Menopause
Menopause is the end of menstruation and fertility in women, and marks the end of the reproductive phase of a woman’s life.
Menopause is defined as the point a year after a woman’s last period. The perimenopause is a descriptive term for the period leading up to the menopause and afterwards when a woman will experience symptoms relating to the change in hormones in particular oestrogen, progestogen and testosterone.
It is a natural biological process that typically occurs in women between the ages of 45 and 55, although the age can vary greatly. During this time, the levels of the hormones estrogen and progesterone, which regulate the menstrual cycle, decrease significantly, leading to the end of menstrual periods. Some of the common symptoms of menopause include hot flashes, night sweats, mood swings, vaginal dryness, and sleep disturbances. But there are many other symptoms that women experience that are unique to the individual, with some women finding their life severely impacted and others not having any symptoms at all. These symptoms can start many years before the menopause and last for many years after.
The EKHO survey showed that 42% of women considered leaving their job because of the menopause. Newson Health Research and Education found that 99% of women felt that the perimenopause had affected their work. One in five women had passed on the chance to go for a promotion they would have otherwise considered, 19% reduced their hours and 12% resigned. Brain fog, tiredness, poor memory and concentration are cited as reasons. This has a massive impact on the remaining work force and leaves women feeling disempowered, unhappy and isolated. The good news is, that there seems to be a movement towards realising that this is treatable and that women don’t need to suffer in silence. Finally it feels like the world is ready to think about menopause properly.
Does treatment increase my risk of breast cancer ?
The Million Women Study was a large-scale, population-based study of the health of women in the United Kingdom. The study was launched in 1996 and enrolled over a million women between the ages of 50 and 64 to examine the relationship between lifestyle factors, such as diet and physical activity, and the risk of developing various health conditions.
One of the key findings of the Million Women Study was the relationship between hormone replacement therapy (HRT) and breast cancer risk. The study concluded that women who used HRT were at an increased risk of developing breast cancer, compared to women who did not use HRT. This finding had a significant impact on the medical community and the general public, leading to a reduction in the use of HRT.
The Million Women Study was a large-scale, population-based study of the health of women in the United Kingdom. The study was launched in 1996 and enrolled over a million women between the ages of 50 and 64 to examine the relationship between lifestyle factors, such as diet and physical activity, and the risk of developing various health conditions.
One of the key findings of the Million Women Study was the relationship between hormone replacement therapy (HRT) and breast cancer risk. The study concluded that women who used HRT were at an increased risk of developing breast cancer, compared to women who did not use HRT. This finding had a significant impact on the medical community and the general public, leading to a reduction in the use of HRT.
What Investigations do I need?
The National Institute for Health and Care Excellence (NICE) provides guidance on the investigation and management of symptoms in perimenopausal women. According to the NICE guidance, the following investigations may be appropriate for perimenopausal women:
Blood Tests
Blood tests to measure hormone levels, such as follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol, can help confirm the diagnosis of perimenopause which is important when symptoms start earlier than the age of 45.
Bone Density Scan
Bone density scan (DXA scan): A bone density scan can be used to assess bone health and determine the risk of osteoporosis, which is a common condition in perimenopausal women and will be particularly helpful if there is a family history.
Mammogram
Women who are over the age of 50 or have a family history of breast cancer should have a mammogram as part of their routine screening for breast cancer.Pelvic ultrasound
Pelvic ultrasound
A pelvic ultrasound can be used to rule out any pelvic problems, such as fibroids or endometrial thickening, that may be causing symptoms in perimenopausal women such as very heavy and / or irregular bleeding.
It is important to note that the need for investigations will vary depending on individual circumstances and symptoms, and not all women will require all of the above tests. In fact the general advice is that a woman over the age of 45 experiencing perimenopausal symptoms does not require any blood tests at all. The NICE guidance recommends that women seek the advice of a healthcare provider to determine the most appropriate investigation plan.
What do we know helps with symptoms?
Lifestyle Factors
There are several lifestyle factors that have been shown to help with the symptoms of menopause and even if you choose to take medication these are worth prioritising. What we know is that the menopause also brings with it an increased risk of cardiovascular disease, diabetes, cancers and bone thinning and therefore optimising our health at this stage (and earlier) will help not just manage perimenopausal symptoms but also prevent these other disorders.
The top factors are:
Exercise
Regular physical activity, can help with hot flashes, sleep disturbances, weight gain and mood swings.There is a lot of evidence for the benefit of resistance training in particular for bone health, balance and mobility being helpful in preventing falls and cardio workouts being good for our cardiovascular system, helping with blood pressure control and decreasing our risk of heart attacks and strokes. The key here is consistency and finding something you enjoy. All these physical benefits are in addition to the psychological benefits that come from being physically active.
Smoking and alcohol cessation or reduction
Quitting smoking and stopping or reducing alcohol can help reduce the frequency and severity of hot flashes. This is as well as improving cardiovascular risks.
Healthy Diet
Consuming a balanced diet that includes a variety of fruits, vegetables, whole grains, and lean proteins can help improve overall health and well-being during menopause. Increasing our “good” fats and omega 3s through eating oily fish, olive oil, avocados and some nuts can also be helpful in reducing inflammation in our body and improving brain function.
Weight Management
Maintaining a healthy weight through diet and exercise can help with hot flashes and reduce the risk of other health conditions associated with menopause. Being overweight has a higher risk of causing breast cancer than HRT so it is worth getting some professional help if you are struggling to do it alone.
Stress Management
Practicing stress-reducing activities, such as meditation, deep breathing, or massage, can help with anxiety, irritability, and insomnia. They have also been shown to improve our immune system and reduce blood pressure.
Vitamin D and calcium supplementation:
Vitamin D and calcium supplementation can help maintain bone health, which is important during and after menopause.
It is important to note that not all women will benefit from the same lifestyle factors and some may need to try a combination of strategies to manage their symptoms. It is always a good idea to speak with a healthcare provider to determine the best approach for individual needs and circumstances.
Hormone Replacement Therapy
What are the benefits?
The benefit on our cognitive functioning has been shown by the prevalence of Altzheimers being less on HRT and the use of oestrogen reduces the risk of AD by 5% annually. In fact, even just 12 weeks of Oestrogen has been shown to increase verbal memory in healthy postmenopausal women. Oestrogen is also a serotonin agonist and several RCTs have shown it to improve anxiety and depressive symptoms in up to 80% of post menopausal women.
How is it taken?
Historically HRT was given as a tablet. This was mostly due to the lower cost of tablet form HRT. What we know now is that HRT that is delivered through our skin has a lower risk of causing blood clots or deep vein thrombosis, something that can be increased with all hormones including the contraceptive pill and HRT. HRT is available as patches, gels and sprays and it can be trial and error ( and frustratingly, supply) that will help an individual women to choose what suits them best.
Why do I need a separate prescription for Progestogen too?
It is important whatever form of HRT you are taking that you have progestogen alongside oestrogen. For some women that will be in the patch, but if you are using a gel or spray you will need to take separate progestogen. This is because oestrogen without the progestogen increases the thickness of the lining of the womb and can increase the risk of uterine cancer. This progestogen can be delivered as a pill, a vaginal pessary or through an intrauterine device like the Mirena coil. Some women are sensitive to progestogen and cannot tolerate taking it orally, other women find the progestogen helps them sleep. Your health care provider will be able to help you make a choice that works for you.
What is the difference between cyclical and continuous HRT?
You may have heard that HRT can be taken cyclically or continuously, but what does this mean? Cyclical HRT involves taking oestrogen through the month but with a break in the progestogen component which stimulates a bleed. This is similar to the natural menstrual cycle and mimics the patterns of oestrogen and progesterone in a woman’s body. Cyclical HRT is typically used to relieve symptoms of perimenopause and reduce the risk of endometrial cancer. It is offered when a woman is under the age of 51 and for up to a year after the menopause.
Continuous HRT, on the other hand, involves taking HRT every day without any breaks. This method provides a consistent level of hormones and is typically used to treat symptoms of menopause and prevent osteoporosis in women over the age of 51 or in those who have not had a bleed for a year. Continuous HRT may also be used to relieve symptoms of endometriosis or other conditions that affect the uterus. A woman with a heavy bleed that is impacting on their life may choose to go to a continuous way of taking the HRT earlier.
The choice between cyclical and continuous HRT depends on individual needs and circumstances, as well as the type of symptoms being treated. Women should discuss the options with their healthcare provider to determine the best approach for their individual needs.
How long should I take HRT for?
This is a very individual choice and will depend on a number of factors such as symptoms and how impactful they are, family history of risks such as heart disease, dementia , osteoporosis and cancers, and convenience of taking HRT and any side effects.
The duration of menopausal symptoms varies from woman to woman and can last anywhere from a few months to several years. The length of time that menopausal symptoms persist is influenced by various factors, including age, lifestyle, and overall health.
In general, the most common symptoms of menopause, such as hot flashes and night sweats, tend to last for 2 to 5 years. Some women may experience these symptoms for a shorter period of time, while others may experience them for several years or more.
What is vaginal oestrogen used for?
Vaginal or topical oestrogen can be very helpful for symptoms relating to changes in the skin around the vulva, anus and vagina caused by the drop in oestrogen around the menopause. These changes can be associated with an increased risk of urinary tract infection alongside sexual discomfort and pain and itching from dryness.
Topical oestrogen can be used on its own or alongside HRT and can be life changing for some women. Topical oestrogen does not come with an increased risk of breast cancer and therefore can be used safely in the small percentage of women who can not use HRT due to their genetic risk for breast cancer.
What about Testosterone?
Testosterone is a hormone that is primarily produced by the testes in men and the ovaries in women. During menopause, levels of testosterone in women can decline, leading to a range of symptoms, including decreased libido, fatigue, and muscle weakness. In some cases, testosterone replacement therapy (TRT) may be used in combination with other forms of hormone replacement therapy (HRT) to alleviate symptoms of menopause. Testosterone therapy can help increase energy levels, improve mood, and enhance sexual function in women who are experiencing a testosterone deficiency.
It is important to note that testosterone therapy is not a standard treatment for menopause and is not recommended for all women. Women who are considering testosterone therapy should discuss their symptoms and treatment options with a healthcare provider. The provider will consider factors such as the woman’s medical history, symptoms, and overall health to determine whether testosterone therapy is appropriate and safe. If testosterone therapy is prescribed, the woman will need to undergo regular monitoring to assess its effectiveness and monitor for any adverse effects.
What about contraception in the perimenopause?
Women can often forget about contraception when they hit perimenopause with the assumption that this means they are infertile. But for a lot of women perimenopause symptoms can start long before fertility has stopped.
The UK National Institute for Health and Care Excellence (NICE) provides guidance on contraception in the perimenopause.
The following are some of the recommendations provided by NICE:
Continue to use contraception
Women who are in the perimenopause and are sexually active should continue to use contraception until they reach the menopause. This is because a woman can still become pregnant during the perimenopause.
Use barrier methods with caution
Barrier methods, such as condoms or diaphragms, are less effective in protecting against pregnancy during the perimenopause, as hormonal changes can lead to an increased risk of vaginal dryness and irritation. But absolutely do continue to use barrier methods to protect against sexually transmitted infections.
Consider a long-acting contraceptive method
NICE recommends that women in the perimenopause consider using a long-acting contraceptive method, such as a hormonal implant or intrauterine device (IUD), to provide ongoing protection against pregnancy.
Hormonal methods
Hormonal contraceptives, such as the pill or the patch, can be used in the perimenopause, but women should be aware that hormonal changes can affect the effectiveness of these methods.
Assess Fertility
Women in the perimenopause can have their fertility assessed. This can be done through a blood test called FSH.
Combined Contraceptive pills
Combined Contraceptive pills should be stopped at the age of 50 and replaced with progestogen only contraception.
All Contraception
All contraception can be stopped at the age of 55 or if a woman has not had a period for 12 consecutive months over the age of 45 and is therefore considered to have reached menopause.
It is important for women in the perimenopause to have open and honest discussions with their healthcare provider about their contraceptive needs and to choose a method that is right for them. Regular follow-up and monitoring are also important to ensure that the chosen method remains effective and to address any side effects or concerns.
What about work and menopause?
As mentioned above, the EKHO survey found that 42% of women consider leaving their job because of symptoms relating to the menopause.
The workplace can play an important role in supporting women who are going through menopause. Here are some steps that a workplace can take to support women during this time:
Raise Awareness
Encourage open and honest discussion about menopause and the challenges that women may face. This can help to break down stigma and create a more supportive and understanding environment.
Accommodate physical needs
Ensure that the workplace has appropriate facilities, such as private rooms or cooling areas, for women to manage physical symptoms such as hot flashes.
Offer flexible working arrangements
Consider allowing women to work flexible hours or work from home if needed to accommodate physical or emotional symptoms related to menopause.
Encourage physical activity
Promote healthy habits and encourage physical activity, such as exercise or yoga, as a way to manage symptoms of menopause. Some companies provide this in house or online for all staff members.
Provide access to resources
Offer resources such as informational materials, workshops, or counseling services to help women learn about menopause and manage symptoms.
Provide support for stress management:
Offer support for stress management, such as mindfulness programs or counseling services, to help women cope with the emotional symptoms of menopause.
It is important for the workplace to take a supportive and proactive approach to menopause, as this can help to create a more inclusive and supportive environment for women during this time. Additionally, supporting women during menopause can help to increase productivity and reduce absenteeism, leading to positive outcomes for both the woman and the workplace.
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