Midi Health’s Dr. Mindy Goldman on Menopause Treatment After Cancer

When you’re already managing breast cancer, dealing with perimenopause or menopause symptoms can feel overwhelming. Not only may you experience early menopause if you take certain hormonal therapies or receive chemotherapy, but symptoms like hot flashes, vaginal dryness, painful sex, and sex drive problems can be especially severe. What’s more, hormone replacement therapy — the most effective treatment for symptoms like hot flashes, night sweats, and vaginal dryness — isn’t appropriate for women with hormone-sensitive breast cancer.

On the much brighter side, experts like Dr. Mindy Goldman, Chief Clinical Officer at Midi Health and Director of the UCSF Gynecology Center for Cancer Survivors and At-Risk Women at UCSF have safe and effective ways to help people undergoing cancer treatment manage the symptoms associated with menopause. Below are some of the options that leading clinicians like Dr. Mindy use to help cancer survivors get lasting relief from their symptoms and feel better in their amazingly resilient bodies.

Treatments that Can Help You Beat Hot Flashes

Hands down the most talked-about menopause symptom, hot flashes affect around 75% of people who go through menopause. Research has shown that as hormone levels in the body change during the menopause transition, the way the brain perceives body temperature changes as well.

Basically, the brain thinks that the body is too hot, even if it isn’t, so the brain kicks off the body’s cooldown processes by opening the blood vessels and triggering the sweat glands. The blood rushing to the skin through the wide open blood vessels causes the skin to get red and hot, and the sweat glands overproduce sweat in an attempt to cool off the body. But instead of cooling the body, this whole process creates a hot flash.

Some people can manage their hot flashes with lifestyle changes like wearing loose clothing, staying hydrated, quitting smoking, changing their diet, engaging in regular exercise, managing their stress levels, and changing their environment by cooling the rooms they’re in or carrying a personal fan. However, many people, experience hot flashes so intense and/or frequent that they interfere with their daily lives.

Non-Hormonal Treatments for Hot Flashes

Normally, the go-to treatment for severe hot flashes is hormone replacement therapy (HRT), but this isn’t an option for many cancer patients. For cancer patients who can’t do HRT, Dr. Goldman recommends a few medications that weren’t created to treat hot flashes but have proven effective in clinical trials – low doses of Effexor, gabapentin, and Paxil are a few of the more common drugs that can be used for hot flashes. These are all equally effective for treating hot flashes, so, when it comes to getting some relief, it doesn’t matter which one is prescribed.

That said, sometimes doctors choose one medication over another because it’s also effective at treating other symptoms. Gabapentin, for example, often has a sedative effect, so it can be a great option for people who have hot flashes at night and/or people who have trouble sleeping. Insurance coverage can also impact which drug is prescribed. Since many insurance companies don’t cover medications when they’re being used “off label,” Paxil is usually the best option if people run into insurance issues.

Each of these medications is typically used in lower doses than is typical for other applications. For antidepressants like Effexor or Paxil, women who are experiencing mood disturbances during menopause may opt to start at a dose that’s effective for depression and see if that helps their hot flashes as well.

Dr. Goldman stresses that medications aren’t a substitute for lifestyle changes. The following habits are all essential to managing hot flashes, even for people taking medications:

• Dressing in loose, light clothing
• Exercising during the day
• Eating a balanced diet
• Minimizing caffeine, alcohol, or spicy foods
• Implementing a stress management program

Integrative therapies that target the mind/body connection like yoga, acupuncture, and hypnosis have also proven effective at reducing hot flashes in clinical trials. Research shows that Cognitive Behavioral Therapy (CBT) can help reduce hot flashes as well.

If you're wondering about supplements, there are some to consider. Black cohosh, in particular, is thought to be beneficial in treating hot flashes, and some recent studies suggest that it's safe in breast cancer survivors. For many supplements there may not be a lot of research regarding their effectiveness or safety. So for breast cancer survivors, it is best to talk with your oncologist prior to using any types of supplements.

The bottom line: A holistic approach that combines lifestyle changes, integrative therapies, and potentially medication is typically the most effective.

Options for Soothing Vulvar & Vaginal Dryness

Just like hot flashes can interfere with daily life in several ways, so can vulvar and vaginal dryness. The tissues of the vulva and vagina are highly dependent on estrogen, especially for lubrication. When the body’s estrogen levels drop or disappear suddenly as they do after surgical or medical menopause, the vulvar and vaginal tissue can become dry and fragile, which leaves the tissue vulnerable to damage and tears.

The most common side effect of vaginal dryness is painful sex because the tissue no longer self-lubricates properly and it’s so fragile that penetrative sex can easily cause abrasions or tears. Some people also experience near constant discomfort because of vaginal dryness. These people often describe the discomfort as “itchy” or “irritated.”

How Cancer ImpactS Vulvar & Vaginal Dryness

While most people experience some level of vaginal dryness during menopause, people who take aromatase inhibitors as part of their cancer treatment are at higher risk for severe vaginal dryness. Aromatase inhibitors shut down estrogen production completely, and as with surgical menopause, the sudden absence of estrogen can make vaginal dryness even worse. Because aromatase inhibitors function to shut down all production of estrogen in the body, survivors on these drugs are "more shut down" than menopause and can have such severe symptoms that they will say the vagina or outside vulvar tissue feels “like sandpaper.”

OTC & at-home Treatments for Vaginal Dryness

For Dr. Goldman, treating vaginal dryness is always a high priority when working with cancer patients because it affects so many aspects of their lives. Like many treatments for menopause symptoms, the most common treatment for vulvar and vaginal dryness is hormone-based. In some cases, cancer patients will be able to use topical hormone creams because they don’t increase systemic hormone levels. But patients with hormone sensitive tumors need alternative treatments.

Luckily, there are multiple non-hormonal options, many of which can be purchased over the counter. Dr. Goldman suggests using vaginal moisturizers and natural oils, like coconut oil, because they not only provide moisture, they trap it as well. Vaginal moisturizers with vitamins D and E work particularly well. Gels and creams that are pH balanced and contain hyaluronic acid can help prevent yeast and bacterial overgrowth in addition to moisturizing the vulvar and vaginal tissues and are particularly helpful for people who are prone to these types of infections.

For people looking for a more natural approach, Dr. Goldman recommends a homemade coconut oil vaginal suppository. Just put coconut oil in an ice cube tray, freeze it, and then insert a coconut oil cube into the vagina. Though this sounds a bit weird, many people find the coldness of the coconut oil cube quite soothing, and the coconut oil absorbs really well as the cube melts in the vagina.

Dr. Goldman emphasizes that being proactive can be really helpful as once symptoms do develop it can take a while to treat them. Treating the tissue before dryness is an issue can prevent tissue damage instead of trying to repair damage after it’s occurred.

Ways to Keep Sex Pain-Free

Painful sex is another common symptom during perimenopause and menopause, and treating this symptom can be difficult because there can be multiple causes, especially in patients with cancer. Where and when someone feels pain during sexual activity can help providers pinpoint the underlying cause.

Sharp, crampy pain particularly when something is inserted in the vagina may be a sign of what used to be called vaginismus (now referred to as genitopelvic pain penetration disorder), a complex physical and emotional condition in which the pelvic floor and vaginal muscles painfully contract before or during penetrative sex. This condition can develop when a person is feeling extreme stress, fear, or apprehension about sex or their relationship, which is common for people undergoing cancer treatment.

Pain in the labia, around the opening of the vagina, and in the vagina during penetration can be a side effect of vulvar and vaginal dryness. Pain with deep penetration can be caused by surgical scarring, endometriosis, or another gynecological condition.

Tools & Treatments that Make Sex More Comfortable

Dr. Goldman suggests using vaginal dilators – small tubes made of medical grade plastic or silicone that are gently inserted into the vagina – to identify where the pain is and what it feels like if patients have trouble describing their pain. The dilators will also gently stretch the vaginal tissues that can also be helpful.

The treatment for painful sex will depend on the cause. Treating vulvar and vaginal dryness with vaginal moisturizers will lubricate and heal the vulvar and vaginal tissue, reducing pain with penetration as well as non-penetrative sexual activity (sometimes called outercourse). Using lubricants during intercourse and outercourse will help as well.

For pain with deep penetration, a ring-shaped device called an OhNut can be very helpful. The ring goes around the penis or sex toy to limit the depth of penetration. If vaginismus or another gynecological condition is contributing to painful sex, pelvic floor physical therapy can provide a lot of relief. Seeing a sex therapist is also likely to be very helpful — certified sex therapists can be found on https://www.aasect.org.

Solutions for Low Sex Drive/Sexual Desire

Cancer impacts libido in a major way. Cancer treatment leaves people physically and mentally exhausted, which can make it difficult to muster the energy required for sex. Additionally, treatments like chemotherapy, radiation, and surgery all have side effects that can impact sex drive and sexual desire. Plus, cancer also has a huge impact on body image, which, in turn, impacts libido. People who’ve lost their hair, lost or gained weight, or had body-altering surgeries like mastectomies might feel uncomfortable with, their bodies, which makes it very difficult to engage in sexual activity.

Before trying to address low sex drive or low sexual desire, it’s important to determine how much it’s impacting quality of life. An important part of this equation is remembering that there’s no such thing as a “normal” sex drive for anyone at any age. Most people are measuring their sex drive/sexual desire against their younger, healthier self. Even those of us without cancer wouldn’t measure up to these standards. So, it’s important to determine whether low sex drive or sexual desire is actually a problem for the person or their partner. If they’re okay with a lull in their sex lives and it’s not impacting their relationship, low sex drive or sexual desire can be a problem for another day.

The best options for boosting libido

If low-libido is causing problems for you, figuring out the contributing factors is the key to treatment. It makes complete sense that people experiencing vaginal dryness or painful sex wouldn’t want to have sex. So treating those issues could improve sex drive and sexual desire. For many people, the psychological stresses of cancer treatment are behind low sex drive and sexual desire. When this is the case, seeing a sex therapist or a therapist that specializes in CBT can help.

Cancer is a complex disease that impacts every aspect of a person’s life. The sexual health issues that arise aren’t going to go away overnight, especially since almost all of these issues have physical and psychological components. But with patience and persistence, people living with cancer and going through menopause can regain their sexual health and find sexual satisfaction again.

Whatever menopause symptoms you’re experiencing, working with a healthcare provider who deeply understands safe and effective treatment options for individuals managing cancer is most important. If you haven’t yet found that provider, you can check to see if Midi is available in your area — or coming very soon.