are some test tube data suggesting that soy may cause breast cancer cells to grow. The bottom line from my standpoint at this point in time is that I do not recommend soy use to prevent breast cancer or for hot flashes. On the other hand, if a woman likes eating soy products in her diet, I do not feel there is information to recommend against that side either.

Latest on effectiveness of black cohosh?

Question from Sheri: What's the latest on the effectiveness of black cohosh? It's being touted a lot, but I thought there was a recent study that didn't find it to be very effective.

Answers —Charles Loprinzi, M.D.: There have been a number of pilot studies suggesting that black cohosh may decrease hot flashes. These have to be taken carefully because we know in our placebo controlled trials that overall in women receiving placebos, there's about a 25-30 percent reduction in hot flashes. And amongst women taking placebos, up to 10-20 percent of can have a major reduction in hot flashes of 75 percent compared to what they had before taking the placebo. A recent placebo controlled trial looking at black cohosh was published in the Journal of Clinical Oncology. In this trial, there was no substantial difference in hot flashes between the women in the placebo and black cohosh groups. However, there was a strong suggestion that women taking the black cohosh had less trouble with sweating than women taking a placebo. We are aware of ongoing studies that are still trying to address the efficacy and toxicity of black cohosh.

Debra Barton, Ph.D:  In my opinion, the jury is still out on black cohosh. One placebo-controlled study in this country doesn't answer the question. Black cohosh is approved for menopause in Germany. There have been studies in Germany looking at general menopausal symptoms, not specifically hot flashes, so it's definitely worth looking at further.

Sepia 30 good for menopause symptoms?

Question from Judy-2: Sepia 30 (homeopathic pellets) 3x a day until symptoms of "power surges" etc. are gone have done the trick for me. I wonder why more folks don't try it (from a "flower"), and it does not cause one to produce estrogen.

Answer —Charles Loprinzi, M.D.:  I'm not aware of this particular substance. There are a number of claims that have been made about a number of naturopathic-type substances. It's not clear for sure what's in these substances. It's also not clear whether they' re more effective than a placebo, as described above.

Does tamoxifen cause weight gain?

Question from Ellen: I am 39 years old and have been on tamoxifen for 1 year and supposedly experienced pre-menopausal symptoms. I have been working out more than ever, but seem to be gaining weight. Is it the tamoxifen? How does tamoxifen cause weight gain?

Answers —Charles Loprinzi, M.D.: If you received chemotherapy, then the weight gain could be blamed on the chemo. It is well known that, following the diagnosis of breast cancer, weight gain is relatively common. It is more common in women receiving chemotherapy than in women who do not receive chemotherapy. The question about tamoxifen causing weight gain, in my mind, has been well answered. There are thousands of women who have been randomized to receive either tamoxifen or a placebo in double-blind studies. Not one of those studies, to my knowledge, has demonstrated that the women receiving tamoxifen have more trouble with weight gain or weight loss than those women who receive placebo. The same thing could be said about nausea and vomiting. Some women complain that tamoxifen causes nausea and vomiting. There's no suggestion that it does so more than a placebo.

Jennifer Griggs, M.D., M.P.H.: Weight gain after breast cancer treatment is one of the most upsetting side effects in women who experience this side effect. It can be hard for women to hear that it's not the tamoxifen. I think they sometimes feel that their doctors don't believe they're gaining weight. It's important to know it's not your destiny to gain weight on tamoxifen, so your efforts to continue exercising and to watch your diet will probably pay off in the end.

Debra Barton, Ph.D: Exercise has been the one intervention or activity that has been shown to help decrease fatigue that is associated with the experience of cancer.

Jennifer Griggs, M.D., M.P.H.: Some women aren't exercising as effectively as they might, and seeking advice from somebody who specializes in exercise can be helpful.

Charles Loprinzi, M.D.:  I don't exercise as much as I should either.

Jennifer Griggs, M.D., M.P.H.: None of us do.

Debra Barton, Ph.D: That's true!

Tamoxifen causes thick endometrium stripe?

Question from Mary:  I have been told from a recent pelvic ultrasound that I have a thick endometrium stripe. I was told that this is normal in pre-menopausal women but I was asked to do a follow-up ultrasound in 6 weeks. Would it be normal for the stripe to be caused by menopause or possibly tamoxifen, which I've been on for 3 months?

Answer —Charles Loprinzi, M.D.: Tamoxifen commonly causes a thickened uterine lining that can be observed by ultrasound. In the recent past, this test has been evaluated as something that might be helpful for picking up early uterine (endometrial) cancer. Nonetheless, the vast majority opinion is that ultrasound is not helpful in asymptomatic women (women who don't have any symptoms of uterine cancer) and that it only shows the thickened stripes, and nothing more necessarily should be done. Therefore, I would not recommend initial or repeat ultrasound of a uterus in an asymptomatic woman receiving tamoxifen.

Raloxifene good for post-menopause?

Question from Susan V: What about raloxifene use for post-menopausal women? Is it as good as or perhaps better for them?

Answer —Charles Loprinzi, M.D.: Raloxifene (brand name: Evista) is a medication that is similar to tamoxifen. They are both termed as SERMS (selective estrogen receptor modifiers). With regard to treatment of recurrent breast cancer or treatment to try to prevent breast cancer, the vast majority of available evidence suggests that tamoxifen is superior to raloxifene. There is an ongoing study addressing the question of which of these two medications is better for preventing breast cancer in women who have never had breast cancer but are at risk for such. The acronym for this study is STAR (Study of Tamoxifen & Raloxifene). The one indication there is for raloxifene is for treatment of osteoporosis. Many oncologists, however, are not inclined to utilize raloxifene in women who have already had five years of tamoxifen.

Chance of post-menopausal pregnancy?

Question from Marcia: At 43 I have been thrown into menopause (blood test was 117). My gynecologist says I have less than 1% chance of getting pregnant and I am not using birth control. Do you agree with this?

Answer —Jennifer Griggs, M.D., M.P.H.: If you have a repeat measurement of your blood work and it continues to be interpreted that you are postmenopausal, it is indeed most likely that you are unable to conceive.

Recommendations for low libido?

Question from I Sing For You: What do you recommend for low libido? I was perimenopausal before chemo, but that ended my sex life. I have no libido, and my vagina is dry and shrunk. It has been almost 6 years.

Answers —Debra Barton, Ph.D: Those are actually two different problems. The dry vagina is one issue; the low libido is another, related issue. When we are talking about non-estrogen alternatives to manage these things, the problems actually take different solutions. For libido, there are lots of behavioral things to do. For instance, pay attention to lighting, mood, candles, how you feel about yourself, preparing for your time with your partner. All the things that when we were younger we took for granted, may take a little extra planning and forethought. That's Number 1. I encourage women not to underestimate that part--it really can set the stage and help increase libido. From a medication standpoint, the one medication that has been tested not in women with a history of breast cancer, but in women with libido problems and with arousal disorders, has been testosterone. There are some new testosterone patches and a gel that are available. There are health care providers that have some experience with these. The studies in the dose and type of testosterone that are needed to increase libido in women with a history of breast cancer have not yet been done.

Charles Loprinzi, M.D.: With regard to the vaginal dryness, there are some things that can be done. There are non-hormonal agents such as Replens and many others that can help a little bit. Local use of estrogen also can be helpful. Either something like a Premarin vaginal cream or something called Estring, which is a ring that is placed in the vagina for a period of time (3 months), can be utilized. There are some concerns which patients and physicians may raise with regard to this use of estrogen, because there is a little bit of systemic absorption with these delivery means, but most physicians are comfortable with this local use of estrogen.

Jennifer Griggs, M.D., M.P.H.: The absorption into the system is early on when the vaginal wall is thin, but as the vaginal wall responds to the local estrogen, absorption goes down.

Charles Loprinzi, M.D.: Because it becomes thicker.

Debra Barton, Ph.D: Something to keep in mind regarding vaginal dryness is that the more intercourse a woman has, the more blood flows to the tissues, and the healthier the tissues will remain.

Jennifer Griggs, M.D., M.P.H.: Interested women may want to read last month's chat on the topic of sexuality after breast cancer.

How long for drug switch to take effect?

Question from Cyn: I switched from tamoxifen to Arimidex this past Saturday. How long does it take for the new drug to take over?

Answer —Jennifer Griggs, M.D., M.P.H.: Assuming that you switched because of side effects from tamoxifen, you should start to notice a change in the next couple of weeks.

Normal to not perspire in hot flash?

Question from Martisia: When I have a hot flash, only my head gets hot and sweaty. I no longer perspire since chemo. Is that normal?

Answers —Charles Loprinzi, M.D.: There's a fairly wide variety of how women experience their hot flashes. This story doesn't surprise me. Nonetheless, I don't have a good explanation for why it happens.

Jennifer Griggs, M.D., M.P.H.: Several of my patients have described exactly the same thing.

Help husband understand low sex drive?

Question from Heather: I have no "drive" whatsoever right now. I don't want to disappoint my husband. How can I make him understand?

Answers —Debra Barton, Ph.D: Open communication is key with any issue that a man or woman is experiencing in their relationship with their significant other. It might be helpful to seek some counseling in order to come to an agreement or a compromise on how both people can get their needs met.

Jennifer Griggs, M.D., M.P.H.: Talking outside the bedroom will probably be easier than trying to bring this up at a moment when your husband is hoping for physical intimacy. Trying to bring the play back into your intimate life may take some of the pressure off of you as well. If you recently completed your treatment for breast cancer, you can expect some return to normal as you start to feel more like yourself. If you were treated a while ago, you and your husband may need to find other ways to rekindle the spark.

Over-the-counter progesterone creams work?

Question from Robin: Do the over-the-counter progesterone creams work to relieve some of the menopause symptoms?

Answers —Charles Loprinzi, M.D.: I suspect that the answer to this question is truly yes. They have not been well studied, and the absorption of such is not evident to me. There is a naturopathic compound called wild yam cream, which appears to be a progestational agent.

Debra Barton, Ph.D: However, there has been some research with wild yam creams showing they have not been helpful for hot flash control.

Charles Loprinzi, M.D.: As we're coming to a close with this chat, it is worth noting that there are a large number of trials ongoing with regards to testing new agents for the treatment of hot flashes. It is very likely that newer treatments will become available over the next couple of years.

Debra Barton, Ph.D: This points back to a more basic fact: that we really don't know the exact mechanism that causes hot flashes in some women but not others. I am encouraged that there is a concerted effort by many scientists all over the U.S. to figure this thing out because by knowing the physiology, we will surely better understand how to treat it or prevent it.

Jennifer Griggs, M.D., M.P.H.: Safe management of menopausal symptoms in women who've had breast cancer is a more and more important area of concern to patients and their health care providers, and because of this interest, we are bound to make progress more rapidly than ever before.

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