Nine million women globally are diagnosed with cancer every year, of whom 66% will survive long term in high-income countries and this trend is likely to continue in low/mid income countries. Cancer affects women and men differently due to the variety of types of cancers, available treatments and sequelae.

WHO Figures from 2020 suggest that 25% of cancers affect the breast, 10% colorectal, 9% lung, 6% cervix and the remainder consisting of thyroid, endometrial, stomach, skin and blood cancers. The consequences of treatment for a number of these, cancers whether treated with chemotherapy, radiotherapy or surgery, include the onset of menopause. Some affected women will also have symptoms following cessation of MHT. However, although 30% of cancer patients develop amenorrhoea, 70% of these will resume menstruation.

Until recently, the focus has primarily been survival, with little attention given to the importance of issues surrounding reproductive and sexual function.

Menopause will occur in every woman, if she lives long enough, with the average age being 51 years in the UK (United Kingdom). However, some women will experience an earlier menopause (premature ovarian insufficiency, POI) because of cancer treatment or treatment aimed at reducing their risk of cancer. Symptoms in this group are very common [1], [2]

Symptoms associated with menopause may negatively affect quality of life and can include hot flushes and night sweats (vasomotor symptoms), difficulty sleeping, mood changes, vaginal symptoms and sexual dysfunction. In addition, menopause at an early age (POI) may also impair long-term health, with increased risks of osteoporosis, cardiovascular disease and possibly dementia.

When treating cancer, every effort must be made to preserve ovarian function without affecting the success of the treatment and where possible, the ovaries should be preserved. In some cases, ovaries can be transposed prior to surgery or radiotherapy and in some instances, ovarian tissue may be cryopreserved. This is possible in cervical or endometrial cancer and some low grade, Stage 1 Ovarian cancers. Transposition may be useful in rectal cancer and where there is a need for pelvic radiation such as anal, vulval tumours or sarcoma.

Cancers occurring in young women can be divided into categories:

‘Female’ Cancers (breast, cervix, ovary, vaginal)

Other cancers (colon, lung, blood, skin)

Women at high-risk of cancer (BRCA, Lynch)

It is vital that during the initial consultation stages the patient and her family have a clear understanding about the following areas should they become menopausal since this will help them to take control of their care.

It is essential that all involved have a knowledge of menopause and the impact on fertility, contraception and sexual dysfunction

General and menopausal symptoms can be significant and may be related to the cancer or its treatment. These include fatigue, gastro-intestinal toxicity and other symptoms depending on the type of cancer.

Mood disturbances and a fear of recurrence are also common.

Although HRT (Hormone Replacement Therapy) is an effective treatment for POI, it is important not to assume that this is what all women want post-cancer to treat their menopausal symptoms, therefore all options should be explored. HRT is also contraindicated in some women and others will wish to avoid it for a variety of reasons. A paucity of evidence regarding the safety of HRT following some cancers, as well as a lack of knowledge and experience amongst healthcare professionals may lead to suboptimal care.

Whilst not all women will choose or require medical interventions, it is important that they are supported to manage their menopause holistically, incorporating their personal views and thus achieving individualised care

The effective management of menopausal symptoms was identified as one of the top 10 critical research gaps and translational priorities in breast cancer by over 100 international specialists [3] and is a focus of the Women’s Health Plan Scotland [4]. The advisability of prescribing hormones to women after cancer will depend on the presence of oestrogen and progesterone receptors (ER and PR), and how responsive the tumour is to the presence of these hormones. With a cancer such as breast where ER and PR are often in abundance, HRT is not usually advised. However, there is no evidence that several other cancers including haematological cancers, which are relatively common in young women, are hormone dependent. This is summarised in Table 1.

This usually occurs as a direct result of cancer treatment which may include oophorectomy or the prescription of chemotherapy that will deplete the pool of primordial follicles that would go onto develop into ovulatory follicles as a result of gonadotrophin stimulation. Although the number of primordial follicles is very large, several hundred will be recruited each month of which, most will become atretic and destroyed by apoptosis. When the number decreases to a certain point, ovarian failure will occur.

Women who carry gene mutations in BRCA1 and BRCA2 have approximately a 44% and 17% lifetime risk of ovarian cancer or fallopian tube cancer, and a 72% and 69% lifetime risk of breast cancer [5]. Risk reducing surgical removal of both fallopian tubes and ovaries (risk-reducing bilateral salpingo-oophorectomy [RRBSO]) reduces the risk of ovarian cancer by 80–95% and reduces all-cause mortality in women with BRCA1/2 mutations [6], [7].

It is recommended that the option of RRBSO should be discussed with all women who are carriers of BRCA1 and BRCA2 mutation. The risk of ovarian cancer with a BRCA1 mutation increases significantly after age 40, therefore age 35–40 years is deemed to be an appropriate age for women to consider surgery [6]. The risk with a BRCA2 mutation does not appear to increase until later [8], so surgery may be delayed until between 40 and 45 years of age.

The National Comprehensive Cancer Network (NCCN) recommends that women who carry mutations of BRIP1, RAD51C and RAD51D consider risk reducing surgery between age 45 and 50 years [7], [9]. Because the risk varies by genetic variant, it is recommended that the timing of hysterectomy ± RRBSO for Lynch syndrome be individualised [10].

However, concerns about surgical menopause are a barrier to RRBSO for high-risk women despite understanding the benefits of reduced cancer risk [11].

Menopausal symptoms are consistently reported in premenopausal women undergoing RRBSO. These may be persistent and impair quality of life (QoL), and include vasomotor symptoms, vaginal dryness, sexual dysfunction, sleep and mood disturbances [12], [13], [14], [15].

HRT can improve these symptoms and is recommended in those women who have had RRBSO who do not have a personal history of breast cancer, up until the time they would have expected natural menopause (average age for natural menopause is 51 to 52 years) [16]. It is becoming clear that HRT, whilst effective for most women, may not resolve menopausal symptoms in all women, and this possibility should be included in the pre-operative counselling. For those with a history of breast cancer, effective non-hormonal options are available and should be offered as a routine to all women (16; 17)

Published recently, international consensus recommendations for the care of women after premenopausal risk-reducing salpingo-oophorectomy in high-risk women [9] highlight the impact of RRBSO on short- and long-term health and provide evidence-based international consensus recommendations for care from preoperative counselling to long-term disease prevention.

Recommendations include preoperative counselling before RRBSO to ensure fully informed consent, setting realistic expectations, and individualised postoperative care, which will address and treat symptoms.