Menopause

• Menopausal symptoms 
• Iatrogenic menopause (medically/surgically induced menopause) 
• Premature menopause  
• Fertility treatment following premature menopause  
• Menopausal vaginal atrophy 
• Menopausal sexual dysfunction 
• Osteoporosis and HRT 
• HRT advice for background of complex medical problems such as blood clotting, breast cancer, BRCA, thalassaemia, progesterone sensitivity 

• Hormone replacement therapy (HRT) – tablets, patches, gels, sprays, Mirena coil 
• Non-HRT alternative medications 
• Testosterone therapy 
• Vaginal oestrogens 

‘Menopause’, sometimes referred to as the change of life, happens when your periods stop permanently signalling the end of reproductive function. Menopause usually occurs when a woman is in her 50s (the average age is 51 in the UK), but some women may experience the menopause in their 30s or 40s. 

For most women, menopause is not an illness and a phase of natural transition in later life. Sometimes this change can be associated with symptoms that can be distressing. Such symptoms may last for several years. Treatment for menopausal symptoms includes lifestyle changes, alternative therapies, non-hormonal medications, and hormone replacement therapy (HRT).

Every woman’s experience of menopause transition is unique, and she can make an informed choice about which of the above strategies she would like to pursue for symptom suppression and better quality of life. While HRT can work well and has some long-term health benefits, it can increase your chances of some health problems. So you need to think carefully and decide whether or not to take it. 

HRT stands for hormone replacement therapy. It is also abbreviated as MHT for menopausal hormone therapy. It consists of the hormone oestrogen either alone or combined with the other hormone progesterone. The aim is to replace some of the oestrogen that your body stops making when you reach menopause. 

Oestrogen only (no progesterone) - when women have had a hysterectomy, they do not need progesterone to protect the lining of the womb.  

Combined HRT (oestrogen and progesterone) - this is necessary if you still have your womb. This can be given in two ways:  

1. Continuous combined HRT - oestrogen and progesterone, taken together daily (one a day) for 28 days - this means that there will be no withdrawal bleeds.  
2. Sequential HRT - oestrogen only for the first 14 days then both hormones for the second 14 days. This usually results in monthly withdrawal bleeds as it tries to copy your natural cycle and give you a period. 

Women with an intact womb need to take a combination of oestrogen and progesterone as part of HRT. Taking oestrogen alone can increase your chance of getting cancer of the womb lining (endometrial cancer). Adding progesterone to oestrogen reduces the chance of getting this kind of cancer. Some common brands of combined HRT are Evorel Sequi, Evorel Conti, Nuvelle, Premique, Cycloprogynova, Kliovance, Kliofem and Prempak-C. If you have had an operation to remove your womb (hysterectomy), you can take oestrogen only HRT (without progesterone) as there is no chance of getting endometrial cancer. Some common brand names of oestrogen only HRT are Premarin, Estraderm and Evorel.  

Cyclical HRT is often prescribed for women who are having menopausal symptoms but are still having periods or for those who have stopped their periods less than one year ago. Continuous HRT (without bleeds) is more suitable for women who have not had periods for more than one year. 

HRT is available for prescription in several different forms. You can take it as a skin patch, tablet, gel, implant, vaginal ring, nasal spray, progestogen releasing uterine coil and vaginal cream or pessary. Some types work best for certain symptoms. As transdermal oestrogen (patch) is associated with fewer risks than oral HRT, a transdermal route may be preferable for many women. This route is also advantageous for women with diabetes, hypertension and other cardiovascular risk factors especially with advancing age. Vaginal oestrogen creams or pessaries do not carry the same risks associated with oral or transdermal HRT. As the dose of oestrogen is so low, they do not require the protective effect of the progesterone. Talk to your doctor to decide which product is likely to suit you most. 

For most symptomatic women, use of HRT for five years or less is safe and effective. Benefits of HRT include:

1. Reduction in vasomotor symptoms such as hot flushes and night sweats 

HRT is the most effective treatment for reducing vasomotor symptoms. Vasomotor symptoms usually improve within four weeks of starting treatment and maximal benefit is gained by about three months.  

2. Improvement in quality of life 

HRT may improve sleep, muscle aches/pains and overall quality of life in symptomatic women. Many women experience improved mood, libido levels and less depressive symptoms.  

3. Improvement of urogenital symptoms 

HRT significantly improves vaginal dryness and sexual function. HRT is also effective in improving stress incontinence (leaking urine when you cough or sneeze). It may also relieve the symptoms of urinary frequency, as it has some effect on the urinary bladder and urethral tissues. Local oestrogen creams or pessaries are the preparations of choice for urogenital symptoms. 

4. Reduction in osteoporosis (brittle bones) risk 

HRT is effective in preserving bone mineral density. Women taking HRT have a significantly decreased incidence of fractures with long-term use. Although bone density declines after discontinuation of HRT, some studies have demonstrated that women who take HRT for a few years around the time of the menopause may have a long-term protective effect for many years after stopping HRT. However HRT is not a treatment of first choice only for treatment of osteoporosis if there is no other indication for its use. Other drugs can be prescribed for osteoporosis. 

5. Reduction in cardiovascular disease 

The relation between HRT and cardiovascular disease is controversial, but the timing and duration of HRT as well as pre-existing cardiovascular disease are likely to affect cardiovascular health. Recent evidence suggests that women, who are above the age of 60 years when they start HRT, have an increased risk of coronary heart disease. But HRT reduces the incidence of coronary heart disease by about 50% if it is started within ten years of the menopause. Women receiving HRT early after menopause have a significantly reduced risk of mortality without any apparent increase in risk of cancer, venous thromboembolism (blood clots) or stroke.  

6. Other benefits 

HRT has a protective effect against connective tissue loss in tissues such as skin, bones, joints and mucous membranes. There may be a possible reduction in the long-term risk of Alzheimer's disease and all cause dementia in those women who take HRT. Although some research studies have suggested an improvement in cognition in women who start taking HRT early in menopause, there is a need for further research to confirm this finding. Colorectal cancer – most studies have demonstrated a reduction in risk of colorectal cancer with use of oral combined HRT.  

There are several risks associated with taking HRT. For most women the increased risks are very small, but you will need to talk to your doctor to weigh up the risks and benefits for you as an individual. Doctors are advised that women should take the lowest dose of HRT that controls their symptoms for the shortest duration of time possible. However, there is no maximum duration of time for women to take HRT; for the women who continue to have symptoms, their benefits from HRT usually outweigh any risks. 

The principle risks of HRT are thromboembolic disease (blood clots in veins and lungs), stroke, cardiovascular event, gallbladder disease, breast cancer and endometrial cancer. Large studies such as the Women’s Health Initiative (WHI) and the Million Women Study (MWS) caused concerns and controversy over the use of HRT when their findings were published. However reanalysis of some of the data and findings from recent studies over the past decade have shown that, in women with symptoms or other indications, initiating HRT near menopause will probably provide a favourable benefit:risk ratio. 

1. Venous thromboembolism 

Oral HRT (combined oestrogen and progesterone or oestrogen only) increases the risk of venous thromboembolism (VTE – venous blood clots), pulmonary embolism (blood clot in lungs) and stroke. The risk of VTE is increased two to three times with oral HRT. In one big study, over five years, less than 1 in 100 women taking HRT got a blood clot in their lungs. But this was about twice the number of women who were not taking HRT. If you've had blood clots before, you should let your doctor know and talk about whether HRT is suitable for you. Overall this risk is a lot lower than taking the contraceptive pill or the risk that you may have had in pregnancy. The risk increases with age and with other risk factors such as obesity, previous thromboembolic disease, smoking and immobility.

In healthy women below 60 years, the absolute risk of VTE is low and mortality risks from VTE are low. The type, dose and delivery system of both oestrogen and progesterone influence the risk of thromboembolic disease. The VTE risk appears to be higher among users of oestrogen plus progesterone than among users of oestrogen alone. The risk is increased especially during the first year of treatment. Previous users of HRT have a similar risk as never users. Transdermal oestrogens (patches) are thought to be safer with respect to thrombotic risk.  

2. Stroke 

The risk of stroke appears to be increased in women taking oestrogen only or combined HRT. It does not appear to be significantly increased in women under 60 years old. If 2 in 100 women not taking HRT have a stroke, then 3 in 100 women taking HRT will have a stroke. Tibolone which is another form of HRT increases the risk of stroke (doubled) in women above 60 years.

Transdermal oestrogen appears to be associated with a lower risk of stroke. The effects of HRT on stroke may be dose-related and so the lowest effective dose is usually prescribed in women who have significant risk factors for stroke. 

3. Breast cancer 

Data regarding the true effect of HRT on the incidence of breast cancer are still contentious. Combined HRT increases the risk of breast cancer. The risk is a little higher for women who take HRT over the age of 60. The risk goes up slowly in the first five years you use HRT, then more quickly if you continue using it after that. However, the absolute risk is small at around one extra case of breast cancer per 1,000 women per year. The risk is greatest in lean women. This is similar in magnitude to the risk associated with late menopause, early menarche, not having children and obesity. This is also similar in magnitude to drinking two to three units of alcohol daily. The risk returns to that of a non-user within five years of stopping HRT. Mortality from breast cancer is not significantly increased in an HRT user. Breast cancers found in women who take HRT are easier to treat than those in women not on HRT.

The risk of breast cancer with oestrogen only HRT is far less than with combined HRT. Most observational studies do not demonstrate an increased risk of breast cancer in women taking oestrogen only HRT for up to five years. Combined HRT also increases breast density and the risk of having an abnormal mammogram.  

4. Endometrial cancer 

Oestrogen only HRT substantially increases the risk of endometrial cancer in women with a womb (uterus). The use of continuous combined HRT (both oestrogen + progesterone) or cyclical progesterone for at least ten to twelve days every month eliminates this risk. Tibolone does not increase the risk of either endometrial hyperplasia or endometrial cancer.  

5. Heart disease 

Women who are over 60 and take HRT more than 10 years after the menopause have an increased risk of heart disease. But the risk is small to begin with. Over five years, nearly 2 in 100 women taking HRT were at risk of heart disease, compared with 1.5 in 100 women not taking HRT. 

6. Other risks 

There is a chance that taking HRT for a year or more could increase your risk of gallbladder disease (gallstones). Ovarian cancer - current data on the role of HRT and the risk of ovarian cancer are still conflicting. Some research suggests HRT may also slightly increase your chance of ovarian cancer, although the risk seems to disappear when you stop using HRT. 

Women react differently to HRT, so there is no one preparation that is better than any of the others. Some of the common side effects which you may experience on HRT include the following:

• Oestrogen related - breast tenderness, leg cramps, skin irritation, bloating, indigestion, nausea, headaches. 
• Progesterone related - premenstrual syndrome-like symptoms, fluid retention, breast tenderness, backache, depression, mood swings, pelvic pain.  
• Nausea can be reduced by taking the HRT tablet at night with food instead of in the morning, or by changing from tablets to another type of HRT.  

There is no evidence of weight gain with HRT. Researchers have found that, although women may put on some weight when they first start to take HRT, after a while their weight is the same as it was before treatment. Women also tend to gain weight during the menopause, so any weight gain may not be a result of HRT. Your body’s fat distribution also changes, with an increase in fat around the waist and less around the hips and buttocks. You can also experience water retention when on HRT. 

Many of these common side effects simply go away when you have been on HRT for a while. Sometimes a change of product helps.  

Monthly sequential preparations should produce regular, predictable and acceptable period like bleeds. Erratic breakthrough bleeding is common in the first 3-6 months of continuous combined and long-cycle HRT regimens (with no regular period like bleeds). 

If bleeding tends to be heavy or irregular on sequential combined HRT then the dose of progesterone can be doubled or increased in duration to 21 days. If there is persistent irregular vaginal bleeding after six months of starting HRT, you will need to have further investigations. If you experience predominantly progesterone induced side effects, then you can have the progesterone dose halved or the duration of taking progesterone reduced to 7-10 days.

If you experience significant nausea or migraine headaches with oral preparations, patches can often be a better option. Progesterone related side-effects can often be minimised if Mirena coil (intrauterine system) is used as the progesterone arm of HRT. 

HRT is not prescribed in certain conditions such as - pregnancy and breast-feeding, undiagnosed abnormal vaginal bleeding, venous thromboembolic disease (blood clots), active heart disease, current or past breast cancer, current or past endometrial cancer, other oestrogen dependent cancer, active liver disease and uncontrolled high blood pressure.

Women who would like to consider HRT but have one of these conditions should seek specialist advice. 

When you start HRT, the doctor or nurse will discuss your age, symptoms and medical conditions before looking at the risks and benefits of HRT which are specific to you. These can change and will be discussed at your yearly review.

Tests are usually not necessary before starting HRT unless there is a sudden change in menstrual pattern such as - persistent heavy/irregular periods, bleeding between periods or after intercourse and postmenopausal bleeding. In these situations, you will be asked to have a pelvic ultrasound scan to assess lining of the womb and a biopsy of the womb lining may be performed.

If there is a personal or family history of VTE - a thrombophilia screen (blood test to look for tendency to develop blood clots easily) may be helpful. If there is a high risk of breast cancer, you will be asked to consider a mammography or MRI scan and referred to familial breast cancer services depending on the level of your risk. A blood test for lipid and glucose profile will be requested if you have risk factors associated with cardiovascular disease.  

The choice of delivery route and type of HRT depends partly on patient preference but there are also other advantages to certain delivery routes. It is recommended that women should be prescribed sequential combined HRT (giving monthly periods) if their last menstrual period was less than one year ago. Women can be prescribed continuous combined HRT (without periods) if they have received sequential combined HRT for at least one year; or it has been at least one year since their last menstrual period; or it has been at least two years since their last menstrual period if they had a premature menopause.

Local preparations such as vaginal creams and pessaries are highly effective for symptoms of vaginal dryness, painful sex and urinary frequency. Their use is safe and not linked to some of the major risks associated with systemic HRT. However, around 10-25% of women still have symptoms with local oestrogen so will require systemic HRT in addition. For other menopausal symptoms – oral, transdermal or other forms of systemic HRT are necessary for effective symptom relief. 

HRT is only available on prescription and will be charged at the current prescription rate. Sometimes your HRT will involve two medicines and you may need to pay two prescription charges.

HRT is not a contraceptive. You may be potentially fertile for up to two years after your last menstrual period if you are under 50 years of age and for one year if you are over 50 years. You should therefore use appropriate contraception during this time to avoid pregnancy.

If you forget to take your HRT do not take the doses that you have forgotten, just take the next dose when you remember. 

Most commercially available combined HRT preparations contain progestogens - compounds which have progesterone like actions. Micronised progesterones are natural progesterones devoid of any androgenic as well as glucocorticoid activities.

These appear to be the optimal progesterone in terms of cardiovascular effects, blood pressure, VTE, probably stroke and even breast cancer. Utrogestan is the only one currently available to prescribe in the UK. 

If you are unable to have HRT, other medications or treatments may be prescribed to help control your menopausal symptoms. For vaginal dryness and painful sex – vaginal lubricants and moisturisers are often effective. For hot flushes and night sweats – antidepressants or selective serotonin reuptake inhibitors such as Venlafaxine and Clonidine (blood pressure lowering agent) are oral medications which are most commonly prescribed. Alternative therapies including homeopathy and acupuncture are also offered at specialist clinics. Testosterone gel is prescribed by some clinics to improve libido. The evidence for effectiveness of these medications is limited but many women chose these options to avoid the risks associated with HRT. If you wish to consider any of these alternatives, you should talk to your doctor in details about the risks versus benefits of these treatment options and make an informed choice. 

Tibolone (brand name Livial) is another type of hormone treatment, but it does not contain oestrogen or progesterone. It does not affect the lining of your womb. This means that, if you start taking it at least one year after your periods have stopped, you should not get any monthly periods. If you take tibolone, you are likely to have half as many hot flushes, less vaginal dryness, improved sexual satisfaction and more sexual arousal. Researchers have found that sex drive increases much more in women taking tibolone than in women taking combined HRT. Tibolone may slightly increase your chance of breast cancer, but less than if you take combined HRT. The most common side effect is spotting or bleeding from the vagina. Some researchers have also found that if you take tibolone your level of 'good' cholesterol (HDL cholesterol) falls by about one-third. There is not enough research to show whether this drop in HDL cholesterol is harmful, or whether women who take tibolone are more likely to have a heart attack or a stroke. 

Phyto-oestrogens are chemicals that are found in some plants. They act like a weak form of oestrogen. Soya products such as tofu and miso are rich in phyto-oestrogens, as are beans, lentils, certain fruits and celery. You can also get over-the-counter supplements such as red clover pills from some pharmacies and health food shops. The research into phyto-oestrogens is not as robust as that for HRT. Most of the research suggests that they do not help reduce hot flushes. Phyto-oestrogens also probably do not help with the sexual problems or bladder infections linked with the menopause. Because phyto-oestrogens act like oestrogen in the body, it is possible that they could increase the chance of breast cancer and cancer of the lining of the womb (endometrial cancer). But there is not enough good research to say whether this happens or not. 

Black cohosh is a popular herbal treatment. You can buy products made from black cohosh from health food shops. Most good quality research suggests that black cohosh does not make much difference to hot flushes. Some people taking black cohosh get stomach pains. You might also feel dizzy and nauseated, and get headaches when you take it. Black cohosh may cause liver problems in some women. You should always tell your doctor if you are taking herbal treatments as they can sometimes react with treatments your doctor may prescribe. 

You will generally be asked to come for a follow-up consultation after starting HRT in about three months' time. Most symptoms are likely to have responded to oestrogen in this time period and any residual problems may require alternative management.

If the chosen HRT suits you and appears effective, you may wish to see your GP or the specialist clinic once or twice every year to review the on-going need for and safety of continuing HRT. Both mammography and cervical screening as per national guidelines are recommended in the postmenopausal women on HRT. 

Most women are able to stop taking HRT after their menopausal symptoms diminish, which is usually two to five years after they start. Gradually decreasing your HRT dose is usually recommended, rather than stopping suddenly. You may have a relapse of menopausal symptoms after you stop HRT, but these should pass within a few months.

If you have symptoms that persist for several months after you stop HRT, or if you have particularly severe symptoms, you treatment may need to be restarted, usually at a lower dose. 

After you have stopped HRT, you may need additional treatment for vaginal dryness and to prevent osteoporosis.