Life after breast cancer surgery

In this section you'll learn more about emotions you may experience after breast cancer surgery and find links to information to help you cope.

Emotional effects

Breast cancer surgery can be a deeply traumatic experience. You may feel that your breasts are very important to your idea of yourself as a woman. The first months are likely to be very upsetting. Many women have conflicting emotions, such as grief, fear, shock, anger and resentment. These emotions may be mixed with relief that the cancer has been found and treated.

Coping with a changed appearance

Any change to your appearance may lower your self-confidence, and you may need time to come to terms with this. Women find different ways of dealing with the change to their bodies. Some prefer to see the results of the surgery for the first time alone. Other women may want the support of a partner or close friend, or doctor or nurse, when they take their first look at the scar.

Effects on your sex life

Although breast surgery will not affect your physical ability to have sex, the emotions you feel may reduce your desire for sex for a while. Women often need to feel relatively happy with their bodies to have a fulfilling sex life. Fear that a partner - even a long-standing one - may be put off by scars or a change in body shape, can make women very nervous about letting anyone see or touch their body. There is no right or wrong time to take this step. You can wait until you and your partner feel ready.

Our section on sexuality and cancer discusses these issues in detail.

While you are still in hospital, the nurses can prepare your partner for how the scar may look. A nurse, or your doctor, can be with you both when you let your partner see it. Alternatively, you may prefer a close relative or friend to be there and talk it over with you both afterwards.

Getting on with life

You will find that the difficulties and emotions get less with time. After the operation, the swelling will go down, the bruising will fade and the scar will gradually become less obvious. As you become more used to the soft breast prosthesis, your confidence should gradually come back.

Getting used to having had breast cancer can take months or years. The emotions and anxieties may come back each time you have to go for a follow-up appointment or if you see cancer mentioned in papers, magazines or on the television.

Many women cope well with the surgery and treatment for breast cancer. This is partly due to support from hospital staff and friends and family. However, women are often surprised that they find it very difficult to cope once the treatment has finished. Instead of feeling able to forget about the cancer and get on with normal life, it is common to feel anxious and tearful for a while once the treatment is over.

Some women are very anxious that the cancer may come back. They worry that any ache or pain is a sign that the cancer has returned. Anxieties and worries can make it hard to sleep. It is not unusual to feel depressed and isolated. These feelings can often feel worse at night.

After breast cancer surgery you may feel emotionally and physically drained. It is important for you to allow yourself plenty of time to recover and to get help if you feel you need it.

Our booklet on adjusting to life after cancer discusses how to cope once treatment has finished.

After radiotherapy

This information is for women who are concerned about the possible long-term (delayed) side effects of radiotherapy to the breast. With modern day radiotherapy equipment and the careful preparation and planning done before radiotherapy for breast cancer, most of these side effects are very uncommon, and most that do occur are treatable.

If you develop any new symptoms after your treatment is over, or if you are concerned that the side effects you developed during your treatment are not clearing up, you should contact your doctor, radiographer or nurse at the hospital for advice. There is often a simple explanation for these symptoms and they do not necessarily mean that you are developing long-term side effects.

Possible long-term side effects include:

• Skin reactions
• Breast changes, including swelling and shrinking
• Soreness or pain
• Restricted shoulder movement
• Changes in the way your heart works
• Breathlessness due to lung problems
• Effects on the bones
• Swelling in the arm (lymphoedema)
• Numbness or tingling in the hand, arm or shoulder (brachial plexopathy)
• Radiation-induced second cancers

We also have information on feelings you may have if your radiotherapy treatment causes long-term side effects.

Changes to the skin

During treatment some women develop a skin reaction similar to sunburn, known as erythema. Pale skin may become red and itchy, and darker skin may appear darker with a blue or black tinge. Usually this side effect will settle down two to four weeks after radiotherapy, but sometimes it can continue. A few women find that their scar remains tender or sensitive for some time after radiotherapy.

Some women may develop changes which can include red blotches on the breast caused by dilated blood vessels under the skin. This condition is known as telangiectasia. Although this affects how the breast looks, it shouldn't cause any other problems.

Skin care

If you have a skin reaction, your doctor, nurse or the radiographer will give you advice on how to look after your skin. The following tips may be helpful:

• avoid using perfumed soaps, talcum powder and deodorants/antiperspirants until the reaction has settled
• avoid shaving under your arm on the affected side
• showers are better than baths, and you should avoid soaking the affected area for too long if you have a bath
• after washing, pat the area dry rather than rubbing it with a towel
• loose clothing may be more comfortable to wear
• avoid exposing the area to strong sunlight for at least a year, as your skin will continue to be more sensitive.

Breast changes

Most women will develop changes in the look and feel of their treated breast due to radiotherapy, although for many women these changes are very slight.

Breast swelling

A few women will develop swelling of the breast area during, or shortly after treatment. The swelling is known as oedema, and it should go away a couple of months after treatment has finished.

Sometimes, a different type of swelling called lymphoedema can develop. This can occur if the lymph nodes have been removed or are damaged by radiotherapy, causing a build-up of lymph fluid. It more commonly affects the arm, but can also cause swelling of the breast. Lymphoedema can develop many months or years after treatment has finished. Talk to your breast care nurse or doctor if you think you may have lymphoedema. If necessary they can refer you to a lymphoedema specialist.

Shrinking of the breast

It is fairly common for the breast to shrink slightly over time, but for it to feel the same. A few women may develop a hardening or thickening of the breast tissue (fibrosis). This can cause the breast to become harder and smaller than it was, although the effect is mostly very mild. In severe cases this can make the breasts look very different to each other.

It is fairly common for a woman's breasts to get bigger as she gets older, or if she puts on weight. A breast that has been treated with radiotherapy may not increase in size as much as the untreated breast. If this is a problem for you, talk to your doctor or breast care nurse, as surgery can sometimes be done to correct an imbalance.

Soreness or pain

Many women find that the area in the breast that has been treated feels uncomfortable or sore. This tends to become less of a problem year by year. If this occurs and is causing you a problem, your doctor can prescribe painkillers to help relieve any pain. Some women find that the pain can be relieved by wearing a support bra. It can also help to wear a soft bra at night, but to make sure it has no under-wire.

Restricted shoulder movement

Radiotherapy can affect how well you can move your shoulder. It is fairly common for women who have radiotherapy to the underarm (axilla) to experience some restriction in shoulder movement, especially if they have had surgery to their underarm area as well. This may make it difficult to carry heavy bags, do household chores or some types of exercise, such as swimming. A physiotherapist can show you exercises to help improve the movement of the shoulder.

Changes in the way your heart works

There is a very small risk of damage to the heart muscle or the major blood vessels around the heart. This is only a possible problem if you have had cancer in your left breast, as the heart is on the left side of the chest. Radiotherapy is now very carefully planned so that the heart is not within the radiation area. As a result, the risk of developing any heart problems has been greatly reduced.

If your heart has been damaged by radiotherapy you may find that you get tired very easily or get breathless when climbing the stairs. You may also notice that you sometimes feel dizzy or get chest pains. It is important to remember that these symptoms can be caused by many things and that they are not always a result of damage to the heart.

Treatment for heart changes

The treatment will depend upon the part of the heart that has been damaged and how it is affecting you. You may just be advised to avoid things that could cause further damage, such as alcohol, smoking and stress, or to improve your diet.

Treatment may include medicines to improve the heart rhythm (anti-arrhythmics), or improve the blood flow around the heart to help reduce chest pain (anti-anginals).

Your doctor or nurse will explain more about the treatment that you need and can answer any questions you may have.

Lung problems

Approximately one in 50 women develop symptoms such as breathlessness, a dry cough or chest pain. These symptoms may happen because the radiotherapy can affect the cells lining the lungs, causing inflammation or a hardening and thickening (fibrosis). If you are going to get these symptoms, they usually develop two to three months after the radiotherapy has finished. The changes are usually temporary, lasting a month or two, but occasionally can become a long-term side effect.

Your risk of developing lung problems is slightly higher if:

• radiotherapy is also given to the lymph nodes in your chest area
• you are older when you have the treatment
• if you have had chemotherapy.

These symptoms may be made worse if you already have a lung problem such as asthma, or if you smoke.

Treatment for lung problems

Most lung problems are treatable, and it is unusual for them to remain a problem over time. Treatment depends on exactly what is wrong with your lungs and may simply involve advice on cutting down or giving up smoking and maintaining a healthy weight.

You may be given inhalers that contain drugs to help open up the airways (bronchodilators). Steroids can be given as tablets or inhalers to reduce inflammation. You may be given antibiotics if you have an infection in the lung.

Your doctor or nurse will explain more about the treatment you need and will teach you how to use an inhaler if necessary.

Effect on the bones

A rare late side effect of radiotherapy to the breast is damage to the bones, especially the ribs and collar bones. This affects fewer than one in 100 women. The bones can become thinner and more brittle. If this happens, it can cause pain and make it hard for you to lift heavy objects or to exercise. The bone may become infected and may break if it is weakened enough. This is rare.

It is important to be aware that this problem can occur, so that if you have any symptoms you can get them checked by your doctor. Radiotherapy damage to the bones is uncommon so it is likely that if you have any symptoms they will have another cause.

Treatment for bone damage

You may be treated to relieve any symptoms that occur. This may involve taking painkillers or anti-inflammatory drugs. Sometimes calcium supplements, vitamin D, or drugs called bisphosphonates, which can help to strengthen the bones, may be helpful.

Very rarely, if the bone has been severely damaged, a treatment known as hyperbaric oxygen therapy may help to prevent further weakening of the bone and improve symptoms. This is a new type of treatment, and the exact benefits are still being researched. It is not available in many places in the UK. The treatment involves being given high concentrations of oxygen while under pressure in a hyperbaric chamber. The chamber is similar to those used to treat divers who have decompression illness (the 'bends'). The treatment may help the bones to repair.

If you have pain, this can usually be controlled with painkillers. If the bone is infected, it can often be treated with antibiotics. You may also need to see a physiotherapist or occupational therapist if the damaged bone is making it difficult to carry out daily activities. Very occasionally surgery may be suggested to remove the damaged ribs.

Lymphoedema in the arm

Lymphoedema can occur in women who had radiotherapy to the armpit (axilla) as part of their treatment for breast cancer. Some women have radiotherapy after having a few lymph nodes removed from under the arm; in this situation, lymphoedema is uncommon, affecting approximately one in 25 women. In women who have radiotherapy after removal of most or all of their lymph nodes, lymphoedema is more common, affecting one in three women.

Lymphoedema in the arm can also occur after radiotherapy to the breast and chest wall, but this is very rare.

Treating lymphoedema

If you develop lymphoedema, you will usually be referred to a lymphoedema specialist for treatment and advice. This may be a nurse, physiotherapist or doctor. The treatment will depend upon how much lymphoedema you have, and aims to help reduce the swelling, prevent further swelling and to relieve any discomfort. There are four main types of treatment:

• care of the skin
• supporting the arm using compression stockings or bandages
• positioning and movement, or exercising the arm
• a particular type of massage called manual lymphatic drainage (MLD) or simple lymphatic drainage (SLD).

We have a separate booklet on lymphoedema you might find helpful, including tips for preventing it and how it's treated.

Numbness, pain and weakness in the arm

About one in 100 women who have radiotherapy to the underarm as part of their treatment will develop some numbness and tingling in the hand; weakness in the hand; or pain around the shoulder, arm or hand. These symptoms will usually be quite mild but very occasionally may be more severe and troublesome.

They are due to damage to the nerves going into the arm, which can sometimes occur after radiotherapy to the armpit. These nerves are known as the brachial plexus, and the long- term side effect is often called radiation-induced brachial plexus neuropathy or brachial plexopathy.

Treatment of brachial plexopathy

Usually this is a mild symptom, but if severe brachial plexus neuropathy develops it can't be reversed. However, treatments can help to control symptoms such as pain, and make the practical aspects of life easier.

One of the priorities of treatment is to find the best way of controlling the pain. People often describe the pain as 'shooting' or 'burning', but you may also have pins and needles, numbness or tightness. There are various painkillers that may be helpful, depending upon how severe the pain is, and your doctor will be able to give you advice on these. Your doctor may prescribe low-dose antidepressants or antiepileptic drugs, as these can be effective in controlling nerve pain. You may be referred to a specialist pain clinic for further advice.

Your doctors may also suggest other treatments, such as massage or applying heat and cold to the painful areas. Another possibility is using a TENS (transcutaneous electrical nerve stimulation) machine. This can be very effective at relieving pain. It involves placing sticky pads that contain electrodes onto your skin. A weak electrical current is passed through the pads. The electrical current can make the body release its own natural painkillers (endorphins), which can help to control pain.

Some women find acupuncture helpful, and some GP or hospital clinics now offer this. Other complementary therapies may also be useful, but you should always discuss these with your doctor first.

You may be referred to a physiotherapist and an occupational therapist (OT). A physiotherapist will help you to keep your arm as mobile and strong as possible. This will involve exercises to strengthen the muscles and keep them supple. The physiotherapist will also be able to show you how to use slings or splints to support your arm. The OT will assess how the nerve damage has affected the use of your arm, and look at how this interferes with your daily life. The physiotherapist and OT can then suggest practical ways of helping you to carry on as normally as possible.

Radiation-induced second cancers

This is a very rare long-term problem following radiotherapy for breast cancer. Fewer than one in 1000 women will develop a second cancer, known as a sarcoma, within the treatment area. This can occur many years later. Secondary cancers are very rare but any new symptoms should always be checked with your doctor.

Your feelings

You may have all kinds of emotions if you are diagnosed as having damage caused by your radiotherapy treatment. Radiotherapy damage is uncommon, and it can take a long time to find out that the problem is related to radiotherapy. You may feel angry about this. You may be relieved that you now know the reasons for your symptoms, or feel cheated that you have survived cancer only to be damaged by the treatment. You may be worried about how you will cope with any disability or about money problems if you have to give up work.

These are all normal reactions and part of the process that many women go through. Everyone has their own way of coping. Some women find it helpful to talk to friends or family members, while others prefer to seek help from people outside their situation, such as counsellors. Other people prefer to keep their feelings to themselves. There is no right or wrong way to cope, but help is there if you need it.

Fertility after breast cancer treatment

Breast cancer treatment can affect a woman's ability to have children (fertility). If you want to have a children, be sure to talk to your doctor about the effects your treatment is likely to have. If your treatment is likely to cause infertility, your doctor can refer you to a counsellor for support and a fertility specialist to discuss options such as egg and embryo storage.

Contraception

It is important not to get pregnant while having chemotherapy treatment for breast cancer, as some treatments can cause harm to a developing foetus. But women who have had breast cancer are usually advised not to take the contraceptive pill because of the risk that the hormones (oestrogen and progesterone) in the pill may stimulate the growth of breast cancer cells. Your cancer specialist or GP can give you advice on contraception.

Choice of contraception

Barrier methods of contraception such as condoms or the cap are the most suitable. Lubricating jelly (available without prescription from the chemist) is completely safe to use with barrier contraceptives if extra moisture is needed during sex. Your GP can also fit you for a cap if this is the method of contraception you choose. Coils (IUDs) can be an effective alternative method of contraception, and your GP can fit you with one. Some women choose to be sterilised (tubal ligation) to prevent the risk of pregnancy.

The choice of an effective contraceptive is a very personal one. Your likes and dislikes, and those of your partner, are obviously important. Some women may also choose to take into account religious and moral considerations. Unfortunately, the withdrawal and rhythm methods of contraception are not safe enough to be effective as protection against pregnancy. Some women find that, if necessary, talking through their situation with their religious leader or a trained counsellor helps them to find acceptable alternatives.

Pregnancy after treatment

Research suggests that becoming pregnant after treatment for breast cancer does not make the breast cancer more likely to come back.

If you want to have a child, it's important for you and your partner to discuss this with your breast cancer specialist, who knows your full medical history and can talk over the risks and implications. It's usually advisable to wait a while after your initial treatment has finished before trying to become pregnant. The longer you are free of the cancer, the less likely it is to come back. However it is very important to carefully consider what might happen if, after having a baby or while pregnant, the cancer did come back, and whether you want to take that risk.

Infertility

Unfortunately, women who have had radiotherapy to their ovaries or an operation to remove their ovaries will not be able to have children naturally. Sometimes chemotherapy can also cause infertility by bringing on an early menopause. Generally, the older a woman is when having chemotherapy the more likely she is to be infertile afterwards.

Becoming infertile can be very hard for some women to live with - whether or not they already have children. Fertility is a very important part of many people's lives, and not being able to have children can seem especially hard when you already have to cope with cancer. Some people find it helpful to talk through their feelings about this distressing situation.

Egg or embryo storage

If your treatment is likely to make you infertile, and you would like to have children in the future, it is sometimes possible to remove eggs from the ovaries, fertilise them and store the embryos to use later. It is also sometimes possible to store unfertilised eggs, although this is very experimental. Eggs need to be removed before you start treatment.

At a later date the fertilised eggs can be thawed and implanted into the womb to start a pregnancy. These techniques may allow some women with breast cancer, who had become infertile due to treatment, to have children in the future. If you want to have children it's very important to discuss this with your doctor before treatment begins. Your doctor can refer you to a fertility specialist for advice on the possible options available to you.

Lymphoedema and breast cancer treatment

Lymphoedema is a type of swelling of the arm or hand that sometimes happens as a result of breast cancer treatment. It can occur if the lymph nodes in your armpit have been removed by surgery, or you have had radiotherapy to the armpit. It is usually mild and develops gradually a few months or several years after treatment. Lymphoedema is more likely if you have had both surgery and radiotherapy to the underarm.

Sometimes swelling of the arm may occur after the initial surgery, but this usually goes back to normal within a few weeks and is not lymphoedema. If you are concerned about any swelling, get it checked by your doctor or nurse.

If your arm is swollen because of lymphoedema it may become stiff, uncomfortable and awkward to move. This can make daily activities like dressing difficult. The skin of your arm may become tight and stretched. Once lymphoedema occurs it can never be completely cured. However, many things can be done to help reduce the swelling and discomfort and allow women to use their arm normally.

If you have lymphoedema, the arm and hand are more prone to infection. These simple tips can help you look after your skin and reduce the risk of infection.

• Treat even small grazes and cuts with antiseptic and keep them clean until they heal.
• See your GP at the first sign of any infection - if the cut is inflamed or feels warm and tender.
• Avoid getting sunburnt.
• Wear gloves for washing up, DIY and other household tasks.
• Try to avoid being scratched - wear gloves and long-sleeved clothing when handling animals or gardening.
• Use a thimble if you sew.
• Use an electric razor if you shave under your arms.
• Keep your skin clean and dry and use moisturising cream daily to keep it supple.
• Use nail clippers instead of scissors to cut your nails.
• Never push back or cut the cuticles - use cuticle cream instead.

Breast cancer treatment and menopausal symptoms

Overview

Some of the treatments for breast cancer, including chemotherapy and hormonal therapy, can affect the function of the ovaries or the level of hormones in the body. As a result, you may begin your menopause earlier than expected, or have menopausal symptoms due to the treatment itself.

The change in hormone levels can cause a number of symptoms. These can include:

• hot flushes and sweats
• vaginal dryness
• passing urine more often (increased frequency)
• lower sex drive
• tiredness
• sleeplessness
• dry skin
• aches and pains
• mood swings
• poor concentration
• loss of confidence and memory.

Women may have one or more of these symptoms, and symptoms can range from being very mild to more severe. There are different ways of controlling these symptoms . Some women find complementary therapies helpful.

Menopause, particularly if it occurs early in life, may cause other effects on the body, such as thinning of the bones (osteoporosis) and heart disease. These effects develop at different rates in different people. Their tendency to develop is, at least partly, passed on from your parents (genetically determined).

Women who have had breast cancer are usually advised not to take hormone replacement therapy. However, if you have troublesome menopausal symptoms, medicines can be used to treat them.

Breast cancer treatments and menopause

Women naturally stop having regular periods, usually at some time between their mid-40s and mid-50s. The menopause, or change of life, happens because the ovaries stop producing the sex hormones oestrogen and progesterone .

The following breast cancer treatments also can affect the levels of these hormones in the body:

Stopping the ovaries from working (ovarian ablation)

Women who develop breast cancer at a young age may be advised to have treatment to stop their ovaries producing oestrogen , as oestrogen could stimulate the growth of breast cancer cells. The ovaries can be permanently stopped from producing oestrogen, using surgery or radiotherapy:

• Surgery will bring on a sudden and permanent menopause. Menopausal symptoms may start within a few days of the operation.
• Radiotherapy will bring on the menopause, although it may take a few months before menopausal symptoms occur and your periods stop.

Chemotherapy

Some chemotherapy drugs will stop the ovaries from working. This can be temporary, but the nearer you are to your natural menopausal age, the more likely it is to be permanent. If it is permanent, the treatment will bring on the menopause and you may develop some of the symptoms described earlier. Even if the treatment does not cause an immediate menopause, it may prompt the menopause start earlier than it would otherwise have done.

It is not possible to predict before your treatment whether the chemotherapy will affect you temporarily or permanently. Your periods could return to normal in time, so you could still get pregnant and should use contraception after your chemotherapy has ended.

Hormonal therapy

Because the sex hormones oestrogen and progesterone can affect the growth of breast cancer cells, treatments for breast cancer often involve hormonal therapy that blocks oestrogen from getting to breast cancer cells, or reduces the level of oestrogen in the body. These treatments may cause an early menopause or menopausal symptoms.

The two main types of hormonal therapy used to treat breast cancer are:

• drugs that block oestrogen from attaching to the cancer cells (anti- oestrogen drugs)
• drugs that stop oestrogen from being produced.

Anti-oestrogen drugs

Hormonal therapy drugs that block the effects of oestrogen (such as tamoxifen ), may cause side effects similar to the symptoms of the menopause. Periods may become irregular or sometimes stop (this is uncommon). However, if the treatment is ended, the menopausal symptoms usually stop - although this can take a few months.

As with chemotherapy, the nearer you are to your natural menopausal age, the more likely it is that hormonal therapy will bring on an early menopause, and that your periods will not start again when treatment has ended. Women who have already had their menopause may have menopausal symptoms again when they begin hormonal therapy.

LHRH analogues

LHRH analogues such as goserelin (Zoladex®) , stop the ovaries from producing oestrogen altogether, but unlike surgery or radiotherapy, this is reversible. These drugs cause menopausal symptoms while you are taking them. However, your periods usually start again when treatment is stopped.

Women who are close to their natural menopause when they start treatment may find that their periods do not begin again after treatment.

Coping with menopausal symptoms

• Hot flushes and sweats
• Vaginal dryness
• Dry skin
• Difficulty sleeping
• Psychological effects
• Hormone replacement therapy
• Your feelings

In this section you will learn about menopausal symptoms that can result from breast cancer treatment, including ways to control them.

Hot flushes and sweats

These are the most common menopausal symptoms, although the exact cause is unknown. Body temperature control seems to be affected by falling oestrogen levels. It is difficult to stop hot flushes and sweats, but their frequency or intensity can often be reduced.

There are a range of medicines that your doctor can prescribe, to try to reduce the severity and number of flushes and sweats.

• Research trials have shown that low-dose progestogens (megestrol acetate, norethisterone and medroxyprogesterone acetate) can help some women. However, they can take at least 3-4 weeks to reduce the number of hot flushes and sweats. Some women have an initial increase (or flare) in the number of the flushes that they have. Other side effects such as breast tenderness and a bloated feeling can also occur.
• Antidepressants such as venlafaxine (Efexor®) may also be helpful when given in low doses. Some women have found that they reduce the number and severity of hot flushes, although research trials have shown differing results. These drugs can take several weeks to work and can cause side effects, such as sickness (nausea), a dry mouth, and a decreased appetite. Your doctor or breast care nurse can discuss the possible side effects with you.
• Clonidine (Catapres®, Dixarit®) is a drug that is usually used to treat high blood pressure or migraines, and it is sometimes prescribed for hot flushes and sweats. However, it can take four weeks to work, and for a lot of women it may not work at all, or only work for a short while. Side effects include constipation, a dry mouth, and drowsiness.
• Tibolone (Livial®) is a type of hormone replacement therapy (HRT) that does not contain oestrogen and does not cause a monthly bleed. It can help to reduce flushes and sweats, and may also protect against bone thinning (osteoporosis). It may also help to reduce feelings of depression, and improve your sex drive. However a large research study has recently found that tibolone increases the risk of breast cancer coming back. Especially for those women taking hormonal treatments like tamoxifen, anastrozole, letrozole and exemestane. You may wish to discuss this further with your specialist. Possible side effects include weight gain, fluid retention, dizziness, irregular vaginal bleeding, headaches, increased growth of facial hair, joint pains, and skin rashes.
• Other types of HRT can be prescribed if the symptoms are severe and nothing else helps. However, taking HRT that contains oestrogen after you have had breast cancer can increase the risk of the cancer coming back if your cancer is oestrogen-dependent. Your cancer specialist can discuss with you the possible benefits and risks of HRT in your situation. You may be offered HRT as part of a clinical trial.
• Progesterone cream, when applied to the skin, may help to reduce hot flushes. However, research trials have not proved that this cream provides any benefit.

Helpful tips for reducing hot flushes and sweats

• Wear several layers of light clothing (preferably cotton) that you can easily take off or put back on, depending on your body temperature.
• Cut down on alcohol and hot drinks that contain caffeine, such as coffee and tea. Sipping cold drinks may help.
• Avoid spicy foods.
• Lukewarm showers and baths are less likely to trigger sweats than hot ones.
• Flushes and sweats are often worse at night. Put a soft cotton towel on your bed that you can easily change if it gets wet during the night.
• Lowering the room temperature and making sure there is good air circulation, by opening a window or using a gentle fan, can sometimes help.
• A yoga breathing technique known as the 'cooling breath' or sheetali, can help to reduce your body temperature. Contact the British Wheel of Yoga (BWY) to find a registered yoga teacher.
• If you are taking tamoxifen, changing the brand, or having half the dose in the morning and half in the evening, can sometimes reduce hot flushes and sweats. Halving the daily dose may help some women.

Vaginal dryness

A low level of oestrogen in the body causes vaginal dryness, and sometimes itching. Some creams can be helpful when applied directly to the vagina (topical treatment).

Some of the creams contain a small amount of the hormone oestrogen. The long-term risks of using creams containing oestrogen after breast cancer are unknown. There is a possibility that these products could increase the risk of the cancer coming back, although this is uncertain. Topical oestrogen treatments may also affect the cells that line the womb.

Your doctor can tell you which of the products below is most suitable for you. Your treatment should be regularly reviewed by your doctor, and you should tell them about any new symptoms.

Some of the creams may damage condoms and diaphragms, so care should be taken to avoid pregnancy.

• Replens MD® is a non-hormonal cream that you apply 2-3 times a week. The cream binds to the vaginal wall and helps to rehydrate cells. It boosts blood flow in the vagina.
• Vagifem® is a tablet that you insert into the vagina (a pessary). It is normally used daily for two weeks, and then dosage is reduced to just twice a week. A small research study has shown that Vagifem can increase the amount of oestrogen circulating in the body. Because of this risk, Vagifem may not be recommended for women who are taking aromatase inhibitors, such as anastrozole (Arimidex®), exemestane (Aromasin®), or letrozole (Femara®). Your specialist or breast care nurse can give you further advice and information about this.
• Ovestin® and Ortho-Gynest® are creams, or pessaries, that can reduce dryness and itching for a short time. They contain a small amount of oestrogen.
• Estring® is a vaginal ring that is worn for three months. It slowly releases a small amount of oestrogen and may help to reduce dryness.
• Water-based lubricants such as Senselle®, KY-Jelly®, Astroglide® and Sylk® can help to reduce discomfort from vaginal dryness during sex.

Dry skin

A little baby oil, or a few drops of bath oil in your bath, helps to moisturise the skin. Some women have found taking one or more of zinc, vitamin B, and linseed oil supplements helpful.

Difficulty sleeping

You may experience sleeplessness, due to hot flushes and sweats or anxiety. The following suggestions may help you to relax and sleep well, and can help you to feel more in control during the day:

• Have a lukewarm bath to relax before bedtime
• A warm herbal or milk drink before bed can help you to relax
• Wear nightwear that is made of absorbent lightweight cotton.
• If you can't sleep, don't just lie in bed - get up and read, listen to the radio or audio-books, or watch TV until you feel sleepy.
• Your GP can prescribe sleeping tablets for a short period of time; these may help to re-establish a sleep pattern.
• Techniques such as listening to relaxation tapes/CDs, doing relaxation exercises, visualisation, massage or meditation can help to reduce anxiety and sleeplessness.

Psychological effects

The psychological effects of menopausal symptoms can be hard to cope with when you already have to deal with the physical effects of cancer.

Some menopausal symptoms are very difficult to deal with. These include a lower sex drive, mood swings, poor confidence and a loss of concentration and memory. You may feel very emotional or anxious without really knowing why. These symptoms may be quite distressing for you and for your partner, if you have one.

A number of organisations provide support to women going through the menopause. Helpful books are also listed later in this section.

HRT is probably the only effective way of treating severe psychological menopausal symptoms. You will need to discuss with your cancer specialist whether or not HRT is appropriate for you.

Hormone replacement therapy

Women who have had breast cancer are usually advised not to take hormone replacement therapy. This is because there is a risk that the oestrogen it contains can increase the chance of the cancer coming back.

However, if you have troublesome menopausal symptoms, medicines can be used to treat them. If the menopausal symptoms continue despite the medicines, your doctor can prescribe a short course of low-dose progesterone to deal with these. It is important that your progress is very carefully monitored if you take HRT.

Your feelings

Coping with menopausal symptoms after cancer treatment can often be very difficult. You may feel anxious, angry, or frustrated that you are now having to cope with more symptoms. These are all normal reactions.

An early menopause and infertility are often difficult to come to terms with, particularly for women who hoped to have children, or who would have liked to have more children. Many people find it helpful to talk through their feelings with their doctor or nurse, or with friends and family members.

Reducing long-term complications

An early menopause can increase your risk of bone thinning (osteoporosis) and heart disease. There are ways of reducing these risks.

Osteoporosis

Oestrogen helps to maintain bone calcium levels and bone density. The risk of osteoporosis therefore increases after menopause. Regular weight-bearing exercises such as walking, dancing, hiking and gentle weight-lifting help to maintain bone density. Swimming is not so helpful, as your bones are not supporting your weight while you swim. If you already have osteoporosis you should avoid exercises that put too much strain on your bones, such as jogging. A physiotherapist or your breast care nurse can give you further advice about exercise after breast cancer.

It is important to make sure that you get enough calcium and vitamin D in your diet. Dairy products are the best source of calcium but, if you prefer not to eat them, you can get calcium from eggs, green leafy vegetables, nuts, and whole fish such as whitebait, sardines, and pilchards. Vitamin D helps the body to use calcium effectively. A well-balanced diet will normally give you all the calcium and vitamin D you need, but calcium and vitamin D supplements may also be helpful. Be aware that smoking and drinking alcohol can reduce your calcium levels.

If other people in your family have had osteoporosis, you may wish to talk to your cancer specialist about using medicines such as bisphosphonates. These drugs can help to prevent osteoporosis and reduce bone weakening.

The drug tamoxifen , which is commonly used to treat breast cancer, helps to protect the bones in post-menopausal women. Another drug, raloxifene (Evista®), can also help to prevent osteoporosis. However, aromatase inhibitors such as anastrozole (Arimidex®), which are also commonly used to treat breast cancer, can increase the risk of developing osteoporosis. Women taking aromatase inhibitors may need to have their bone density monitored during their treatment.

If you already have osteoporosis, you can talk to your doctor about taking calcium and vitamin D supplements. Warm baths can help to relax stiff joints and regular exercise will keep you supple. Be aware of dangers or trip hazards that could lead to falls. The National Osteoporosis Society can give you more information about prevention of osteoporosis and can let you know about helpful treatments.

Heart disease

The risk of heart disease increases in women after menopause, so you need to follow the well-established advice on reducing your risks:

• Stop smoking if possible, or at least cut down the number of cigarettes smoked each day
• Eat less animal fat and dairy produce, and eat more fresh fruit and vegetables
• Take regular gentle exercise.

If there is heart disease in your family, you may wish to talk to your cancer specialist or GP about using medicines to try to prevent it.

Complementary therapies

There are a variety of complementary therapies that may help you to control your menopausal symptoms. Some of these have been researched, but for others the evidence is only anecdotal (based on personal accounts rather than facts).

Some of these therapies may be available on the NHS, and your GP can give you further details. If you would like to find a complementary therapist, make sure that they are properly qualified and registered. The British Complementary Medical Association has lists of registered therapists throughout the UK.

It is a good idea to discuss the use of any complementary therapy with your doctor, as some therapies may interfere with your cancer treatment.

Types of therapies

Acupuncture

Acupuncture involves putting sterile needles through the skin and into energy points, to help restore health and balance in the body. There is some evidence that acupuncture may help to reduce the number and severity of hot flushes.

Homeopathy

Homeopathy aims to cure 'like with like' by using tiny amounts of substances that would normally produce the symptoms being treated. There is no scientific proof that this works, but some women find that it helps to improve their menopausal symptoms.

Mind therapies

Different relaxation techniques, such as progressive muscle relaxation (slowly tensing then releasing each muscle group), audio tapes/CDs, or paced respiration (a technique using slow controlled breathing), may help to reduce hot flushes.

There is some evidence to suggest that hypnosis can help to reduce the length and severity of hot flushes. It is unlikely to be available on the NHS.

Dietary supplements

Some women find evening primrose oil helpful for relieving menopausal symptoms, although it is expensive and there is no scientific evidence that it works.

Plant oestrogens (phytoestrogens) can have a very weak oestrogen-like effect, and may help to improve menopausal symptoms. However, there is concern that they may also increase the risk of a recurrence of an oestrogen-dependent breast cancer, so it is wise to discuss their use with your doctor. The two most commonly used plant oestrogens are black cohosh and red clover.

• Black cohosh contains phytoestrogens and may help to improve flushes, although the evidence is inconclusive. Side effects include sickness (nausea), vomiting, headaches, and possible liver disease. It should not be taken for more than six months at a time.
• Red clover contains chemicals called isoflavones, which are a type of phytoestrogen. There is conflicting evidence as to whether or not it can help to reduce menopausal symptoms. It may increase the risk of bleeding and should not be used by women taking medication to thin their blood (anticoagulants).

Vitamin E may help to reduce the frequency of hot flushes, and has very few side effects. Women with heart disease, diabetes, or high blood pressure should consult their doctor before taking vitamin E supplements.