Ovarian cancer, the menopause and HRT

Understanding your options if you have had, or are at risk of, ovarian cancer

Ovarian cancer mostly affects women who have been through the menopause
But menopausal symptoms may be triggered following cancer treatment
What you need to know about HRT and ovarian cancer risk

If you’ve had ovarian cancer or have a gene mutation that increases your chances of getting ovarian cancer, you may be wondering how menopause affects you. You may have been through menopause before your cancer diagnosis, so it can come as a shock to experience further menopausal symptoms after your cancer treatment. Here, we take a deeper look at ovarian cancer and menopause, and the treatment options open to you.

Ovarian cancer mostly affects women over the age of 50, with more than half of all cases in the UK occurring in women aged 65 and over [1]. It can sometimes run in families, and you may have a higher chance of getting ovarian cancer if you have inherited a faulty gene, such as the BRCA genes or those linked to Lynch syndrome. Other factors that increase your risk of ovarian cancer include: having had breast or bowel cancer, radiotherapy for cancer, endometriosis or diabetes.

There are also some lifestyle risks, including being overweight or smoking. The more you have ovulated can also contribute: so, if you started your periods at a young age or went through the menopause late (over 55) or have not had a baby, these mean you have released more eggs. Not having ever used any hormonal contraception, such as the pill or an implant, may also be a risk factor, as is being on HRT.

It might sound strange, but it is also possible to get ovarian cancer even if you’ve had your ovaries removed as it can also affect your fallopian tubes, or the lining inside your tummy (peritoneum).

Symptoms of ovarian cancer – such as persistent bloating, pain in your tummy or pelvis, loss of appetite and feeling full quickly – are not always obvious. This means ovarian cancer is often diagnosed late.

It is more treatable if it’s diagnosed early, and you may have surgery to remove your ovaries and fallopian tubes (bilateral salpingo-oophorectomy), the opening to your womb from your vagina (cervix) and your womb (hysterectomy). If your cancer has spread, you may need further surgery, for example to parts of your bowel. You might have chemotherapy after surgery, or both before and after surgery, or on its own without surgery.

Life after treatment

Understandably, when you receive a cancer diagnosis, your focus is on your cancer treatment. So, for some women it can come as a shock when treatment can lead to menopause.

Most women who experience ovarian cancer will have already been through menopause. Yet you may experience a return of your menopausal symptoms or develop new ones after you go through surgery to remove their ovaries.

Chemotherapy can also affect the function of your ovaries and lead to menopausal symptoms.

If you were pre-menopausal prior to treatment for ovarian cancer and have both of your ovaries surgically removed, you will become menopausal straight away – specialists call this a surgical menopause.

For some women, a surgical menopause can be hard-hitting owing to the sudden, dramatic loss of oestrogen, as well as progesterone and testosterone. You have oestrogen receptors all over your body, which is why the loss of oestrogen can cause a myriad of symptoms. Hot flushes and night sweats are common, but you may also notice joint and muscle aches, vaginal dryness, mood changes, fatigue and poor sleep, brain fog and urinary symptoms such as recurrent UTIs.

Some women may not experience symptoms of menopause, or not be too troubled by them, but you may still want to consider the long-term effect on your health of having low hormones. HRT lowers your future risk of developing heart disease, osteoporosis, type 2 diabetes and dementia.

Can I take HRT?

HRT is the first-line treatment for menopausal symptoms and for most women, the benefits outweigh the risks. However, if you have been treated for ovarian cancer and are experiencing menopausal symptoms, the decision on whether to start HRT can be difficult.

There is not enough data to fully reassure women that there is no increased risk of ovarian cancer recurrence with the use of HRT after diagnosis and treatment, but, having said that, there is no convincing data to deny HRT either [2].

Several studies have shown that taking HRT after ovarian cancer does not increase recurrence of the cancer (in some studies, it even significantly increases the overall survival of patients) [3].

So, women who have had ovarian cancer in the past can usually take HRT. Speak to your healthcare professional to weigh up the benefits and risks for your individual case. Ideally, any conversation should be had ahead of your surgery so you can plan in advance – there is no need to wait until you have the symptoms of menopause before starting HRT.

If you have not had ovarian cancer before, research has shown that using oestrogen only or combine HRT increases the risk of ovarian cancer. A 2015 study found for every 1,000 women taking HRT for five years, there will be one extra case of ovarian cancer [4]. Stopping HRT will reduce this risk over time.

If you have the BRCA1 or BRCA2 genes associated with hereditary breast and ovarian cancer, you already have a high lifetime risk of cancer and taking HRT does not usually increase this further.

What HRT can I take and what else can help?

If you have your ovaries removed but still have a womb and would like to take HRT, you’ll need to take both oestrogen and progesterone. For those aged under 45 who have a surgical menopause, you may need a higher dose of oestrogen than someone who has gone through menopause naturally, at an older age.

If you have your womb removed, you don’t usually need progesterone – you can have oestrogen alone. In most instances, you will be offered transdermal oestrogen, which has no risk of clot.

If you can’t take HRT, you may still be able to take vaginal oestrogen. Many women who go through the menopause will experience genitourinary symptoms such as vaginal dryness (which can affect 60 per cent of postmenopausal women), pain from sexual intercourse or recurrent UTIs [5]. Vaginal oestrogen, which works locally only, can relieve and prevent discomfort.

For vasomotor symptoms, women who can’t take HRT may be offered antidepressants or other prescription drugs such gabapentin, pregabalin, clonidine or oxybutynin to relieve hot flushes and night sweats. Cognitive behavioural therapy (CBT) and hypnotherapy can help anxiety-related symptoms.

It is worth remembering that herbal medicines, such as black cohosh, red clover, ginkgo biloba and St John’s wort, and bio-identical hormones are not regulated.

While it can feel overwhelming at first to face both ovarian cancer and menopause, it’s important to realise that you do have choices. Take time for yourself to check in and recognise your symptoms, and to read up on as much as you can so that you can have ongoing conversations with your healthcare professional about how best to access support. Be active in your recovery by learning about your options, including lifestyle management and complementary therapy, so that you feel in charge of your life.

References

NHS: Ovarian cancer
MacLennan, A. H. (2011), ‘HRT in difficult circumstances: are there any absolute contraindications?’, Climacteric, 14(4) pp. 409–17, doi: 10.3109/13697137.2010.543496
‘Use of hormone replacement therapy before and after ovarian cancer diagnosis and ovarian cancer survival’, International Journal of Cancer, 119 (12), pp. 2907–15. doi:10.1002/ijc.22218
Eeles, R. A, et al. (2015), ‘Adjuvant hormone therapy may improve survival in epithelial ovarian cancer: results of the AHT randomized trial’, Journal of Clinical Oncology, 33 (35) pp. 4138–44. doi: 10.1200/JCO.2015.60.9719
Pergialiotis, V. et al. (2016), ‘Hormone therapy for ovarian cancer survivors: systematic review and meta – analysis’, Menopause, 23 (3), pp. 335–42. doi: 10.1097/GME.0000000000000508
Collaborative Group on Epidemiological Studies of Ovarian Cancer. (2015), ‘Menopausal hormone use and ovarian cancer risk: individual participant meta-analysis of 52 epidemiological studies’, The Lancet, 385 (9980), p1835-1842. Doi: https://doi.org/10.1016/S0140-6736(14)61687-1
Sarmento ACA, Costa APF, Vieira-Baptista P, Giraldo PC, Eleutério J Jr, Gonçalves AK. (2021), ‘Genitourinary Syndrome of Menopause: Epidemiology, Physiopathology, Clinical Manifestation and Diagnostic’, Front Reprod Health. 15;3: 779398. doi: 10.3389/frph.2021.779398