Managing Early Menopause and Fertility Concerns During Cancer Care

Cancer treatments can trigger early menopause, causing symptoms like hot flashes, mood changes and irregular periods, according to Dr. Monica Avila.

She goes on to emphasize that patients should discuss these signs, fertility preservation, and symptom management options with their oncologist early to improve quality of life during and after treatment.

In an interview with CURE, Avila sat down to discuss this topic even further. She serves as the assistant program director of the Gynecologic Oncology Fellowship, as well as an assistant professor at Moffitt Cancer Center, located in Tampa, Florida, and treats gynecologic malignancies and specializes in complex surgical approaches.

CURE: What are some of the most common signs that cancer treatment may be triggering early menopause? How can patients distinguish these from typical treatment side effects?

Avila: Sometimes it can be difficult to differentiate between treatment-related side effects and early menopause symptoms. However, early menopause symptoms tend to be pretty specific. You can experience things like irregular menstrual periods, changes to your periods or your periods stopping altogether. You might also start getting hot flashes, night sweats, mood changes and sleep disturbances, which are all part of what can happen.

Some patients report thinning hair, vaginal dryness and just overall difficulty getting through their day. It is very important that your oncologist or the patient identifies these symptoms early on so we can get a handle on them at the beginning of the process. This helps patients navigate further chemotherapy or other cancer treatments.

How does chemotherapy affect the hypothalamic-pituitary-ovarian axis, and why does this sometimes cause menstrual cycles to stop during cancer treatment?

Chemotherapy can have many secondary effects. One of those side effects is that it can impact what we call the HPO, or the hypothalamic-pituitary-ovarian axis. This is essentially a signaling cascade that goes all the way from the brain to the ovaries to initiate the onset of monthly menstruation in women.

We don't know exactly how that mechanism is hijacked by chemotherapy, but we do know that it can pause it or stop it altogether. What you'll see is a sometimes gradual and/or sometimes stepwise progression in the symptoms that women can experience with early-onset menopause due to chemotherapy.

For younger women diagnosed with cancer, what factors increase the likelihood of regaining regular menstrual cycles after treatment?

A lot of the information we have learned comes from early-onset breast cancer patients who have undergone chemotherapy or chemotherapy and radiation for their treatments. We know that age is probably the biggest factor in all of this. The younger a patient is, especially if they don't have a history of ovulatory dysfunction from things like PCOS or endometriosis, the more likely they are to retain their ovulation cycles after chemotherapy is over.

Additionally, some chemotherapies are more “heavy-hitting” and require a longer duration. The longer a patient is on chemo and the more it suppresses their cycle, the more likely it is that menstruation will not return.

What are the safest and most effective ways to manage hot flashes, mood changes and vaginal dryness for cancer survivors who experience early menopause?

This is a really exciting and interesting topic, and it's near and dear to my heart because one of the things that most cancer patients don't know is that you can actually get hormone replacement therapy while on active cancer treatment. If you feel like you're going into early menopause, we can help bridge that and manage the symptoms with hormone replacement therapy for the majority of cancers.

The exceptions are a few gynecologic cancers, most specifically uterine cancers that are what we call estrogen-responsive, meaning they could potentially grow with hormone replacement therapy. Most cancers are not estrogen-responsive and can actually respond really well to hormone replacement therapy. I think that's something most patients can keep in mind.

If you happen to be one of those patients with a cancer that is estrogen-responsive, whether that be uterine cancer or breast cancer, there are a multitude of different medications and techniques we can use to try to minimize symptoms during the course of cancer treatment and beyond.

What fertility preservation options should women consider before starting cancer treatment, and how soon should these conversations take place with their oncology team?

I would say that the earlier you start the conversation, the better. Be a self-advocate and raise questions and concerns with your oncologist early in the process, because the faster we can get to a fertility-sparing option, the better it will be for getting you to your eventual cancer treatment. A lot of the fertility-sparing options are actually available for most patients.

The options can range from things like egg or embryo harvesting with a reproductive endocrinology doctor (whom we usually work alongside) all the way to a surgical intervention where we can do things like ovarian or uterine transposition to relocate the pelvic organs so that they remain functional. Even in other cancer types, like uterine cancer specifically, we actually have medications that can try to reverse the effects of the cancer itself to help the patient avoid a hysterectomy.

There's always a range of possibilities, but if we don't initiate and engage the patient early on, or if they don't engage their oncologist early on, there can be missed opportunities.

What do you hope patients take away from today’s conversation?

I think the biggest thing, whether you desire fertility preservation or management of early menopause symptoms, is to be a self-advocate and a self-starter throughout your entire oncological journey. Just because you're a patient with cancer doesn't mean you have to go without hormone replacement therapy. Just because you're a cancer patient doesn't mean you don't have fertility options.

So, always be advocating for yourself and letting people know that there are other parts of your life that are worth preserving.

Transcript has been edited for clarity and conciseness.

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