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 “premature ovarian failure” and needs investigation for underlying causes. The menopause between 40 and 44 is “early” and may need some investigation.
What are the symptoms of the menopause?
Typical symptoms of the menopause 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 do 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.”
The symptoms of depression around the menopause tend to be different from depression at other times. In particular, there’s often less in the way of ‘sadness’ and more in the way of fatigue, reduced quality of sleep, and irritability. Other symptoms can include weight gain, reduced self-esteem, low libido, a ‘disconnect’ and a poor concentration.
Are any blood tests needed to diagnose the menopause?
This is a common cause of confusion! 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 FSH. The FSH level rises as the woman approaches the menopause. The FSH also goes up and down along the way, and so a single FSH level is only a guide. Put another away, the woman with perimenopausal hot flushes may have a normal FSH on that particular day the blood was tested. It’s the bumpy hormone levels that cause the fluctuation in symptoms.
The doctor may suggest a blood test:
- in younger women
- Ater a hysterectomy
- or when the woman is using a mirena IUD.
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.
How can The Menopause by treated?
Menopausal Symptoms need treating when the symptoms are affecting qualify of life.
There are two main prescribed treatment options for hot flushes:
- MHT (Menopausal Hormone Therapy – used to be called HRT).
- SSRI’s (serotonin reuptake inhibitors) – in the same class of medication as Prozac. Prescribed at low doses and reduces hot flushes by affecting the chemical messages involved in the nervous system’s temperature regulating system. Typical brands used are Efexor (Venlafaxine), Cipralex (Escitalopram) & Citalopram.
There are other treatment options for hot flushes such as Clonidine & Gabapentin.
Topical Oestrogen (eg. via an applicator) often helps menopausal vaginal symptoms.
The combined contraceptive pill “may help to improve some of the symptoms of the menopause”4.
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.
Does MHT work?
There is no question that Menopausal Hormone Therapy can be of huge benefit for women with troublesome hot flushes or sweats, and there are lots of types to choose from. The NICE 2015 guideline concludes that hormone therapy is generally the most effective treatment for typical menopausal symptoms.
Hormone therapy can help 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.
Is MHT Safe?
MHT (also called HRT) is very safe in the majority of women in their early to mid 50’s.
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’ – this is code to doctors that has been a misunderstanding.
A recent major review of MHT & cardiovascular risk² showed an overall small reduced cardiovascular risk in women taking MHT under the age of 60 and for less than 10 years. Overall, you wouldn’t take MHT to prevent cardiovascular disease but at least the data is pretty reassuring. Another major review³ is even more reassuring and states that “MHT does not increase cardiovascular disease when started before age 60.”
Concerns over breast cancer and vascular disease are generally issues related to older women (in their 60s) with specific risk factors or with lonterm term use.
There is a small increased risk of Venous thrombosis with 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. There is no increased risk with MHT patches.³
What are the risks of breast cancer with MHT?
Short term MHT for an average 50 year old (without vascular or thrombotic risk factors) for 2-3 years is really very safe.
There is an increased risk of breast cancer 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
The breast cancer risk with medium to long term use needs to be discussed. A small number of women experience long term flushes, have considered or tried other treatment, accept these risks and take MHT long term. 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).
What is Micronised Progesterone?
Micronised Progesterone was approved by The TGA in 2016 as ®Prometrium. 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 prometrium that is required to “protect” the uterus. A dose of 200mg is taken as 2 x Prometrium capsules at night. A lower 100mg dose may be considered with lower doses of oestrogen.
What other types of MHT are there?
Let’s briefly recap. Oestrogen is the hormone in ‘HRT’ that treats the menopause, and progestogen (progesterone) is the hormone that protects the Uterus from The Oestrogen.
®Tibolone is a synthetic ‘progestin’ that has similar hormonal effects to HRT.
A newer medication called ®Duavive is a ’tissue-selective oestrogen complex’ which allows the uterus to be protected without taking a progestogen. This can be helpful for women who experience side effects of progestogens.
The ®Mirena 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.
I need contraception and treatment for the menopause at the same time
There’s no single solution here but the renowned FSH guideline suggests a number of hormonal options that include
- MHT (estrogen-only) with the Mirena Intrauterine device.
- MHT (combined) with the progesterone-oral contraceptive pill.
- The combined oral contraceptive pill (COCP) on its own may also help menopausal symptoms.
Most women would clearly prefer to take a single combined pill than both MHT and the progestogen-only contraceptive pill. It’s not clear which is best, so a trial of the COCP first is a common scenario for women who don’t already have a mirena in place.
I hear a lot of conflicting information about the menopause. 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:
Australian Menopause Society
International Menopause Society
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