Information
Questions and answers about HRT
Will I put on weight whilst taking HRT?
A number of medical studies have looked at this issue, and most have demonstrated that the amount of weight gain is the same for women on HRT as for those who are not. As women get older, they naturally put on weight. Some women, however, do seem more sensitive to HRT, which makes them balloon. It could be that once they commence HRT they feel better and therefore their appetite increases. Weight gain suffered during mid-life tends to gather around the waist, with some weight loss around the bust and hips. Once on HRT, however, this changes; women put on less weight around their waist and gain more around their bust and hips.
Does HRT have side effects?
Yes. These can include headaches, breast tenderness, leg cramps and nausea, all due to release of oestrogen. The side effects generally occur in the first few months and eventually disappear, which is why you need to stick with HRT. If the side effects are particularly troublesome, your doctor may be able to lower the dose if you are on oral HRT or change you to a gel or a patch. Other side effects, caused by progesterone, can include depression, bloatedness, and PMT-type symptoms. These should also subside eventually.
How soon does HRT work?
You may notice a difference within the first month of taking HRT and definitely by three months. You should sleep better and your flushes and sweats should gradually improve.
Will HRT make me look younger?
When women are not on HRT, they lose collagen in their skin, which makes them wrinkle more, and their skin loses its softness and becomes drier. Their hair may also dry out, become thinner or even fall out. HRT can help to maintain your skin and hair by stopping this deterioration but unfortunately - it won't make you look younger.
Will HRT improve my sex life?
If you have a normal sex life, HRT won't improve this, although you may experience increased vaginal secretions, which make intercourse easier. If you have libido problems, whether HRT helps or not will depend on why these have arisen. Not all libido problems are hormonally related. Libido naturally reduces as women get older. If you have had a hysterectomy and your ovaries were removed, you will be producing few androgens, which cause a loss of libido, headaches and tiredness. It may help if you use a form of HRT that breaks down into androgens in the body or if you have androgen supplementation, usually by an implant.
Will the oestrogen gel irritate my skin?
Various HRT products work through the skin and this is the one least likely to cause problems. Reservoir patches cause irritation in up to 50% of women and matrix patches may do so in up to 10% of women. Oestrogen gels cause irritation in just 1 - 3% of women and the irritation is less severe than with other forms.
Will the patch fall off when I bathe, shower or swim?
For most women the answer is no. Some women find that patches don't stick well or have a tendency to fall off, especially is they have oily skin or put a patch on during a hot flush. If a patch falls off, stick it back on or use another one. Pressing down on the patch for 30 seconds may help the adhesive to stick.
Editor's note: I took this article from The Menopause Exchange, a new support group for menopausal women. For more in formation or to register with the group please contact: The Menopause Exchange, P0 Box 205, Bushey, Herts WD2 1ZS. There is an annual membership charge of £15, which entitles you to four copies of their newsletter a year.
Sexual health and Ovarian Cancer
Ovarian cancer and its treatments can cause physical and emotional changes in women. This may include changes in the way that they look and feel about their bodies as well as expectations of themselves as women, partners, friends and sexual beings, now and in the future. The emotional response to gynaecological cancer is very individual and each woman needs to be able to explore her feelings, ask questions and receive information, advice and support. Women need to be aware of how the cancer or treatment may affect them so that care is planned with their needs in mind.
Cancer affects sexuality perhaps especially when a female organ is involved. How a woman adapts to her cancer may depend on the importance she attaches to the female organs. It is important to consider these issues and the implications for the future. Tact, sensitivity, knowledge and experience from the health professionals involved in care should enable women to discuss these aspects, correct misconceptions, address fears and encourage women to talk to others about feelings as an initial and ongoing part of care and treatment. Social situation is also important. Women often consider the support available to them at a diagnosis of cancer, the quality and key aspects of a relationship and the impact on your partnerships and friendships.
Sexuality is the awareness of being a woman and includes the presentation to others of being feminine. It is part of a whole personality incorporating self-concept, body image, communication and sexual ability and cannot be destroyed by cancer or its treatments. In the early days of a cancer diagnosis, and possibly at varying stages of a cancer journey, anxiety and fear may reduce frequency and interest in sexual activity. However, this is often a time when women need reassurance and support.
Sexuality and sexual health have different meaning and emphasis to women at different stages of their lives. Sexual and emotional needs vary. This includes the fulfilment and expression of being sexual, the potential for childbearing, expectations of the future as a woman and aspirations. In adolescence or early adulthood ovarian cancer may impact at a stage in life when womanhood is being recognised and may have significant consequences with regard to fertility and sexuality. In later adulthood comfort, respect and corn pan ionship may become more important, but at each point partners and friends should be encouraged to continue to provide support and reassurance.
The emotional response to gynaecologicaf cancer may include feelings of loss, anger, guilt, fear and shame. It is important to challenge misconceptions about cancer and its treatment. Women may feel isolated as a result of their cancer or treatment and it is reassuring for women to continue to share feelings, touch and express themselves physically.
- Ovarian cancer is not related to sexual behaviour
- Cancer cannot be passed to a partner
- Radiotherapy does not make a woman radioactive and there is no danger associated with sexual intercourse
- You should discuss with your medical team your sexual health with chemotherapy and whether barrier contraception is necessary
Some treatments for ovarian cancer can impact particularly on sexuality and sexual health. Side effects can vary from temporary to permanent and in intensity and duration. In some circumstances, changes are irreversible.
Surgery
Initial surgery for ovarian cancer involves removal of the ovaries and depending on age may also include the uterus and tubes. This will for some, depending on age, result in an acute surgical menopause. There can be problems associated with this drop in hormone levels. Symptoms of the menopause can be alleviated in varying degrees with hormone replacement therapy or alternatives, e.g. soya, red clover. Women are often aware of vaginal dryness and this can affect sexual relationships. Oestrogen cream to the vagina or water-based lubricants such as KY Jelly and Replens (both available over the counter) or Astraglide (available by mail order) are recommended rather than oil-based ones. Longer periods of foreplay can also reduce fears or discomfort or anxiety. Libido or sexual desire can be affected in a variety of ways. Lack of hormones can have this effect and also anxiety associated with a diagnosis may mean that you are not feeling desire, but require reassurance.
Surgery can also affect sexual identity and fertility. The complex individual feelings of a changing body and womanhood, loss, sadness and, in some cases, relief at the removal of cancer, need to be addressed by the health care professionals involved. Women should be encouraged to talk through their feelings with those close to them. In this way they are supported and reassured. Scarring can be both physical and emotional. Women should feel that they are encouraged to touch and reacquaint themselves with their bodies and consider the changes.
Resuming sexual relations after an operation may induce some feelings or anxiety and uncertainty. Timing, care and thought in preparation can make this easier. Talk to your team about these issues. Women are encouraged to initiate sexual interaction rather than wait for their partner to express interest. Communication is the key to exploring anxieties. It also helps to maintain a semblance of normality in a strange, changing world. It is important in reminding couples of who they are and how they work together as a couple and in expressing emotions for each other.
Chemotherapy
Each woman is different but the side effects of chemotherapy can have an impact on a women's sexual wellbeing. Hair loss, fatigue, nausea and loss of libido are the most common side effects of chemotherapy and can all result from treatment. Good advice and symptom control is necessary to reduce any of these side effects.
Weight loss can also affect how women view themselves and good dietary advice is available.
Drugs commonly used in the management of ovarian cancer which can affect libido include cimetidine and rantidine (used with the combined Carboplatin and Paclitaxol regimen), and amitriptyline which is often used for nerve pain. It is important to note, however, that some of these drugs are used for symptom control and may therefore create an improved sense of well-being. This may positively influence sexual drive and confidence. A number of other drugs can also affect libido. Discuss this with your team if this is a concern.
Conclusion
This article has hoped to generate thought and offer advice on prompting sexual health for women with ovarian cancer. Sexuality and sexual health is an important and acceptable topic to discuss with those involved in your care. Feelings and needs may change and vary in importance during the journey of ovarian cancer and its treatment. Sexual adjustments are part of the healing process. An honest and trusting relationship between all partners provides expression, reassurance, advice and support at each stage to promote comfort and confidence
Suggested reading
Sexuality and Cancer, CancerBACUP
Sexuality and Fertility after Cancer, by Lesley Schover
The Natural Menopause by Miriam Stoppard, published by Dorling
Kindersley
Understanding the Menopause by Dr Anne MacGregor, published by the
British Medical Association
Coping with common problems
Fatigue:
* Plan for intercourse, think about the time of day when you feel that you have more energy and allow for rest before and after
* Avoid heavy meals just before sexual activity
* Avoid rooms that are too hot or cold
* Experiment with positions that require less energy (women to take a less dominant role)
Pain:
* Use medication and time sexual activity around this
* Relaxation techniques: aromatherapy and massage as distraction, relaxation and arousal
* Discover most comfortable position - use pillows for support
* Consider alternatives to penetrative intercourse
Nausea and vomiting:
* Use medication and plan sexual activity around this
* Small frequent meals
* Avoid foods/substances with strong odours
* Avoid sight, sounds and smells that trigger nausea
* Consider links to nausea and plan activity around these
* Relaxation or distraction techniques
Catherine Spencer
Clinical Nurse Specialist
Gynaecologist Oncology
St Bartholomew's Hospital, London
An update for patients with early recurrence
This trial was launched in 1998 to test a new way of working out which chemotherapy drugs to give individual patients with recurrent ovarian cancer. The trial has now recruited 55 patients from doctors in eight UK centres and two in Germany. The results cannot be analysed until the end of the study, which needs a total of 1 82 patients. We hope that more centres will join in and that the study can be completed in the next year.
Chemotherapy for ovarian cancer can be very effective, but sadly some patients relapse quickly because their cancer did not respond to the drugs used. It has long been a goal of cancer specialists to be able to tailor therapy to individual patients, but this has proved difficult to achieve. Our trial involves culturing patient's cancer cells for a short time with up to 1 2 different anticancer drugs to find out which ones kill the cells most effectively in the laboratory. Usually the cells are obtained from fluid in the abdomen (ascites), if this is not present a biopsy may be taken by keyhole surgery (laparoscopy) or during open surgery if justifiable.
This is a randomised trial to compare the outcome of treatment based on the test result against the best standard therapy chosen on an individual assessment by the specialist without knowing the test result. In half the patients, allocated at random, the lab result is available immediately. In the other half the result is held in reserve and is made available to the treating doctor on request.
Due to constraints within the NHS and other trials, only some centres are able to take part in the study. These include: Southend, Preston, Guildford, Airedale, Poole, Portsmouth, Mount Vernon and Wolverhampton. Dr Alan Lamont at Southend is co-ordinating the clinical aspects of the UK part of the study. Dr Ian Cree at the Institute of Ophthalmology in London is doing the laboratory tests. Interested oncologists are welcome to contact either doctor, patients can get the best advice by going through their own specialist or GP. Dr Lamont's team at Southend (tel:01 702 435555 ext 3899) is pleased to deal with enquiries from doctors who may wish to participate or who wish to discuss cases and will be able to answer general questions about clinical aspects of the trial. We try to avoid discussing individual cases by telephone with patients or carers to avoid undermining any existing health care relationships.
Further information on the study is also available on the Lancet website (http:www.thelancet.com/).
Ian A Cree
Clinical Senior Lecturer, LONDON
