at Terenure Medical

What is Menopause?

• Every woman who lives long enough experiences menopause – defined as one year and one day after their last period when hormone levels that have been fluctuating erratically during perimenopause, eventually plummet to very low levels.
• Typically, it occurs around age 51, although the timing can vary widely. Early menopause (before age 40) can occur due to factors such as genetics, medical conditions, or surgical removal of the ovaries (hysterectomy).

Menopause and perimenopause are natural stages of life, but they can have a significant impact on a woman's physical and emotional well-being.

What is Perimenopause?

• Perimenopause is the time leading up to menopause that typically starts in a woman's 40s, but can begin earlier or later. During perimenopause, hormone levels, particularly oestrogen and progesterone, begin to fluctuate and decline, leading to changes in the menstrual cycle and various symptoms.
• Perimenopause can last for several years, with the average duration being around four years, but it can range from a few months to more than a decade.
• Fertility declines during perimenopause, and women may experience changes in their menstrual cycle, including shorter or longer cycles, heavier or lighter periods, or skipped periods.

Symptoms of Menopause and Perimenopause

Symptoms of perimenopause can vary widely among women. While some women have very few mild symptoms, about 25% can experience severe symptoms.

• The most common symptoms include hot flushes, night sweats, joint pain, intimate health changes, increased anxiety and mood changes, sleep disturbances, weight gain, and changes in hair, nails and skin.
• Symptoms of menopause are similar to those of perimenopause but may be more pronounced.

Contraception and Menopause

Once a woman has gone through menopause, she is no longer able to conceive naturally, as her ovaries stop releasing, marking the end of her reproductive years. It is, however, still possible to get pregnant around the time of the Menopause. For those who are sexually active:

• Contraception remains relevant until a year after the last period for those aged 50 or over.
• Contraception remains relevant until two years after the last period for those aged under 50.

If you are using a contraceptive, it can be difficult to know if you are post-menopausal and no longer need a contraceptive to prevent reproduction. Your doctor can advise.

Does Menopause negatively affect anything else in the body?

After menopause, women are at increased risk for certain health conditions, including osteoporosis, heart disease, diabetes, Alzheimer’s disease and dementia.

Skin, nails and hair can suffer too while bladder, bowel control and intimate health can be negatively affected. Anxiety levels can rise and mood swings are common.

• Skin and hair. Your skin can become drier, thinner and itchier as you may lose some skin protein (collagen). Hair may also become thinner.
• Intimate Health: In the months or years after Menopause, the tissue in and around your vagina can become thinner and drier and may cause increased pain during sex. The skin next to your vagina (the vulva) can become dryer and itchier. Libido may be reduced. Women may also experience the need to urinate more frequently, have leakage and experience recurrent urinary tract infections.
• Bones. The reduction of hormones in the body around Menopause accelerates bone density loss. HRT has a protective effect on bone density and combined with resistance/weight training and other lifestyle factors and supplements, can delay the possible onset of osteoporosis.
• Heart disease. At menopause, the risk of heart disease and stroke increases. Lifestyle changes including stopping smoke, eating a healthy diet, staying at a healthy weight and exercising can help to counteract this cardiovascular risk.
• Mood during Menopause: Changes in your hormones during menopause can impact your mental health and you may experience feelings of anxiety, stress or even depression. Menopausal symptoms may include anger and irritability, anxiety, forgetfulness, loss of self-esteem, loss of confidence, low mood and feelings of sadness or depression. You may experience poor concentration, often described as 'brain fog'. Often you will experience problems with your sleep which can also make symptoms including irritability, inability to concentrate or anxiety worse.

How is Menopause Diagnosed?

Your doctor can usually diagnose Menopause based on your symptoms. Sometimes your doctor will order hormone blood tests, especially if you are under 45 years old or if you do not have typical symptoms.

Treatment for Menopause

Hormone Replacement Therapy (HRT) is the first and most effective treatment for all women experiencing menopause symptoms.

Types of Hormone Replacement Therapy

The mainstays of HRT are oestrogen and progesterone. Both are naturally produced in the female body but decline during perimenopause and menopause, causing a range of symptoms, that can be mild or severe. The goal of hormone therapy is to replace what your body no longer makes, with the lowest amount of hormone therapy that delivers your needed results. Depending on whether a woman has her uterus, the type of hormone therapy recommended will vary. 

• Oestrogen-only Therapy:
  
  Oestrogen-only therapy is given to women who do not have a uterus.

Combined Oestrogen and Progesterone Therapy:

For women with a uterus, a combination therapy of both oestrogen and progestogens is necessary. During perimenopause and post-menopause, when the endometrial lining no longer sheds during menstruation, oestrogen alone can promote excessive growth of the uterine lining. Progestogens play a crucial role in safeguarding the lining and mitigating the risk of uterine cancer development.

For perimenopausal women, the recommended treatment is oestrogen as a patch/gel/spray combined with progestogen in the form of a Mirena intrauterine coil or cyclical progestogen tablets for 14 nights per month.

NOTE: cyclical progestogen will trigger a withdrawal bleed/period each month.

For postmenopausal women, the recommended treatment is oestrogen as a patch/gel/spray combined with progestogen in the form of a Mirena intrauterine coil or continuous progestogen tablets every night.

NOTE: continuous progestogen SHOULD NOT trigger a withdrawal bleed/period.

Non-Hormone Therapy Prescription medication

Some prescription medications, originally intended for other use, help ease some menopause symptoms. However, they must be prescribed by your doctor on review of your current health.

Dietary non-HRT Supplements

Some non-HRT nonprescription dietary supplements are suggested to help alleviate menopausal symptoms. However, there is limited scientific evidence to support their efficacy and they can also have negative side effects and interact with other medications, so it is always important to discuss their use with your pharmacist:

• Black Cohosh: Some studies suggest that black cohosh may help alleviate hot flashes and other menopausal symptoms, although results are mixed.
•  Soy Isoflavones: Soy foods and supplements containing soy isoflavones may help reduce hot flashes and improve overall menopausal symptoms in some women.
• Dong Quai: Dong quai, an herb used in traditional Chinese medicine, has been used to relieve menopausal symptoms such as hot flushes and vaginal dryness, although scientific evidence is limited.
• Vitamin E: Some studies suggest that vitamin E supplements may help reduce hot flushes in menopausal women, although results are inconclusive.Please watch the video from the British Menopause Society on Complementary and alternative therapies.

What are the Benefit of Hormone Replacement Therapy (HRT)?

The benefits of hormone therapy outweigh the risks for the majority of healthy women without contraindications going through perimenopause, menopause and post-menopause (when given within 10 years of post-menopause).

• Hormone therapy can help women whose menopausal symptoms interfere with their everyday lives by addressing sleep quality, fatigue, mood, and overall quality of life.
• Hot flushes and night sweats (vasomotor symptoms) can be effectively treated with hormone therapy. Hot flushes and night sweats should be reduced within a few weeks of commencing HRT.
• Hormone therapy can reduce the risk of Osteoporosis and fractured bones.
• The genitourinary syndrome of menopause, which includes painful sex, frequent UTIs, and dry vagina, can be treated with topical hormone treatment – vaginal oestrogen creams or rings (2), and within 1-3 months, improvements should occur.

Hormone Replacement Therapy Risks

When progesterone and oestrogen are taken by women who have not had a hysterectomy:

• There is no higher risk of uterine cancer.
• The difference in breast cancer incidence is an additional 4 cases over 5 years per 1,000 women aged 50-59. However, as women on hormone therapy are closely monitored, breast cancer is likely to be at an earlier stage with a lower risk of death than for women not taking hormone therapy. (2,3)

For women taking oestrogen who have had a hysterectomy:

4 fewer cases of breast cancer incidence per 1,000 women aged 50-59 over 5 years. (3)

For women with a history of breast cancer in the family:

The use of appropriate hormone therapy does not increase the risk of breast cancer. (2,3)

There is no upper time limit on how long HRT can be taken, though some of the risks do increase the longer it is used.

How do I take HRT?

Formulation Matters: There are several ways to take HRT but not all forms of HRT are equally effective or safe. Specific transdermal (applied to the skin) versions of oestrogen are regarded as safer than oral oestrogen while specific versions of oral progesterone / Mirena Coil (needed if you have a uterus) are regarded as providing the most benefit and the least risk to women’s health.

Depending on your lifestyle, there is a choice of therapy applications that may be best suited to you:

• Oral medication: tablets
• Patches: a clear sticker, placed on your lower abdomen (never on the breasts) that you replace twice a week.
• Gels or creams: easily applied, takes a minute to dry in.
• Sprays: relatively new to the market, they dry faster than gels.
• Vaginal rings & Gels: applied directly to the area for symptoms of incontinence and intimate health issues.

While side effects are uncommon, some women do experience nausea in the weeks after commencing HRT as well as breast pain, leg cramps, headaches, and migraines. These usually resolve within a few months. Using patches and gels (rather than tablets) reduces the likelihood of headaches and migraines, though they can occasionally cause skin irritation. Sometimes a change of brand of HRT may cause side-effects to diminish or cease.

Note that the Mirena coil must be changed every 5 years if used as part of menopausal HRT.

It is essential for women considering hormone therapy to discuss the potential risks and benefits with their doctor. Treatment decisions are specific to each individual based on many factors such as age, menopausal symptoms, medical history, and personal preferences. Regular monitoring and re-evaluation of treatment is necessary, firstly after 3 months of use and then annually unless indicated by the doctor.

Regardless of whether or not HRT treatment is commenced, all women are encouraged to adopt healthy lifestyle habits, maintain a healthy weight, limit alcohol consumption and refrain from smoking.