- WHAT IS THE MENOPAUSE?
The MENOPAUSE is the last period. It is a natural stage in a woman’s life. It is diagnosed if you have not had a period for 12 months. This means that you diagnose the menopause by looking back over the last 12 months. So even If you haven’t had a period for 2 months, or 4 months, or 6 months, or 10 months, or even 11 months, you are not technically in the menopause until your periods have stopped for 12 consecutive months. If you are taking hormonal contraception or have had a hysterectomy, this rule does not apply as both affect periods. You will need to speak to your doctor about alternative ways of assessing the menopause.
2. WHAT IS THE PERI-MENOPAUSE?
The PERI-MENOPAUSE is the time leading up to the menopause. It is sometimes referred to as the ‘transition phase’ before the menopause. During this time the body goes through changes in response to a decline in the level of hormones produced by the ovaries, mainly Oestrogen, as well as other hormones such as Progesterone and Testosterone. It is a natural part of getting older. The perimenopause usually starts around the age of 45 but can be earlier in some women. There are receptors for Oestrogen, Progesterone and Testosterone in organs all over the body such as the brain, heart, gut, bladder, uterus, vagina, urethra, pelvic floor, bones, and skin, which means that these organs need these hormones to function effectively.
During the peri-menopause, due to the declining level of these hormones, women can experience quite a constellation of symptoms, such as: irregular periods, brain fog, mood changes, depression, anxiety, insomnia, headaches, night sweats, hot flushes, palpitations, digestive problems, urinary symptoms, vaginal dryness, changes in vaginal discharge, reduced sex drive, joint pain, muscle aches, fatigue, dry skin, skin irritation or abnormal skin sensations, hair loss, loss of muscle mass, and more. Symptoms can continue for years after your last period, on average 4-7 years, but can be longer. About 42% of women between the ages of 60-69, still experience symptoms.
Interestingly, the Peri-menopause is a term that many women are less familiar with (when compared to the term ‘menopause’) but is probably the condition that impacts the psychosocial and emotional well-being of women the most, with many left feeling as though they are facing an uninvited, objectionable life crisis, wondering whether they are suffering from the early stages of dementia, cancer, and even finding themselves in situations of extreme psychological debilitation. As symptoms of the Perimenopause can start in the early 40s (and in some women even earlier), many women are unprepared for it, as they are of the misplaced impression that such symptoms would only occur in their 50s and beyond. There needs to be more consistent and structured education around the perimenopause to raise awareness about recognising the signs and symptoms early. Only then will this trigger timely discussions with a trained health professional about individualised management, prevent unnecessary physical, psychological and emotional debilitation, and fracture entrenched myths and stigma around the condition.
3. DO I NEED BLOOD TESTS?
Many women ask for blood tests to find out if they are ‘going through the menopause’. Unfortunately, blood tests carried out around the perimenopause are unreliable because they can fluctuate quite considerably, making interpretation rather difficult. Blood tests can be normal, even up to 8 years after a woman starts to experience symptoms. Blood tests should therefore not be used to diagnose the perimenopause or menopause in women over the age of 45yrs, rather the diagnosis should be based on your symptoms. A blood test to measure your hormone levels may be carried out if you are under the age of 45yrs. It is important to remember, that around the time of the perimenopause or menopause, other health issues can co-exist, so your doctor may request blood tests or other investigations to ensure that your symptoms are not related to problems or diseases other than the perimenopause or menopause.
4. BUT I AM STILL HAVING PERIODS?
Women can still have periods during the perimenopause. In fact, some women can continue to have regular monthly periods, so the presence or absence of periods, in isolation, should not be used to confirm the perimenopause.
5. SO, WHEN CAN I START HRT?
Hormone Replacement Therapy (HRT) or Menopause Hormone Treatment (MHT) is the mostly commonly prescribed treatment to relieve symptoms of the Perimenopause and the Menopause. Treatment aims to replace the hormones that are at low levels. The consensus recommendation from the British Menopause Society is that HRT or MHT can be started once symptoms of the perimenopause start, and as previously mentioned, you do not need any tests.
6. IS IT SAFE?
It’s fair to say that the public opinion regarding HRT or MHT has been through swings and roundabouts over the years mainly fuelled by the historical evidence on its safety profile.
So, let’s look at the evidence
In 2002, data was published by the Women’s Health Initiative (WHI) investigators which raised concerns about the health risks to women on HRT. The data came from a study made up of over 16,000 women aged 50-79yrs on combined oestrogen and progesterone HRT. The outcome was concern about the increased risk of breast cancer and heart disease. Following this study, many women discontinued their HRT and considered non-hormonal options. 5 years later, there was a re-analysis of the study data, and the following considerations were highlighted:
- The study design: The average age of the women recruited to the study was 63 and as old as 79yrs. This group of women is not a typical representation of the profile of the women that are prescribed HRT to treat peri-menopausal and menopausal symptoms.
- The risk of BREAST CANCER was found to be highest in those women who used HRT for a long period (over 10yrs), and in the older age groups aged 70-79yrs (in whom we would expect the rates of cancer and cardiovascular to be higher).
- The trial was stopped early and so the preliminary findings were inaccurately extrapolated to ALL age groups, which included women entering the menopause in their early 40s and 50s.
- Review of the data also revealed that there is no significant increased risk of cardiovascular disease. A more recent study, Cochrane analysis by Boardman et al. 2015 demonstrated a significant reduction in cardiovascular events, cardiovascular mortality and all-cause mortality in women who commenced HRT within 10 years of onset of menopause compared to placebo. The Cochrane data-analysis shows that HRT initiated within 10 years of the menopause is likely to be associated with a reduction in coronary heart disease and cardiovascular mortality.
- Women on Oestrogen-only HRT had a lower risk of breast cancer.
So where does this leave us?
Following the unpicking of the negative hype around the use of HRT, it does sound like good news for women considering HRT, particularly women starting HRT under the age of 60yrs, however the facts remain that HRT RISKS AND BENEFITS vary with duration of use, age at start of treatment, the regime and dosage of treatment. For this reason, NICE have recommended an individualised approach to the diagnosis, investigation, and management of the menopause. It is recommended that women should be able to access up-to-date advice and treatment by an experienced menopause health-care professional
Oestrogen replacement remains the most effective treatment for menopausal symptom control. It should also be considered as first line therapy for the prevention and treatment of Osteoporosis in women under the age of 60yrs (as long as other causes of osteoporosis have been excluded
7. WHAT TYPE OF HRT DO I NEED?
There are different types of HRT that either contain Oestrogen, Progestogen (synthetic Progesterone), or a combination of the two. HRT can be taken as a tablet by mouth or inserted into the vagina, or across the skin as a patch, gel, spray, or implant. Creams and pessaries are also available as local treatment for vaginal symptoms. As a general rule of thumb, you will need at least two forms of HRT: Oestrogen and Progesterone. If you do not have a uterus, you will only need oestrogen at start. Testosterone should also be replaced, particularly with persistent symptoms of sexual dysfunction, low libido, fatigue, however, NICE currently recommend that Oestrogen and Progestogen (if a uterus is present) is replaced in the blood stream first, before a trial of testosterone is considered. The use of testosterone as part of HRT in women is currently off licence.
Regulated ‘Bio-identical Hormone Replacement Therapy’ (rBHRT) has lower risks of breast cancer, heart disease and blood clots and tends to be the preferred first line choice of HRT. rBHRT refers to hormones that have a similar molecular structure to those produced by the ovaries or elsewhere in the body. They are generally derived from soy and yams, but the plant product needs to be chemically altered before it can become a useful therapeutic treatment in humans. rBHRT is authorised by regulators such as the Medicines and Healthcare Products Regulatory Agency (MHRA) in the UK.
How oestrogen is delivered in the body is also important. Oestrogen delivered across the skin (transdermal route) is associated with a lower risk of strokes and blood clots so may be appropriate if a woman has a history of, or increased risk of, blood clots, cardiovascular risk factors, such as obesity, uncontrolled high blood pressure, or high levels of a type of cholesterol called triglycerides.
Women who have had a hysterectomy only require oestrogen and so have a lower risk of breast cancer compared to women who take a combination of Oestrogen and Progestogen.
Local (vaginal) Oestrogen Treatment:
The vagina, urethra, bladder and pelvic floor muscles, all have receptors for oestrogen and progesterone. Oestrogen and Progesterone help to keep these structures healthy. With falling levels of oestrogen around the menopause, the following changes occur:
- Vaginal epithelium becomes thin, loses its collagen support and elasticity, loses its rugae, becomes pale or erythematous with fine petechial haemorrhages.
- Vaginal pH increases due to reduced production of lactic acid, which permits the growth of pathogens.
- Reduction in vaginal and cervical secretions leading to reduced lubrication
- Change of mucus to thick or watery/runny (‘no-blood period’) consistency; changes in mucus can be accompanied by a change of smell
The resulting symptoms include pain during sex (which can lead to avoidance of intimacy or avoidance of penetrative sex), itching, burning and dryness down below. You may also experience urinary symptoms such as urgency to pass urine, passing urine more frequently, pain on passing urine, difficulty passing urine, leaks, as well as urine infections. These symptoms are collectively referred to as Genito-Urinary Syndrome of the Menopause (GSM).
Vaginal oestrogen-based treatments are very effective in treating local symptoms. As treatment is applied locally to the vagina there is no increased risk of breast cancer. Vaginal oestrogen is available either as a tablet, ring, or cream.
8. CAN I TAKE HRT IF I OR A FAMILY MEMBER HAS HAD CANCER?
Women with a significant family history or personal history of cancer, should be referred to a specialist clinic to assess their individual risk. HRT or MHT is usually avoided in women who have a history of oestrogen-dependent cancers.
9. HOW LONG CAN I TAKE HRT FOR?
There is no arbitrary value for how long you can use HRT or MHT. The duration should be individualised with an annual review with a Health Care Professional trained in the management of the Menopause. The recommendation from NICE is that use of HRT can continue as long as the benefits outweigh the risks.
10. WHAT IF I DON’T WANT OR CAN’T TAKE HRT?
Many women prefer not to take HRT or can’t take HRT. So what are the other options available to control menopausal symptoms?
(A) LIFESTYLE OPTIMISATION:
Lifestyle optimisation should be incorporated into the routine management of all women in the menopause transition and beyond:
Diet: A protein-rich diet is recommended (with a good balance of plant and animal-based proteins) as women are less able to use food to build muscle mass compared to men of the same age. Examples include: lean meat, fish, eggs, and pulses. Avoid excessive red and processed meat.
Fibre is effective in reducing bad cholesterol and nourishing our good bacteria in the gut. Go for:
– Wholemeal products (brown rice, wholemeal pasta, wholemeal bread), wholegrains provide many vitamins and minerals that are no longer present in white flours.
– Increase the portions of vegetables (vegetables should take up half the plate for lunch and dinner!),
– Consume pulses, seeds and oilseeds and certain vegetal oils (rapeseed, walnut)
A high-fibre diet also has the advantage of making you feel fuller and therefore helps with weight management and prevents constipation.
Slow carbohydrates (‘slow carbs’) such as oat bran, rolled oats, whole-grain, whole-wheat bread, spaghetti, brown rice, pearled barley and wheat tortillas will help prevent sugar cravings.
Omega 3 fatty acids are believed to lower the levels of ‘bad cholesterol’ (mainly triglycerides) in the blood. At the menopause, there is often a deficiency in Omega 3 fatty acids, which leads increases cardiovascular risks. Omega 3 fatty acids can be found in small oily fish (sardines/mackerel/herring), rapeseed and linseed oils (to be used cold) and flaxseed. Omega 3 also has a positive effect on our mood and skin.
Avoid foods high in saturated and trans-fats such as commercial baked goods, for example, cakes, cookies and pies; microwave popcorn; high-fat content red and processed meats, pizzas, fried food, margarine. They increase the risk of heart disease.
A dietary allowance of 1200mg of Calcium is recommended ideally by diet or as a supplement. It is essential for good bone density. Vitamin D, is recommended at a dose of 10mcg (or 400IU) per a day. Not only is it needed to help build bone density but also immunity, mood, muscle strength, prevention of chronic diseases.
Keep alcohol intake to a minimum. There is evidence that the risk of breast cancer increases even in women consuming low levels of alcohol (one unit a day!). Excessive use of alcohol has negative effects on bone density and so increases the risk of osteoporosis and fractures. Smoking is a significant risk factor for cardiovascular disease and cancer. Speak to your doctor about ‘Stop Smoking Support Services’ in your local area.
Movement: Regular physical activity: can help to manage the hot flushes and night sweats. It also reduces the risk of premature death, cardiovascular disease, Type 2 Diabetes, high blood pressure, colon cancer, obesity, and has a beneficial effect on bone density, muscles and psychological well being. The World Health Organisation (WHO) recommends at least 150 mins of moderate intensity aerobic exercise or 75mins vigorous exercise a week for all adults. Weight-bearing exercise and resistance exercise are particularly important for improving bone density and helping to prevent osteoporosis. Just start moving!
Good quality sleep: 7 to 8 hours are necessary for physical and mental recovery and a good regulation of hunger and satiety hormones.
Stress management: It is important to manage your stress levels! Cortisol is a hormone that maintains our ability to respond to stress. If your stress levels are high, the body is overexposed to cortisol which can lead to health problems such as high blood pressure, heart disease, stroke, anxiety, depression, muscle tension and generalised pain, headaches, and gut problems. Cortisol also breaks down collagen and elastin in the skin leading to negative effects on skin ageing. It’s probably a good time to try relaxation techniques, think about your schedule, and ways in which you can spend more time focusing on you!
(B) MENTAL HEALTH AND WELL-BEING
Psychological symptoms such as anxiety, depression, low confidence and self esteem, low mood, brain fog, irritability, poor concentration, and mood swings are common in women going through the peri-menopause and menopause. NICE recommends that as symptoms are likely caused by low hormone levels, conventional treatments such as antidepressants should not be used unless there has been a pre-existing diagnosis of clinical depression or anxiety. There may be other intercurrent lifestyle factors that can contribute to these symptoms (related to work, relationships, dependants, economic challenges, and health), and where possible these should be addressed. Psychological therapies can be helpful such as Cognitive Behavioural Therapies, Mindfulness and Life Coaching. Speak to your doctor about referral to your local Psychological Therapy Service for support.
NON-HORMONAL VAGINAL TREATMENTS:
Non-oestrogen-based treatments: There are many lubricants and vaginal moisturisers available without prescription. Lubricants include: ‘YES’ and ‘SYLK’ brands. Moisturisers include: Replens, Regelle, and Hyalofemme. Lubricants should be applied before penetrative sex. Moisturisers should be used regularly every few days and not just before penetrative sex.
Please be aware that some lubricants can compromise the integrity of condoms and diaphragms. The ‘YES” brand is available as a water-based lubricant and an oil-based lubricant. The oil-based lubricant should not be used with condoms. The ‘SYLK’ brand is a water-soluble lubricant and can be used with condoms. The vaginal moisturisers are water-based and can be used with condoms. Please be aware that some lubricants can compromise the integrity of condoms and diaphragms. The ‘YES” brand is available as a water-based lubricant and an oil-based lubricant. The oil-based lubricant should not be used with condoms. The ‘SYLK’ brand is a water-soluble lubricant and can be used with condoms. The vaginal moisturisers are water-based and can be used with condoms.
The Pelvic floor:
Because there are receptors for oestrogen and progesterone in the pelvic floor muscles, the pelvic floor is also affected by loss of oestrogen and progesterone during the perimenopause/menopause.
The Pelvic floor is a group of muscles that support the bladder, lower part of the bowel, womb, and vagina (also known as pelvic structures). You can think of the pelvic floor as a hammock or upside-down gazebo that holds up all the structures in the pelvis.
With loss of oestrogen and progesterone, the pelvic floor muscles become weaker and provide less support for the pelvic structures. Sometimes these structures can sag or droop down, and this is called a ‘prolapse’ with women commonly reporting a feeling of a ‘lump or swelling down below’, or ‘something coming down’, or a ‘dragging sensation’ especially towards the end of the day. It may get worse when coughing or walking.
Other symptoms of a weak pelvic floor can include urgency to pass urine, passing urine more frequently, difficulty passing urine, and leaks, leakage of faeces, feeling that you haven’t completely emptied your bowels, straining to pass stools, urgency to pass stools, discomfort during penetrative sex, reduced sexual sensation and reduced sexual arousal.
Studies show that supervised pelvic floor exercises for 6 months significantly improve bladder, bowel and sexual function. It does require good motivation but it’s worth it! You can check out the Squeezy App at www.squeezyapp.com to learn more about exercises to strengthen your pelvic floor muscle. Alternatively, speak to your doctor about a referral to a Pelvic Floor Physiotherapist.
(D) ALTERNATIVE THERAPIES FOR MENOPAUSAL SYMPTOMS
Complementary therapies are popular choice for women going through the peri-menopause and menopause. It is important to be aware that there is currently a lack of robust evidence to support their effectiveness and lack of data about their safety. Always inform your doctor if you are taking any complementary or alternative treatments or supplements as these may interfere with prescribed medication.
Alternative therapies include: Isoflavones and lignans (these are plant-based substances that have effects similar to that of conventional oestrogens); Herbal remedies such as Black Cohosh, Evening Primrose Oil, St John’s Wort, Ginseng, Sage, Gingko Biloba and Dong Quai; Other therapeutic approaches such as Acupuncture, Reflexology, Yoga, Homeopathy, Cognitive Behavioural Therapy
(E) WOMEN’S HEALTH AND MENOPAUSE SUPPORT GROUPS
Women’s Health and Menopause Support Groups should be considered in conjunction with any treatment/therapy for peri-menopause and the menopause. It’s important to stay connected! Check out some of the following resources: