Chemo-Induced Menopause & Hot Flash Relief

Chemotherapy can shut down the ovaries. When that happens, menopause does not arrive gradually over several years — it can arrive in a matter of weeks, in the middle of cancer treatment, often at an age when you were not expecting it.

The National Cancer Institute explains that certain chemotherapy drugs stop the ovaries from producing mature eggs and estrogen. NCI singles out alkylating agents, which "present a high risk to your fertility." High doses, or several drugs given at the same time, raise the risk further. Radiation to the pelvis, surgery to remove the ovaries, and hormone-blocking endocrine therapy can each have the same effect.

NCI calls the resulting condition primary ovarian insufficiency. This is not always the same as permanent menopause. NCI says the changes "may be temporary or permanent." Some people go into early menopause; others with primary ovarian insufficiency "still ovulate and have irregular or occasional menstrual periods." Whether your ovaries recover depends partly on your age and on which drugs you received — questions worth asking your oncologist directly rather than guessing at.

NCI lists the symptoms of primary ovarian insufficiency as hot flashes and night sweats, irregular or absent periods, joint pain and muscle aches, mood swings or mood disorders, sleep problems, vaginal dryness, and loss of libido. Importantly, NCI notes these symptoms "can be more intense than in natural menopause."

A hot flash is described by NCI as a sudden warm feeling over your face, neck, and chest that may make you sweat, often with reddening of the face. When it happens during sleep, it is called a night sweat. In people treated for breast cancer, NCI reports that severe hot flashes have been linked with sleeping problems, a lot of pain, and poor mental health; among premenopausal survivors they have also been linked with depression. If your hot flashes are wrecking your sleep, that is a medical problem worth raising, not a nuisance to absorb quietly.

Estrogen. Estrogen replacement controls symptoms well, but NCI states it is contraindicated in patients with breast cancer, and that hormone replacement combining estrogen with progestin "may increase the risk of breast cancer or breast cancer recurrence."

Non-estrogen prescription options. NCI lists megestrol and medroxyprogesterone, certain antidepressants, anticonvulsants, and clonidine (a blood pressure drug). For men treated for prostate cancer, progestin and antidepressants are used. NCI is blunt about the trade-off: studies report these drugs "do not work as well as estrogen replacement or have side effects." Antidepressants can cause nausea, fatigue, dry mouth, and appetite changes, and NCI warns some "may change how other drugs, such as tamoxifen, work." Anticonvulsants can cause fatigue, dizziness, and trouble concentrating. Clonidine can cause dry mouth, fatigue, constipation, and insomnia. If one drug does not help, NCI notes that switching may.

Non-drug approaches. NCI describes cognitive behavioral therapy, relaxation techniques, and hypnosis as ways to gain a sense of control and build coping skills, and says these may be effective when used together with drug therapy. Practical comfort measures NCI suggests: wear loose-fitting cotton clothing, and use fans or open windows to keep air moving.

Supplements — where the evidence is weak. This is where honesty matters. NCI reports that vitamin E was "only slightly better than a placebo." Soy and black cohosh were "no better than a placebo in reducing hot flashes." Ground flaxseed and magnesium oxide produced "mixed results." For dong quai, milk thistle, red clover, licorice root extract, and chaste tree berry, NCI says little is known about how they work or whether they affect breast cancer risk, and advises talking to your doctor before using them. Tell your team about every supplement you take alongside your medicines.

Acupuncture. A review of studies showed slight or no effect in people with breast cancer who had hot flashes, though some individual trials — including one using electroacupuncture in survivors — did show a reduction. The picture is genuinely mixed.

Primary ovarian insufficiency is not only about symptoms. NCI states it causes low bone mineral density, weakening of the bones (osteoporosis), and increased risk of heart and cardiovascular problems. Ask who is monitoring your bone density and cardiovascular risk over the long term.

If fertility matters to you and treatment has not started, NCI notes that survivors were less regretful if they had met with a fertility specialist — regardless of what they ultimately decided.

• National Cancer Institute — Hot Flashes and Night Sweats (PDQ), Patient Version: https://www.cancer.gov/about-cancer/treatment/side-effects/hot-flashes-pdq
• National Cancer Institute — Female Fertility and Cancer Treatment: https://www.cancer.gov/about-cancer/treatment/side-effects/fertility-women