Menopause is when your ovaries stop releasing an egg every month and no longer produce as much of the hormone oestrogen. You are termed menopausal 1 year after the last period.
Peri-menopause is the time leading up to this which can last years. During this time, periods may be erratic, shorter, longer, lighter or heavier. This is because you are not ovulating reliably every month. It is normal but if problematic there is lots that can be done to help.
Blood tests are not normally needed to diagnose menopause and should not be done in women over 45. The diagnosis can be made based on symptoms.
Menopause in the UK typically happens at the age of 51. If it happens before 40 is considered early and the doctor may recommend treatment.
Typical symptoms women may experience are tiredness and lack of energy, hot flushes, sleep disturbance, mood swings and changes, aches and pains, poor concentration or “brain fog”, loss of libido, dryness down below and weight gain particularly around the tummy.
You may know that younger women have a lower risk of heart attacks and strokes than men of the same age. This is because of the hormone oestrogen. After menopause this risk becomes similar to men. This is one reason doctors suggest women with premature menopause consider HRT.
As we get older, our bones get thinner (osteopenia or osteoporosis). This leads to an increased risk of fracture. The risk of osteoporosis increased after menopause for women. HRT can reduce the risk of osteoporosis however there are other treatments available.
Ideally HRT should be started as soon as possible after experiencing menopausal symptoms. If your menopause was several years ago, the risks may outweigh the benefits.
It can take 3 months to take effect.
HRT
HRT stands for hormone replacement therapy. It involves taking synthetic forms of oestrogen and progesterone. Replacing oestrogen will treat many of the menopausal symptoms however if it is given without progesterone then it can lead to changes in the womb including an increased risk of cancer. If you have had a hysterectomy then you do not need to take progesterone.
Oestrogen is available in tablets, gel and patches. Progesterone is available in tablets, patches and via the mirena coil which is inserted into the uterus.
The choice of which type to use is based on a number of factors including patient preference and safety.
Patches
If you are still having periods you will be offered sequential combined which gives you a regular cycle. Evorel Sequi is the usual one, change twice weekly. If you have side effects from the progesterone, try FemSeven Sequi change once weekly. These both contain 50mcg oestrogen.
If your periods have stopped you can have Continuous combined. This is normally Evorel Conti changed twice weekly, but if you have side effects then FemSeven Conti changed once a week.
If you have no uterus, or have a mirena then an oestrogen only patch like Evorel which comes in different strengths 25, 50,75,or 100 twice a week is used. Or Estrodot, Estraderm MX, Elleste Solo or Progynova.
The major advantage of patches is that they do not increase the risk of blood clots, so if you have additional risk factors for clots like high blood pressure, obesity or smoking they are a safer option.
Gel
Oestrogen also comes in gel form (oestrogel or sandrena). This is a good option if you experience skin irritation from patches. It does not increase risk of blood clots. If you have a uterus you will need to take progesterone along with this, either mirena coil or utrogestan capsules.
Tablets
If still having periods you will get sequential combined like Elleste duet which comes in 1mg or 2mg strengths. If you experience side effects then Femoston 1/10 or 2/10 is an option. Other brands include clinorette, cycloprogynova, novofem, tridestra and trisequens.
If not having periods then Continuous combined. Elleste duet conti is standard, femoston conto used if having side effects. Tibilone is used occasionally. Alternative brands include kliovance, kliofem, angeliq, indivina and premique low dose.
You would normally switch to continuous combined after a year on sequential.
Tablets can potentially increase your risk of blood clots which is why it is so important you attend for Blood pressure and weight checks as part of starting HRT and regular reviews.
HRT and breast cancer risk
A few years ago there was a lot of media attention regarding HRT and breast cancer. Like any medicine HRT should be used when benefits outweigh risks. The increased risk of breast cancer is very small and is reversible on stopping.
- HRT with oestrogen alone is associated with little or no increase in the risk of breast cancer.
- Combined HRT with oestrogen and progestogen is associated with an increased risk of breast cancer that is dependent on duration of treatment, and reduces after stopping HRT.
- HRT does not affect the risk of dying from breast cancer.
Utrogestan is thought to be the safest form of progesterone as it has not been shown to increase breast cancer risks.
Being overweight, drinking alcohol, smoking and a family history are more significant risk factors than HRT but it is still worth considering.
Here are some information leaflets with more detail
Family History of Breast Cancer FINAL2.pdf (d2931px9t312xa.cloudfront.net)
HRT-patient-sheet-3008.pdf (publishing.service.gov.uk)
We would not normally prescribe HRT for someone who has already had breast cancer.
We would encourage all women to attend for mammograms when called and report any concerning changes in their breasts to the GP right away.
Topical vaginal oestrogen
One of the commonest side effects of menopause is dryness and discomfort down below. This can be treated by applying a hormone cream containing oestrogen cream. This will improve the condition of the skin fairly quickly, hopefully this relieves discomfort and can also reduce the chances of urinary tract infection. It is a safe option as very little is absorbed into the blood stream and so it does not increase the risk of breast cancer or blood clots. This is now becoming available over the counter.
Traditionally this was not given to patients who had previously been diagnosed with breast cancer, however following discussion with an oncologist this may be an option.
Mirena coils
As mentioned before these can be used to protect your womb when taking HRT. They can be a good option if you are experiencing heavy or problematic bleeding.
These are arranged by booking an appointment at the Sandyford online. Welcome to Online Booking for Sexual Health (nashonlinebooking.com)
Here is some more information
https://sandyford.scot/sexual-health-services/contraception/intrauterine-contraception-coils/
When is HRT not a good idea?
If there is a history of breast cancer HRT is not generally used. If there is a history or known increased risk of blood clots, heart attacks or strokes it may not be offered. HRT cannot be started in uncontrolled high blood pressure, however we may treat the high blood pressure and then start it. If there is abnormal vaginal bleeding we would not start HRT until this has been investigated by gynaecology. HRT cannot normally be used in liver disease. If there is a history of cancer of the womb or ovaries, we would need to check with oncology if HRT is safe.
If it is a long time since your menopause then the risks may outweigh the benefits.
Alternatives to HRT
There are many herbal, homeopathic and non-drug alternatives to HRT. Unfortunately there is no evidence any of them make much difference so we are unlikely to recommend them.
If HRT is not an option for you there are other prescribed medications which may be helpful. A type of antidepressant called SSRI can be useful in treating hot flushes as well as the mood changes many women experience during the menopause. Examples of this include fluoxetine (Prozac) sertraline and citalopram. Clonidine which is a blood pressure medication can also help hot flushes but can have side effects so isn’t used very often.
We would always recommend maintaining a healthy weight and regular exercise. There is evidence this can help menopausal symptoms.
Starting HRT
We would recommend you book in with the Healthcare Assistant for a blood pressure check and updated height, weight and calculation of BMI (body mass index). Please also let her know if you are a smoker.
After this please pre-book a telephone consult with the doctor of your choice. They will ask about your family history in particular breast cancer risk and about a history of blood clots.
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