- Dimpling/puckering of skin (like orange peel)
- Changes to either or both nipples, changes in size or shape of breast
- Lumps in breast tissue or axilla, pain in one or both breasts or axillae
- Inflammation, erythema, eczema to breast
About 35% of patients with breast cancer will develop metastases. 80% of these will be in the bone, 60-70% in the lung, 50% in the liver and 10-20% in the brain.
With metastases in the bone, osteoclasts (dismantle and remove damaged bone) become overactive which means more bone is broken down than replaced. Symptoms of this include pain near the affected area (this can worsen at night or at rest), hypercalaemia, fractures. Treatment for bone metastases can involve radiotherapy, surgery or biophosphate therapy which decreases the number of osteoclasts (and also their function), to allow new bone to be produced.
Frequently breast cancer metastasises first into the lung. This may present as shortness of breath, pain, or a dry cough. Other patients may be completely asymptomatic, and therefore a chest x-ray may be required to show the metastasis. A biopsy may be taken to ensure correct diagnosis.
Treatment is determined by the presence of other metastases, the patient’s health status and previous treatment history. Options include chemotherapy, hormone therapy and targeted therapy. Surgery is generally not an option because of the frequent distribution of the metastases, but may be considered if there are solitary tumours. Sometimes vena cava obstruction can occur due to lymph nodes or tumour putting pressure on the superior vena cava. This can cause stridor, faical swelling or dilation of major superior veins. This requires urgent assessment and treatment. Radiotherapy and steroids may be prescribed to reduce the obstruction caused by the swelling, occasionally a stent may be required. Pleural effusions are also a symptom of lung metastases, these need to be drained if large.
Liver metastases however, may present as bloating, nausea, ascites, abdominal pain, weight loss, back pain, jaundice or abnormal liver function tests. Liver metastases are generally diagnosed through liver function tests, CT scans, and ultrasound scans. A liver biopsy may be required if there is insufficient evidence of levels of oestrogen or human epidermal growth fact receptor-2 (HER-2). Liver metastases are generally treated with chemotherapy, hormone therapy or targeted therapies. Surgery is generally not employed because of the multifocal nature of liver metastases. Occasionally selective radiotherapy may be used or cryoablation.
Systemic treatments for metastatic breast cancer are generally either chemotherapy or hormone treatments.
Because the side effects of chemotherapy can be very severe (nausea, vomiting, hair loss, diarrhoea, neutropenia) the treatment needs to be finely balanced to enable maximum quality of life and effectiveness. These drugs may include: docetaxel, cyclophosphamide, paclitaxel, gemcitabine, epirubicin, doxorubicin (all IV) or oral drugs: capecitabine or vinorelbine.
Most breast cancers are sensitive to hormones; metastatic breast cancer that is oestrogen receptor positive and not immediately life-threatening is suitable for hormone therapy.
Tamoxifen is an anti-oestrogen which blocks the action of oestrogen in the tumour cells; this is suitable for women who are pre or post-menopause. Aromatase inhibitors are only licensed for post-menopausal women. Goserelin implants may be administered to reduce circulating oestrogen, this can also be achieved by surgical ovarian ablation or radiotherapy. This is generally a successful and well-tolerated therapy, although there are side effects including vaginal dryness, hot flushes, weight gain and problems with body image.
Menopause occurs when the ovaries become less responsive to FSH (follicle-stimulating hormone) and ovulation subsequently ceases.
Symptoms of menopause occur before the menopause itself. Oestrogen production gradually declines to a stop, by this time ovarian function has also declined. Symptoms tend to occur when women are in their mid 40s, although the menopause itself generally tends to take place when women are about 50 years old. This can differ quite widely in women with different lifestyles, health status and also genetic factors.
When assessing patients it is important to note the date the patient first encountered symptoms, details of last period, such as flow, duration, anything unusual. If there was abnormal bleeding, this would need to be investigated. It is important at this stage to find out what the patient’s views/concerns regarding menopause are, whether they use herbal remedies, what form of contraception they use (this will need to be continue for 2 years after the last period if the woman is under 50 and for one year after the last period if she is over 50). Current HRT use needs to be noted as does any risk factors for cardiovascular disease and osteoporosis, or any contraindications for HRT.
It is important at this point to check cervical screening is up to date, carry out breast and pelvic examination if necessary, also check BMI, BP and waist/hip ratio.
Common symptoms of menopause include hot flushes/night sweats; these affect about 4/5 of women. There may also be a decrease in libido, palpitations, interrupted sleep patterns, and weight gain.
Because of the changes occurring in the body, increases may occur in LDL and a decrease in HDL which increases the risk of cardiovascular disease.
Diagnostic blood tests can be carried out but hormones will naturally be fluctuating at this time so they may be of limited value.
TFT helps to exclude thyroid disease which can present similar symptoms to the initial stages of menopause.
Lipid levels need to be checked as these may be increased at menopause, increasing the risk of cardiovascular disease.
Hormone tests as mentioned may be of limited use, but include FSH (which is likely to fluctuate). FSH and LH ought to be taken on days 2-4 of the cycle, if known, or if unknown, two blood samples can be taken two weeks apart.
Depending on the symptoms a woman experiences, certain modifications in lifestyle may be in order. Diet assessment and advice may be required as weight is often increased at menopause, increasing the risk of CVD. Exercise needs also to be encouraged as it helps keep weight down, decreases the risk of CVD as well as osteoporosis (by increasing bone density). Weight decrease has also an effect on decreasing hot flushes. Hot flushes can also be minimised by avoiding hot/spicy foods and wearing light clothing.
HRT is generally effective for women who are experiencing urogenital, vasomotor and psychological symptoms of menopause. These may include:
- Urogenital – urinary frequency. urgency, stress and urge incontinence, decreased libido, painful sex or post-coital bleeding, decreased lubrication, itching/irritation.
- Vasomotor – hot flushes, night sweats, palpitations, interrupted sleep patterns, or insomnia, tachycardia, faintness, nausea, shivering.
- Psychological – anxiety, irritability, mood swings, depression, loss of self-esteem, deterioration in memory.
It is best practice to use the lowest strength hormone for the shortest possible period, although withdrawal from HRT can lead to symptoms returning. There are a variety of products available administered via a variety of routes, which requires informed discussion with the patient.
Continuous combined HRT contains oestrogen and progestogen; it is taken orally once daily and after the first 6 months should stop bleeding completely. Transdermal patches are also available.
Women who have had a hysterectomy should be given oestrogen-only HRT which can be given in the form of implants, patches, gel, or tablets.
For women who have a history of endometriosis, progestogen may need to be taken.
Sequential HRT enables a scheduled bleed as it is taken orally for 12-14 days.
A mirena coil can be fitted to provde progestogen, this prevents bleeding and also can be used as a contraceptive. If the coil is used for HRT as well as contraception it will need to be changed 4-yearly rather than 5-yearly.
Vaginal oestrogen can be administered as a cream and this has the added benefit of helping with urogenital symptoms.
Testosterone tends to be used in the form of patches/implants particularly in women experiencing a loss of libido.
There are risks associated with HRT; CHD, DVT/PE, breast cancer and CVA. Therefore all treatment options must be considered prior to commencement.
This is menopause experienced before the age of 45. These patients are more at risk of health conditions associated with the menopause, such as CHS, CVA and osteoporosis if they don’t take HRT.
Early menopause can be caused by a variety of factors such as; viral infections, enzyme deficiencies, chromosome abnormalities such as fragile X syndrome, and Turner’s syndrome. It may also be caused by FSH receptor gene polymorphism and mutation of inhibin B. Other medical factors include hypothyroidism, type I diabetes, Crohn’s disease, SLE, rheumatoid arthritis, Addison’s disease and myasthenia gravis.
There are other factors of a secondary nature which include chemo/radiotherapy, or oophrectomy.
Assessment and diagnoses will require blood tests for FSH, if necessary two weeks apart if there is no calculable cycle, bloods for testosterone, prolactin (to exclude polycystic ovary syndrome) TSH, progesterone (for fertility). Chromosome analysis for fragile X syndrome may be required, also the assessment ought to include a BMI, BP and bone density scan.
Because women with early onset menopause are at greater risk of the associated conditions, it is essential that they are screened initially and also that these checks are made regularly. Patient education regarding reversible risks factors of these conditions is vital.
For early menopause, HRT or a combined contraceptive pill can be prescribed; particularly as contraception still needs to be considered.