After her diagnosis with breast cancer at the age of 46, Rachel Bowman’s only thoughts were how to get through her treatment – and beat the disease.
‘I was devastated to be told I had cancer,’ she recalls of her diagnosis in September 2022. ‘I am a fit woman, I run regularly and eat well and no one in my family has any significant health issues,’ says Rachel, 48, who lives in Hove, East Sussex.
She’d gone to her GP after finding a ‘broad bean-sized lump’ in her left breast. An ultrasound scan and two biopsies revealed she had invasive ductal carcinoma – an aggressive, hormone-sensitive cancer, which was stage 2 (i.e. it hadn’t spread beyond the breast).
In October 2022, Rachel, who works in retail, underwent a mastectomy, followed by chemotherapy and hormone treatment with Zoladex then tamoxifen to help prevent a recurrence.
While she was anticipating the treatment would be gruelling, Rachel didn’t realise how horribly she would suffer with crippling menopausal symptoms as a result of these two drugs – or how little support she would receive from the NHS.
‘My joint pain was so bad I couldn’t stand up in the morning,’ she recalls. ‘I was like an old lady. I also had terrible brain fog – I would lose the thread of conversations – and was suffering around 20 hot flushes a day. It was horrendous.’
Before her diagnosis, she’d been taking HRT for 18 months for her menopausal symptoms – anxiety, fatigue and heavy periods. But having a hormone-sensitive cancer meant HRT was no longer suitable, as it might fuel the tumour growth, so she was pitched into full menopause.
Although she was warned to expect some menopausal symptoms, ‘I was so focused on dealing with the Big C, that I couldn’t really think beyond that,’ she says.
While having treatment for breast cancer, Rachel Bowman suffered crippling menopausal symptoms as a result of the hormonal drugs she was on, but she received very little support from the NHS
‘I asked my oncologist and he said that it wasn’t his area of expertise and just suggested ‘supplements’.’
Rachel’s experience is typical. More than 100,000 women undergo cancer treatment in England each year – ‘and many women tell us that navigating the menopause after cancer can feel even more of a challenge than the surgery, chemotherapy and radiotherapy they have already been through’, says Dani Binnington, founder of the patient support organisation, Menopause and Cancer.
‘There is rightly emphasis on saving their lives, but there is also a shocking lack of support on how to live a good quality life afterwards from the NHS in general.’
Dani, now 45, was diagnosed with an aggressive triple negative breast cancer at the age of 33. Tests confirmed she had the faulty BRCA1 gene linked to cancer and she opted to have a double mastectomy and her ovaries removed, putting her into the menopause aged 39.
Thanks to her own research, she was able to get good treatment but quickly became aware that this was badly lacking for many other women so began her patient support group with several distinguished doctors as advisors.
One of them, Dr Vikram Talaulikar, an associate specialist in reproductive medicine at University College London Hospitals, says that while there are ‘increasing numbers of women having successful treatment for many types of cancer, what is less well known is what happens when their treatment ends’.
Some treatments – surgery, chemotherapy and radiotherapy – can suddenly plunge a woman into temporary or permanent menopause, regardless of age.
The older the woman, the more likely the menopause will be permanent. It also depends on the cancer: some cancers need very little or a mild dose of chemotherapy, so treatment is less toxic.
‘But if you have surgery to remove your ovaries, for example, hormonal changes will happen very quickly, within 24 hours, and you will go straight into the menopause,’ says Dr Talaulikar.
Some cancer treatments – surgery, chemotherapy and radiotherapy – can suddenly plunge a woman into temporary or permanent menopause, regardless of age
This abrupt change means the patient usually suffers far more severe symptoms than a woman who has gone through the menopause naturally, where oestrogen levels drop off over time.
‘With chemotherapy you can also go into the menopause within weeks or a few months, as chemotherapy drugs are designed to seek and destroy dividing cells and do not differentiate between cancer cells and the follicles containing a woman’s eggs, which are also very active,’ says Dr Talaulikar.
‘For a woman aged around 20, who has a huge number of eggs remaining and only has mild chemotherapy, her store will normally reduce but likely not disappear completely. But for a woman in her late 30s or early 40s, chemotherapy will likely wipe out her remaining egg store.’
It’s a similar story with radiotherapy in the pelvic area, which also does not distinguish between cancer cells and eggs.
If you have had cancer treatment, then you have the right to be referred for specialist menopause treatment. In reality, though, the few specialist NHS cancer and menopause centres that exist – there are around 20 in the UK – are usually attached to major city hospitals and waiting lists are long.
‘Sometimes I see women who’ve been suffering with horrendous menopause symptoms, including hot flushes, sleep problems, mood swings, depression and vaginal soreness, for 12 or 18 months,’ says Dr Talaulikar. ‘Often, they are suitable for HRT or another treatment and could have enjoyed a good quality of life.’
There is also a lack of psychological support for women after cancer treatment.
‘Not only are they coming to terms with the fact they have been treated for something
potentially life-threatening, in addition, many may be coming to terms with the fact that they cannot now have children,’ he adds. ‘They may have survived cancer but the life they are left with can be different from the one they planned.’
A lack of awareness among oncologists, GPs and other health professionals is another key stumbling block. ‘Oncologists are so pushed for time and it’s too specific an area for most GPs to address,’ says Dani Binnington.
Furthermore, many oncologists are still nervous about prescribing HRT after studies in 2003 suggested it might increase the risk of breast cancer, heart disease and stroke in healthy women – despite more recent research that counters some of these findings and the advent of newer, safer forms of HRT, according to Dr Talaulikar.
‘HRT preparations known as body identical hormones, available as topical sprays, patches and gels rather than tablets, are much safer than the old HRT preparations,’ he says.
Body identicals are plant-based and closely match the body’s own hormones. They are safer because trials show they carry less risk of inducing blood clots and a lower risk of developing breast cancer in the long term than the older synthetic hormone versions.
‘Nowadays, we know that HRT is suitable for treating menopausal symptoms in almost all women following cancer treatment, apart from certain categories.
‘These include hormone sensitive cancers, such as oestrogen sensitive breast cancer, advanced endometrial cancer, some forms of uterine sarcoma (womb cancers), some ovarian cancers and other rare cancers such as certain brain meningiomas (brain tumours).
‘But even then, we consider individual cases and balance the benefits of relieving menopause symptoms against the risks of cancer returning.’
For instance, vaginal oestrogen creams or pessaries for vaginal dryness can also be safely used by most women, adds Dr Talaulikar, as there is very little absorption of these hormones into the bloodstream.
Breast cancer in particular is complex with many variations, so women need menopause advice based on their own circumstances, agrees Dr Melanie Hacking, a GP and menopause specialist at the private Oxford Hormone Clinic.
‘Women really want to do the right thing – and their biggest fear is doing anything to risk a recurrence of their cancer,’ says Dr Hacking.
The clinic recently started offering menopause advice to cancer patients based on assessment by a hormone specialist and an oncologist. If HRT is not suitable, there are several other medications that can be prescribed, as well as evidence-based lifestyle changes you can adopt, adds Dr Hacking.
Through her own research Rachel came across the advice and podcasts available on Menopause and Cancer’s website as well as the support of the group’s Facebook community.
After a second operation in December 2023 to remove a small locally-recurring tumour, she was treated by a different NHS oncologist who suggested a
number of lifestyle changes and products, including a moisturiser to help with vaginal dryness, yoga to alleviate joint pain and cold-water immersion (turning the shower to cold for the last 30 seconds), which Rachel says has eased her hot flushes.
‘Collectively these all helped enormously,’ says Rachel, who also runs for 30 minutes four times a week and does weight training to guard against osteoporosis.
She has just finished her course of radiotherapy and says she feels fatigued but is regaining her energy levels. ‘But I’d just like other women to know that there are options out there to help you – you are not alone,’ she says.
- The British Menopause Society website, thebms.org.uk, has a postcode locator for finding NHS and private specialists near you. Most major NHS hospitals have specialist menopause clinics which can normally provide advice post-cancer but there are long waiting times – although it is possible to be referred outside your area.
- For further information visit menopauseandcancer.org; macmillan.org.uk
I was only 28 when the hot flushes began
School teacher Jade Diebelius went through the menopause at 28 after being diagnosed with Hodgkin lymphoma, a blood cancer
Jade Diebelius, a primary school teacher from Southend in Essex, went through the menopause at 28 after being diagnosed with Hodgkin lymphoma, a blood cancer. ‘I was incredibly shocked to be diagnosed with cancer at my age,’ she recalls.
Warned that treatment might damage her fertility, Jade – who was then just 25 – had her eggs frozen.
While chemotherapy and radiotherapy put her cancer into remission, it returned two years later. Jade was then told that she needed a stem cell transplant. This involved chemotherapy to destroy her unhealthy blood cells, followed by a transplant using her own healthy stem cells from her bone marrow.
‘Although I was warned the menopause would be a side-effect, as my ovaries would be damaged by the high-dose chemotherapy, I didn’t really focus on this as I didn’t feel I had an option,’ she says.
The transplant, in 2021, was a success, but just three weeks later, Jade was battling unbearable symptoms of the menopause.
‘I had hot flushes, moods all over the place, brain fog and my joints ached so much I struggled to move,’ she recalls. I really felt a lot of grief, too. My partner Ryan [now 32] and I have been together for 11 years and would love to have children. Even though I had eggs frozen and IVF may be an option in future, it still felt as if the life we planned had been taken away.’
Faced with an eight-month wait to be seen at an NHS menopause clinic, Jade asked to be referred to a gynaecologist at her local hospital, who prescribed her HRT.
‘Within a week, around 90 per cent of my hot flushes disappeared,’ says Jade, now 31. My mood improved hugely and I felt more like my old self. I’m still coming to terms with the fact that my treatment forced me into an early menopause and how my path has changed – but I am grateful to be here.’
Which drugs could help
There are other prescription drugs you can take to help alleviate menopausal symptoms if HRT is not suitable for you
If HRT is unsuitable (or undesirable), there are other prescription drugs that can help with menopausal symptoms, says Dr Melanie Hacking, a GP at Oxford Hormone Clinic. These include:
- SSRIs (selective serotonin reuptake inhibitors, a type of antidepressant) in lower doses can reduce hot flushes by 50-70 per cent, research shows.
- Gabapentin, usually used to treat epilepsy and nerve pain, can also reduce hot flushes, relieve joint pain and improve sleep.
- Clonidine, used to treat high blood pressure, can reduce hot flushes by up to 40 per cent.
- Oxybutynin, used for an overactive bladder, has a side-effect of reducing hot flushes by up to 75 per cent.
- Fezolinetant (brand name Veoza), known as an NK3 receptor antagonist, was approved in the UK to treat hot flushes and night sweats. Currently only available on private prescription, it targets the brain’s temperature control centre. It is expected that fezolinetant will be available on the NHS later this year.
- Vaginal oestrogen. Studies show this gives localised relief for symptoms such as dryness.
It is important to discuss these drugs with a specialist, as every woman’s circumstances and cancer are different, stresses Dr Hacking.
From yoga to sage tea, natural ways to tackle the problem
Alternative therapies can be effective in easing menopausal symptoms, according to a 2023 review by University College London, based on 30 studies with 3,500 women.
The researchers concluded that although HRT remains the gold standard treatment, doctors should consider suggesting these therapies alongside pills and patches – or as an alternative where HRT is not suitable. Dr Melanie Hacking, a GP and menopause specialist at Oxford Hormone Clinic, suggests:
Studies show that meditation can help to activate the parasympathetic nervous system – responsible for digestion and slowing the heart rate
Acupuncture: Studies show 80 per cent of women experienced an improvement in moderate to severe hot flushes, mood and sleep quality after six weeks of weekly treatments.
CBT: There is strong evidence that talking therapy such as cognitive behavioural therapy (CBT) helps women manage menopausal symptoms better.
Dr Hacking recommends a CBT-based programme developed by Myra Hunter, an emeritus professor of clinical health psychology at King’s College London and detailed in her book, Managing Hot Flushes And Night Sweats: A Cognitive Behavioural Self-Help Guide To The Menopause. For more information, visit womens-health-concern.org.
Yoga and meditation: Studies show that both yoga and meditation can help to activate the parasympathetic nervous system – responsible for digestion and slowing the heart rate – which in turn will dampen down levels of the stress hormone cortisol.
Stop smoking, reduce alcohol, caffeine and spicy foods: Nicotine disrupts the conversion of androstenedione (a precursor hormone) to oestrogen, while alcohol can cause the blood vessels to dilate, heating up the body. Caffeine is a stimulant and can raise body temperature, as can spicy foods.
Weight-bearing exercises: Activities such as running, skipping and strength training (e.g. squats, push-ups and using dumbbells) help maintain bone health, reducing the risk of fractures after the menopause.
Supplements: In particular, vitamin D and calcium for bone health, magnesium for heart health and to improve low mood, omega 3 to help with night sweats, vitamin E for hot flushes and turmeric for joint stiffness.
‘Magnesium works in combination with oestrogen and progesterone to improve mood and reduce anxiety,’ says Dr Hacking.
‘A review in 2022 on the effects of oral vitamin E and omega 3 on hot flushes showed this combination significantly reduced the intensity of hot flushes, compared to a placebo.’
Joint stiffness is a common symptom in menopause – oestrogen plays an important role in protecting and lubricating joints, Dr Hacking explains – and ‘turmeric (containing curcumin) reduces inflammation associated with joint pain, with research showing it works as well or better than non-steroidal anti-inflammatory drugs.’
Herbal remedies: ‘Herbal does not necessarily mean safe,’ warns Dr Hacking.
‘If considering these products, then you should look for those with the THR certification mark to give assured standards of doses and purity.
‘There is some evidence that sage tablets or drinking sage tea can help to reduce hot flushes by up to 40 per cent.’
