Chemo-Related Amenorrhea ‘Not Just About Having a Period’

Chemotherapy-related amenorrhea in premenopausal women with breast cancer is more than just a missed period, an expert explained.

In premenopausal women with breast cancer, having persistent chemotherapy-related amenorrhea (CRA; absence of menstruation during reproductive years) is common, although researchers have found that menstruation cycles may return later, according to a study.

Researchers have determined that because persistent CRA is common among premenopausal women with breast cancer, factors including quality of life, seeking counseling and discussions about fertility are important.

A study published in JAMA Network Open included 1,636 premenopausal women, of which 1,497 women had their menstrual cycle at one year after evaluation, 1,323 at two years and 906 at four years. Regarding CRA, the researchers found that 1,242 women reported CRA at one year after evaluation, 959 women at two years and 599 women at four years. The average age within the cohort was 42.2 years.

The study’s researchers noted that quality of life was affected by CRA, specifically because the symptoms they experienced were associated with premature menopause and diminished ovarian reserve.

“When a woman gets cytotoxic, chemotherapy or hormonal therapy, even with things like tamoxifen, their periods may stop, either temporarily or permanently. And obviously, you don't know if it's permanent until it's permanent,” Dr. Ann Partridge said during an interview with CURE®.

Partridge is a professor of medicine at Harvard Medical School, vice chair of medical oncology at Dana-Farber Cancer Institute and serves as the chief scientific advisor for Susan G. Komen.

She noted that when patients experience temporary or permanent menopause from CRA, they will likely experience symptoms of low estrogen, which could affect their quality of life.

“These are similar symptoms to what people experience when they are on tamoxifen, or when they are given an aromatase inhibitor in the postmenopausal setting, which includes hot flashes, vaginal dryness, musculoskeletal complaints, insomnia — for some, a lot of that has to do with the hot flashes — and other associated symptoms including sexual dysfunction when people are having vaginal dryness, among other symptoms. So, it can be very challenging,” Partridge explained.

Seeking counseling from several doctors is important, Partridge said.

“It's crucial that oncologists inform (their patients) of (CRA) and help to manage the symptoms of their treatments. Having a gynecologic doctor or provider is important when symptoms need help with management, number one,” she explained. “Number two, the gynecologist needs to know in breast cancer survivors that we don't generally want to give hormones back, although sometimes we do. And so, you have to find other ways to manage it. Certainly, you want (patients) to be examined to make sure that there's nothing else going on.”

However, Partridge also emphasized that having discussions about fertility via gynecologic counseling is crucial, whether patients want children or not.

“If a person's interested in future fertility, then (they) want to preserve eggs or embryos ideally before chemotherapy if that person's at significant enough risk to go into permanent menopause, which is associated, obviously, within fertility, or even some fertility and it's not permanent menopause, they may be less fertile, and therefore, they will become less fertile over time.

“So (they’re) probably going to have to wait a couple of years to get pregnant, then they may be less fertile over time. So, they may want to preserve for that reason alone, and now of course added to toxic chemotherapy, and they need more fertile with time and the treatments. So you want to bring in a gynecologic team to help with that too. The reproductive endocrinologists do a lot of the fertility preservation beyond ovarian suppression treatment through chemo, which is what oncologists can do,” Partridge said.

For patients who may experience temporary CRA, Partridge said that “it’s not just about having a period.”

“It's also about whether or not someone can potentially have a biological child if they want one. And the safety and feasibility of that is related. If someone's not interested and/or we all decide it's not a safe thing to get pregnant, then having appropriate contraception (is necessary). If this person's not having a period at a year, and we don't know this, but their ovaries are going to wake up in a year or two, then (we) want to make sure that they're using appropriate contraception.”

Overall, Partridge advises patients with CRA to manage related symptoms with their oncologist and receive care from a therapist if they experience emotional components of CRA.

“Be as proactive as possible with regard to symptom management, especially sexual health because it's something that doesn't get better on its own, typically. It's often more than just the vaginal dryness symptom because there are a lot of things that can be at play — both emotionally and physically.

“Breast cancer survivors are getting (more) involvement not just to the oncologist, but sometimes the therapist and a gynecologist and others. If they're experiencing CRA-associated symptoms, and especially if they're experiencing psychosocial, emotional components of that, to not be afraid to discuss that and make sure that they can tolerate their (treatment),” Partridge noted.

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