Menopause Information Pack

Introduction

The menopause means the last menstrual period but many women will talk about ‘going through the menopause’ when discussing the time from when they first noticed changes in their monthly cycle or other symptoms.

Every woman will go through the menopause and for each the experience will be different. The menopause doesn’t begin at a particular age or last for a definite and fixed period of time and symptoms can vary from woman to woman, from no symptoms to deeply troubling symptoms that affect life at home and work.

What is the menopause?

The three stages:

• Peri-menopause: the stage from the beginning of menopausal symptoms to the post-menopause. This is the time when a woman’s periods become lighter, heavier, or more irregular until they stop altogether. The average time is four years but it can last up to ten years
• Menopause: the last menstrual period to 12 months if 50+ years (or to 24 months in women under 50 years)
• Post-menopause: the time that follows the menopause (or immediately following surgery if the ovaries are removed).

The menopausal period is the point in a woman’s life when her periods become more irregular and infrequent and then eventually stop. In the UK the average age for a woman to reach the menopause is 51 but a woman can start to experience natural menopausal symptoms between the ages of 45 and 55.

What are the symptoms?

Reducing oestrogen hormone levels in the three stages, may cause a variety of symptoms in up to three quarters of women. In addition to changes in the monthly periods, symptoms include:

Physical symptoms	Mental symptoms
Hot flushes and night sweats	Mood swings
Palpitations	Irritability
Headaches	Insomnia (can't sleep)
Aching joints, muscles and tendons	Anxiety and panic attacks
Pain during intercourse (due to vaginal dryness)	Poor attention and concentration, ‘brain fog’
Vaginal discomfort (dryness, burning, itching)	Loss of sex drive
Dry skin

It’s worth noting that mental health symptoms without the physical symptoms of menopause, make a mental health diagnosis more likely. If you are in this situation, it is worthwhile looking at our mental health information pack. This has been put together by nation-leading experts and is packed full of proven ways to improve your mental health.

The severity of symptoms and the overall duration of the menopause vary, depending on factors such as lifestyle, genetics, stress and overall health.

Can I diagnose the perimenopause or menopause?

Yes. Further tests are not needed if you are 45 years or older and have the recognised symptoms outlined above along with changes in or absence of periods.

It is unusual (but not impossible) for your periods to suddenly stop with no menopausal symptoms. In this situation (particularly if you are younger) a pregnancy test is advised, as although pregnancy is less likely, it can still happen until you are post-menopausal. Contraception during the menopausal period is still important and you can find out more information here.

Early and premature menopause (also known as premature ovarian failure):

Early menopause occurs when symptoms and changes in periods begin between ages 40-45. It affects 1 in 20 women under 45 and is confirmed on laboratory hormone testing.

Premature menopause occurs when symptoms start below age 40. It affects 1 in 100 women under 40 and the diagnosis requires GP confirmation and input and sometimes specialist referral.

In some cases there is no obvious cause but premature ovarian failure can be associated with:

• Hysterectomy
• Certain types of radiotherapy and chemotherapy
• In rare case some infections such as TB, mumps, malaria, varicella (the virus that causes chickenpox and shingles) and shigella (a type of bacteria that causes dysentery)
• Certain medical conditions such as enzyme deficiencies, Down’s Syndrome, Turner Syndrome, Addison’s Disease and hypothyroidism (under-active thyroid)

Women affected should see their GP for further investigations if under 45.

Managing your symptoms:

Many women are able to manage the symptoms of the menopause themselves. Simple diet and lifestyle changes and easy self-help approaches can help to relieve symptoms and these are discussed below. For those with more severe symptoms or symptoms that interfere with their day-to-day life there are medications available.

Diet:

A healthy, balanced diet should provide a good supply of calcium. Tips for healthy eating include:

• Eat less saturated fat
• Choose lean cuts of meat
• Choose low or reduced fat dairy foods
• Reduce salt
• Eat at least 2 portions of oily fish a week
• Eat at least 5 portions of fruit and vegetables a day
• Include plenty of fibre in your diet

Further information can be found on the British Dietetic Association food fact sheet.

Exercise

Regular exercise is an important part of staying healthy during and after the menopause with studies showing that women who exercise regularly and have a more active life suffer less with menopausal symptoms. It also keeps your muscle and bone strong. This increases flexibility, mobility and balance, and reduces risk of osteoporosis.

The best exercises are those that are aerobic, sustained and regular, for example walking, jogging, cycling and swimming along with strength and flexibility exercises. If you are not able to do this or are looking for advice and ideas check out the Active Devon website, One You Plymouth, or look at Couch to 5K.

Alcohol

Alcohol can increase the severity of the symptoms of menopause and can be a trigger for hot flushes and night sweats. Although some women with insomnia may have a drink before bed to help sleep it is not a restorative sleep. Alcohol is also a depressant, worsening the mental symptoms of menopause.

Drinking more than recommended guidelines can increase the risk of breast cancer in all women, and the risk can increase further in women using HRT. Further info is available on

For more information see NHS Choices and Drink Aware UK webpages.

Smoking

Women who smoke have an earlier menopause than non-smokers, have worse hot flushes and often don’t respond well to tablet forms of HRT. For further advice on giving up, see One You Plymouth.

Management of specific symptoms.

Specific symptoms can be improved though a variety of non-medical measures and women are encouraged to try these before considering medical options like HRT.

 Hot flushes and night sweats:

The intensity and frequency of hot flushes can be reduced with the following:

• Wear natural fabrics such as cotton and dress in layers that can be easily removed when needed
• Use cotton sheets and layers of bedding
• Open a window or use a fan to keep the room cool at home and at work
• Have cold drinks in preference to hot drinks
• Try to lose weight if you are overweight or obese
• Eat a healthy diet
• Take more regular exercise
• Try complementary therapies such as yoga, meditation or controlled breathing and mindfulness

Insomnia:

Here is an excellent guide on treating insomnia.

Dry skin:

Loss of oestrogen can cause dryness of the skin. Try out the following:

• Eat a balanced diet (as above)
• Avoid really hot showers and baths
• Drink 1.5 litre of water a day
• Use gentle soaps
• Exfolliate and moisturise regularly
• Reduce alcohol consumption
• Stop smoking

Vaginal dryness:

You can buy vaginal lubricants and moisturisers which can ease vaginal dryness and can help if you have pain when having sex.

Lower sex drive:

Managing vaginal dryness and improving general wellbeing through healthy lifestyle changes are useful way to improve your sex drive in the first instance. If the problem persists, HRT may be the next option.

Mental health:

Hormonal changes during the menopausal period can contribute to psychological and emotional symptoms. However, the menopause is often happening at a time in your life when significant changes/stresses are going on around you.

As a result, it is difficult to work out whether your mental health symptoms are directly related to hormone changes, life stressors or both. However, studies have shown that women who are generally happy in their lives experience fewer problems in the menopause.

Your mood will often improve with managing hot flushes, night sweats and insomnia as you will get a better night’s sleep. Taking regular exercise and relaxation techniques (yoga, tai chi, meditation, mindfulness) will also improve your mood.

What to do if this doesn’t work? Treatment for your symptoms:

Complementary and alternative therapies:

There is a big market for these therapies and drugs such as black cohosh, red clover, dong quai, evening primrose oil, ginseng, and St John’s wort are all used. However, herbal remedies are not regulated by a medicine authority in the same way as prescribed medicines and should not be considered as safer alternatives. Advantages and disadvantages are shown below:

Herbal remedy	Notes
Isoflavones and black cohosh	May improve hot flushes but multiples preparations of these products exist and their safety is uncertain. They may interact with other medicines you take
St John’s Wort	It can improve symptoms in some but does not necessarily affect mood or anxiety. There is uncertainty around a safe dose and it can interfere with other medicines e.g. tamoxifen
Soy and red clover	There is conflicting evidence and they should not be taken in women with breast cancer or those on tamoxifen.
Bioidentical HRT or “natural hormones”	Clinics that use these hormones claim that they are safer and more natural than HRT. However, this is not regulated in the same way as other medicines and their safety and effectiveness is unknown. NOTE: this is different from “body identical hormones” which are available on the NHS as HRT

Antidepressants:

Antidepressants such as venlafaxine, sertraline and others in this class can potentially reduce hot flushes for women in the menopausal period. A trial of 1-2 weeks is usually enough to see if it will work. Side effects may include nausea and reduced sex drive among others and vary from person to person.

These medications are currently not licensed to treat menopausal symptoms but may be of some benefit in women where HRT is not recommended e.g. a patient with previous breast cancer or multiple risk factors.

Hormone replacement therapy (HRT):

All types of HRT contain oestrogen, which replaces the reducing oestrogen hormones during the menopausal period and aftermath.

If you were to just take oestrogen however, you would risk developing cancer of the womb (endometrial cancer) so oestrogen in HRT is combined with another hormone, progesterone to eliminate this risk.

Types of HRT:

Topical vaginal HRT:

If vaginal dryness is your dominant symptom, then vaginal oestrogen delivered via a vaginal tablet (pessary) or a ring containing oestrogen will often improve these symptoms.

HRT that acts across your whole body:

The safest way to take HRT is a combination of oestrogen delivered through the skin (patch, gel or spray) to help with menopausal symptoms and a separate progestogen (utrogestan orally at night OR the Mirena coil) to protect the womb lining.

Delivering oestrogen via the skin (transdermal route) significantly reduces the risk of blood clots, stroke and heart disease. As a result, we very rarely prescribe/recommend the oral tablets now unless patients are still on the young side, have no risk factors and have a specific preference for tablets.

Separating out the oestrogen and progestogen (rather than combining them into one patch or tablet) has been shown to reduce the breast cancer risk and so we advise this combination as the first-line gold-standard approach.

How to take it: In summary, there are three ways to take HRT:

• Cyclical combined HRT: Used in women who are still having periods or may have just finished. Oestrogen is taken every day with progestogen added in for 2 weeks (usually the first 14 days) of a monthly treatment cycle. This causes a regular light period every month but is not a “true period” as HRT does not restore fertility.
• Continuous combined HRT: Used in women who have been taking cyclical combined HRT for at least one year or it has been at least a year since your last menstrual period. This means you take oestrogen and progesterone every day. You may experience some light bleeding for 3-6 months after starting this form of HRT but if it continues past six months you should speak to a GP to consider other causes such as womb cancer.
• Oestrogen only HRT: If you have had your womb removed (hysterectomy) or have a mirena (progesterone secreting) coil you do not need to take an additional progestogen.

Testosterone:

This can be helpful for persisting low libido where good doses of standard HRT used for at least 6 months have not helped and in whom testosterone levels are noted to be low/low-normal on laboratory testing.

Unfortunately, testosterone is not licensed for use in menopausal women and has a number of potential adverse effects. For these reasons we use careful consideration before prescribing and only after 6 months of standard HRT has been trialled.  We ask for specific consent prior to starting it given its unlicenced use and it also requires careful blood test monitoring including at 3 months and then 6 monthly thereafter.

What are the benefits of HRT?

HRT can make a big difference to quality of life in some women by reducing menopausal symptoms. Furthermore, it can reduce the risk of osteoporosis.

How long does it take to work?

HRT will often work within a few weeks to improve hot flushes and night sweats. It may take 1-3 months to improve vaginal dryness. If there are no changes after three months, then the dose or type of HRT could potentially be changed.

What are the side effects of HRT?

HRT is generally well tolerated but side effects may include:

• Nausea, breast discomfort and leg cramps which often settle after a few months
• HRT skin patches and gels can irritate the skin
• Headaches and migraines (reduced by using patches and gels)

Changing to a different brand or altering the dose may improve things.

What are the risks of HRT?

Risks are small but potentially serious and include:

• Clot in the veins (DVT) or lungs (PE): These can be potentially life threatening emergencies. You are more likely to develop a clot if you have risk factors such as past history of clotting, obesity or being a smoker. These risks are not present in women who use patches or gels. You should consult a doctor urgently if you develop a red swollen painful leg or sudden shortness of breath and chest pain.
• Breast cancer: whilst the risk of breast cancer is increased in all women on HRT it remains low. In the UK around 1 in 16 (about 63 per 1000) women who have never used HRT will be diagnosed with breast cancer between the ages of 50 and 69 years.

Among women of average weight who use systemic HRT from menopause in their 40s or 50s, and continue for 5 years, the extra number of cases of breast cancer by age 69 are estimated from the study to be:

• ~1 extra case per 200 women (corresponding to about 5 per 1000) who use oestrogen-only HRT
• ~1 extra case per 70 women (corresponding to about 14 per 1000) who used oestrogen combined with progestogen for part of each month (sequential HRT)
• ~1 extra case per 50 women (corresponding to about 20 per 1000) who used oestrogen combined with daily progestogen HRT (continuous HRT)

Other key findings include:

• There is little or no increase in risk if HRT is used for less than a year
• The risk of breast cancer increases the longer a person is on it. Values approximately double for systemic HRT for 10 years of use compared with 5 years of use.
• Risk of breast cancer is lower after stopping HRT but remains increased in ex-HRT users for more than 10 years compared with women who have never used it
• There is no evidence of increased breast cancer risk with vaginal oestrogens

Further information on breast cancer risk can be found here and it is essential to read this carefully before HRT is started.

• Heart disease: there is an increased risk of heart disease when HRT is started in women 60+ years old and this is generally not recommended
• Stroke: HRT tablets (not patches or gel) offer a slight increased risk of stroke but the absolute risk of stroke is low in women under 60.
• Cancer of the womb: there is no increased risk if oestrogen is used along with a progestogen and doesn’t exceed maximum recommended doses or when oestrogen is used with a mirena coil or after hysterectomy
• Ovarian Cancer: there is a small increased risk and it is thought that around 1% of ovarian cancers are linked to HRT

Important information about the risks associated with HRT:

In most women HRT is relatively safe and the benefits are thought to outweigh the associated risks. Unfortunately, this is not the case for everyone.

When to avoid HRT:

There are conditions where HRT is be completely avoided eg previous breast cancer, recent heart attack or stroke.

These will be covered in the attached questionnaire.

When to use HRT with caution:

There are circumstances where the risks of HRT potentially outweigh the benefits and this is often due to a combination of risk factors eg smoker with hypertension and/or diabetes or strong family history of breast cancer and BMI >35. Under these circumstances, you may be asked to address the risks where possible before we consider HRT.

These will be covered in the questionnaire you will be sent.

Starting HRT over the age of 60:

We generally advise against starting HRT in patients over 60 as this significantly increases risk particularly relating to heart disease.

Using higher than recommended doses of HRT:

It is our policy not to increase the dose of oestrogen above the recommended licensed doses due to the increased risk of cancer of the womb lining and other increased risks. This may be something done in private clinics but our GPs at Pathfields are not willing to accept this risk.

IMPORTANT INFORMATION LEAFLET ON RISK:

 Please take some time to explore the information provided and it is particularly important that you read the MHRA leaflet on risk and are happy to accept the risk-benefit balance prior to considering HRT.

 Excellent online resources:

In addition to the information above and linked leaflets, there are some excellent websites to visit for a range of helpful and empowering information about managing the menopause:

Menopause matters: https://www.menopausematters.co.uk/

Rock my menopause: https://rockmymenopause.com/

Balance-menopause: https://www.balance-menopause.com/

women’s health concern: https://www.womens-health-concern.org/help-and-advice/factsheets/menopause/

The Balance App is another excellent resource which ‘allows you to track your symptoms, access personalised expert content, download a health report and share within the community: https://www.balance-menopause.com/balance-app/

If you are ready to explore medical treatment options including HRT, we need some further information.

Please fill in/request the Menopause Assessment Questionnaire which is in text format delivered via a link sent to your mobile number. Email or paper formats are also available depending on your preference. Please be advised that in the questionnaire, you will be asked for an up-to-date weight and blood pressure reading so it will be handy to have these ready beforehand.

Once received back, we will add you to our menopause waiting list and arrange a clinician appointment to discuss the best option for you.