Early menopause

If you are premenopausal or perimenopausal, breast cancer treatments — including surgery to remove ovaries, chemotherapy, and hormonal therapy — may cause your menstrual periods to stop for a while or, in some cases, permanently.

• You are in menopause if you have no periods for 12 months in a row. The average age of natural (not treatment-related) menopause is 51.
  • If you had regular periods before chemotherapy, they may return afterward. The younger you are during treatment, the more likely your periods will return.
  • Talk with your doctor if your period returns after you have missed three or more cycles.
• You are in early menopause if your periods end due to treatment that began when you were still premenopausal.
  • Doctors sometimes call this premature menopause if it occurs at age 40 or younger.

If your periods stop temporarily or permanently, know that you are not alone. Many young women who are treated for breast cancer experience the same thing.

Understanding early menopause will help you discuss this possibility and your concerns with your healthcare team.

How some treatments can cause early menopause

The types of treatments young women tend to receive for hormone receptor-positive and hormone receptor-negative disease may affect your menstrual cycle by lowering the amount of estrogen in your body, stop your ovaries from producing estrogen, or both. These can:

• Stop your periods
• Lessen or end fertility
• Cause menopausal symptoms such as hot flashes, bone loss, and vaginal dryness

Surgery

Surgery that removes your ovaries to reduce estrogen, called oophorectomy, causes immediate permanent menopause. This is also called medical menopause.

• If you are premenopausal and have estrogen receptor-positive breast cancer, especially if you test positive for a BRCA1 or BRCA2 mutation, your doctor may suggest this type of surgery.
• Many women start having menopausal symptoms as soon as their ovaries are removed. Those effects may be stronger than if you had natural menopause.
• Ovary removal is the only surgery treatment that results in early menopause. Lumpectomy or mastectomy alone will not put you into menopause.

Chemotherapy

Chemotherapy for hormone receptor-positive or hormone receptor-negative disease can stop your periods for several months, or permanently.

• Chemotherapy destroys egg follicles, which disrupts ovarian function. This can make your period stop and cause menopausal symptoms.
• Although any chemotherapy medicine can trigger early menopause or menopausal symptoms, certain types are more likely to do so, including:
  • Adriamycin, Cytoxan, and Taxol (AC-T)
  • Cytoxan, Methotrexate, and Fluorouracil (CMF)

Hormonal therapy

Hormonal therapy interferes with estrogen production or activity. The following hormonal therapies do not cause permanent menopause, but they do cause menopausal symptoms for as long as you take them:

• Hormonal medicines called GnRH agonists work to suppress ovarian function. These medicines include leuprolide (Lupron), goserelin (Zoladex), and triptorelin (Trelstar).
• Aromatase inhibitors, a type of hormonal therapy that lowers estrogen in the body to slow or stop hormone receptor-positive breast cancer from growing, can cause menopausal symptoms for as long as you take them. These medicines include anastrozole (Arimidex), exemestane (Aromasin), and letrozole (Femara).
• Tamoxifen is another type of hormonal therapy that can cause menopausal symptoms. Tamoxifen works by blocking estrogen from helping hormone-receptor positive breast cancer cells to grow.

Will my periods return?

The younger you start treatment for breast cancer, the more likely your periods will begin again after chemotherapy or hormonal therapy:

• Young women have more egg follicles, so they have more left after treatment.
• Women under 35 have a better chance of seeing their periods return.
• After age 40, treatment-related menopause is more likely to be permanent.

If your periods stop during chemotherapy or hormonal therapy, you may still be able to become pregnant. So if you’re sexually active, it’s important to avoid pregnancy while you’re undergoing these treatments, because they could harm an unborn baby. Use barrier birth control, such as a diaphragm, condoms, or a non-hormonal intrauterine device (IUD), even if you’re not having periods. Birth control pills and other methods that contain hormones are generally not advised during or after breast cancer treatment.

Before starting treatment, let your care team know if having children is important to you. It’s possible to preserve your fertility before chemotherapy or surgery to remove the ovaries. One option is to have eggs removed from your ovaries, frozen, and stored for later use. Learn more about preserving your fertility.

Managing early menopause symptoms

Treatment-related early menopause can bring on symptoms associated with natural menopause. Here are some ways to manage symptoms:

• Hot flashes:
  • Dress in layers you can easily remove to stay cool.
  • Avoid common hot-flash triggers such as hot drinks, smoking, spicy food, caffeine, and alcohol. Find your triggers by noting what you ate or did shortly before a hot flash.
  • If you're feeling stressed, try Mindfulness-Based Stress Reduction (MBSR) or other complementary therapies.
  • Try lifestyle changes before talking with your doctor about medicine.
  • Low doses of certain antidepressants have been shown to decrease hot flashes and night sweats. These medicines may be helpful for you if these symptoms are very bothersome. Talk with your care team about options if hot flashes are interfering with your daily life.
  • Know that hot flashes usually resolve over time.
• Night sweats:
  • Keep your bedroom cool.
  • Avoid heavy comforters or flannel sheets. Sleep with layers of covers that can be removed.
  • Wear lightweight sleepwear, or nothing.
  • The medicines used to help with hot flashes can usually help with night sweats, too.
  • Know that night sweats usually resolve over time.
• Vaginal dryness:
  • Use non-hormonal vaginal moisturizers such as Replens or Me Again. Oil from vitamin E capsules may also help.
  • Before having penetrative sex, use a sexual lubricant such as Astroglide, K-Y, or Good Clean Love. Do not use lubricants advertised as warming or arousing. They can be irritating.
• Tight pelvic floor muscles:
  • Sometimes, having one painful sexual experience can cause you to unintentionally tighten the pelvic floor muscles when you attempt sex again. Tightening these muscles can make penetration more uncomfortable. If you think this is happening to you, ask about physical therapy focusing on pelvic floor dysfunction. A trained therapist can help you learn how to relax those muscles and improve comfort during sex.
• Lower sexual desire:
  • If sex has been painful because of vaginal dryness, you may have less sexual desire. Try these tips:
    • Use vaginal moisturizers to help with vaginal dryness.
    • If sex is painful, spend time enjoying your body (and your partner’s, if you have a partner) in whatever way is comfortable for you.
    • Apply sexual lubricant generously on yourself, a partner, or a sex toy before penetration or other sexual activity.
    • If you’ve had difficulty with sexual activity, you may need to rebuild positive sexual experiences before your libido returns. You’re not alone, and this is a normal reaction to the effects of some breast cancer treatments. Be kind to yourself and take your time exploring what works for you.
  • Some antidepressants may reduce sexual desire. Ask your care team about good options less likely to cause this effect.
  • Talk with your care team or an oncology social worker about other ways to improve desire. You can also ask for a referral to see a sexual health specialist with experience helping people who’ve been diagnosed with cancer.
• Bone loss:
  • Eat calcium-rich foods, such as kale, shellfish, and dairy.
  • Walk or run regularly. Weight-bearing exercise strengthens bones.
  • Ask your healthcare provider about whether calcium and vitamin D supplements are appropriate for you and if you should have a bone density DEXA scan test.

Learn more strategies on the menopausal symptoms page.

Early menopause resources

Here are some online sources for vaginal moisturizers, lubricants, and more:

• A Woman’s Touch
• Vaginismus.com
• Drugstore.com (Sexual Well-Being section)