Breast Cancer Survivorship: Health and Fertility After Treatment

About 1 in 10 new cases of breast cancer are found in women younger than age 45. Treatment options for breast cancer can include surgery, chemotherapy, radiation therapy, and estrogen-blocking medication.

In premenopausal women (those who have not yet reached natural menopause), some types of treatment can trigger early menopause symptoms, sexual problems, and fertility problems. Some of these treatments can also increase the risk of certain long-term health problems

Natural menopause occurs when the ovaries stop making estrogen. Normally, this happens over a period of several years. But certain forms of breast cancer therapy, like chemotherapy, can affect the function of the ovaries. This can trigger symptoms of early menopause in premenopausal women.

Chemotherapy can damage the ovaries. This can cause your menstrual periods to become irregular or even stop. The older you are, the more likely your periods will not return. After chemotherapy, you may also experience hot flashes, vaginal dryness, urinary problems, and sleep problems.

Two thirds of all cases of breast cancer are estrogen-receptor positive. This means the cancer cells grow in response to estrogen. Women with estrogen-receptor positive breast cancer may take tamoxifen to stop the cancer from coming back. This medication blocks the action of estrogen in the body and sometimes causes menopause symptoms.

Another type of medication, aromatase inhibitors, lowers levels of estrogen in the body. This lowering of estrogen can also cause menopause symptoms. Aromatase inhibitors are not given to premenopausal women unless they also take a medication to stop the ovaries from making estrogen. This is called estrogen suppression.

• Heart health—Some types of chemotherapy can increase the risk of heart disease. Estrogen-blocking medications may also increase the risk of heart disease in some women.

• Bone health—Cancer treatments that reduce estrogen levels can increase the risk of osteoporosis.

• Brain  health—Cancer treatment can cause problems with memory, focus, and concentration.

Chemotherapy and radiation therapy can damage the eggs inside the ovaries, resulting in infertility. For some women, this infertility is permanent. For others, pregnancy may be possible after treatment, but it may be harder to get pregnant. Read “Preserving Fertility” below.

Talk with your oncologist (cancer doctor), obstetrician–gynecologist (ob-gyn), or other health care professional about your cancer treatment and whether menopause symptoms are a possible side effect. Together, you can plan for safely managing side effects before they happen.

• Some lifestyle changes may help. These changes include avoiding spicy foods, alcohol, caffeine, and hot drinks; dressing in loose layers; doing breathing exercises and meditation; and getting regular exercise.

• Cognitive behavioral therapy (CBT) has shown promise in treating hot flashes, sleep problems, and mood disturbances in women being treated for cancer.

• Some antidepressants, antiseizure medications, and blood pressure medications may help relieve hot flashes.

• Vaginal moisturizers replace moisture of the vagina. These moisturizers do not contain hormones. There are several brands that you can buy online or at your local pharmacy.

• Lubricants can be used when you have sexual intercourse.

If nonhormonal treatment methods do not work, vaginal estrogen may be the best option for some breast cancer survivors. Vaginal estrogen comes in a cream, tablet, or ring. This therapy releases small doses of estrogen into the vagina.

Vaginal estrogen is absorbed by the body in very small amounts. This small, temporary increase in estrogen levels does not appear to increase the risk of breast cancer coming back. Talk with your ob-gyn and oncologist to weigh the risks and benefits.

Estrogen therapy that is given as a pill, patch, gel, or spray is called systemic therapy. With systemic therapy, estrogen is released into the bloodstream and travels to the organs and tissues where it can have a positive effect. Systemic estrogen therapy often is not recommended for breast cancer survivors. There are concerns that systemic estrogen may trigger breast cancer cells to grow and cause the cancer to come back.

Your oncologist should check your overall health and ask you about any new signs and symptoms. You may have blood tests or scans to check for cancer. Follow-up visits may become less frequent the longer you stay healthy and cancer-free.

Yes. Your ob-gyn can give you well-woman exams and screenings. You can also discuss the following with your ob-gyn:

• Birth control methods that are safe for breast cancer survivors

• Your sexual health and sexual satisfaction

• Your future plans to have children

• Possible treatment if you have difficulty getting pregnant

Yes. Your primary doctor can help you stay healthy over time. Your primary doctor can recommend screening tests to check other areas of your health not related to your cancer. This can include screenings for diabetes mellitus, arthritis, and other conditions that often come with aging.

A test to check bone mineral density may be recommended. If results show that you are at increased risk of osteoporosis, medications can prevent bone loss and protect against fractures. There are things you can do to help lower your risk of fractures, including

• increasing your intake of calcium and vitamin D

• doing regular weight-bearing exercise

• limiting alcohol

Living a heart-healthy lifestyle means

• eating a healthy diet

• limiting alcohol

• staying at a healthy weight

• not smoking

• getting daily exercise

A heart-healthy diet includes fruit, vegetables, whole grains, dairy products, and lean protein. Also, you should routinely have your blood pressure checked. Your health care professional may also recommend testing for diabetes and checking your cholesterol levels.

Some people have cognitive problems after chemotherapy for breast cancer. Researchers are looking at whether certain lifestyle changes can help with this common side effect, including

• dietary changes (more fruits and vegetables, limiting fat intake)

• getting more exercise

• increasing social interactions

• “brain exercises” (games and puzzles)

Even though more research is needed, it makes sense to make these changes. They may have other benefits for your health.

Many people with breast cancer feel self-conscious after their treatment. Feeling sexual after breast cancer treatment can be a challenge. If you have sexual concerns, the following suggestions may be helpful:

• If you have a partner, talk about how you are feeling. An open, honest talk can lead to greater understanding about your feelings related to your cancer treatments.

• Consider talking about your concerns with your ob-gyn or other health care professional. If you are not sure what to say, you can begin with a statement like the following:

  • “I am having some concerns about my sex life.”

  • “I am worried about how having cancer is affecting my sex life with my partner.”

  • “I am feeling sad because I do not feel the same way about sex.”

  • “How do I tell my partner that I feel unattractive since my cancer treatment?”

  • “Sex is painful for me. What can I do?”

• Give yourself time to adjust. Cancer treatment is a life-changing experience and may affect your self-image. If you have a partner, you may want to focus on other ways of being close rather than sexual activity.

If you want to have children after your breast cancer treatment, your oncologist may recommend that you take steps to preserve your fertility. One option may be to see a fertility specialist before your treatment. A fertility specialist can explain possible options, including in vitro fertilization (IVF) and oocyte cryopreservation (freezing your eggs).

With IVF, a man’s sperm is combined with a woman’s egg in a laboratory. The resulting embryo is then transferred to the uterus. Embryos can be frozen and transferred many years later. With egg freezing, several eggs are removed from the ovaries. The unfertilized eggs are then frozen for later use in IVF.

Embryo freezing and egg freezing have benefits and drawbacks. A fertility specialist can explain your options, help you make decisions, and plan your fertility treatment before you start cancer treatment.

Antidepressants: Drugs that are used to treat depression.

Aromatase Inhibitors: Drugs that lower the level of estrogen in the body to treat breast cancer.

Chemotherapy: Treatment of cancer with drugs.

Cholesterol: A natural substance that is a building block for cells and hormones. This substance helps carry fat through the blood vessels for use or storage in other parts of the body.

Cognitive Behavioral Therapy (CBT): A type of psychotherapy. During CBT, you learn specific skills that help you change the way you think about and cope with problems.

Diabetes Mellitus: A condition in which the levels of sugar in the blood are too high.

Eggs: The female reproductive cells made in and released from the ovaries. Also called the ova.

Embryo: The stage of development that starts at fertilization (joining of an egg and sperm) and lasts up to 8 weeks.

Estrogen: A female hormone produced in the ovaries.

Hormones: Substances made in the body that control the function of cells or organs.

Infertility: The inability to get pregnant after 1 year of having regular sexual intercourse without the use of birth control.

In Vitro Fertilization (IVF): A procedure in which an egg is removed from a woman’s ovary, fertilized in a laboratory with the man’s sperm, and then transferred to the woman’s uterus to achieve a pregnancy.

Menopause: The time when a woman’s menstrual periods stop permanently. Menopause is confirmed after 1 year of no periods.

Menstrual Periods: The monthly shedding of blood and tissue from the uterus.

Obstetrician–Gynecologist (Ob-Gyn): A doctor with special training and education in women’s health.

Oocyte Cryopreservation: A procedure in which eggs are removed from a woman’s ovaries and frozen for later use with in vitro fertilization (IVF).

Osteoporosis: A condition of thin bones that could allow them to break more easily.

Ovaries: The organs in women that contain the eggs necessary to get pregnant and make important hormones, such as estrogen, progesterone, and testosterone.

Radiation Therapy: Treatment with radiation.

Sexual Intercourse: The act of the penis of the male entering the vagina of the female. Also called “having sex” or “making love.”

Tamoxifen: An estrogen-blocking medication sometimes used to treat breast cancer.

Uterus: A muscular organ in the female pelvis. During pregnancy, this organ holds and nourishes the fetus. Also called the womb.