More women, and especially more premenopausal women,
are surviving their cancer diagnosis. However, due to their therapy, these women
may become symptomatic from iatrogenic ovarian failure. For some, the use of
hormone replacement therapy (HRT) is contraindicated because it may affect the
course of their disease. Other women and their physicians may feel uncomfortable
with the use of hormones because research is inconclusive regarding long-term
survival or disease recurrence. Women who experience a cessation of menses due
to adjuvant therapy for breast cancer are more likely than women undergoing a
natural menopause to experience severe hot flashes, night sweats, and
fatigue. However, nonhormonal interventions appear to benefit many of these
women and should be used to decrease their symptoms. Barton, Loprinzi, and
Gostout address these concerns in their excellent review and offer
recommendations for pharmacologic and nonpharmacologic interventions.
The treatment of hot flashes, probably the most common symptom associated
with menopause, is addressed in detail. In particular, the dosing information on
venlafaxine (Effexor), a selective serotonin-reuptake inhibitor (SSRI), is
helpful. A number of other SSRIs are also being investigated for the abrogation
of vasomotor symptoms, not only in breast cancer patients but also in men with
prostate cancer undergoing hormonal therapy. The SSRIs appear to be most
effective in controlling these symptoms.
However, side effects of SSRIs include difficulties with sexual arousal and
orgasm. This may complicate the treatment of other menopausal symptoms related
to sexual function. The authors appropriately mention their concerns regarding
the use of progestational agents to treat vasomotor symptoms, and the possible,
although unproven, risk of reducing breast cancer survival.
Vaginal Dryness and Incontinence
The management of vaginal dryness is also problematic. The most effective
therapies appear to be those that contain estrogen. The amount of estrogen
systemically absorbed from either the low-dose estrogen implanted ring (Estring)
or the vaginal tablet (Vagifem) is considered small, as discussed in the review.
Plasma estradiol levels do not increase significantly above baseline in most
postmenopausal women, possibly because current assays are not sensitive
enough. However, many oncologists and patients may feel uncomfortable with
the addition of any amount of estrogen that may be absorbed systemically.
In the excellent section on therapy for urinary incontinence, both stress and
urge incontinence are addressed with suggestions offered for pharmacologic,
nonpharmacologic, and surgical management of these symptoms. However, it should
be noted that the once-promising intervention phenylpropanolamine is now
considered by the Food and Drug Administration to be unsafe for use in women, as
it has been associated with an increased incidence of hemorrhagic stroke,
especially in younger women. The other alpha-agonists, such as pseudoephedrine,
have not been associated with this risk and may still be used.
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