Long-term health effects of early menopause: Health Practitioners’ perspectives

There’s all the other stuff about long-term life in a post-menopausal state to do with cardiovascular disease, and memory, and Alzheimer’s, and general health. And so one of the statements I read recently was saying that even if you have normal age of menopause, you may easily live for as many years post-menopausally as you may live pre-menopausally with the average age of survival going up and up and up. So similarly for women who have premature ovarian insufficiency, then they’re going to have a very long life most of the time with an increased risk of things like heart disease, and Alzheimer’s, and inability to have intercourse, and hot flushes… And joint problems – the other thing people kind of tend to dismiss a bit is the joint issues that women have.

The younger women who present to me with early menopause, they’re certainly told about it by their doctors and they will have their bone density test and they are encouraged to exercise. But I find that I have to push it a bit more for them to think about and I sense it’s something to do with their age and their thinking that it’s something that won’t happen ‘til later so much. But we know with things like bone health that the exercise you put in as a young woman goes a long way to helping to prevent things like that later on in life. So it is really important to talk with the younger women about it now to encourage them to do strength training, weight-bearing exercise, to be thinking about calcium in their diet.

I’ll always take a very good family history, and make sure, is there a family history of cardiac disease at a young age without risk factors like smoking or whatever? Do they have high blood pressure? Do they have any other risk factors themselves? Blood sugars, do they have diabetes, or do they have diabetes in pregnancy if they’ve been pregnant? So it’s a matter of looking at their risks and looking at their family’s risks.

And then sometimes you will test. But they’re pretty young, and they are women. So it’s unusual to find cardiovascular – but you certainly don’t want them to develop cardiovascular disease earlier than they should or earlier than was programmed. So definitely those, that baseline assessment is very important to be very thorough and find those risk factors.

You have to also look into their long-term protection, towards the osteoporosis, towards the cardiovascular issue, towards the cognitive – dementia, which a lot of us worry about, as we live longer… I suppose because the cardiovascular, they feel it probably because the heart, or the protection towards the blood vessels is actually not doing so well.

The other thing of course, very important, is the lifestyle issue. Anything you can improve in reducing the risks of the long-term issues, I think that’s where you have to look into it. So if you’re talking about lifestyle issue, about the cardiovascular, you want to make sure they’re not overweight, you might want to make sure their cholesterol and everything is okay, they’re not a diabetic and everything else. The calcium itself, the vitamin D, the exercise they’re doing, stop smoking. You know, within range, alcohol, those kinds of things are important.

We need to talk about the positivity of the actual Hormone Replacement [Therapy]. There is so much of the positive things… Beside it gets rid of most of your symptoms, of menopausal symptoms; it also has a protective effect, into your bone, into your cardiovascular, into the development of dementia or neurocognitive issue. So that the benefit to it, you can see that benefit for a long-term. In itself, Hormone Replacement [Therapy] has also been found to reduce things like colon cancer, and all those kind of things. … I don’t think anyone likes to take medication every day, but you know, they will agree to take it.

Long-term it’s actually preventative. That’s the one, I think. Until they’re at least 50, I think [women] need to be coordinated all the time, and to be looked at, to follow up. Once [women] come into the natural progression of age, like everybody else, then they go back into the same way, how we look after the others. But until then, I think you have to… you just have to make sure that if you give Hormone Replacement [Therapy], that it does help the bone; you know, that it does help the symptoms…. So those kind of things, you need to follow it up. But once [women] become natural menopause age… if they are okay, they need to be looked after the same way, like we look after the general women’s population.

We have drugs for osteopenia, for osteoporosis, I think that it’s very difficult to get people to exercise but it’s our job to tell them so I often tell them about weight bearing exercises for example to increase bone strength, Vitamin D and calcium is becoming fairly regular. I think monitoring of osteopenia and osteoporosis is getting much better so yes, I think there’s, in general, fairly good awareness of bone health issues.

From my understanding early menopause can impact on cardiovascular health long-term?

So, I think that would not be something that is routinely discussed in an oncology clinic and I think part of the art of oncology is to figure out how much patients need to know and what they can do about it. So when you have the challenge of a woman who needs to have chemotherapy for breast cancer and we know that it will induce menopause, early menopause, I guess all you can do is try to counsel people about general health, lifestyle etc.

We try to be really proactive about osteoporosis, so I do a Vitamin D on every new breast cancer patient. … Every new patient as part of my screening assessment, they have a Vitamin D. Because, I know that almost all of them I can do something to impact on their bone health. And pretty – all the post-menopausal patients will have a bone densitometry, if they haven’t had one within the last six to 12 months with their GP, we’ll do one, that’s a baseline. I do that for everyone. And then the girls that we put into a premature menopause, we’ll do a baseline bone density as well. So we try to then talk to them about bone health and you know, talk about Pilates, make sure their Vitamin D’s an acceptable level.

We talk about weight bearing exercises, I just have a script basically that we talk about, we talk about weight bearing exercise, encourage people to look for pink Pilates or clinical Pilates. Now downstairs, we have a newly set up breast cancer rehab program and the concept of bone health gets introduced very early.

So, that’s – osteoporosis is – is a very significant one and we try to be as proactive as possible. The other longer-term health issues I suppose, obesity, so you know premature menopause, our drugs that make your joints creaky and stiff and what have you. There’s clear evidence that getting your BMI down actually enhances your breast cancer specific survival. There’s quite a lot of data on that, so we talk about that all the time as well. And then the cardiovascular things, I tend to leave them more in the hands of the oncologist.

Sometimes what we, what oncologists would recommend is that for younger women, because aromatase inhibitors have been shown to give a slightly better result at decreasing risk of reoccurrence compared to tamoxifen which is what young women are normally prescribed, they will put the ovaries into, they’ll shut them down. They’ll give them ovarian suppression therapy and – because aromatase inhibitors are indicative for women who are post-menopausal, so it’s about getting the woman at the correct stage where we can offer the best treatment. So if we can suppress ovarian function – albeit very minimal ovarian function after being through normally a course of chemotherapy anyway – but if we pop them onto ovarian suppression, that then means we can prescribe aromatase inhibitors.

Now one of the biggest risks of being on aromatase inhibitors is osteoporosis, as it is with menopause in general, so we would always do bone density tests at around about the time the women is scheduled to commence the endocrine therapy – as a baseline reading. And then around about six months into that treatment they would have another bone density test, just to determine whether or not it is affecting the strength of their bones.

If it’s found to at that six month stage, they’ll possibly start a course of Vitamin D and calcium supplements. They need to be on both because we obviously can’t absorb calcium without being on Vitamin D. That would then go for another six months. They’d possibly have another bone density test to see how they were going at that point. There are other aromatase inhibitors that women could trial if bone density was an issue. But bone density as far as the medication goes, when we’re talking about tamoxifen, is not a risk but if we consider putting somebody into, after chemotherapy, putting them into a menopausal state, well then it’s still an issue, the potential of that naturally occurring reduction in bone density.