Menopause

Menopause is when you stop having periods, which usually happens between the ages of 45 and 55. For a small number of women, menopause occur earlier. If this happens before you are 40 it is called premature menopause (or premature ovarian insufficiency).

Menopause happens when your ovaries stop producing a hormone called estrogen and no longer release eggs. For some time before this – it could be a few months or for several years – your periods may become less regular as your estrogen levels fall. This is called perimenopause.

Symptoms

During perimenopause you might have symptoms such as

  • hot flushes
  • night sweats
  • joint and muscle pain
  • vaginal dryness
  • mood changes 
  • lack of interest in sex

Menopause affects women differently. You may have no symptoms at all, or they might be brief and short-lived. For some women they are severe and distressing.

Osteoporosis (Weak bones)

Osteoporosis is a condition that causes bones to weaken as a result of lower level of estrogen in the body. It can lead to the bones becoming fragile and breaking easily. Whether a woman develops osteoporosis after the menopause depends on

  • The strength of your bones before the menopause.
  • The age at menopause. Women who develop menopause early are at higher risk of osteoporosis.
  • The rate of bone loss.

Do I need any hormone tests before I can start treatment?

If you have symptoms of the menopause and are over 45 years of age, you will not usually need any hormone tests to diagnose menopause. Treatment options are usually based on your symptoms alone.

Treating menopausal symptoms

Lifestyle changes

Maintaining healthy weight and keeping fit and strong can improve some menopausal symptoms. Regular aerobic exercise, such as running and swimming may help, as may low intensity exercise as yoga. Reducing intake of caffeine and alcohol may also reduce hot flushes and night sweats.

Hot flushes and night sweats

For women who seek help for their menopausal symptoms, HRT (hormone replacement therapy) is the most commonly prescribed treatment. HRT helps to relieve symptoms by replacing estrogen levels that naturally falls in menopause. If you are finding them a problem, you should be offered HRT after the health provider discusses with you the risks and benefits. You can start HRT as tablets, or through a patch or gel on your skin.

If you have a womb you should be offered HRT that contains estrogen and progesterone. This is because estrogen-only HRT can be harmful to the lining of the womb. If you do not have a womb you should be offered estrogen-only HRT.

Some women find that dietary supplements black cohosh and isoflavones can reduce their hot flushes and night sweats. However, the ingredients of these products may vary, and their safety is unknown. They may intervene with other medicines you are taking.

Low mood

Low mood is a common symptom of menopause – it is different from depression.

If you are feeling low as a result of menopause you may be offered HRT. Another possible treatment is CBT (cognitive behavioural therapy) and you may be offered this if you have low mood or anxiety as a result of menopause.

It has not been shown that antidepressant drugs can help with low mood during menopause if you have not been diagnosed with depression.

Lack of interest in sex

Some women have less interest in sex during the menopause. If HRT doesn’t help, you might be offered a testosterone replacement.

Vaginal dryness

If you have vaginal dryness you should be offered vaginal estrogen, which is put directly into the vagina as a pessary, cream or a vaginal ring. You can use vaginal estrogen for as long as you need, even if you are already using HRT. Moisturisers and lubricants can also help. If vaginal estrogen doesn’t help to start with you may be offered a higher dose.

It is rare for vaginal estrogen to cause problems, but if you have unexpected bleeding you should tell your GP. Vaginal estrogen might be suitable for you if you can’t take HRT for medical reasons.

Premature menopause (premature ovarian insufficiency)

If menopause happens before you are 40 it is called premature menopause (or premature ovarian insufficiency). Usually, no cause is found for this. It can be caused by surgery on the ovaries, chemotherapy or radiotherapy to the pelvis. It can also run in families. Other less common causes include chromosomal problems and autoimmune disease when the body immune system attacks the developing eggs.

Diagnosis

Premature menopause is diagnosed using your age and symptoms, as well as information about your family history and medical history. If you are under 40 and having scanty periods you should be offered blood tests to measure your FSH levels. You should be offered 2 blood tests for FSH and should be done 4-6 weeks apart. When tested, you should not be on combined hormonal contraceptive pills or on high dose progestogen.

Treating premature menopause

Treatment of premature menopause usually involves HRT or combined hormonal contraception.

  • It is important to continue treatment until at least the age of natural menopause, to give you some protection from osteoporosis and other conditions that develop after the menopause.
  • The risk of conditions such as cardiovascular disease and breast cancer is very low in women under 40.
  • Both HRT and combined contraceptive pills are good for bone health.
  • HRT may be better for your blood pressure than the combined contraceptive pills.
  • HRT is not a contraceptive.

Hormonal treatment is not suitable for some women, for example if you have a history of breast cancer or any other type of cancer that is stimulated by the hormone estrogen.

Hormone replacement therapy (hrt)

What is hrt

HRT is hormone replacement therapy, which is designed to counteract the effects of reduced estrogen levels. It mainly consists of natural, low dose estrogen and can be taken as a daily tablet, a weekly or twice weekly patch or daily gel. Most women start with tablet form of HRT, but non-tablet form can be used:

  • If you prefer that option.
  • If you have a specific medical problem for which non-tablet is advisable.
  • If menopausal symptoms are not controlled with tablet therapy.

Types of hrt

There are two types of HRT:

Combined HRT (estrogen and progestogen)

For women in whom the uterus (or womb) is present, a progestogen is added to reduce the risk of estrogen causing thickening of the endometrium (lining of the womb). Progestogen can be taken in tablet form, by patch, vaginal gel, or by using the progestogen-releasing intrauterine system (Mirena Coil).

If combined HRT is started before you have the menopause or within 12 months of your last period, then you will be offered ‘cyclical’ combined HRT which give you a regular monthly bleed.

If you start combined HRT more than 12 months after your last period, you may be offered ‘continuous’ combined HRT (bleed-free HRT). You may experience some vaginal bleeding in the first 3 months, but after this it should stop.

Estrogen-only HRT: If you have had a hysterectomy then you will be offered estrogen-only HRT.

Women who notice a low sex drive after the menopause may be offered another hormone called testosterone.

Benefits and risks of hrt

Benefits of HRT

HRT can provide significant benefits both for relief of distressing symptoms, reducing vaginal dryness, improving quality of life and prevention and treatment of osteoporosis.

Symptom relief

Systemic HRT is very effective at relieving menopausal symptoms. If HRT is taken for symptom relief after the age of 50, then it would be worthwhile considering stopping it every 2-3 years to determine whether or not treatment is still required. If symptoms return, HRT can be restarted after discussion of the risks and benefits which should be weighed up on an individual basis. If HRT is commenced following an early menopause (before the age of 45), then it should be continued at least until the age of 50 (average age of menopause) for both control of symptoms and bone protection. There are no arbitrary limits on the use of HRT, and this should be an informed, individual choice.

Improve sexual desire and reduce vaginal dryness

Estrogen given vaginally in the form of tablets, cream or ring is effective in treating vaginal dryness. Low-dose vaginal oestrogens can be used for as long as you need to and can also be safely used in combination with HRT. These can also reduce bladder infections and help urinary symptoms. If you experience unexpected vaginal bleeding, you should tell the healthcare professional.  

Prevention and treatment of osteoporosis

When your ovaries stop making oestrogen your bones become thinner and you have a higher risk of osteoporosis, where your bones break more easily.

You should be given advice about your bone health and osteoporosis at your first appointment and again when reviewing the treatment. HRT is beneficial in the prevention of bone loss and treatment of osteoporosis. It is particularly important for women with an early menopause and women who have increased risk of osteoporosis.

The benefit only lasts while you are taking HRT but may last longer if you have taken HRT for a long time.

Risks of HRT

The risks of HRT vary from women to another and depend on many individual factors. In case where HRT is said to increase risk, this usually means a very small increase in most women. 

Breast cancer

  • HRT with estrogen alone is associated with little or no risk of increased risk of breast cancer.
  • HRT with estrogen and progestogen can be associated with a small increased risk of breast cancer, which is related to the duration of treatment and risk reduces after stopping HRT. Progestogen is still recommended for women who have a uterus to reduce the risk of endometrial cancer.

It should be noted that being overweight, smoking and alcohol are associated with a greater risk of breast cancer than HRT.

Blood Clots (venous thromboembolism)

  • HRT in tablet form are linked with a higher risk of blood clots (an additional 1.5 per 1000 women per year from a baseline risk of 1 per 1000 women per year).
  • There does not seem to be the same risk with non-tablet form (patches or gels). Women at high risk of blood colts, including those with body mass index (BMI) of 30 or over should use non-tablet forms.
  • If you have a strong family history of blood clots or theirs is another reason why you are at high risk of blood clots, you may be referred to a haematologist (a doctor who specialises in blood conditions).

Heart disease and stroke (Cardiovascular disease)

  • If you start HRT before you’re 60 it does not increase your risk of cardiovascular disease.
  • HRT does not affect your risk of dying from cardiovascular disease.
  • Starting HRT before age 60, or within 10 years of menopause may reduce the risk of heart disease, but current evidence is not strong enough to recommend this.
  • HRT tablets (but not patches or gels) slightly increase the risk of stroke. However, it is important to remember that the baseline risk of stroke in women under 60 is very low.  

Endometrial Cancer

Estrogen alone can lead to increase in the thickness of lining of womb and endometrial cancer. Progestogen for 10-14 days of the cycle reduces this risk. Daily progestogen (no bleed preparations) eliminates this risk.

Type 2 diabetes

HRT does not increase your risk of developing type 2 diabetes.

If you already have type 2 diabetes, HRT is unlikely to have a negative effect on your blood sugar control. When deciding if HRT is suitable for you, your GP will take into account any health problems related to diabetes and may ask a specialist for advice before offering your HRT.

Balancing the risks and benefits of HRT

The benefits of HRT outweigh the risks in most women. However, it is essential that individual factors, such as medical conditions, body weight, smoking, are all taken into consideration to provide women with individualised benefit risk profile. There is no arbitrary limit on the duration of use of HRT and the decision should be based on individual basis.

Side effects

The majority of women who take HRT do not have troublesome side effects but for those who do, adjustments can be made, and many different treatment options are available.

Mild symptoms of headache, nausea, bloatedness, breast tenderness and mood changes can occur with use of HRT. These symptoms usually settle down gradually in about 3 months. If symptoms persist, different preparation or change of the dose should be considered.

Irregular bleeding may occur during the first few months of treatment. This is quite common and usually settles. If not, HRT can be changed to help the problem.

When should I seek advice after starting HRT?

You should have a review appointment with your healthcare professional after 3 months of starting or changing HRT, then yearly thereafter.

You may notice some vaginal discharge in the first 3 months of starting or changing HRT, but if you experience bleeding after 3 months then you should see your healthcare professional straight away.

How long can I take HRT for?

There are no set limits for how long you can be on HRT. The benefits and risks of taking HRT will depend on your individual situation, and your healthcare professional should discuss these with you.

How do I stop HRT

You can stop your HRT suddenly or reduce gradually before stopping it. The chances of the symptoms coming back is the same either way.

Do i still need to use contraception when taking HRT?

HRT does not provide contraception. You need to continue using contraception for 1 year after your last period if this happens after the age of 50 years. If your last period happens before you are 50 years of age, then you need to continue using contraception for 2 years.

What are my options if I do not choose HRT?

Not every woman chooses HRT for menopausal symptoms. This may be because of your own or family history, or because your concerns about the safety or side effects of HRT. Treatment options are described below:

Non-hormonal medical treatment:

Non-hormonal medical treatments, which need to be prescribed by your doctor, include clonidine or gabapentin for hot flushes

Psychological treatments:

Cognitive behavioural therapy (CBT) is a type of psychological treatment. You may be offered CBT for low mood or anxiety related to menopause.

Herbal medicines

Plant or plant extracts, such as St John’s wort, black cohosh and isoflavones (soya products), can help reduce the hot flushes and night sweats for some women. However, their safety is unknown, and they can react with other medicines that you may be taking for other medical conditions.

Alternative therapy

Alternative therapies such as acupressure, acupuncture or homeotherapy may help some women. More research is, however, required on the benefits from these therapies and, if they are used, this should be done with advice from qualified professionals.

Complementary therapy

You may wish to try a complementary therapy, such as aromatherapy, although the effects of these therapies specifically on your menopausal symptoms are not well known.

Bioidentical hormones

Commercially available ‘bioidentical’ hormones are not regulated or licensed in the UK owing to lack of evidence that they are effective or safe to use.

Ref:14/21/184
Review: 04/23