Menopause and Medicine
If you are dealing with classic and challenging symptoms of menopause you may like to consider a range of treatments including the medical route and HRT. Dr Rachel Mackey is a women’s health specialist with extensive obstetric and gynaecological expertise, her clinic offers a wide range of health services to women including specialist menopause treatment. She is the author of "The Women’s Health Book, A Guide for the Irish Woman". In this extract from the book she explains her common sense approach to menopause and discusses HRT and other treatments.
About 70 per cent of women will experience menopausal symptoms, but only 10 per cent will need to ask for help from their doctor. This is because most women will find their symptoms manageable. Nevertheless, some women will experience symptoms that are sufficiently severe to significantly affect their quality of life. Symptoms can differ quite a lot depending on where you are in relation to the menopause process.
The most important thing to do is to talk to your doctor about your symptoms. If you don’t feel he/she will be the right person for you to discuss this with, find another doctor! This is not a mystery illness – there are lots of competent doctors who are able to diagnose and treat the menopause appropriately.
Sometimes just putting a name to what is causing your symptoms is such a relief that no drug treatment is necessary. Most women are not looking for medication. Once they understand what is happening to them, and are given lots of information about why this is happening, how long it will last, and what to expect over the next few years, most women are happy just to continue on as they are without medical intervention. Some simple advice about life-style measures can also make an enormous difference.
What You Can Do
There are several things you can do when you reach the menopause to help ease your symptoms:
There are lots of changes that you can make to your diet to try to improve your general well-being. You will undoubtedly have come across some of them in relation to weight loss, but they are particularly important at the menopause when energy levels are low, weight gain can be a problem and certain foods will improve or worsen menopausal symptoms.
The following are some guidelines on how to eat better during the menopause:
- Avoid hot, spicy foods, particularly around your prime hot flush time of the day.
- Change to decaffeinated drinks, and try having an iced version instead of a hot drink.
- Reduce your intake of high fat, high sugar foods – they reduce your energy levels and leave you sluggish.
- Have five portions of fruit and vegetables every day.
- Eat smaller but more frequent meals each day You can eat up to six very small meals per day - big meals make you hotter.
- Have a well-balanced breakfast – it will stabilize your sugar levels and make it less likely that you will snack during the day.
- Increase the amount of fibre in your diet – brown bread, bran and cereals; fibre keeps you feeling fuller for longer.
- Increase your water intake.
- Try to introduce foods rich in folic acid, vitamin B12, selenium, calcium and omega 3 fatty acids, as they are all useful for energy and mood.
- Avoid alcohol – it causes hot flushes and depresses your mood.
- In some cases, the introduction of phytoestrogen-rich foods may help to alleviate some symptoms of the menopause.
Non-hormonal Menopausal Treatments
These are drugs used for a range of other medical conditions, which have also been noted to reduce menopausal symptoms. They tend to be reserved for women whose symptoms are extremely severe but who cannot use oestrogen-containing HRT in any circumstances - such as women with breast cancer. The side effects of these medications can be quite noticeable, so they would not be suitable for everyone.
This is a medication used in the control of high blood pressure and also for migraine control. Its effect is to reduce the intensity of hot flushes, but its success is limited. The dose is usually 50 to 75 mg twice daily, and side effects include dry mouth, dizziness and insomnia. It is not prescribed very often nowadays.
A particular type of antidepressant medication called selective serotonin re-uptake inhibitors (SSRIs) and serotonin-noradrenaline re-uptake inhibitors (SNRIs) can help to reduce the quantity of hot flushes. They work in the brain near the heat control centre. Venlafaxine (Effexor) fluoxetine (Prozac) and paroxetine (Seroxat) have all been shown to work. Venlafaxine can reduce flushes by up to 50 per cent.
These are synthetic forms of progesterone, a hormone produced by our ovaries. When these are given in high doses they can relieve hot flushes, but side effects include bloating and fluid retention, which women cannot always tolerate.
Hormone Replacement Therapy (HRT)
The advantages and disadvantages of HRT have been debated for decades. There is undoubtedly a role for HRT in some patients, but the idea that it is suitable for all and to be recommended for all women is long gone. The main reasons for using HRT are primarily the control of menopausal symptoms and, to a lesser extent, the treatment of osteoporosis in women of menopausal age. The general rule when using HRT is as follows. ‘Use as little as possible for the shortest time possible.’
Types of HRT
Depending on your situation, different types or regimens of HRT are recommended:
- If you still have a womb, a combination of oestrogen and progestogen is needed. The daily dose of oestrogen relieves the menopausal symptoms, whereas the progestogen balances the oestrogen and prevents the lining of the womb from thickening up excessively. Long-term use of oestrogen without progestogen can lead to cancer of the lining of the womb (endometrium).
- Women who are still having periods, or who have had a period in the last year, require a combination of oestrogen for 28 days and progestogen for 14 days, which allows them to have a monthly bleed. This is known as sequential HRT.
- Women who have not had a period for a year or more require a combination of both oestrogen and progestogen daily for 28 days in a lower dosage, which allows them to be bleed free. This is known as continuous combined HRT.
- Women who have had a hysterectomy require only oestrogen as their hormone replacement.
Ways of Taking HRT
There are several ways of taking HRT, although our options in Ireland are slightly more limited than in the UK or USA. These include:
Both oestrogen and progestogen come in tablet form. They can be taken individually or combined in a single tablet.
Patches can be in oestrogen-only form for women who have had hysterectomies, or in combination with progestogen. They can be given as a weekly or twice-weekly dose, depending on the particular brand.
The only vaginal form of hormone replacement is that of local oestrogen. This is not absorbed into the bloodstream and, therefore, is not effective in relieving menopausal symptoms. It is very useful in relieving local vaginal and urethral symptoms, such as dryness, soreness and urinary frequency and urgency seen in postmenopausal women. It can be used safely in almost all women, as its effect is localized in the vagina.
Intrauterine System (IUS)
An IUS such as the Mirena coil delivers a daily dose of progestogen directly into the women via a slow-release system, which lasts for five years. This is sufficient progestogen to balance oestrogen given in any other form and, therefore, makes delivery of HRT easier.
How Quickly Does HRT Work?
HRT works very quickly to relieve menopausal symptoms, and you will feel a significant improvement within ten days of starting treatment.
When Do You Stop?
While you are on HRT, the natural process of the menopause is continuing on. In other words, HRT disguises the menopause; it does not postpone it. For most women HRT is so successful at disguising their symptoms of menopause that they have to stop it in order to find out if they are still going through the menopause. For this reason it is advisable to stop every year to assess whether you have any remaining symptoms. When stopping HRT you should wean off it slowly over a period of about eight weeks, as this reduces the risk of getting ‘rebound’ symptoms. If you have been started on HRT in your forties for early or premature menopause you should continue to take it until you reach the age of 50.
Among those women who are starting it after the age of 50, there is often a big worry that they will end up taking it for long periods of time. The opposite is true. The average length of time that women use HRT is approximately eighteen months. This is usually because you become naturally curious as to what stage you are at in terms of the menopause process, and the temptation to come off it in order to find out is great. In a lot of cases the HRT never gets restarted, as women find that their remaining symptoms are manageable without HRT. Only a very small percentage of women will find their menopausal symptoms are adversely affecting their quality of life over a very prolonged period of time, and for those women long-term use of HRT can be an option. For everyone else, their HRT use comes to a natural end after a surprisingly short time.
Long-term Health Benefits of HRT
The long-term benefits of HRT include potential protection against cardiovascular disease and proven protection against osteoporosis. Some studies have shown mixed results with regard to the effect of HRT on the cardiovascular system, and this has caused confusion as to whether there is a risk of cardiovascular disease or a protective effect by using it. It seems that both may be true. Some large-scale American studies showed a slight increase in stroke and heart attack during the first year of use, but the average age of women in these studies was 67. The significance of this is that women in this age group are not the target age group for HRT use. It would appear from looking at women between the ages of 45 and 55 who have used HRT in the past that there is a protective effect on the heart and blood vessels with HRT use, and that this age is the ‘window of opportunity’ in which to use HRT in order to protect the cardiovascular system later in life.
HRT use has long been known to have a protective effect against osteoporosis. Generally speaking, different drug therapies may be recommended for women depending on the severity of the osteoporosis and on their age. HRT is ideal for women who are between the ages of 45 and 55 and who have been shown to have osteopenia or mild bone density loss, but who also need HRT to control their menopausal symptoms. HRT is not necessarily appropriate to treat osteopenia or osteoporosis.
Short-term Side Effects of HRT
This refers to the side effects that you might experience within the first few weeks or months after starting HRT. These are usually minor and will disappear if you persevere. They include irregular bleeding, headache, nausea and water retention. Occasionally, in some women they can be more severe, so it is always very important to let your doctor know if you are experiencing any side effects within the first few weeks of starting HRT. They will probably be able to reassure you that what you are experiencing is normal.
Long-term health Worries with HRT
I think most women have heard something over the last decade about the concern regarding HRT use and an increase in the risk of developing breast cancer. Luckily this valuable information has come to light and allows us to inform patients accurately about the risks of HRT use. It has also helped to clarity the ideal length of time that patients should stay on HRT, and prevents patients from being left on it unnecessarily for long periods of time. The concept of taking as little HRT as possible to relieve symptoms and to stay on it for as short a time as possible is now universally accepted, and this is in no small part due to the large studies conducted which have uncovered the information regarding the breast cancer risk.
However, this information must be put in perspective. The international media did women in general no favours when they decided to pick the ‘HRT and breast cancer’ story and publicise it as they did. What has happened now is that many women whose lives would be greatly improved by using HRT for a short period of time without any increased risk of breast cancer are not being prescribed it. Indeed, they themselves have formed an opinion that HRT is dangerous, based on media reports.
The Facts about HRT
- HRT does not increase a woman’s risk of breast cancer unless it is taken for more than five to seven years, after which time a slight increase in breast cancer is seen. For women taking oestrogen only, i.e. women who have had a hysterectomy, no increase in risk is seen.
- For women between the ages of 50 and 70, breast cancer affects 45 per 1,000.
- If HRT is taken for more than five years, this increases to 47 per 1,000.
- If HRT is taken for more than ten years, this increases to 51 per 1,000.
- If HRT is taken for more than fifteen years, this increases to 57 per 1,000.
Source: the above information is based on research conducted by a Collaborative Group on Hormonal Factors in Breast Cancer, 1987, ‘Breast Cancer and HRT Collaborative Reanalysis of Data from 51 Epidemiological Studies of 52,705 Women with Breast Cancer and 108,411 Women without Breast Cancer’, The Lancet, Vol. 350, Issue 9,089, pp. 1,484.
For women starting HRT for an early menopause who are between the ages of 40 and 45, and women who are experiencing a premature menopause (under the age of 40), there is no additional risk of breast cancer. This increased breast cancer risk is only seen in women aged over 50 using HRT for longer than five years. The increased risk is gone within five years of stopping HRT.
It should also be pointed out that several other risk factors for breast cancer pose a far greater risk than HRT, as the following chart highlights:
|Number of Women Developing Breast Cancer Over Next Five Years||(per 1,000 women)|
|BMI over 35||30|
Source: adapted from a Women’s Health Initiative trial, which studied 160,000 postmenopausal women over 15 years in the US.
As you can see, there is a reduction in the number of breast cancer cases in women using oestrogen-only HRT, a small increase in the combined HRT group, and a significantly larger increase in obese women and women who consume more than 2 units of alcohol per day.
Increased Risk of Blood Clotting with HRT
Tablet forms of HRT cause a slight increase in the risk of blood clots
The risk of a woman who is not on HRT getting a blood clot is 1 in 1,000 per year
The risk of a woman who is on HRT (tablet only) getting a blood clot is 2.5 in 1,000 per year
It is usually advised that if a woman has had a clot in the past she should not use HRT, unless under the guidance of a specialist. If there is a family history of blood clotting or thrombosis, a blood test can be done for the women to determine for herself whether she is at increased risk, HRT patches are preferred if there is any increased risk of thrombosis, as they reduce the risk of developing a clot while on HRT.
This is a cancer which can develop in the lining of the womb or endometrium. It is a reasonably uncommon cancer, but it is seen in women who take oestrogen-only HRT when they still have an intact womb. This is because the oestrogen over-stimulates the womb. HRT preparations specifically for women with a womb are balanced with progestogens, and so this risk is completely eliminated.
So there you have it. The menopause comes in all shapes and sizes, and every woman is different. There are lots of things you can do yourself to help get through it as easily as possible. You should talk to your doctor about your symptoms and your health in general. Look on the menopause as the beginning of a new phase in your life which is different, but not necessarily any less fulfilling, than your younger years. It certainly marks the beginning of a new stage in your general health, and you need to spend a little more time monitoring it. There are very successful, safe treatments available for you if you are finding that the menopause is affecting you to a significant degree. HRT is a safe and efficient option for relief of your menopausal symptoms, but not every woman will need it.
Checklist for Menopausal Women
- Mammograms from the age of 50 onwards (BreastCheck is a breast-screening programme available to women aged 50 to 64 which provides a free mammogram every two years)
- Cervical smear every five years (CervicalCheck, the National Cervical Screening Programme, provides free smear tests to women aged 25 to 60)
- Annual blood tests – fasting cholesterol and glucose, thyroid testing
- DEXA scan for osteoporosis at the onset of menopause, then every five years if the results are normal
- Weight management
- Regular exercise
- The average age at which your periods stop is 50.
- The perimenopause starts much earlier, when your menstrual cycle starts to change.
- Symptoms of the menopause can by physical, psychological and emotional.
- Treatment options include diet and exercise, alternative therapies and HRT.
- Premature menopause occurs when your periods stop at the age of 40 or less
- Long-term problems associated with the menopause include vaginal dryness and osteoporosis.
- HRT can be safely used in the 45 to 55 –year-old age group for less than five years to relieve symptoms of the menopause.
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