Intro to The Menopause
My Friends cope really well with it, so why do I seem to have difficulties coping?
Some women experience mild or no symptoms with around a third of women never getting flushes. These lucky friends or colleagues may wonder what all the fuss is about!
At the other end of the scale, around 25% of women experience severe flushes.
It seems fair to say that there’s a tendency for women to underestimate the effect of the menopause on themselves perhaps for these reasons:
- It’s a natural process – it is, but so are most medical issues.
- A feeling that the symptoms will soon go. Flushes last longer than previously thought with the average duration being 7.4 years¹. Almost 1/3 of women experience symptoms lasting longer than 14 years.
- Concerns regarding side effects of treatment.
Are the symptoms affecting your quality of life? Be honest with yourself, and if the answer is “yes” then get some help.
What else could be causing my excessive sweating?
The medical term for excessive sweating is Hyperhidrosis. The causes of hyperhidrosis are either ‘no cause’ (primary hyperhidrosis) or a specific cause (secondary hyperhidrosis). The primary type usually starts in childhood or adolescence and is quite easy to diagnose in someone whose had it for a few years.
The secondary type is commonly caused by medication (SSRI’s for depression or Anti-Inflammatories) or an overactive thyroid. More unusual causes include Parkinson’s disease and diabetic neuropathy may sweat excessively.
There are rare causes of excessive sweating that include endocrine conditions such as Phaeochromocytoma and Carcinoid syndrome. Infections & lymphoma usually make themselves known with other clues.
To conclude, excessive sweating around the menopause is common but other conditions may rarely ‘mimic’ perimenopausal sweating.
How do I know I’m starting the menopause?
The first symptoms of the menopause are usually:
- A longer menstrual cycle (greater time between periods).
- Flushes – which may start whilst the periods are still regular
The menopause is confirmed after 12 months of absent periods. This definition is not that useful in women who are experiencing symptoms prior to this 12 month period.
The average age of the menopause is 51 but varies from 40 to 58.
Menopause prior to 40 is called ‘ Spontaneous Premature Ovarian Insufficiency‘ and needs investigation for underlying causes. The menopause between 40 and 44 is ‘early’ and may also need investigation.
What are the symptoms of the menopause?
The classical symptoms of the menopause that we all know about are:
- Flushes and/or night sweats. Flushes may be triggered by spicy food, alcohol & caffeine.
- Sleep disturbance. Research has shown the women tend to have more difficulty sleeping around the menopause even without hot flushes disrupting sleep – the hormonal changes have a direct effect on sleep.
- Vaginal Dryness.
Some women going through the menopause get down or depressed. It’s only recently that this self-evident truth has been backed up in recent menopause guidelines:
‘More recent longitudinal studies now support an association of the menopause transition with depressed mood, major depressive episodes, and anxiety.’ Women and Their Doctors have honestly known this for years. However, the symptoms of depression around the menopause tend to be different from depression at other times.
There is less in the way of ‘sadness’ and more in the way of fatigue, reduced quality of sleep, and irritability. In other words, your partner will probably notice more than you! Other symptoms of ‘peri-menopausal depression’ include reduced self-esteem, low libido, a ‘disconnect’ and a poor concentration.
Weight gain is common around the time of the menopause. Weight gain itself tends to be caused by the same biological causes that lead to weight gain at other times of our life eg calories, exercise and genetics. The weight tends to be put on ‘in the middle’ because lower oestrogen levels results in the fat being deposited around the waist rather than the thighs or hips. You may want to consider intervention for your weight.
Are any blood tests needed to diagnose the menopause?
The guidelines and evidence is strong that blood tests are not normally required. Why is this?! The blood test is a hormone test and the main hormone tested is Follicle Stimulating Hormone (FSH).
The FSH level rises as the woman approaches the menopause but not in a straight line. The FSH goes up and down along the way. The fluctuation in symptoms is caused by the ‘bumpy’ hormone levels.
The doctor may suggest a blood test:
- in younger women
- Ater a hysterectomy
- When a progestogen IUD is used
- To look for other causes than the menopause
Treatments for The Menopause
Treatments are very effective.
What can I do myself for menopausal symptoms?
Exercise has been shown to reduce menopausal symptoms
- Alcohol: Keep to moderate amounts because alcohol may trigger flushes
- Healthy Diet
- Relaxation – eg. yoga or mindfulness
- Alternative remedies – although trials into red clover and black cohash have been disappointing. Vitamin E may help a little.
What are the best treatments available?
There are two main prescribed treatment options for hot flushes:
- MHT (Menopausal Hormone Therapy that used to be called HRT).
- Serotonin reuptake inhibitors.
MHT consists of Oestrogen to make you feel better, and a progestogen (progesterone) to protect the Uterus from The Oestrogen. Hormonal therapy is generally more effective than SSRIs.
Oestrogen given topically (eg. via an applicator) often helps vaginal and/or bladder symptoms.
The combined contraceptive pill ‘may help to improve some of the symptoms of the menopause’4 whist providing good contraception. The dose of Oestrogen in ‘The pill’ is around 5 times higher than in MHT and therefore helps to alleviate symptoms. The old wives’ tale says that women in their late 40’s should not take the pill. In fact, the contraceptive pill is a safe choice for many peri-menopausal women.
Does MHT work?
There is no question that Menopausal Hormone Therapy can be of huge benefit for women with troublesome hot flushes or sweats. Recent UK, European, US and Australian guidlines all conclude that hormone therapy is generally the most effective treatment for typical menopausal symptoms.
Hormone therapy can also improve mood. The possibility of improved mood with MHT is something that goes back to the 1990’s and then fell out of favour. It’s good news that the benefit of hormonal therapy on mood has resurfaced. Doctors can once again ‘Consider MHT to alleviate low mood due to menopause.’³
The 2015 Endocrine society guideline states that Estrogen Therapy improves flushes, genitourinary symptoms, sleep disturbance, menopause-associated anxiety and depressive symptoms, and joint pains.
The symptoms most likely to respond to hormone therapy are flushes and genital symptoms, but it’s great news that it may also help sleep and mood.
What types of Oestrogen are found in MHT?
Oestrogen in MHT is generally in the form of Oestradiol.
Oestrogen comes in the form of tablets, patches or gel. There may be advantages to the patches or gel over the tablets. There are three patches available in Australia which are applied either weekly or twice weekly.
The Gel is applied every day and is useful in women who have concerns over the patch sticking. There is only one official dose of gel in Australia which may be considered a little limiting but Oestrogen absorption may be altered by changing how the gel is applied.
What types of Progesterone are there?
Progesterone has the very important job to do, namely to stop the uterus from being stimulated by Oestrogen. Oestrogen used on its own may otherwise cause Cancer of The Uterus.
Progesterone is commonly in the form of Norethisterone, with Dydrogesterone & Drospironone being somewhat more recent additions. Women who have had a hysterectomy do not require progestogen.
What is Micronised Progesterone?
Micronised Progesterone was approved by The TGA in 2016. Note that The TGA do not approve micronised progesterone that has been compounded.
There is increasing interest in Micronised Progesterone in women:
- Who experience progestogenic side effects such as mood disturbance.
- Who are at risk of cardiovascular disease.
There is debate regarding the dose of micronised progestogen that is required to ‘protect’ the uterus. A dose of 200mg is taken as 2 x 100mg capsules at night. A lower 100mg dose may be considered with lower doses of oestrogen.
Is MHT Safe?
MHT (also called HRT) is very safe in the majority of women and the Safety of MHT should be emphasized. Women may remember the ‘HRT scare’ of 2002. The scare was caused by The WHI study. It’s been shown time and time again that MHT is safe for women in their 40’s and 50’s. Even the WHI investigators themselves recently stated in a highly esteeemed medical journal (NEJM) that these WHI studies are ‘now being used inappropriately in making decisions about treatment for women in their 40s and 50s who have distressing vasomotor symptoms.’
A recent major review of MHT & cardiovascular risk² showed an overall small reduced cardiovascular risk in women taking MHT under the age of 60 for less than 10 years. Overall, you wouldn’t take MHT to prevent cardiovascular disease but the studies are very reassuring. Another major review³ is even more reassuring and states that ‘MHT does not increase cardiovascular disease when started before age 60.’
There is a small increased risk of Venous thrombosis with oral MHT (around 1 per 1000 women taking MHT per year) and this risk is highest in the first year of use but is also ongoing. The metabolism of oral oestrogen by the liver causes an increase in clotting fators.
There is no increased risk of blood clots with MHT patches.³
Now let’s look at breast cancer and MHT.
What are the risks of breast cancer with MHT?
There is an increased risk of breast cancer in older women with long term use. Take 1000 women taking MHT for 10 years: There are an extra 24 cases of breast cancer (after 5 years use there are 6 extra cases). Any increased risk occurs during treatment and ‘returns to baseline after stopping.’³
Note that the oestrogen-only MHT (after a hysterectomy) has a much smaller breast cancer risk (around 6 extra cases in 1000 women after 10 years use).
A paper published in The Lancet in August 2019 has rightly received a lot of attention. The Australian Menopause Society responded with a number of comments, including:
- The research uses data from over 20 years ago.
- Hormone Therapy used in the original research used Progestogens that are no longer recommended.
- Women with an early menopause were found to have a 30% increased risk of breast cancer with long term MHT. The ‘baseline risk’ of breast cancer in women with an early menopause is lower. The increased risk of breast cancer with MHT balances out the lower baseline risk. Of course, a low risk of breast cancer is a ‘good thing.’ The point is that women with premature menopause have higher overall mortality and cardiovascular risk. In other words, you can’t just think about breast cancer risk without considering other benefits of MHT.
What other types of MHT are available?
®Tibolone is a synthetic ‘progestin’ that has similar hormonal effects to HRT.
A new class of medication is called a ’tissue-selective oestrogen complex’ and allows the uterus to be protected without taking a progestogen. This can be helpful for women who experience side effects of progestogens, for example who experience breast tenderness.
The Progesten Intra Uterine Device provides the progesterone needed to protect the uterus, allowing you to take ‘only’ the oestrogen.
In a nutshell, there are stacks of options without needing to look at so-called ‘bio-identical hormones’ that the mainstream menopause & medical societies do not generally endorse.
How and when is MHT Stopped?
Figures show that half of women decide to stop HRT within 12 months, and two thirds within two years.
If and when the hot flushes return and are severe then the HRT can be restarted – and later gradually reduced in dose.
The menopause clinic isn’t just about Hormones!
- Bone density reduces slowly because of the lower Oestrogen levels. Osteoporosis is very common with increasing age after the menopause. A bone density scan is recommended where there are risk factors for osteoporosis. Exercise, calcium & Vitamin D help reduce bone loss, and exercise reduces risk of falls.
- There’s an increased risk of cardiovascular disease in post menopausal women caused by the drop in oestrogen levels. Also, high Blood Pressure is more common in women than men over the age of around 45. Keep an eye on blood cholesterol / lipids as required.
- Cancer Screening – ongoing screening for cervical cancer, and screening for breast & bowel cancer.
Don’t forget Contraception!
Women attending a menopause clinic naturally tend to focus on their menopausal symptoms rather than contraception. However, women remain potentially fertile until 12 months after the last menstrual period if over 50 years, and 24 months if below 50 years. For example, a 48 year old woman has a 12% chance of becoming pregnant over 12 months.
Importantly, MHT does not provide contraception.
There is no one-size-fits-all contraceptive solution. Women who require ‘hormonal therapy’ to treat the peri-menopause or early menopause may consider these options:
- Combining MHT (estrogen-only) to treat the menopause with the Progestogen Intrauterine device for contraception and Endometrial protection.
- Combining MHT (combined) to treat the menopause with the progesterone-oral contraceptive pill for contraception.
- Combining MHT with other forms of contraception such as progesterone injection, implant, copper IUD, Oestrogen ring, or condoms.
- Asking their partner to get a vasectomy – particularly for women <50 years who are still having periods.
- The combined oral contraceptive pill (COCP) ‘on its own’ of course provides good contraception but also helps menopausal symptoms. A well respected review in 2019 states ‘There is some evidence’ that hot flushes are improved – not an overwhelming endorsement. COCP is not safe for older women with a body mass index >35, migraine with aura, or at increased cardiovascular risk including women age >50.
Don’t put contraception into the too hard basket!
I’ve heard that Testosterone can help
Testosterone levels are highest at around the age of 20 and gradually decline after that. At the age of 40, testosterone levels are half of what they were at the age of 20. Testosterone levels fall abruptly after the ovaries are removed by surgery to the extent that symptoms are more likely.
There is evidence that low dose testosterone therapy may help women who:
- Have symptoms of low Androgen. For example, low sex drive & fatigue.
- Have no other explanation for the symptoms.
- Have confirmed low Testosterone levels on two blood tests.
- Have no other cause for low testosterone (eg the contraceptive pill).
The Global Consensus Position Statement on the Use of Testosterone Therapy for Women was published in September 2019. The paper emphasises that Testosterone is not the only reason for low sexual desire. Hypoactive sexual desire disorder (HSDD) is diagnosed when there is a low sex drive for no other medical, social or psychological reason. Testosterone can help women with HSDD.
Pharmaceutical-grade Testosterone therapy in women is available as a patch from Western Australia. The blood levels rise to the upper level of the normal range. Side effects are rare. Women who have had surgery to remove both ovaries are most likely to benefit.
The following terminology is used in this discussion:
- rBHT: Regulated Body identical Menopause Hormone Therapy – available from a standard pharmacy on prescription. This form of MHT offers some benefits over convential MHT – such as micronised Progesterone or transdermal Oestrogen. All evidence-based and regulated with plenty of options.
- cMHT: Compounded Menopause Hormone Therapy, also known as Bioidentical Hormones – available from a compounding pharmacy. Compounding pharmacies make products that are not made by pharmaceutical companies as a branded product.
Bioidentical hormones (cMHT) are not fully regulated whereas rBHT is fully regulated. By regulated we mean checks on safety.
Does it matter that cMHT is not regulated or approved by Australia’s Therapeutic Goods Administration (TGA)? Consider that compounded MHT is also not approved by The European Medicines Agency or The American safety agency. Have the world’s regulators of medical products have got together to ban something that is good for us? Do you believe in conspiracies? Let’s be honest – regulation is really boring, and no-one likes to be told what they can or can’t take. However, The International menopause society advised that cMHT is not recommended because of lack of:
- rigorous safety and efficacy testing
- batch standardisation
- purity measures.
Being honest, this is a decision for women to make but you should go into this with your eyes open and be aware that all major Australian and international menopause guidelines do not recommend Bioidentical hormone therapy. You’ll also have to find a doctor willing to prescribe compounded MHT which will be less likely in the future because AHPRA (that regulate doctors) are currently looking into the regulation of doctors ‘who practice unconvential medicine.’
In summary, there over 60 forms of MHT that are regulated by The TGA, including several bio-identical hormones.
An Endocrine Society Scientific Statement in 2016 put out that there is ‘no rationale for the routine prescribing of unregulated, untested, and potentially harmful custom-compounded bioidentical hormone therapies.’ Do flick down the above reference – if only to appreciate the amount of expertise and thinking that goes into the strongly-worded statement. There are 254 scientific references appended!
Menopause Specialists in Australia are increasingly concerned about the safety of ‘Bioidentical Hormones.’
Let’s be frank. Advocates of bio-identical hormones may tap into fear or mistrust of science. Ask yourself honestly whether you are open to reason, or have already made up your mind. If you are persuadable then it’s worth looking at the headlines in the Australian Menopause Society position statement on bio-identical hormones.
Serotonin Reuptake Inhibitors (SRIs) and Serotonin Noradrenaline Reuptake inhibitors are the best known non-hormonal treatments for the perimenopause. The prospect of taking an ‘antidepressant’ for the menopause is a hard one to sell but it just so happens that serotonin is a key chemical messenger that triggers the hot flushes. The dose is lower than that dose used for the treatment of depression. In a nutshell you are taking an antidepressant at a dose that is not an antidepressant but works on the serotonin pathways to reduce sleep and improve wellbeing.
Other non-hormonal treatments include:
- Alpha-agonist has been around for over 30 years but recent studies confirm that they are effective in reducing hot flushes.
- Anticonvulsant that is taken three times per day and reduce the number of hot fluhes by around 45%.
Many women try alternative therapies. The doctor will be happy to discuss these with you. You may wish to look at the following impartial Australian Menopause Society bulletin on complementary and herbal therapies. The NICE guideline 2015 does state that there is some evidence that black Cohash may help. A recent review states that the ‘use of chinese herbal medicines and black cohosh is not recommended‘ because there is insufficient evidence with regards to their safety and effectiveness.
Where else can I get reliable information?
Yes, there’s a lot of conflicting information! Fortunately, though, there are very reliable sources of information out there. The first two of these links are Australian Organisations, and the third is international:
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1: Avis NE, Crawford SL, Greendale G, et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med 2015; 175: 531-539.
2: Boardman Henry MP, Hartley L, et al. Hormone therapy for preventing cardiovascular disease in post-menopausal women. Cochrane Database Syst Rev 2015; CD02229
3: NICE guideline 2015. Diagnosis and management of menopause.
5: Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline; J Clin Endocrinol Metab. 2015 Nov;100(11):3975-4011. doi: 10.1210/jc.2015-2236. Epub 2015 Oct 7.