Menopause (HRT)

Menopause is the name for the point in a woman’s life when she no longer has a menstrual cycle. Because of this, she becomes unable to have a pregnancy naturally.

Most women will notice that, over a period of months or years, periods gradually happen less frequently. For some women, however, this happens quite suddenly.

For British women, the average age of menopause is 51. The normal range is between the ages of 45 and 55.

Levels of oestrogen production begin slowly to decline in a woman’s thirties, and so it is common to experience early menopausal symptoms while still having regular periods. The duration and severity of these early symptoms vary greatly between individual women.

Also known as premature ovary insufficiency, this occurs when a woman experiences the menopause before she reaches the age of 40. This occurs only in around one per cent of women.

Depending on their severity, some menopausal symptoms can have a substantial effect on a woman’s day-to-day life.

These symptoms can include:

• Hot flushes
• Vaginal dryness, leading to discomfort during sex
• Insomnia and night sweats
• Reduced libido
• Anxiety and inability to focus
• Issues with memory

Experiences with menopausal symptoms vary significantly depending on the individual. They can begin multiple years prior to the menopause itself and remain for many years.

Women will, on average, experience symptoms for about four years. In roughly ten percent of women, symptoms will persist for much longer – up to twelve years.

Three-quarters of menopausal women experience hot flushes, making it the most common of these symptoms. In a hot flush, a woman feels a spontaneous heat that spreads throughout the body. You might notice sweating, an unusually strong heartbeat, and a sudden red blush of the skin. This is likely caused by irregularities in the body’s temperature control as a result of hormone changes.

There is a huge variance in the possible severity of hot flushes. For some women, they occur very infrequently and so are only a mild nuisance. Others, however, experience up to 20 episodes each day. At this frequency, they can become very disruptive and problematic. Most women experience flushes for around four years after their menopause, but others deal with episodes until old age.

In Hormone Replacement Therapy (HRT), a woman takes oestrogen to counteract the decline in naturally-produced oestrogen that is associated with menopause. This helps to relieve many of the symptoms mentioned above.

Cognitive Behavioural Therapy consists of changes to lifestyle, which include exercising, improving sleep patterns, and relaxing with techniques such as yoga.

Vaginal moisturisers or lubricants are an alternative to vaginal oestrogen in managing vaginal dryness.

There are multiple possible methods of HRT, including tablets, patches, gels and implants. These contain oestrogens which are ‘natural’ in the sense that they mimic the substances that the body produces. These include oestrone, oestradiol and oestriol, which are extracted from yam and soya.

HRT can very effectively mitigate the symptoms of menopause, including night sweats and hot flushes.

Women undergoing HRT can experience headaches, vaginal bleeding and breast tenderness as side effects.

Furthermore, combined HRT (oestrogen plus progestogen) was shown to  increase the risk of breast cancer, in a trial by The Women’s health Initiative. No such increase was found for women on oestrogen-only HRT. However, progestogen is in many cases necessary to prevent the known risk of uterine cancer. If she has had a hysterectomy, it is not usually necessary to give a patient combined HRT.

Even for women taking combined HRT, the risk of cancer tended only to increase after a sustained HRT treatment. So, the medical consensus is that the benefits of HRT exceed its risks, so long as it is not used for more than five years. Risk increases with the duration of HRT, so your individual risk of cancer should be assessed each year with your doctor.

Some forms of HRT are also associated with a heightened risk of blood clots, especially deep vein thrombosis and pulmonary embolism (a blockage of the artery leading to the heart). Other medicines without these risks may be a better option for some women.

Hormone Replacement Therapy can be oestrogen-only, or combined with progestogen. Oestrogen-only HRT can increase the risk of uterine cancer, and so is advised only for women who have had a hysterectomy.

Combined HRT is associated with heightened risk of some other cancers, but only after treatment spanning many years.

Many menopausal symptoms will cease after two to five years, so most women can stop HRT after this amount of time.

In order to prevent a relapse of symptoms, hormone intake should be gradually reduced. Any symptoms that do recur should stop within the following months. If these symptoms do continue for several months, it may be necessary to resume HRT at a lower dose. Discuss your treatment options with your GP.

Once hormone replacement has finished, it may be necessary to seek other treatments to prevent osteoporosis and/or vaginal dryness.

HRT is unsuitable for pregnant women, or those with a history or high risk of:

• Breast cancer, ovarian cancer or uterine cancer
• Heart disease
• Blood clots or stroke
• Liver disease

Other issues such as high blood pressure or irregular periods must be resolved before HRT can begin.

Osteoporosis is a weakening of bones that is caused by reduced oestrogen levels. It is much more prevalent in women who have reached their menopause.

There are many ways of decreasing your risk of osteoporosis:

• Oestrogen from HRT can prevent osteoporosis in the short term – this effect will not last after HRT finishes.
• Resistance and weight exercises will help with strength
• A diet rich in fruit and vegetables, as well as calcium sources such as dairy
• Regular exposure to sunlight for the natural production of vitamin D
• Calcium and vitamin D supplements – you should discuss the appropriate intake with your GP
• Quitting smoking and reducing the consumption of alcohol

Menorrhagia, or heavy periods, is very common in women between thirty and fifty years of age. There will sometimes be an identifiable cause, such as fibroids, blood blisters, cysts or polyps in or around the uterus. Otherwise, it can just be a result of the changing hormone balance around the time of menopause, or of the process of ovaries ageing and failing.

You should consult your GP if you experience menorrhagia, as it is often a cause of further illness.

Specific treatments are not always required for Menorrhagia. If, however, your periods are severely heavy, multiple options are available:

• Cyclokapron or Tranexamic Acid – an effective drug which mitigates blood flow by controlling clotting within uterine vessels. There are no significant side effects, and it can be taken up to twelve times daily.

• Mefenamic Acid or Ponstan – an anti-prostaglandin drug which reduces pain and prevents heavy bleeding.
• Mirena Coil – a small device that is inserted into the uterus, similar to an IUD. It releases progestogen to thin the uterine wall, reducing the volume of periods. There is an initial side effect of irregular bleeding, but this usually stops as the body adjusts to the coil. The Mirena has the added benefits of providing the progestogen component of a combined HRT, as well as acting as a contraceptive.

• Cyclical progestogen hormones – pills containing progestogen, taken for a section of the menstrual cycle. They regulate menstruation, preventing Menorrhagia from following an occasional missed period. The hormones may also prevent other menopausal symptoms like hot flushes and night sweats.

• Surgical treatments – surgery to ablate the uterine wall might be recommended by a GP. This is a one-day operation which occurs under anaesthetic. It will cause periods to lighten or cease entirely.
• Hysterectomy – the removal of the uterus, a major surgical procedure requiring four days in hospital followed by a recovery of up to three months. This is the most effective method for Menorrhagia, but is done less and less frequently due to the other safer and very reliable alternatives which are now available.

If you are taking HRT to treat premenopausal symptoms, your HRT must involve both oestrogen and progestogen given sequentially. Under sequential HRT, you will take oestrogen every day and progestogen for a minimum of ten days each month. This will allow your menstrual cycle to continue – for most women, a period will occur either at the beginning or end of each pack. As this HRT will neither regulate nor lighten menstruation, it should not be used as a treatment for Menorrhagia.

Upon reaching the menopause, sequential HRT can easily be switched to continuous combined HRT. Under this routine, you will take both oestrogen and progesterone each day. After the first six months of this HRT, the body will adjust and no more bleeding should occur.

Vaginal tissues can become thin and dry as a result of decreased oestrogen levels. This can cause discomfort and sometimes pain during sexual activity.

If systemic HRT is not an option, other topical oestrogen treatments are available. These include creams, vaginal tablets, waxy pessaries and vaginal rings. Each of the first three requires a daily application for the first fortnight, and two doses per week subsequent to that. Vaginal rings can remain in for up to three months.

At the low regular dose, none of these oestrogen treatments will have significant side effects. Unlike in HRT, no progestogen is required to protect the uterine wall.

Non-hormonal treatments for vaginal dryness are available, including a range of bio-adhesive vaginal moisturisers, which can be purchased over the counter. These are preferable to regular lubricants because they need not be applied at the time of intercourse, and can prevent infections by virtue of being somewhat acidic. Other products that are available via prescription are Yes, Replens MD, Hyalofemme and Sylk.