Menopause Information & Treatment Options at Raheny Medical

About Menopause

As a natural part of ageing, and as your ovaries stop producing eggs and make less hormone (oestrogen), your periods will usually become less frequent over several years before they stop altogether. This normally occurs between the ages of 45 and 55. Up to seven years before your periods stop completely, you may start to experience symptoms. This is known as Perimenopause. Menopause is reached when you stop having periods completely and have not had a period for twelve months.  The average age for a woman to reach Menopause is 51. It often takes several years to go through the Menopause completely.

Some women experience Menopause early (before the age of 45) which may occur if you have had surgery to remove your ovaries, if you have radiotherapy to your pelvic area to or have had certain chemotherapy medications to treat cancer, or if you have had your womb (uterus) removed (hysterectomy) before Menopause. Early Menopause can also run in some families.

Menopause Symptoms

Every woman reaches Menopause at some point and around 8 out of 10 women will develop symptoms. A quarter of women have very severe symptoms. The duration of symptoms varies, ranging from a few months to many years. Including symptoms experienced in Perimenopause, over half of all women have symptoms for more than seven years. Typical symptoms include:

• Hot flushes. These tend to commence just before Menopause and can last for several years. A hot flush (or flash) lasts a few minutes and causes flushing of your face, neck and chest. You may also sweat, experience giddiness, weakness, nausea (feeling sick), heart palpitations, and anxiety during the episode. Around three-quarters of women will experience some or all of these symptoms and they can occur infrequently in some women and many times a day in other women.
• Sweating. This usually occurs in bed at night and can lead to interrupted sleep as well as the need to change bedding and nightwear.
• Changes to your periods. In the lead up to reaching Menopause, the time between your periods may become shorter or periods may be much further apart.
• Other symptoms. A range of other symptoms may develop, including headaches, tiredness, irritability, depression, joint pain, and reduced sex drive.

Changes to Your Body during Menopause

Menopause may lead to changes in your body in a number of ways:

• Skin and hair. Your skin can become drier, thinner and itchier as you may lose some skin protein (collagen). Hair may also become thinner.
• Genitals. In the months or years after Menopause, the tissue in and around your vagina can become thinner and drier and may cause increased pain during sex. The skin next to your vagina (the vulva) can become dryer and itchier. You may also experience the need to urinate more frequently, leakage, or even recurrent urine infections.
• Bones. Bone loss is a natural part of ageing. Female hormone (oestrogen) helps prevent bone loss. After the Menopause, as oestrogen levels fall, loss of bone tissue may accelerate. As you become older, you gradually lose bone tissue and your bones may become less dense and strong. If you experience a lot of bone loss then you could develop a condition call osteoporosis, which cause bones to break more easily than usual, especially if you have a fall.
• Heart disease. Similarly, as oestrogen levels fall, the risk of heart disease and stroke increases. Lifestyle changes including stopping smoke, eating a healthy diet, staying at a healthy weight and exercising can help to counteract these issues.
• Fertility. It is still possible to get pregnant around the time of the Menopause. You will need therefore need to consider contraception if you are sexually active until a year after your last period if you are 50 or over or until two years after your last period if you are under 50. In some cases, it can be difficult to know when to stop contraception due to the type of contraceptive that you are using. For example, contraceptive implants, coils and some pills can cause your periods to stop. You should discuss this with your doctor who can provide advice as to when to cease contraception.

Changes to Your Mood during Menopause

Changes in your hormones during menopause can impact your mental health and you may experience feelings of anxiety, stress or even depression. Menopausal symptoms may include anger and irritability, anxiety, forgetfulness, loss of self-esteem, loss of confidence, low mood and feelings of sadness or depression. You may experience poor concentration, often described as 'brain fog'. Often you will experience problems with your sleep which can also make symptoms including irritability, ability to concentrate or anxiety worse.

Menopause Diagnosis

Your doctor can usually diagnose Menopause based on your symptoms. Sometimes your doctor will order hormone blood tests, especially if you are under 45 years or if you do not have typical symptoms.

Treatment for Menopause

Hormone Replacement Therapy (HRT) is the most common treatment for Menopause, though there are a range of other options available, each of which has benefits and risks.

HRT

HRT replaces the oestrogen that your ovaries stop producing in Menopause. While there are a variety of types of HRT, all contain an oestrogen hormone. In order to completely decrease the risk of developing cancer of the womb, the oestrogen in HRT is usually combined with a progestogen hormone. The oestrogen and progestogen are usually combined in the same patch or tablet, although they can also be taken separately. If you have had a hysterectomy or have a contraceptive IUD system fitted, you do not need progestogen.

Most women take HRT for a few years until their symptoms stop, and then they usually reduce the treatment gradually to minimise the recurrence of symptoms. There is no upper time limit on how long HRT can be taken, though some of the risks do increase the longer it is used.

There are several different methods of taking HRT, including patches, tablets, gels, or spray. Patches and gels are the most popular due to convenience of use and because they do not increase the risk of blood clots (unlike tablets).

Depending on your Menopausal stage and/or other medical history, there are different options for HRT which you doctor will discuss with you. Doctors will usually recommend a trial of HRT for three months. If it is not effective they may recommend a different dose or different type of HRT.  

• Cyclical combined HRT. If you are still having or have just finished periods, you will normally be advised to use cyclical combined HRT. This entails taking oestrogen every day with progestogen added in for 14 days of each 28-day treatment cycle. This causes a regular bleed every 28 days, similar to a light period. Note that these are not periods.
• Continuous combined HRT. After your periods have stopped for a year or more, you will normally be advised to take continuous combined HRT, which entails taking both oestrogen and progestogen every day. This can cause irregular bleeding for the first 3-6 months.
• Oestrogen HRT. If you have had a hysterectomy or use a contraceptive IUD, you only need to take HRT that contains oestrogen only. IUDs already contain enough progestogen to stop the lining of your womb from building up.
• Vaginal oestrogen cream and other topical preparations. For some women who are just seeking to ease symptoms in the vaginal area, or who cannot take other forms of HRT, there is the option to use a cream, vaginal tablet, or vaginal ring that contains oestrogen. These can also be used in addition to other forms of HRT to ease symptoms.

The risks and benefits of HRT vary according to your age and medical history, which your doctor will discuss with you.

• Benefits. The key benefits are that symptoms and quality of life usually improve. Hot flushes and night sweats diminish or stop, changes to the vagina and vulva can be reversed (reducing dryness, itchiness, the frequency of urinating and urine infections), sleep and mood are improved, joint aches and pains reduce, and the texture of hair and skin often improves. HRT also reduces the risk of broken bones and fractures due to osteoporosis.  Within a few weeks of commencing HRT you should see reduction of hot flushes and night sweats and within 1-3 months you should start to see reversal of many of the changes to the vagina and vulva.
• Risks. While side-effects are uncommon, some women do experience nausea in the weeks after commencing HRT as well as breast pain, leg cramps, headaches, and migraines. These usually resolve within a few months. Using patches and gels (rather than tablets) reduces the likelihood of headaches and migraines, though they can occasionally cause skin irritation. Sometimes a change of brand of HRT may cause side-effects to diminish or cease.

HRT can increase your risk of developing medical conditions, though the risk is usually very small. These medical conditions include:

• Blood Clots. Women who take combined HRT as tablets have an increased risk of developing a blood clot which can cause deep vein thrombosis (DVT) and which can in some cases travel to your lung and cause a pulmonary embolism (PE). This is more likely if you are obese, have had a clot in the past, or are a smoker. There is not an increased risk of clots if you use patches or gel rather than HRT tablets.
• Breast Cancer. The risk of breast cancer is higher for all women taking HRT, though the risk is generally not high, depending on what type of HRT you take and how long you take it. For example, for women starting HRT at age 50 and taking it for five years, an extra one woman will be diagnosed with breast cancer between age 50 and 69 years for every:
  • 50 women taking continuous combined HRT.
  • 70 women taking combined monthly cyclical HRT.
  • 200 women taking oestrogen-only HRT.
• Womb (Uterine) Cancer. By taking combined HRT containing oestrogen and progestogen, this risk reduces completely.
• Heart Disease and Stroke. While there is no increased risk of heart disease when HRT is started under the age of 60, there may be a small increased risk when HRT is started over the age of 60. HRT tablets (but not patches or gels) slightly increase the risk of stroke.

Symptoms caused by the Menopause there are oestrogen creams which are applied directly to the vagina. They are in fact a form of HRT but since the dose is much smaller than other forms of HRT they carry far less risk compared to taking HRT tablets or patches.

In order to prevent or treat osteoporosis, there are medications which can help to restore some lost bone and help to prevent further bone loss. Talk to your doctor about these options.

Alternatives to Standard HRT

There are a number of alternatives to HRT including the use of ‘Natural Hormones’. Somewhat confusingly, there are two types of natural hormones available in the market, regulated and unregulated:

• Regulated (known as Bioidentical/Body-identical HRT). These are regulated in Ireland and licensed by the HRPA. They are made from a plant source and are precise duplicates of human hormones developed in a conventional way by the pharmaceutical industry. Like normal HRT, there is good evidence of efficacy for these products.
• Unregulated (compounded bioindentical hormones). The hormones are compounded in special pharmacies to produce customised tablets. While it is claimed that these products are safer and more natural than standard HRT, they are not regulated in the same way as standard HRT or other medications and there is no evidence of their safety or effectiveness.

For specific Menopause symptoms there are other alternatives to HRT. For hot flushes and sweating, these include:

• Lifestyle Modification. Healthy lifestyles, such as regular aerobic exercise (e.g. swimming or jogging) can improve symptoms. Weight loss and cognitive behavioural therapy may also have some impact on symptoms. Sleeping in a cooler room and wearing lighter clothing can also help as may avoiding spicy foods, caffeine, smoking, and alcohol. Quitting smoking will also reduce the risk of developing other serious health conditions.
• Complementary and Alternative Treatments. Rather than HRT, some women use ‘natural’ therapies to alleviate symptoms, though there is little evidence that they are effective and in some cases they may be unsafe. There are many such products available on the market including black cohosh, red clover, dong quai, evening primrose oil, ginseng, soy and St John's Wort. Such herbal remedies are not regulated and can have unpredictable doses, purity, and side-effects.
• Certain Antidepressants (SSRIs and SNRIs). Some prescription antidepressant medications such as paroxetine, fluoxetine, escitalopram, citalopram, and venlafaxine may reduce or stop hot flushes in some Menopausal women even when they are not depressed, though the effect is usually only temporary. It is not clear how these medications reduce hot flushes and there can be side-effects. Moreover, such medications are not licensed for this use.
• Tibolone (also known as Livial). This prescription medication is a synthetic steroid which works similarly to oestrogen, progesterone and testosterone and is sometimes used for the treatment of Menopause symptoms. It may reduce hot flushes and improve sex drive. It does, however, have a similar risk profile to HRT.
• Gabapentin. This prescription medication is used to for epileptic seizures and nerve pain, yet like some antidepressants there is some evidence that hot flushes are reduced in some women. Once again, there are possible side-effects and the medication is not licensed for treating menopausal symptoms.

Counselling. Therapy can address mental health issues such as anxiety, stress, or depression.

To address genital symptoms caused by the Menopause there are oestrogen creams which are applied directly to the vagina. They are in fact a form of HRT but since the dose is much smaller than other forms of HRT they carry far less risk compared to taking HRT tablets or patches.

In order to prevent or treat osteoporosis, there are medications which can help to restore some lost bone and help to prevent further bone loss. Talk to your doctor about these options.