What is the menopause?
The menopause is when you stop having periods. Clinically, menopause is diagnosed when one does not have periods for more than 12 consecutive months. Menopause occurs because the ovaries have run out of eggs and ovulation stopped. Women are born with a set number of eggs and gradually use the eggs over time. They do not develop new eggs. When the pool of eggs is exhausted, menopause will commence.
The process of ovulation stimulates the release of oestrogen hormone from the ovaries. In the menopause oestrogen levels in the body will significantly diminish, causing symptoms such as night sweats, hot flashes, and vaginal dryness.
Most women in the UK would have the menopause after 40 years of age, with the average menopause age being 51 years of age.
Menopause can occur earlier in some women. If it occurs before the age of 40 years, it is known as premature menopause or premature ovarian insufficiency.
Leading up to the menopause, menstrual cycles are irregular due to infrequent ovulation. Oestrogen levels will also be diminishing. This is known as the peri menopause. It could last for several months to years, before eventually merging into 12 consecutive months without periods, confirmed as the menopause.
What are the symptoms?
The most common symptoms of menopause are:
- hot flushes
- night sweats
- vaginal dryness
- low mood and/or feeling anxious
- joint and muscle pain
- loss of interest in having sex.
The symptoms of menopause vary, with some women experiencing very mild, to no symptoms at all. Others experience more severe symptoms that could have a significant impact on their quality of life.
Depending on the symptoms, some women will choose not to have any medical interventions. Others will require hormone replacement therapy (HRT) or an alternative treatment.
How is it diagnosed?
If you have symptoms of the menopause and are over 45 years of age, you will not usually need any hormone tests to diagnose menopause.
Tests if required include blood test for follicle stimulating hormone (FSH), luteinising hormone (LH) and oestradiol. Pelvic ultrasound scan may also be required. In cases of premature ovarian failure, more specialised tests will be required to determine cause for the early menopause. Treatment options are offered based on your symptoms alone.
If you want more information about how we can help you, have a look at our private Menopause Health Check Package
What are my options for treatment?
Treatment options for menopausal symptoms include:
Regular aerobic exercise as well as reducing caffeine and alcohol intake may help reduce hot flushes and night sweats.
Hormone replacement therapy (HRT)
HRT is prescribed to replace the hormone oestrogen in your body, which decreases around your menopause. You may sometimes also need other hormones (such as progestogen and testosterone) that your body is no longer producing.
The benefits and risks will be discussed with you before you start the treatment. This discussion will cover both the short-term (over the next 5 years) and the longer term (beyond the next 5 years) benefits and risks for you.
What are the different types of HRT?
The type of HRT prescribed depends on your individual situation. If you have a uterus (womb) then a combination of oestrogen and progestogen HRT (combined HRT) would be recommended.
Oestrogen alone can cause abnormal thickening of the lining of your uterus, which can lead to bleeding. Adding progestogen will prevent this. Progestogen may be given in the form of tablets, patches, or a hormone-containing coil.
If combined HRT is started before you have the menopause or within 12 months of your last period then you will be offered a ‘cyclical’ combined HRT, which should give you regular monthly withdrawal bleeds.
If you start combined HRT more than 12 months after your last period, you may be offered ‘continuous’ combined HRT (bleed-free HRT). You may experience some vaginal bleeding in the first 3 months, but after this it should stop.
If you have had a hysterectomy then you will be offered oestrogen-only HRT.
Women who notice a low sex drive after the menopause may be offered another hormone called testosterone. This is a hormone linked to sex drive in both men and women.
HRT is available as oral tablets, skin patches, injections, body gel or spray, or vaginal ring, cream, or pessary.
Is HRT safe and does it work?
The effects of HRT have been studied worldwide and research shows that, for most women, HRT works and is safe.
What are the benefits of HRT?
- It is an effective treatment for hot flushes and low mood associated with the menopause.
- It can improve sexual desire and reduce vaginal dryness.
- It helps keep your bones strong by preventing osteoporosis.
What are the risks of HRT?
- HRT with oestrogen alone (used for women who have no uterus) is associated with little or no increased risk of breast cancer.
- HRT with oestrogen and progestogen can increase your risk of breast cancer. This risk is higher the longer you stay on it and reduces when you stop HRT.
- Your individual risk of developing breast cancer depends on underlying risk factors, such as your body weight and your drinking and smoking habits.
- HRT taken as a tablet increases your risk of developing a blood clot, which is not the case if HRT is taken as a patch or gel.
- HRT in tablet form slightly increases your risk of stroke, although the overall risk of stroke is exceptionally low if you are under the age of 60 years.
In our practice, we only recommend HRT gel or patches as they have a much lower risk.
Can I still have HRT if I have had breast cancer or clots in my legs or lungs?
HRT may still be an option for you, and you should discuss this with your healthcare professional, who may seek advice or refer you to a menopause specialist.
Can I take HRT if I have diabetes or high blood pressure?
HRT should not affect your blood sugar control. If you are diabetic or have very high blood pressure, your healthcare professional may consult with a specialist before prescribing HRT.
Would taking HRT prevent dementia?
It is not known whether HRT affects the development of dementia.
Do I still need to use contraception when taking HRT?
HRT does not provide contraception. You need to continue using contraception for 1 year after your last period if this happens after the age of 50 years. If your last period happens before you are 50 years of age, then you need to continue using contraception for 2 years.
When should I seek advice after starting HRT?
You should have a review appointment with your healthcare professional after 3 months of starting or changing HRT, and then yearly thereafter if all remains well.
You may notice some vaginal bleeding in the first 3 months of starting or changing HRT, but if you experience any bleeding after 3 months then you should see your healthcare professional straight away.
How long can I take HRT for?
There are no set time limits for how long you can be on HRT. The benefits and risks of taking HRT will depend on your individual situation, and your healthcare professional should discuss these with you.
How do I stop HRT?
You can stop your HRT suddenly or reduce gradually before stopping it. The chances of your symptoms coming back is the same either way.
If you would like to read more about the menopause and HRT, see our special extended article here – Menopause and HRT
Which treatment is best for my vaginal dryness?
Many women find using vaginal moisturisers and lubricants helpful for vaginal dryness. Ask your healthcare professional about the best one for you.
Oestrogen given vaginally in the form of a tablet, cream or ring is effective in treating vaginal dryness. Low-dose vaginal oestrogens can be used for as long as you need to and can also be safely used in combination with HRT. These can also reduce bladder infections and help urinary symptoms, known as genitourinary syndrome of menopause (GSM). If you experience any unexpected vaginal bleeding, you should tell your healthcare professional. Other forms of HRT can also help with vaginal dryness.
There is growing evidence that laser vaginal rejuvenation alone or in combination with HRT significantly improves vaginal and urinary symptoms (GSM). In our practice we use Femifine laser vaginal rejuvenation (add link here), a painless, 15-minute office procedure with particularly good results.
What is premature menopause (premature ovarian insufficiency) and what causes it?
This is when you go through the menopause before the age of 40 years. Usually, no cause is found for this. It can be caused by surgery on the ovaries, chemotherapy, or radiotherapy to the pelvis. It can also run in families. Other less common causes include chromosomal problems, such as Turner syndrome, and autoimmune disease when the body’s immune system attacks the developing eggs.
How is premature menopause diagnosed?
If your periods become infrequent or stop before the age of 40 years and/or you experience menopausal symptoms, you should see your healthcare professional. You will be offered blood tests to measure your hormone levels to help diagnose premature menopause. The diagnosis is made after two blood tests are performed 4–6 weeks apart.
Are there any health risks related to premature menopause?
You are likely to notice the symptoms of menopause, such as hot flushes and mood changes. There is also an increased risk of developing osteoporosis and cardiac disease in later life. Osteoporosis can lead to broken bones if not treated. Premature menopause will affect your fertility, and your chance of getting pregnant will be greatly reduced.
What is the treatment for premature menopause?
Treatment for premature menopause involves the replacement of hormones in the form of either HRT or the combined oral contraceptive pill. Both are effective in treating hot flushes and keeping your bones strong.
While the combined oral contraceptive pill has the advantage of also providing contraception, HRT is a safer option if you have high blood pressure.
It is important for you to continue the treatment at least until the average age of natural menopause. By taking HRT, you are simply replacing the hormones your body is lacking, and so there are no added risks.
If you are thinking about getting pregnant, you will need a referral to a fertility specialist. Your healthcare professional may also suggest referral to a menopause specialist.
Non-hormonal medical treatment
Non-hormonal medical treatments, which would need to be prescribed by your doctor, include clonidine or gabapentin for hot flushes.
Laser treatment for genitourinary syndrome of menopause (GSM)
In the last decade, laser treatment of stress urinary incontinence (SUI) and of the genitourinary syndrome of menopause (GSM) has been shown a promising treatment method in peer-reviewed literature. Laser vaginal rejuvenation alone, or in combination with HRT significantly improves vaginal and urinary symptoms (GSM). In our practice we use Femifine laser vaginal rejuvenation (add to femifine laser link here), a painless, 15-minute office procedure with particularly good results.
Plants or plant extracts, such as St John’s wort, black cohosh and isoflavones (soya products), can help reduce hot flushes and night sweats for some women. However, their safety is unknown, and they can react with other medicines that you may be taking for conditions such as breast cancer, epilepsy, heart disease or asthma. Herbal medicines are unlicensed, and you should check with your healthcare professional before taking any herbal medicine.
Alternative therapies such as acupressure, acupuncture or homeopathy may help some women. More research is, however, required on the benefits from these therapies and, if they are used, this should be done with advice from qualified professionals.
Cognitive behavioural therapy (CBT) is a type of psychological treatment. You may be offered CBT for low mood or anxiety related to menopause.
More detailed information about the menopause has been developed by the Royal college of Obstetricians and Gynaecologists which can be found here
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