European Breast Cancer Conference, Vienna, March 2012
Non-drug treatments to help alleviate symptoms of treatment-induced menopause
Dr Marc van Beurden – Netherlands Cancer Institute, Amsterdam
Due to the treatment, ovarian damage can occur and the result of that is that early onset of menopause will happen with primary menopausal symptoms like hot flushes, night sweats, vaginal dryness and urinary incontinence. Secondary symptoms include insomnia, weight gain, mood swings and compromised age-related quality of life. The hot flushes are the most disruptive and the cause of the menopause is disruption of thermoregulatory dysfunction in the hypothalamus, that’s a centre in the brain, due to changes in oestrogen level.
There are several medical treatments for menopausal symptoms, first of all hormonal replacement therapy which is, of course, for obvious reasons contraindicated for patients with breast cancer. There are several non-hormonal treatments like clonidine, which is an anti-hypertensive agent, and venlafaxine, which is an SSRI, an anti-depressant agent. Both can be effective but adverse effects may occur and limit their use. Moreover the two, clonidine and venlafaxine, their efficacy has not yet demonstrated in acute menopause and that’s the topic we are talking about.
There are two behavioural interventions for menopausal symptoms, that’s cognitive behavioural therapy and physical exercise. Cognitive behavioural therapy focuses on the relation between thoughts, feelings and behaviour, and the following strategies are applied. Information about symptoms is given, the symptoms are monitored, stress management and relaxation is applied, cognitive restructuring of automatic thoughts is discussed and the behavioural therapy strategies are encouraged. Physical exercise affects the thermoregulatory system by moderately intensive cardiovascular exercise.
The study aim was in the context of a randomised controlled trial to establish the efficacy of the intervention programme, cognitive behavioural therapy, physical exercise or a combination of those two versus usual care in reducing menopausal symptoms in women with primary breast cancer who undergo premature treatment-induced menopause.
More than 2,500 women were retrieved retrospectively by hospital registries and prospectively by their physicians and they received a letter with the information about the study and the question if they suffered from menopausal symptoms like hot flushes, night sweats and vaginal dryness. 1,500 women returned the questionnaire and all those women were phoned and they were asked about if they had any more questions and if the eligibility symptoms were really present. 603 of those 627 women agreed to fill in a baseline questionnaire and an informed consent, of whom 422 really did. Those 422 were randomised between cognitive behavioural therapy, physical exercise, the combination or the control. More than 80% of those women filled out the follow-up questionnaires at twelve weeks and at six months. After the programme the waiting group, the control group, could go for the physical exercise programme or for the cognitive behavioural therapy programme.
The CBT was given by social workers and psychologists in six weekly group sessions of 1.5 hours per session with 6-8 participants per group and they had homework, those homework assignments were 15 minutes per day. The programme was focussed on hot flushes, night sweats and relaxation.
The physical exercise was given by a physiotherapist who saw the patients, who had a contact with the patients four times: at intake, two times by telephone and after the treatment period by an end evaluation and the patients could choose their favourite exercise so it was individually tailored. They had to train 2.5 – 3 hours per week for twelve weeks with a heart rate of 60-80% of their maximum heart rate and that was monitored by a heart rate monitor.
Here are the results. Cognitive behavioural therapy and physical exercise, either alone or in combination, have a clinically significant positive affect on menopausal symptoms and urinary symptoms. Sexuality is also positively affected, particularly by cognitive behavioural therapy, and physical exercise has a sustained positive effect on physical functioning. The problem is the adherence and we are currently investigating by internet programmes if we could enhance the adherence of those patients that suffer from those menopausal symptoms.
Thank you very much.