After a patient with cancer has undergone treatment, the potential impacts they can experience during survivorship include hormone deficiencies.
“Hormone deficiencies are when good glands go bad,” as Dr. Bradley S. Miller stated at the 2023 Cancer Survivorship Conference presented by the Masonic Cancer Center at the University of Minnesota.
Miller, a pediatric endocrinologist who is a professor in the department of pediatrics and director of the division of pediatric endocrinology at the University of Minnesota, stated that, among cancer survivors, “essentially (hormone deficiency) is something that’s acquired over time as a complication of treatment.”
Tara Rick, a research associate in cancer survivorship, hematology, oncology and transplantation as well as a physician assistant in hematology and oncology at the University of Minnesota and an adjunct professor in the master of physician assistant studies program at St. Catherine University, spoke with CURE® via email.
Q: Why can hormone deficiency be a factor among cancer survivors?
A: A lot of cancer treatments that we offer can affect hormone levels in many different ways. The most common examples that we think of are (among patients with) breast cancer, because breast cancer is the most common cancer worldwide, and in the US, there are 2.2 million breast cancers diagnosed every year, and 80% of breast cancers are estrogen- or progesterone-positive, meaning that hormones actually fuel the cancer. So, by design, a lot of the treatments are meant to reduce hormone levels. So, breast cancer is a really large example. That’s a huge population of people that are experiencing low estrogen levels.
But also, any type of cancer where there is surgery, specifically, like oophorectomy (surgical removal of one or both ovaries), or bilateral (orchidectomy), when both of the testicles are removed, (or) radiation to the pelvis can affect hormone levels, (and) radiation to the brain as well. And then there are a lot of different oral therapies or even injections that are meant to reduce hormone levels as well. So, a lot of our different cancer treatments can affect hormone levels.
Q: What can the impact be in a patient’s day-to-day life because of these deficiencies?
A: It depends if there is a gradual decrease in hormones or a sudden decrease. For example, if somebody’s ovaries are removed, it’s going to be a big change all at once. And some medications cause really, really low levels — for example, aromatase inhibitors for breast cancer, they’re causing pretty low levels of estrogen whereas (with Soltamax [tamoxifen]), there will be higher levels of hormones that are circulating. So, it really depends on the treatment, and it depends on the person.
But some potential side effects, say, of low estrogen or progesterone would be hot flashes, night sweats, mood changes, insomnia, feeling tired or having mental fog, weight gain, decreased libido, vaginal dryness, pain with intercourse, which is particularly an area that I’m interested in, I think it’s an unmet need for our patients in talking about sexual side effects from cancer treatments and especially with hormone deficiencies.
Some other side effects could be dry skin, thinning hair, dry (and) brittle nails, joint aches. I could continue to go on and on. There are a lot of effects that that people can experience. And not everybody experiences all of them or severe(ly), it can really depend on the person.
Q: You said that sexual side effects were a topic you’re particularly interested in, because that is an unmet need. Can you tell me why that remains an unmet need, and what treatments, remedies or ways of addressing that are currently available?
A: There was a study that was reported out in 2021 that showed that up to 80% of patients after cancer treatment, especially breast cancer treatment, have some degree of sexual side effect, and only about 25% of people feel comfortable bringing it up to their health care provider. So, unless we make it our prerogative to ask patients about it, I think we’re missing a lot of opportunity.
And for example, with breast cancer or with gynecologic malignancies, with the low estrogen and progesterone levels there over time can be vaginal dryness. There can be shortening or narrowing of the vagina. And these types of side effects make intercourse uncomfortable, even painful. And also, with the decrease in hormone levels that also can decrease libido. And we know that sexual health is an important component for a lot of people in regards to their well-being (and) quality of life. So, it’s something that when we’re talking about treating patients holistically, we need to also remember sexual health.
Q: For patients who are facing hormonal deficiencies, what sort of ways of addressing that are available from the lifestyle perspective, such as diet and exercise?
A: We always recommend exercise. Exercise is one of the most important things that we can recommend for our patients in regards to not only risk reduction for cancer recurrence, and all the other positive health effects, but also with improving overall sense of well-being.
Typically, what we recommend is 150 minutes of exercise a week, and that can be broken down in in any particular way that works for the patient. I always recommend something that is enjoyable, that somebody would look forward to doing.
Other than that, just really working on other aspects of well-being, one thing that I see a lot with cancer survivors is that there’s a lot of support around people when they’re going through treatment, and then there comes a point where you’re transitioning more into the surveillance mode, and sometimes the support can back up. And this is a time where usually people are really processing and coping with what they’ve been through and can have some mood changes related to that. And that’s when I really encourage people to draw back in their support system. And when people feel supported, sometimes some of these side effects can also feel less debilitating.
Other things (include) healthy diet, (I) usually recommend a very plant-forward diet, minimizing alcohol, working on sleep — again, insomnia can be a side effect of hormone deficiencies, but really trying to be mindful about that. And there can be different things from a lifestyle perspective. There’s what’s called cognitive behavioral therapy for insomnia, which is a type of therapy for insomnia that people can pursue.
Q: And in terms of pharmaceutical means of addressing this, I know there has been some discussion over the years regarding hormone replacement therapy and some providers being hesitant around that.
A: Yeah, hormone replacement therapy isn’t something traditionally that we looked to first for management, particularly with breast cancer or any sort of hormone-sensitive cancer. However, there is growing evidence and acceptance of topical estrogens for specific side effects.
So, for example, for the sexual side effects that I was talking about, vaginal dryness or pain with intercourse, we usually recommend non-hormonal lubricants and daily moisturizers first, but if those are not working to the level that we want them to, we will consider using topical estrogens. And with topical estrogens, there is very little systemic absorption, so very little risk that if there were cancer cells left behind that we were fueling them, and those can be really helpful with some of those sexual side effects.
So, it really kind of depends on what side effects you’re talking about. You know, for example, hot flashes. When we think about the whole constellation of side effects, hormone replacement therapy would be something that could treat all the symptoms but potentially cause risk of cancer recurrence. However, there are other cancers that are not estrogen- or progesterone-sensitive that this can be considered (for) and there are menopause clinics at big academic centers that can be helpful for helping talk about the risks and the benefits of these treatments with our patients.
Q: Say there is someone reading this who is undergoing treatment for cancer, what sorts of conversations should they be having with their doctor regarding hormone deficiencies and ways they can address that?
A: I would always encourage people to advocate for themselves. So, if there is a symptom that you’re experiencing that is affecting your quality of life, please do not hesitate to bring it up to your healthcare provider. Hopefully, as we get better about talking with our patients about things like sexual side effects, we can also help this conversation along, if you’re uncomfortable bringing it up.
In regards to testing, testing for hormone deficiencies hasn’t really shown to be that effective, so there isn’t really a lab in sort of mainstream academic research-based, evidence-based medicine, there really isn’t a great way to sort of track this by labs. It’s mainly treating side effects and how a patient feels.
This transcript has been edited for length and clarity.
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