The menopause, by definition, is said to have occurred following cessation of periods for at least 12months and occurs as a result of the ovaries no longer producing any hormones.
The stage leading up to the menopause is called the climacteric and during this time, hormones can fluctuate and can lead to symptoms.
Many women have no symptoms but some have mild to very severe symptoms which can include:
- Hot flushes
- Night sweats
- Sleepless night and fatigue
- Mood swings
- Joint aches and pains
- Urogenital symptoms: Dryness of the vagina, urinary frequency, urgency and nocturia, pain with intercourse (dyspareunia)
- Loss of libido
These symptoms occur predominantly as a result of the ovary no longer producing the hormone Oestrogen (although the ovary also produces progesterone and testosterone as well).
The severity of the symptoms can be very variable and will have a differing impact on women’s lives. Whether or not a woman wants to seek treatment will clearly depend on how the woman feels and how the symptoms affect everyday life.
There is no doubt that hormone replacement therapy (HRT) will alleviate symptoms in most women. It may not provide complete resolution of all symptoms but will certainly improve the way a woman feels.
A great deal of concern, however, has been raised concerning the use of HRT, particularly following the release of data from WHI (Women’s Health Initiative) in 2002 which claimed a significant increased risk of breast cancer and thrombosis in women using HRT. More recently this data has been questioned and further evaluate and there is now a much more rational approach to the use of HRT.
The current advice is that HRT has a minimal risk for the development of breast cancer, particularly when HRT is initiated within a few years of the menopause. In women taking oestrogen therapy alone, no risk was identified. The risk of thrombosis is small and can be reduced by the use of the transdermal route of administration.
The use of HRT may be contraindicated in some women or should be used with caution in others. The main concerns regarding the use of HRT is, of course, a family history of breast cancer and thrombosis and this should be discussed with the GP or consultant Gynaecologist to weigh up the risks and benefits to the individual woman. Indeed when considering the use of HRT in any woman, the benefits should outweigh any risks and individualisation of treatment is essential.
All women who have a uterus must have a HRT that contains the 2 hormones, oestrogen and progesterone. This is because continued use of oestrogen therapy alone has been shown to cause an overgrowth (hyperplasia) of the lining of the uterus (endometrium) and cancer of the uterus. Women who have had a hysterectomy only need oestrogen.
Women can choose between having no bleeds or having a monthly bleed. In women who have only just stopped menstruating (less than 12 months), a preparation that causes a monthly bleed is necessary but can be changed at a later date to a no bleed preparation. This is because, at less than 12 months after the last period, the ovary can still produce small amounts of hormone and can cause irregular bleeding when a ‘no bleed’ preparation is used.
The recommendation is to use the minimum dose of HRT that will alleviate symptoms. Low dose (1mg oestradiol) and ultra low doses (0.5mg oestradiol) of HRT are available.
Routes of administration include both oral and transdermal and ultimately the best route of administration is the one which the woman will remember unless there is an absolute necessity for a woman to use a particular route.
The duration of HRT is at the discretion of the woman and is dependent on the benefits vs the risks.
Benefits of HRT:
- Supression of vasomotor symptoms (hot flushes, night sweats)
- Improvement in urogenital symptoms (vaginal dryness, urinary frequency. Nocturia and pain with intercourse)
- Beneficial to the cardiovascular system through improved vascular function, improved cholesterol levels, glucose levels and blood pressure. There is a decrease in the risk of diabetes in HRT users and also a reduction in the morbidity and mortality from coronary artery disease.
- Prevention of osteoporosis. There is a decrease in osteoporosis related fractures
- Improvement in Libido
- Increase in energy levels
- Stabilisation of mood and reduction in anxiety levels
If a woman does not want to use HRT, then alternative treatments need to be considered depending on the symptoms of the woman.
*Vagifem 10 is a low dose oestrogen tablet that goes into the vagina and has been shown to have minimal, if any, absorption into the systemic circulation. Significant improvement in vaginal dryness has been clearly shown.
Ospemifene is a selective oestrogen receptor modulator (SERM) and oral administration has been shown to improve vaginal dryness.
Vaginal DHEA may be beneficial for vaginal dryness and sexual dysfunction
Vasomotor Symptoms (hot flushes and night sweats particularly)
SSRI (Selective Seretonin Re-uptake inhibitors) can reduce vasomotor symptoms short term. Examples include: Venlafaxine (75mg) and Paroxetine (10mg)
Lifestyle changes to reduce ‘triggers’ of hot flushes such as stopping smoking, reduction of alcohol intake and better diet and reduction of stress levels.
Bone Density –osteopenia and osteoporosis
Bone Density scans (DEXA) can be used to identify any bone loss and the extent of that loss. Loss of bone can be treated using Bisphosphonates (non hormonal) and a referral to the Rheumatologist for on going management of osteoporosis.
- Dietary supplements: Vit E, Vit B6, B12 and folic acid may have an impact on the reduction of coronary artery disease. Vit D and Calcium and magnesium may be beneficial for bone density.
- Aromatherapy: There is no evidence for the benefit of aromatherapy but there have been no trials
- Reflexology: There is no evidence for the benefit of aromatherapy but there have been no trials.
- Evening Oil of Primrose: May help with breast tenderness but there are no specific benefits for menopausal symptoms.
- Transdermal Progesterone: Can decrease vasomotor symptoms
- Black Cohosh: May decrease symptoms if taken at a dose of 40mg daily
- St John’s Wort: No benefit shown
- Angus Castus: Has shown some benefit
- Phyto-oestrogens: Are100-1000x weaker than oestradiol. They comprise: Isoflavones (soybeans, red clover) and Lignans (flaxseed and linseed). They have been shown to improve vasomotor symptoms and mood.
Women experiencing a spontaneous or iatrogenic menopause before 45 and particularly before 40 are at a much higher risk of developing cardiovascular disease and osteoporosis and may also be at an increased risk of dementia. Use of HRT may decrease these risks and is recommended until the average age of menopause which is 52
The British Menopause Society (BMS) recommends that ‘Women should be empowered to live as full, healthy and active life as possible’ It is important to remember that women going through the menopause who have symptoms do have options open to them and should seek advice and guidance on how to improve the way they feel.