Navigating the Menopause

Introduction - Setting you up for the journey, working out your preferred route
Many women have questions about the menopause. This normal and natural phenomenon affects all women by the time they reach their mid-50s, and is nothing to be alarmed about. However, while for some women the menopause passes by almost unnoticed, for others it may bring symptoms which are noticeable enough to disrupt normal life – and for a few it can seem to make life quite miserable. In addition to the physical and psychological changes associated with the menopause, its timing often coincides with other life events which women can find difficult, such as children leaving home. It is important that women feel fully informed about what it happening to them during the menopause, including which options exist to manage any symptoms that they wish to control. It is also important that women feel fully supported, and sensitively listened to by a doctor who views them holistically, and respects their decisions regarding treatment – some women are keen to try HRT, others are keen to try complementary and alternative therapies, some only want advice about what to expect, and so on. There is no “one-size-fits-all” in menopause management, and a good doctor will work with you to create a plan which suits you, your priorities and your preferences.

Getting to know the lay of the land
The menopause is, broadly speaking, the permanent end of a woman’s menstrual cycle, and can really only be diagnosed definitively after 12 months have passed during which a woman has not had a period. The average age in the UK is 52; if menopause happens before age 45 it is called “early” menopause and if it occurs before age 40 it is “premature” menopause. The menopause happens because the older ovaries are no longer able to produce oestrogen in the same quantities as before, despite being stimulated by the brain to do so – women experience the effects of their oestrogen levels declining in different ways, and may develop symptoms of oestrogen deficiency well before their periods eventually stop (this time is termed the perimenopause, and it ends at the menopause). The most common perimenopausal symptoms women experience are irregular periods, which may be more or less frequent, or more or less heavy or painful, than before; and so-called vasomotor instability (hot flushes). It can be more difficult to diagnose the perimenopause in women who have had a hysterectomy, or who are taking hormonal treatments (for heavy periods, for example), but in most cases blood tests are not helpful and the diagnosis is made on the basis of symptoms alone.

Potential rocky terrain - Hot flushes...
Apart from changes in the menstrual cycle, and an eventual permanent end to periods, the symptom of oestrogen deficiency that most women notice is that of vasomotor instability, or hot flushes. This tends to be the symptom which most women seek help for – many describe really unpleasant feelings of being intensely warm despite normal environmental temperatures, and “flushing” uncontrollably (sweating, going red, and feeling very hot). Many women find it very difficult to sleep comfortably at night, because of these feelings, and can become quite embarrassed by the flushing, especially if it occurs in social or professional circumstances when they are in view of others. Some patients say they feel as though their face is tomato-red, and that there is sweat pouring from them.

...dryness 'down below'...
Another symptom of oestrogen deficiency which can affect women is urogenital atrophy – this means that the delicate tissues of the vagina and surrounding area become dry and thin. This in turn can lead to problems with intercourse, the sensation of dryness or irritability “down below”, and problems with frequent and/or uncomfortable urination. Sometimes the dry vaginal and surrounding tissues can crack and bleed. Many menopausal women attend the GP describing frequent, stinging urination and are treated for a presumed urinary tract infection; it is important that that doctor examines women carefully to check for any signs of urogenital atrophy and tailors any treatment accordingly.

...emotional symptoms...
Some symptoms of oestrogen deficiency are more psychological than physical – some women describe a low mood or irritability; others may experience forgetfulness; a significant proportion report reduced sexual desire. The sexual difficulties experienced by many women often go unreported, as they are reluctant to disclose their issues to their doctors – in fact, women most often choose to discuss their sexual problems with the practice nurse at the time of their cervical smears. Mood changes can be difficult for women to cope with, particularly if they have never experienced anything like it before; likewise, those around them can find it hard to cope with, and distressing to see someone they care about seeming to suffer.

...changes in skin, hair and nails, weight gain.
Finally, some women experience changes in skin, hair and nails; whilst others may notice aches and pains which they did not have before and which do not have any other obvious cause. Weight gain is extremely common after the menopause, and so-called “middle-aged spread” is due to a reduction in basal metabolic rate (basically, the body burns fuel more slowly than before) as well as an altered fat distribution around the body – but going through the menopause does not mean that getting fatter is an inevitability! It is just as important, if not more important, than before the menopause, for women to look carefully at their lifestyle choices and make the necessary adjustments to stay well and feeling at their best.

Lifestyle measures to set you up for the journey
These non-menstrual symptoms may all sound quite challenging, but it is important to remember that not all women experience all, or even any, of the symptoms; of those women who do experience symptoms, many find them easy to cope with provided they understand what is happening. There are ways in which lifestyle changes can make the menopause less noticeable; women who are smokers tend to have more troublesome symptoms, as do larger ladies, so stopping smoking and losing weight may be enough to bring the symptoms into the realm of the manageable, and reducing caffeine and alcohol and taking regular aerobic exercise can help with hot flushes. In fact, the menopause might be seen as an ideal opportunity to look closely at a woman’s overall general health. For women who have symptoms which are unacceptable, despite lifestyle changes, there are many different treatment options available. It is advisable to talk these through in detail with your doctor, in order that she/he can understand what matters the most to you – this is not something which can be decided quickly or without fully understanding the intended benefits, as well as any risks, of each of your options.

How your doctor can help- HRT is one of many options
Many women believe that Hormone Replacement Therapy (HRT), in which the oestrogen which is no longer being produced by the ovaries is instead given in medication form, is the only option for treating the symptoms of the menopause. HRT is widely used and many women find it extremely effective – but it is not the only choice open to women, and your doctor ought to discuss other possibilities with you. There are quite a few uncertainties and anxieties about HRT, particularly its associated risks; and, following the publication of the Women’s Health Initiative (WHI) randomised controlled trial in 2002, in which safety concerns were raised, prescriptions for HRT fell by about 50%. The data contained in the WHI study has since been re-examined and the risks are not as high as were once thought; however, women understandably seek reassurance and explanation.

HRT is very good at relieving the symptoms of the menopause – up to 90% of women who take it feel that it helps them. This is, obviously, the main reason why it is taken. HRT has also been shown to reduce the risks of colon (bowel) cancer and osteoporosis (thinning of the bones that can lead to fractures). However, HRT also increased the risks of blood clots in the leg or lung, strokes, and breast cancer. (The jury is till out on whether HRT increases or decreases the risk of heart disease; it seems to depend on how old the patient was when she started to take it.) The way these increased risks are expressed can make it difficult for women to make a fully informed decision about what they want to do – to take one statistic as an example: if 1000 women take combined (oestrogen plus progestogen) HRT for 5 years between the ages of 50 and 59, six more of them will develop breast cancer compared with an identical group of 100 women of the same age who do not take combined HRT. Individuals’ perception and acceptance of risk vary hugely – doctors cannot possibly predict what will happen to any one individual should they choose to go on to take HRT, they can only explain the odds. In any case, women are usually counselled that the increased risks of HRT are “small” – one could argue, of course, that these risks will feel anything but “small” to the six extra women who may have avoided breast cancer had they chosen differently. It is, needless to say, very important that women are encouraged to continue to take up their various screening appointments (cervical, breast, etc.) whether or not they are on HRT.

HRT is available in a wide number of different preparations and forms. Most women taking HRT use an oral (tablet) form. If women have an intact uterus (womb) – i.e. they have not had a hysterectomy – then the oestrogen in HRT has to be given with progesterone, to protect the womb lining from growing uncontrollably, which can lead to womb cancer. The combination of oestrogen and progesterone is called, unsurprisingly, combined HRT, and the regimen for combined HRT dosing depends upon the stage of the menopause that the woman has reached. Sequential combined HRT tends to be given to women who are still having periods (are perimenopausal rather than postmenopausal) to reduce the symptoms of the menopause and regulate periods; in this dosing regimen, progesterone is only given for half the month and the patient can expect a monthly bleed. Continuous combined HRT gives progesterone every day of the month, and does not lead to any bleeds – this is used for menopausal women (whose last natural period was more than a year ago). There are many, many different brands and preparations of HRT on the market; conventional wisdom suggests that women should be treated with the lowest possible dose to control symptoms, but personal choice ought to come into the equation too. To complicate things yet further, women who have had a hysterectomy do not need progesterone and can take just oestrogen instead; HRT can be given as patches or gels that are applied to the skin, which may reduce risks and side effects; and the progesterone component of combined HRT can be given as a coil inside the uterus that releases progesterone. There is a medication called tibolone, which is a synthetic hormone derived from yams, which acts like oestrogen and progesterone and can be used as HRT. In addition, oestrogens can be given topically in vaginal creams to help with symptoms of vaginal atrophy. Quite a choice! No wonder consultations about HRT choices are rarely short (and nor should they be)!

HRT, like any other medications, has side effects, and these are primarily either the fault of the oestrogen (breast tenderness, nausea, bloating, leg cramps and indigestion), the progesterone (PMSA-like symptoms, backache, acne), or both (headaches, fluid retention). But before you decide to avoid HRT like the plague, rest assured that most side effects are short-lived, and are almost completely gone within three months. Breakthrough bleeding is common, too, especially after initiating continuous combined HRT. Doctors usually recommend giving HRT a fair three-month trial before deciding whether to carry on or not; as alluded to above, there are certainly plenty of different preparations to try in order to find one which is suitable.

If not HRT, then what? 
Some women, quite understandably, decide against HRT – and there are some women, for example those who have already had breast cancer, for whom it is absolutely not advisable. Happily, there are several non-hormonal treatments which can really help with management of the most troublesome of the symptoms – the hot flushes. Some medications which were initially developed as antidepressants (such as fluoxetine and venlafaxine), anti-epilepsy treatments (gabapentin) and even blood pressure medications (clonidine) have been shown to reduce the severity of hot flushes compared with placebo (dummy treatments). Ask your GP to talk you through your options.

Thoughts on the 'alternative' options
Many women ask their GP about herbal alternatives to HRT – although GPs aren’t trained herbalists, and aren’t really supposed to advise on the use of complementary and alternative medicines (CAM) in which they are not trained, it is such a frequent question that most will be able to give you some sensible advice. Generally speaking, the most commonly used herbal preparations tend to be based upon plant derivatives which have oestrogen-like properties, such as soya (anecdotally, populations such as the Japanese, whose diet is very high in soya, report far fewer problems with hot flushes than other populations) and red clover. There is some scientific evidence that these are helpful in reducing the symptoms of the menopause, but it’s not clear whether the chemical similarity of the derivatives to oestrogen might increase risk of breast cancer in the same way as HRT does – the data simply aren’t available. There are other herbal medications which are also commonly used as menopause treatments, such as black cohosh, evening primrose oil, dong quai, ginko biloba, and so on. At this stage, there is no evidence to support their use in the treatment of the menopause, but open-minded doctors ought to be encouraging their patients to explore all their options – and supporting them in the choices that they make, provided they are fully informed. Herbal preparations ought to be used at the lowest dose to relieve symptoms, just like HRT, and patients need to be aware that they have the potential to interact with many other medications.

Keeping sex enjoyable
And, finally, let’s talk (again) about sex! Vaginal moisturisers can help with the dryness associated with the menopause, and can make intercourse more comfortable. Low sexual desire ought not to be accepted as an inevitable part of growing older; once other causes (such as side effects of other medications, or depression) are ruled out, many women benefit from psychosexual counselling, which is available on referral from your GP, or even from testosterone (the “male” sex hormone). Some women report that their sex drive actually increases at the menopause, as they no longer have to worry about pregnancy – this is great, and all doctors ought to be encouraging and supporting their patients to enjoy active and fulfilling sex lives for as long as they want to, but beware! Just because a woman is old enough to be perimenopausal does NOT mean that she is too old to get pregnant! HRT is not a contraceptive (unless the progesterone-releasing coil is being used) and women need to use contraception for at least a year after their last period if they are over 50, and for at least 2 years if they are under 50. The incidence of women in their late 40s falling pregnant, having thought it was impossible, is on the rise. Please, always practise safe and responsible sex – but enjoy it to the max!

If you have any questions about how to make your menopausal life fantastic (and you can expect a good three decades of it), please make an appointment to see your GP.

“Our mothers were largely silent about what happened to them as they passed through this midlife change. But a new generation of women has already started to break the wall of silence.” Trisha Posner

“I call the Change of Life "Orchids" because menopause is such an ugly word. It's got men in it for goddsakes.” Lisa Jey Davis, Getting Over Your Ovaries....