Links between early menopause and medical treatment: Women’s accounts

Early menopause (EM) can be caused by medical treatment, including chemotherapy, radiotherapy, bone marrow/stem cell transplants, or surgical removal of both ovaries (bilateral oophorectomy ). In some cases, surgical removal of the uterus (without removing the ovaries) or ovarian surgery (for example to remove cysts) can lead to EM. Reasons for having a bilateral oophorectomy or hysterectomy include cancer, endometriosis, fibroids, or to reduce cancer risk in women with particular gene mutations including BRCA 1/2 or Lynch Syndrome. Women who still have their ovaries and are undergoing ovarian suppression therapy with monthly gonadotrophin releasing hormone (GnRH) agonist injections (e.g. goserelin) for breast cancer or endometriosis usually experience menopausal symptoms; but they are not considered to have EM because ovarian suppression is reversible when therapy is stopped.

To learn more about ovarian suppression therapy, please see the Box at the end of this Talking Point.

Women’s accounts of cause of medically-induced early menopause

Compared with women who experienced spontaneous EM or premature ovarian insufficiency (POI) (Causes of spontaneous early menopause: Women’s accounts), women with medically-induced EM were in general more able to identify the reason they had experienced EM. However, their ability to link medical treatments to EM varied according to the type of medication or procedures they experienced. This reflects the fact that some medications or procedures are certain to cause EM, while other treatments may or may not cause EM, or may cause menopausal symptoms rather than EM.

Bilateral oophorectomy

Women who had both their ovaries surgically removed (for cancer treatment, to reduce cancer risk, or to treat endometriosis) identified their surgery as causing EM. As Louise, who had both ovaries removed after being diagnosed with ovarian cancer, said, ‘…anyone that knows what an ovary’s job is in your body knows that that equals menopause, once they're removed.’

Linda attributed her EM to a hysterectomy and oophorectomy in her early 30s for endometriosis.



A radical hysterectomy Alex had at 32 as part of her ovarian cancer treatment caused early menopause.



Chemotherapy and radiotherapy

A couple of women who had chemotherapy, radiotherapy or a bone marrow/stem cell transplant for Hodgkin’s Lymphoma linked EM directly to chemotherapy (see Finding out about medically-induced early menopause).

Julia explained how treatment for Hodgkin’s Lymphoma led her to experience early menopause. 



For women with oestrogen sensitive breast cancer, chemotherapy and radiotherapy typically occurred after lumpectomies or mastectomies, and before other follow-on treatments to reduce their oestrogen levels (e.g. bilateral oophorectomy and/or hormone/adjuvant endocrine therapy). Disentangling which treatments had caused menopausal symptoms and which had caused EM was not easy. Women who had had a bilateral oophorectomy attributed EM to this surgery.

Maree explained the different effects of chemotherapy, bilateral oophorectomy, and hormone (adjuvant endocrine) therapy (anastrazole).



Ovarian suppression with GnRH agonists

Women who had not had a bilateral oophorectomy and were undergoing ovarian suppression therapy with monthly GnRH agonist injections (see Box at the end of this Talking Point) were aware the medication caused them to be in a ‘menopausal state.’ However some indicated that they had received unclear information about the difference between early menopause and ovarian suppression.

Kate described having ‘no idea’ if her periods would return after stopping ovarian suppression therapy in future, but recalled the term ‘menopause’ being used to explain her symptoms during chemotherapy and radiotherapy, then later ovarian suppression therapy.



Eden reflected on the meaning of being in a ‘menopausal state’ as a result of undergoing ovarian suppression therapy as opposed to having ‘real menopause.’



Ovarian and uterine surgery

Several women had repeated ovarian or uterine surgeries to remove tumours (cancerous and benign), cysts or fibroids, or for endometriosis-related problems. Most reported that they were diagnosed with EM after a hysterectomy with oophorectomy, or removal of any remaining ovarian tissue. However, they described noticing changes in their menstrual cycles, menopausal symptoms, or feeling as though they were in ‘perimenopause’ before ‘final’ surgeries or before formal diagnosis (Finding out about medically-induced early menopause). A few suggested that their ovaries had ‘shut down’ or been ‘damaged’ as a result of either disease (e.g. cancer, cysts, endometriosis) or treatment (e.g. surgery).

Naomi had repeated ovarian surgeries for ovarian cancer. She recalled experiencing menopausal symptoms before her final ovarian surgery (after which she was diagnosed with early menopause) but wasn’t sure why.



Women’s perceptions

Some women had different views from their doctors about the cause of their EM. Natalie was diagnosed with EM after a hysterectomy for endometriosis. However, she recalled experiencing menopausal symptoms two years beforehand following removal of a fibroid, and noted that her sister had experienced spontaneous EM. She reflected that, ‘[i]t just happened to be everything on top of each other, and that kicked [EM] off.’

Mary, who had a history of surgeries for ovarian cysts and benign tumours, shared her thoughts on why she experienced early menopause at age 39.



What is Ovarian Suppression Therapy?

Ovarian suppression therapy refers to any treatment that lowers or stops the amount of oestrogen made by the ovaries. It includes chemotherapy, radiotherapy, bilateral oophorectomy, and the use of certain drugs. Ovarian suppression can be permanent or temporary. Bilateral oophorectomy before the age of 45 causes early menopause (EM). Chemotherapy and radiotherapy before age 45 may cause EM. Women undergoing ovarian suppression therapy with gonadotrophin-releasing hormone (GnRH) agonists such as goserelin (ZOLADEX) for breast cancer or endometriosis usually experience menopausal symptoms; but they are not considered to have EM because the ovarian suppression is reversible when therapy is stopped. If women have chemotherapy followed by ovarian suppression therapy, they may develop EM due to chemotherapy, but EM may be hidden until their ovarian suppression is stopped and they find that their menstrual periods do not return.

Tamoxifen may cause menopausal symptoms as it has an anti-oestrogen effect on some parts of the body (breast and brain temperature regulation) but does not cause menopause itself. Aromatase inhibitors (e.g. exemestane, letrozole, anastrozole) block the chemical pathway producing oestrogen, causing very low oestrogen levels and thus menopausal symptoms, but do not cause menopause itself.

Terminology
Therapy involving GnRH agonists, tamoxifen or aromatase inhibitors, may also be referred to as “hormone therapy” or “adjuvant endocrine therapy”. The term “hormone therapy”, used to describe treatments where the aim is to block or lower oestrogen in the body, can be confusing as it is similar to the term “hormone replacement therapy” (HRT). However, HRT is designed to increase oestrogen levels to relieve menopause symptoms.

For more information

Talking Points (Women)

Talking Points (Health practitioners)

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