Professor Bill Ledger answers your questions

For Jo Hello Jo,

First point is that women with PCOS do not seem to have a higher risk of breast cancer compared with other women - there was a big study in Iwoa that looked at this, so it is very unfortunate that you have both conditions. The question of risks of fertility treatment, be it clomid for anovulation or IVF for women with an oestrogen receptor positive tumor is frequently asked. Opinions differ amongst breast cancer experts but many will allow women to have low dose treatment, accepting that the levels of oestrogen that appear in the body during pregnancy are much higher than would be seen during clomid or IVF treatment.

However, any fertility treatment will elevate levels of oestrogen, albeit modestly, so it is possible at least theoretically that this might increase chance of recurrence. It is a matter of weighing up your desire to have children against the possibility of recurrence.

For Katey Hello Katey,

Modern chemotherapy for breast cancer is less toxic to the ovaries than in the past. Oncologists are very aware of the need to preserve fertility if possible, while not jeopardising chances of successful treatment. It sounds as if you are one of the luckier patients who's ovarian function has returned after chemo - this happens in over 50 percent of younger women (those under 30) who have standard chemotherapy for breast cancer.

There is no evidence that chemotherapy affects the health of the eggs that lie dormant in the ovaries and that later ovulate and give chance of pregnancy. There is a reassuring paper in BMJ (2007:334 pages 194 - 6) my advice therefore would be to try for a natural pregnancy and to use your frozen embryos if natural conception does not occur within 12 months or so (this assumes that your age is less than 40).

The BMJ paper also suggests that it is safe enough to try for pregnancy six months after ALL treatment for breast cancer has finished. This includes Tamoxifen, Arimidex and other hormonal treatments.

For Sarah Hello Sarah

Women who have received a diagnosis of breast cancer are often advised to wait 2 years after treatment before they attempt to conceive. However, there is no good evidence to suggest that postponing pregnancy will alter the outcome of the cancer or the pregnancy. The two year wait is based upon anecdotal evidence and is designed to prevent pregnancy in women unlucky enough to have early recurrence of their disease and need further chemotherapy or radiotherapy. The Australian study published recently in BMJ (see above) shows that for women with localised disease, early conception at least six months after completing treatment is unlikely to reduce survival.

For Stephanie Hello Stephanie,

As mentioned above, standard modern chemotherapy for localised breast cancer is less toxic to the ovaries than in the past. For younger women, the chances of entering permanent menopause are now less than 50 percent although the majority of women over 40 will still not have periods after chemotherapy.

So my first question would be whether your periods have returned after finishing chemotheraphy. Women taking Arimadex or Tamoxifen often don't have periods, but assuming that you are now off treatment, return of regular periods suggests return of ovulation and hence fertility.

Your GP could take a blood sample to check levels of FSH and Oestradiol on the second or third day of a period. If the level of FSH is less than 8 then the ovaries are probably working normally, and if the level is between 8 and 12 then fertility is also probably okay.

To discover whether you are ovulating, a blood test taken three weeks from the start of a period for measurement of progesterone can also be done in general practice. A level above 25 usually indicates ovulation.

Don't forget to have your partner checked - an experience most men really enjoy!

For Emma Hello Emma,

Most women who will resume ovulating after chemotherapy will see resumption of normal periods within 12 months of completing ALL treatments. Late recovery of ovulation is well reported.

If you are not ovulating and hence are experiencing early menopause as a side effect of chemotherapy then resumption of natural ovulation often produces disruption in the monthly cycle of hormone induced bleeding - women experience bleeding at odd times, for example.

I advise my young patients on HRT after chemotherapy to take a six week holiday from HRT every couple of years. If a natural period occurs, have a blood test for FSH and Oestradiol on the second or thrid day of that period. If there is no period within six weeks then do the blood test anyway and restart HRT.

Women in menopause will have a high FSH - levels above 50 are frequently seen, but you have to let the HRT wear off because it artificially lowers the FSH levels and you can have false reassurance unless you wait sufficient time before doing the tests.

For Antonia Hello Antonia,

You are unlikely to conceive while using Tamoxifen continuously on a daily basis but the human body is naturally very fertile and it is probably wise to take sensible precautions such as use of a condom or a coil while on Tamoxifen particularly if your doctors have advised against pregnancy. Some women using Tamoxifen experience annoying break-through bleeding and the Mirena coil can be helpful. It also reduces the risk of Tamoxifen induced uterine polyps, which are a great nusiance.

soft trial vs zoladex injections... Hi i am 38 just finished chemo and radiotherapy. am on tamoxifen. onc suggested soft trial or zoladex injections as I am oestrogen positive. I am thinking possibly of zoladex as I live 40 miles from hospital and too be honest feel I have spent alot of time at hospital recently. would you recommend removal of ovaries by surgery to someone of my age? am also having to have genetics done as my sister had bc at 37. would welcome your opinion.
thanks.

For Bakers Hello Bakers,

I am not an Oncolgy specialist but I do prescribe a lot of Zoladex to women. The side effects of Zoladex are of menopause - hot flushes, particularly at night, sweats, mood swings, loss of sex drive and changes in hair, nails and skin. Some people have loss of concentration. Having given that somewhat scary list of problems it's important to stress that some women have very few problems on Zoladex whilst others have more severe side effects.

One of the advantages of Zoladex is that it can be given as a three monthly injection so less trips to hospital. The drawback is risk of Osteoporosis with long term use, although it is possible to take tablets to protect against Osteoporosis - this might be an HRT based drug like Livial or a non hormonal drug like Fosamax. You need to discuss this with your specialist.

Removal of ovaries can be done with keyhole surgery perhaps with a one night stay in hospital. However this does induce permanent menopause and so you need to think carefully and discuss with your medical team before going ahead. Many breast cancers are sensitive to oestrogen hormone and either Zoladex or removing ovaries will reduce oestrogen levels and hence may help treat the disease.