Managing side effects of uterine cancer treatment

The ovaries produce the hormones oestrogen and progesterone. If both ovaries have been removed or you’ve had radiation therapy to the pelvic area, your body will no longer produce these hormones and you will stop having periods. This is called menopause. For most women, menopause is a natural and gradual process that starts between the ages of 45 and 55. If you have not already entered menopause, these treatments will cause sudden menopause. If you have already been through menopause, the symptoms of menopause may come back.

Menopause symptoms include hot flushes, night sweats, dry or itchy skin, mood swings, trouble sleeping (insomnia), tiredness, aching joints, vaginal dryness, weight gain and bladder problems. You may also have a decreased interest in sex (low libido).

The symptoms of menopause caused by cancer treatment are usually more severe than during a natural menopause because the body hasn’t had time to get used to the gradual decrease in hormone levels.

Menopause may cause other changes in the body. For example, your cholesterol levels may rise, which can increase your risk of heart disease. Over time, your bones may become weak and brittle, and break more easily. This is called osteoporosis. Radiation therapy to the pelvis can also weaken the bones.

Managing menopause symptoms

• Vaginal moisturisers available over the counter from pharmacies can help with vaginal discomfort and dryness. Talk to your nurse for suggested products.
• Your doctor may suggest using a vaginal oestrogen cream to help with vaginal dryness and prevent painful sexual intercourse.
• If you need to avoid products containing oestrogen, your doctor can suggest non-hormonal medicines to relieve the symptoms of menopause.
• If your menopause symptoms are severe, talk to your doctor about the risks and benefits of taking menopausal hormone therapy (MHT). Previously called hormone replacement therapy (HRT), MHT is not usually used if you have cancer of the uterus, but may be considered in some cases. If you were on MHT when the cancer was diagnosed, your doctor will usually advise stopping its use as oestrogen can cause these cancers to grow.
• Talk to your doctor about having a bone density test or taking medicine to prevent your bones from weakening. Call 1800 242 141 or visit Healthy Bones Australia for more information.
• Ask your doctor for a referral to a menopause clinic if needed.
• Have your cholesterol levels checked. If they are high, regular exercise and a balanced diet may help, or talk to your doctor about cholesterol-lowering drugs.
• Learn meditation and relaxation techniques. These may be helpful in reducing stress and some menopause symptoms.
• Some types of psychological therapy may help with menopause-related anxiety, low mood, sleep troubles and the impact of hot flushes. Talk to a psychologist about the best approach for you.
• Exercise can also help with mood and energy levels. Talk to an exercise physiologist or physiotherapist.

Surgery or radiation therapy for cancer of the uterus may mean you are unable to become pregnant. Before treatment starts, ask your doctor or a fertility specialist about what options are available to you if you were hoping to have a baby.

It may be possible to preserve the ovaries (e.g. if you are 45 years or under) and sometimes the uterus, so you can still have children. However, this is an option only in certain cases, and your doctor will explain the risks and benefits.

Learning that your reproductive organs will be removed or will no longer function and that you won’t be able to have children can be devastating. Even if your family is complete or you did not want children, you may still experience a sense of loss and grief. These reactions are normal. Speaking to a counsellor, psychologist, social worker or a cancer nurse about your feelings and individual situation can be helpful. You can also call Cancer Connect on 13 11 20 to talk to a health professional about your concerns.

It is common to feel very tired and lack energy during and after treatment. This can be a side effect of the treatment itself or a symptom of menopause (see above). Travelling to hospitals and clinics for treatment and appointments can be exhausting. Dealing with your emotions can also cause fatigue. Your tiredness may continue for a while after treatment has finished.

Fatigue may affect your ability to keep working or care for your home and family. It may help to talk with your family and friends about how you feel, and discuss ways they can help you.

Managing fatigue

• Do some light exercise, such as walking or stretching, to help increase your energy levels. Check with your doctor if these activities are suitable for you. You can also ask for a referral to an exercise physiologist or physiotherapist.
• Plan your day. Set small, manageable goals so you can rest regularly, and allow yourself plenty of time to get to appointments.
• Ask for and accept offers of help from family and friends (e.g. with shopping, housework, meals and driving).
• Learn to recognise signs of tiredness before you feel exhausted.
• Talk to your employer about taking time off work, reducing hours or working from home.
• Don’t expect to be able to instantly do everything you used to do. Your body is still recovering and it will take time for your energy levels to return.

For more on this, see Fatigue and cancer  and Living well after cancer.

Treatment for cancer of the uterus can cause bladder problems. Most bladder side effects are temporary or can be managed.

Urinary incontinence – This is when you have trouble controlling your bladder and you leak urine (wee). Strengthening the pelvic floor muscles can help control the flow of urine. A women’s health physiotherapist or continence nurse can develop a bladder training program – ask your doctor for a referral or contact the National Continence Helpline on 1800 33 00 66. You can also find a guide to exercising the pelvic floor muscles at Exercise for people living with cancer. Using continence pads or special types of absorbent underwear can help you manage leakage.

Radiation cystitis – Radiation therapy can irritate the lining of the bladder. You may feel like you want to pass urine often or have a burning sensation when you pass urine. Called radiation cystitis, it usually gets better after treatment. Try to drink plenty of water or use a urinary alkaliser (e.g. Ural) to help reduce the burning sensation. You can buy urinary alkalisers from your pharmacy. Your doctor may also prescribe medicine to treat cystitis.

Blood in urine – The blood vessels in the bladder can become more fragile after radiation therapy. This can cause blood to appear in your urine, even months or years after treatment. Always let your doctor know if you notice new or unusual bleeding.

Treatment for cancer of the uterus can affect the way the bowels work. These changes are usually temporary, but for some people, they can be permanent and can have a significant impact on quality of life. Talk to your treatment team if you are finding bowel issues hard to manage.

Constipation – Constipation is when you have difficulty having a bowel movement (pooing) regularly or often. It is important to avoid constipation, especially in the days after surgery, because it may lead to more discomfort or cause you to strain when you’re sitting on the toilet. Talk to your dietitian or doctor about making changes to your diet or taking medicines if you are constipated.

Diarrhoea – Diarrhoea is the frequent passing of loose, watery faeces (poo) from the bowels. A dietitian can suggest changes to your diet to reduce the number of bowel movements.

Radiation proctitis – Radiation therapy can damage the lining of the rectum, causing inflammation and swelling known as radiation proctitis. This can cause a range of symptoms including blood in bowel movements; diarrhoea; the need to empty the bowels urgently; and loss of control over the bowels (faecal incontinence). Radiation proctitis usually gets better after treatment has finished, but it can develop some time after treatment (called a late effect). Talk to your treatment team about your risk of developing radiation proctitis. If you have any ongoing bowel problems, they may refer you to a gastroenterologist.

Blood in bowel movements – Blood vessels in the bowel can become more fragile after radiation therapy. This can cause blood to appear in your faeces, even months or years after treatment. Always seek advice from your specialist or GP if you notice any new or unusual bleeding.

Managing bowel changes

Constipation

• Drink more water – aim to drink at least 8 glasses during the day.
• Eat regular meals throughout the day.
• Try to eat more fibre-rich foods (e.g. wholegrain breads and cereals, legumes such as beans and  lentils, vegetables, fruits, nuts and seeds).
• Avoid drinking alcohol.
• Do some gentle exercise, such as walking. Check with your doctor about the amount and type of exercise that is right for you.
• Cut down on sweets, soft drinks, takeaway food, fried foods, potato chips and other savoury snacks.
• Limit foods containing added sugars and salts.
• Take medicines for constipation as directed by your doctor.

Diarrhoea        

• Drink plenty of fluids such as water, herbal teas, sports drinks and electrolyte-replacing fluids.
• Avoid drinking alcohol.
• Eat fewer high-fibre foods (e.g. wholegrain breads and cereals, raw fruits and vegetables, legumes).
• Eat more low-fibre foods (e.g. white rice, white pasta, white bread, potatoes).
• Limit spicy, fatty and greasy foods, as these can make diarrhoea worse.
• Cut down on coffee, cola and other drinks that contain caffeine.
• Choose low-lactose or soy-based dairy products (eating small amounts of cheese and yoghurt is usually okay).
• Ask your doctor about suitable medicines for diarrhoea. Take as directed.

After surgery or radiation therapy to the pelvic area, one or both legs and/or the vulvar area may become swollen. Called lymphoedema, this occurs when lymph fluid doesn’t circulate properly and builds up. The swelling may appear during treatment or months or years later.

Lymphoedema can make movement and some types of activities difficult. It is important to maintain a healthy body weight, avoid pressure, injury or infection to the legs, and manage lymphoedema symptoms as soon as possible.

Mild lymphoedema is usually managed with exercise, skin care and a compression stocking. To find a health professional who specialises in the management of lymphoedema, speak to your treatment team or visit the Australasian Lymphology Association.

The skin on the legs may become infected more easily after lymph nodes are removed. A common skin infection is called cellulitis. Signs of cellulitis include redness, painful swelling, warm skin and fever. If you have any symptoms, see your GP as soon as possible.

To reduce the risk of infection, keep the skin healthy and unbroken, exercise regularly and avoid tight-fitting clothing. Use moisturiser and sunscreen, and avoid scratches, cuts, burns, insect bites, and injections in your legs. Also, keep your feet clean and dry to avoid fungal infections.

Radiation therapy to the pelvic area can cause vaginal tissue to lose its elasticity and shrink, narrowing the vagina (vaginal stenosis). If your ovaries were removed, your vagina may also become dry. These side effects may make it painful to have sex or pelvic examinations. Even if you don't plan to have sex again, your doctor will need to do regular pelvic examinations after treatment, so it is important to prevent these side effects. Your treatment team may recommend using a vaginal moisturiser or lubricant or a hormone cream (available on prescription and safe with many cancers of the uterus). They may also advise you to use vaginal dilators.

Using vaginal dilators

Vaginal dilators can help keep your vagina open and flexible after treatment. They are made from plastic or silicone and come in a range of sizes. You usually start with the smallest dilator, and as each one becomes more comfortable, you can move on to using the larger dilators. Make sure any soreness has settled down before you start using dilators (usually 4–6 weeks after your last radiation therapy session).

To use the dilator, find a private space. Apply a water-based lubricant to the dilator, slowly insert it into the vagina, then gently rotate it. Leave the dilator in for 5–10 minutes. You can do this once or twice a day for the first few months, and then 2–3 times a week for several months after that, as advised by your treatment team. You may also like to see a women’s health physiotherapist. If you have a history of sexual trauma, speak with a psychologist or counsellor.

Cancer of the uterus can affect your sex life in both physical and emotional ways. Some treatments can cause dryness and narrowing of the vagina, which can make sexual penetration difficult or painful. Also, removal of the uterus, cervix and ovaries can change how you experience sexual pleasure and orgasm.

Your treatment team may advise using vaginal dilators, lubricants, moisturisers or hormone creams (see above). It may be helpful to explore ways to orgasm (climax) without penetration or to use masturbation to see what might work for you.

You may lose interest in intimacy and sex (low libido) because of the hormonal changes of menopause, the stress of the cancer experience, the fatigue caused by treatment, and changes in how you feel about your body (body image). It may help to remember that for most people, sex is more than arousal, intercourse and orgasm. It involves feelings of intimacy and acceptance, as well as being able to give and receive love. Closeness and sharing can still be part of your relationship.

If you have a partner and do not feel like having sexual intercourse, or if you find it uncomfortable, talk openly with them about how you’re both feeling, and take things slowly by starting with hugs or a massage rather than penetrative sex. You may both need to be patient – things often improve with time and practice.

If you have ongoing concerns about how treatment has affected your sex life, talk to your GP or gynaecological oncologist or ask for a referral to a psychologist or sexual therapist.

For more information, see Sex, intimacy and cancer and listen to Cancer Council's Sex and Cancer podcast episode.