Menopause

What is the menopause?

Menopause is said to have occurred when a woman has had no periods for 12 months.  In the UK the average age of menopause is 51 with an age range of 45-55 years.  Menopause that occurs age 40-45 is called Early Menopause and below the age of 40 it is called Premature Ovarian Insufficiency (POI).

For the majority of women, menopause is a normal part of life. Some women have a surgical menopause when their ovaries are removed at operation and some will experience menopause as a result of chemotherapy or radiotherapy to the pelvis.  Symptoms can be particularly problematic for women who have a surgical menopause.

Symptoms can occur for many years before the menopause; this is the perimenopause. At this time women may notice a change in periods with lighter or heavier blood loss and a shorter or longer cycle. This, in combination with symptoms, is usually enough to make a diagnosis and offer support.
 

How will I feel?

This is different for everyone. Some women have few symptoms, and their periods simply stop. After 12 months, they can say that they are postmenopausal.

However, the majority of women will have symptoms with 80% experiencing one or more symptoms and in around 25% of women these will be severe. A change in periods is often noticed before the periods stop.  Symptoms can begin at this time and last from months to years with an average duration of 7-8 years.  Some women continue to have symptoms for decades.
 

What are the symptoms?

There are hormone receptors throughout the body. Low estrogen levels that occur after the menopause can result in a wide range of symptoms including the following:

  • Hot flushes
  • Night sweats
  • Palpitations
  • Tiredness
  • Headache/worsening migraine
  • Muscle and joint pains
  • Poor sleep
  • Anxiety
  • Low mood
  • Irritability/rage
  • Tearfulness
  • Poor memory
  • Loss of confidence
  • Low libido
  • Vaginal dryness
  • Pain on intercourse
  • Urinary symptoms such as frequent passing of urine or recurrent urinary tract infection
  • Dry skin/dry eyes/dry mouth
  • Hair loss
  • Weight gain
  • Breast tenderness
  • Itchy skin

This list is not exhaustive but represents the wide variety of symptoms that can affect a woman in menopause. You can chart your symptoms using the Menopause Symptom Questionnaire.
 

How is menopause diagnosed?

For women age 45 or over with typical symptoms, no blood tests are required to diagnose menopause. These women may be recommended to have blood tests to exclude other common conditions at this age such as anaemia, an underactive thyroid gland or iron deficiency. Blood tests may also be recommended as part of a general health check to assess cholesterol and check for pre-diabetes.

For women age below 45 hormone blood tests are usually advised although these can be unreliable in the perimenopause.
 

What can I do to help myself?

This is an opportunity to pause and reappraise lifestyle choices. The decisions that you make now will impact your long-term health and determine your quality of life in your postmenopausal years.

  • Diet – try to eat the rainbow. The British Heart Foundation has guidance available at https://www.bhf.org.uk/informationsupport/heart-matters-magazine/nutrition/5-a-day/colourful-foods.
    A diet rich in calcium will help to keep bones healthy and should be supplemented with a daily dose of Vit D 10 micrograms once daily. Dietary calcium intake can be calculated at https://www.osteoporosis.foundation/educational-hub/topic/calcium-calculator
    Weight gain around the menopause is common due to changes in metabolism that result from a reduction in bone and muscle mass. Try to keep a food diary to better understand your eating habits. Record:
    • Date and time
    • Description of the food
    • Description of quantity
    • Any symptoms that you are getting
    • Why you are eating it
  • Exercise - It is never too late to get moving. NHS guidelines recommend 30 minutes of moderate exercise 5 times per week. Impact exercise such as walking, running, jumping, skipping, racquet sports and dancing can all help to strengthen bones and prevent osteoporosis. Furthermore, regular exercise improves mental health, reduces stress, lowers blood pressure and reduces your future risk of breast cancer.
  • Alcohol – many women find that alcohol precipitates and exacerbates hot flushes. Alcohol is a depressant and disrupts normal sleep. Tolerance to alcohol is often reduced around this time. Government guidelines recommend that alcohol intake be limited to 14 units per week and that two days are kept alcohol free. Calories in alcohol can contribute to unwanted weight gain.
  • Smoking – women who smoke are more likely to have an early menopause and can experience more severe hot flushes and night sweats. Try to reduce the number of cigarettes smoked with a view to stopping completely.
  • Stress management – this can be a demanding time of life with work, children, partners and elderly relatives making demands on your time. Self-care is particularly important. How you relax will be personal to you but may include yoga, meditation, relaxation, walking in nature, spending time with friends or loved ones. Make a commitment to yourself to stick with this no matter what demands are placed upon your time.
  • Sleep – this can be disturbed by night sweats, anxiety, itchy skin, vaginal dryness, the need to get up to pass urine etc. Attention to the cause will help.
    • Aim for 7-8 hours of sleep per night.
    • Try to stick to a routine and avoid “catching up” at the weekend.
    • Go outside in the day. Exposure to daylight reduces melatonin, our sleepy hormone, so we feel more alert
    • Avoid caffeine after 6pm, earlier if it is particularly stimulant for you
    • Avoid alcohol - while it is initially sedative, it disrupts the sleep cycle
    • Have a bedtime routine and stick to it. This is your way of signalling to the brain that now is the time for sleep. Taking a warm shower or bath can help as the drop in core temperature facilitates sleep.
    • Ban mobile phones, laptops and TVs from the bedroom. Your brain needs to associate bed with sleep
    • If you waken in the night and fail to get back to sleep after 10-15 minutes, get up and go and do something. Only return to bed when you feel sleepy.

What if I am struggling to do all of this?

We can all aspire to achieve lifestyle change but it can be a challenge when you do not feel at your best. This is not failure but an acknowledgement that you need help. If you have symptoms that are reducing your quality of life and impacting on your home life, work life or relationships, speak to a health care professional to get specific advice about what might work for you. Everyone is different, no two women have the same experience of menopause. Knowledge is key.
 

What about HRT?

In menopause, the ovaries have stopped producing hormones and these hormone levels remain low unless they are replaced.  Hormone replacement therapy refers to the replacement of one or more of the hormones estrogen, progesterone and testosterone:

  • Estrogen – the type of estrogen in HRT is 17 beta-oestradiol and it is derived from the root vegetable, the yam. This has an identical biological structure to the estrogen produced in the body. It can be given as a patch, gel or spray delivered across the skin, and also as a tablet taken orally.
  • Progestogen – all women who still have a womb and who use estrogen replacement will also need a progestogen. If given alone, estrogen causes the lining of the womb to thicken with an increased risk of abnormality and cancer. The progestogen keeps the lining of the womb thin and prevents this from becoming abnormal.  Natural progesterone (Utrogestan in the UK) is taken orally as a capsule and is also derived from the root vegetable, the yam. It is used as part of Body Identical HRT. The Mirena coil is often a good choice as it releases progestogen into the womb to prevent the lining from thickening and can remain in place for 5 years before it needs to be changed. Other progestogens are available in combination patches or tablets.
  • Testosterone – some women continue to experience symptoms of low libido, low arousal and poor sexual satisfaction despite adequate replacement of estrogen. This is often accompanied by fatigue and brain fog. For these women a trial of testosterone can be of benefit. Currently there are no testosterone products licensed for use in women in the UK, but menopause doctors and some GPs are happy to prescribe a cream or a gel off license and under supervision.
  • Local vaginal estrogen – symptoms of vaginal dryness, pain on intercourse, soreness of the vulva and vagina, recurrent urinary tract infection and urinary frequency benefit from treatment with vaginal estrogen. This can be used alone or in combination with HRT. Vaginal estrogen can be used as a pessary, cream, gel or a ring that remains in the vagina for 90 days.
     

What about alternatives to HRT?

  • Cognitive Behavioural Therapy – this talking therapy is recommended by NICE for the management of anxiety and low mood. There is evidence of benefit in the relief of hot flushes with women experiencing less severe hot flushes and less distress resulting from these.
  • Prescription Medications – NICE recommends HRT for first line treatment of symptoms of the menopause in women who have no contraindications. For women who cannot take HRT or who choose not to, there are various prescription medications that are indicated for the relief of menopausal symptoms. These include antidepressants such as Venlafaxine and Citalopram which show some benefit in reducing hot flushes. However, they are not first line for the management of low mood or anxiety associated with the menopause. Other medications such as Clonidine and Gabapentin can be considered but are frequently associated with side effects.
  • Herbal remedies – some women find traditional herbal medicines such as black cohosh, red clover, sage and St John’s Wort to be helpful. However NICE guidelines state that there is insufficient evidence of benefit beyond that which would be expected from placebo. Natural does not equate with safe and some herbal medicines can interfere with prescribed medications. If you are considering using herbal medicines, please consult with a health professional specialising in this field and ensure that all herbal medicines carry the Traditional Herbal Registration (THR) mark to certify safe standards of manufacture and delivery.
     

What can I expect from HRT?

  • Relief of your symptoms. This is the primary indication for the use of HRT. Often the dose needs some adjustment, but generally hot flushes and night sweats are relieved within a few weeks of starting; low mood, anxiety and sleep disturbance take longer to settle but have usually improved within 3 months. Symptoms of vaginal dryness can take longer to settle and, in some women, can take up to a year.
  • Reduced risk of osteoporosis. After the menopause there is a period of rapid bone loss. HRT reduces this bone loss resulting in reduced risk of osteoporosis and future bone fracture.
  • Reduced risk of cardiovascular disease. There is evidence that HRT started within 10 years of the menopause or below the age of 60 is associated with a reduced risk of cardiovascular disease; cardiovascular disease is the second most common cause of death in post-menopausal women.
     

Are there any risks from taking HRT?

NICE guidelines state that for the majority of women, the benefits of HRT outweigh the risks. For each individual this decision is based on your medical history, any pre-existing medical conditions, your family history and whether or not you still have a womb (uterus).

Many women worry about two risks:

  • Breast cancer
  • Blood clots
     

Breast Cancer

Your personal breast cancer risk depends on many things including age, family history, age at puberty, number of pregnancies etc. Lifestyle factors play an important role in breast cancer risk with obesity, smoking and alcohol consumption of 2 or more units per day all increasing breast cancer risk while regular moderate exercise of 2 ½ hours per week reduces this.

Studies have shown that women who take estrogen only HRT do not have an increased risk of breast cancer. Women who take combined HRT, containing estrogen and progestogen, may have a small increased risk of breast cancer. This risk can be minimised by using Body Identical HRT (estrogen through the skin in combination with micronised progesterone if required) as some studies have shown the risk of breast cancer with HRT is reduced if micronised progesterone is used.
 

Blood Clots

There are many risk factors for thrombosis (blood clots) and the risk increases with age. HRT taken orally as a tablet is associated with a small increased risk of blood clot and should be avoided in anyone with a personal history of blood clot, liver disease or migraine. HRT taken across the skin as an estrogen patch, gel or spray carries no increased risk of blood clot.

It is important that each woman has an individual assessment and discussion to facilitate a shared decision on the way forward.

Dr Alice Duffy

Last updated May 2021

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