Menopause and breast cancer

2017-02-09T05:57:55Z (GMT) by Sayakhot, Padaphet
Background: Although 27% of women will be premenopausal at diagnosis; treatment for BC may cause menopause/menopausal symptoms in up to 80% of these women. Both short term symptoms and long term health problems such as osteoporosis and heart disease are associated with early menopause (EM). Menopausal symptoms have a major negative impact on quality of life, sexual dysfunction and changes in body image and self-esteem in BC women. Overseas studies indicate that 2/3 of postmenopausal women with BC report hot flushes and more severe menopausal symptoms are experienced by women with BC, however there is little Australian data. Women with BC and menopause benefit from partner support yet little is known about partners experience/perception of menopause. BC women consult multiple clinicians including gynaecologists, endocrinologists, oncologists, breast surgeons and general practitioners (GPs); however, there is a lack of evidence based guidelines and management practices of these clinician groups regarding menopause. Culture also influences menopause symptoms/perception with limited information and understanding of the menopausal experience of women in a developing country (Laos) compared to a Western developed country (Australia). Aims: This work aimed to: (1) investigate the perception/experience of menopause, diagnosis and therapies, information provided and health behaviours, in younger women with BC, (2) investigate menopausal symptoms, psychological function, sexual function and body image and the effect of different BC treatments on these parameters, (3) describe the partners’ perception, understanding and personal experience of menopause, and menopausal therapy in women with BC, (4) determine current clinical understanding and management of menopause by Australian clinicians (gynaecologists, endocrinologists, oncologists, breast surgeons and GPs), (5) examine culture influences on women’s understanding and management of menopausal symptoms as assessed in a group of Australian and Laotian women, and (6) to inform a translation program providing information to consumers and health professionals. Methods: Participants: Participants for study 1 and 2 included 114 menopausal/perimenopausal women aged 40-51 years with non-metastatic BC. Participants for study 3 included 50 partners of BC women. Participants for study 4 included 176 clinicians: 35 gynaecologists, 35 endocrinologists, 36 oncologists, 35 breast surgeons and 35 GPs. Participants for study 5 included 108 women (56 Australian and 52 Laotian; aged 40-65 years) attending gynaecological outpatient clinics in Australia and Laos. Procedure: Studies 1, 2 and 3 utilised both validated and internally developed questionnaires. Women with BC and their partners were recruited from the general community, from hospital outpatient clinics, from community support groups and via the Jean Hailes for Women Health (JH) website. A questionnaire including an index case was used in study 4 to assess the understanding and management of EM by Australian clinicians. Clinicians were randomly selected from Medicare Australia, referring doctors to menopause/oncology clinics and the general medical community via the JH website. The same questionnaire in English and Lao was completed by women in study 5. Analysis: Analysis was performed using SPSS software (version 17.0). Descriptive statistics, chi-square tests, student t-test, Mann-Whitney U were used where appropriate. Results: Study 1: Most BC women were satisfied with the manner in which they were informed of both BC (69%) and menopause (59%) diagnosis. Although 80% of women were given BC information, only 54% were given menopause information at diagnosis. Weight gain (68%) and osteoporosis (67%) were the most common problems/fears regarding menopause; however, only 56% reported having relevant screening investigations including blood sugar and bone density tests. Study 2: Commonest reported menopausal symptoms in BC women were tiredness/lacking energy, loss of libido and hot flushes. Anxiety/depression scores were high overall. Women perceived exercise (68%) and improving lifestyle (61%) as most effective in alleviating symptoms of menopause. Most women reported that they did not understand the risks/benefits of “bioidentical hormones” (79%) and herbal therapies (78%); while 58% perceived hormone replacement therapies as associated with an increased risk of BC. Psychological symptoms, vasomotor symptoms and sexual dysfunction scores were significantly higher in BC women with ovariectomy compared to BC women without ovariectomy (p<0.05). Feelings of physical health, attractiveness, overall appearance and satisfaction were significantly lower in ovariectomised women (p<0.05). Study 3: Most partners of BC women perceived hot flushes as the meaning of menopause (68%) and loss of sexuality as the key problem/fears about being menopausal (60%). Partners perceived exercise (72%) and reducing stress (64%) as most effective in alleviating menopausal symptoms. Most partners reported that they did not understand the risks/benefits of hormone therapy (50%), “bioidentical” (90%) and herbal therapies (84%). As with BC women, the GP was considered the best source of information on menopause (68%). Partners expected menopause to affect a women’s everyday life and relationships with family and partner, particularly to cause intermittent stress on the relationship (66%) and decrease libido/sexual interest (64%). Study 4: There was a lack of consensus between gynaecologists, endocrinologists, oncologists, breast surgeons and GPs in their investigation, diagnosis and management of EM in BC women. Significant differences between clinician groups regarding EM diagnostic criteria were observed (p<0.05). Non-hormonal treatment was preferred by most clinicians for treatment of menopausal symptoms. Exercise and nutrition were selected by most gynaecologists for relief of hot flushes, whereas most endocrinologists, oncologists, breast surgeons and GPs prescribed Venlafaxine. Most clinicians reported that the main problem with therapies was failure to resolve hot flushes. Exercise, life style and stress management were commonly recommended by all groups as treatment for anxiety/depression. Study 5: Psychological symptoms, depression, vasomotor symptoms and sexual dysfunction were significantly higher in Australian women compared to Laotian women (p<0.05). Australian women perceived the meaning of menopause as ageing (57%), whereas most (81%) Laotian women reported not knowing the meaning of menopause. Laotian women demonstrated a lack of knowledge regarding menopausal therapies compared with Australian women (83% reporting “don’t know” compared with 21% respectively). Conclusions and future direction: The studies performed in this thesis demonstrate the importance of the provision of BC and menopause information to women at the time of BC diagnosis. The present study showed that women experienced a range of menopausal symptoms and anxiety/depression is common in younger BC women. Importantly, we have highlighted the significant adverse effect of ovariectomy on menopausal symptoms, psychological impact and sexual function. Healthcare providers and women with BC need to be aware of the impact of BC treatment, particularly ovariectomy, in younger women with BC and further education resources and support should be targeted to these women. These novel studies provide understanding of the personal experience of having a female partner with BC and emphasise the gaps in understanding of menopause/menopausal therapies that partners of women with BC have. In another novel study, we revealed a lack of consensus between clinician groups in their investigation, diagnosis and management of EM in BC women. As a consequence, women may receive different diagnosis or treatments depending on the type of clinician consulted. In the cross-cultural study, we observed differences in symptoms experienced, understanding, attitude towards and perception of the meaning of menopause between Laotian and Australian women. This study revealed a lack of understanding of menopause/menopausal therapies by Laotian women compared to Australian women, highlighting the importance of education for women. This work has informed education and translation to address these knowledge gaps and highlighted the need for more research.