Menopause and Medicine

Article by
Rachel Mackey.

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.

Very often naming and acknowledging the menopause helps women to deal with symptoms.

Very often naming and acknowledging the menopause helps women to deal with symptoms.

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.

Treatments Available

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:

Dietary Changes

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:

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:

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:

Oral Form

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.

Bone Protection

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

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)
No HRT15
Oestrogen-only HRT11
Oestrogen/progestogen HRT23-30
BMI over 3530

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.

Endometrial Cancer

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

Key Points

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