Breast cancer unfortunately
causes ovarian insufficiency.
I should say breast cancer treatment
typically causes ovarian insufficiency.
So in the course of the chemotherapy
regimen, most women will receive
a combination of alkylating
agents likely cyclophosphamide
which results in ovarian toxicity
or ovarian gonadotoxicity.
And so that can impact the
overall health of the patient,
Their bone health can be deleteriously affected
and it's recommended that primary care clinicians
refer postmenopausal breast cancer
survivors for a baseline DEXA scan.
You should repeat the DEXA every 2 years for
women who are taking aromatase inhibitors
or premenopausal women who were taking
Tamoxifen and/or a GnRH agonist
Unfortunately, infertility can be a
result of chemotherapeutic agents
and it's advisable that you refer patients
to a reproductive endocrinologist
and infertility specialist as soon as
possible prior to treatment ideally.
It's recommended that when attempting
to concieve, stop their Tamoxifen,
1-2 months prior to attempting
Breast cancer survivors should
be advised that although
cyclophosphamide and other
alkylating chemotherapeutic agents
can cause ovarian insufficiency or ovarian
failure, they still could become pregnant.
They should be advised to use
non-hormonal methods of contraception
including barrier methods such
as condoms and diaphragms
or the copper intaruterine
device and sterilization.
Hormonal methods can actually
propagate tumor cells.
There are guidlines that are published regarding
menopausal symptoms and sexual health.
Primary care physicians should assess sexual
dysfunction or problems with sexual intimacy.
There could be other contributing
factors for sexual dysfunction
and patients should be offered non-hormonal
water-based lubricants for vaginal dryness.
Patients who suffer from other issues should
also be referred for psychoeducational support,
group therapy, sexual counselling, marital
counselling and potentially intensive psychotherapy.
So there are other guidelines for
premature menopause or hot flashes.
SNRIs or Selective Serotonin
Norepinephrine Reuptake Inhibtors,
SSRIs which is Selective
Serotonin Reuptake Inhibitors,
Gabapentin, lifetyle modifications
and environmental modifications.
An example of an environmental modification
would be to keep your room cool at night
and to sleep in less clothing to keep
yourself cool, to not have hot flashes.
Let's go over a case.
This scenario is a 37 year old G0
or woman who's never been pregnant,
with ductal carcinoma in-situ with lobular
features who will have a bilateral mastectomy
and be treated with cyclophosphamide and
she's currently now taking Tamoxifen.
How would you counsel this patient?
What type of anticipatory
guidance would you give her?
Well, one - she's actually
had a bilateral mastectomy.
That could be a very disfiguring for a woman and you
may want to address some psychological concerns
that she may have that may
affect her body image.
In addition, she's actually
Cyclophosphamide as we've
reviewed is kinetic toxic
and she's not producing the
estrogen that she normally would.
So she may be experienceing these motor
symptoms, such as hot flushes and hot flashes,
she may be experiencing vaginal
and you know that bones are affected
by not having estrogen present.
and so when should she have a DEXA scan?
Normally if this patient has actually
already had cyclophosphamide,
she should have a baseline DEXA scan.
What about her fertility concerns?
As we've addressed previously, the
ovaries may not be functioning normally
and she can have either ovarian
insufficiency or ovarian failure.
So ideally, this patient should be counselled
before she undergoes any kind of treatment
to preserve her fertility either through oocyte
cropreservation or embryo cryopreservation.
If her treatment has already
happened and she's taking Tamoxifen,
she should stop Tamoxifen 1-2
months before planning to concieve.
What about her sexual health?
So we've talked about the fact that she is
hypoestrogenic, meaning her estrogen is low
because her ovaries have been
affected by cyclophosphamide
This can make sex very painful
- this is called dyspareunia.
So unfortunately, these women
cannot receive hormonal treatment
and so water-based lubricants are ideal for
treating this type of sexual dysfunction
Routine screening for other
cancers should occur.
At 50 if she's not African-American,
she should have a colonoscopy.
At 45, if this woman is African-American,
she should have a colonoscopy.
She should still have cervical screening
and she's over 21 which this case is,
she should continue to have