- Simple lifestyle changes such as exercise and weight loss can help reduce vasomotor symptoms
- Adequate calcium intake in a balanced diet helps maintain bone health
- Approximately 70% of women will complain of menopausal symptoms
Recent evidence suggests that the average age of the menopause for European women is 52 years. Menopause symptoms result from falling levels of 17-ß estradiol and progesterone produced by the ovary. The depletion of oocyte numbers, and hence hormonal steroids, causes the pituitary to release increasing amounts of follicle stimulating hormone (FSH) – often erroneously measured by healthcare professionals to ‘diagnose’ the menopause. With many of us spending over a third of our lives in the post-menopausal years we commonly seek help from primary care healthcare professionals who need to keep up to date in this field. This article explores common menopausal symptoms experienced by women, available hormonal and non-hormonal treatments, prevention strategies for osteoporosis, and the role of practice nurses in managing menopausal women.
Up to 70% of women will experience some menopausal symptoms. Forty five percent of women find these symptoms distressing, however only 20% will seek medical help. In general, menopausal symptoms last between two and five years, but some 10% of women will still be experiencing symptoms 15 or even more years after their last menstrual period.1 Vasomotor symptoms are more common and severe in those women experiencing an acute menopause following chemotherapy, or surgical removal of the ovaries.
Early and Premature Menopause
Around one in 12 women experience an early menopause (before the age of 45) and one in 100 a premature menopause (before the age of 40). As a result of the abnormally early depletion of hormones, these women are at increased risk of osteoporosis and cardiovascular disease thus treatment with hormonal supplementation is advised unless there is a strong contraindication to its use. Taking hormone replacement therapy (HRT) until the average age of the menopause is not associated with any increased risk of breast cancer, cardiovascular disease or dementia compared to women with normally functioning ovaries of a similar age.2,3
Diagnosing the Menopause
Carefully assessing a woman’s symptoms may be the best way to diagnose the menopause, however many will request a blood test to detect whether they are menopausal or not. There is no specific biological marker but FSH levels are frequently measured. The problem with FSH is that it can be raised in women with no hot flushes or sweats, and normal in those with severe symptoms. FSH levels can also fluctuate in women under 50 years old, being high one month and low the next.
FSH measurement may be useful, however, in the following circumstances when menopausal symptoms are present:4
- In young women (under the age of 45 years).
- In women using progestogen-only contraception and experiencing amenorrhoea.
- In women who have had a hysterectomy with ovarian conservation.
If a woman is still menstruating, blood should be taken for FSH analysis within the first three days of the cycle and at any time if she is amenorrhoeic. Two FSH levels ≥30IU/L suggest some degree of ovarian failure.4
Many women may ask at what point it is safe for them to discontinue contraception. If two FSH levels have been taken and both are ≥30IU/L then contraception can be discontinued after a further two years if she is under 50, and one year if over 50. Table 3 summaries the guidance from the Faculty of Sexual and Reproductive Health guideline ‘Contraception for women over 40’:
All perimenopausal and menopausal women should be encouraged to exercise regularly and eat healthily. This will help them cope with their menopausal symptoms and help protect against the development of osteoporosis and cardiovascular disease. Some basic lifestyle changes that may significantly improve menopausal symptoms include:
- Regular exercise: reduces flushes and weight bearing exercise can prevent osteoporosis. Women should aim to do two and a half hours of moderate aerobic activity every week.
- Stop smoking: reduces flushes and osteoporosis risk plus will helps improve response to HRT.
- Reduce weight: normalising a BMI to 25kg/m² or less will benefit vasomotor symptoms.
- Avoiding alcohol, spicy food and stimulants such as caffeine decreases flushes and sweats.
- Lifestyle changes: wear lighter natural fibre clothing and sleeping in a cool room.
- Help relieve stress and anxiety by taking up yoga, meditation and ‘mindfulness’ training.
Some symptomatic women may not wish to use hormone replacement therapy (HRT), or its use may be contraindicated. There are a number of herbal and alternative therapies bought by menopausal women but limited data suggesting any benefit.5
Non-hormonal medications which may help with hot flushes include:6
- Clonidine – slowly increase the dose to 75µg daily.
- Venlafaxine – initially start with 37.5mg and increase to 75mg
- Paroxetine – start with 12.5mg and it can be increased to 25mg a day depending on symptom control.
- Fluoxetine – start with 10mg and it can be increased to 20mg a day depending on symptom control.
- Gabapentin – slowly increase to 900mg a day.
Hormone Replacement Therapy
HRT is indicated for the management of vasomotor and urogenital symptoms – when compared with placebo in clinical trials, HRT decreases vasomotor symptoms by 77%.7
Oestrogen-only HRT should only be used in women who have had a hysterectomy. For women who still have a uterus, oestrogen is given continuously alongside progestogen. The addition of progestogen is vital to provide endometrial protection against endometrial hyperplasia or adenocarcinoma. There are three different ways in which combined HRT can be prescribed:
- Sequential HRT: This should be chosen if the last menstrual period was less than 12 months ago. Oestrogen is given every day for 28 days with progestogen added in for 10 to 14 days of the cycle. This results in a monthly bleed in the majority of women.
- Continuous combined HRT: This should be chosen if the last menstrual period was more than 12 months ago. Oestrogen and progestogen are given continuously. Initially women may experience some bleeding in the first few months but this settles in the majority of users. For users of Mirena® levonorgestrel intrauterine system oestrogen can be added to provide ‘period-free’ HRT in the peri-menopausal years.
- Long cycle HRT: Oestrogen is given for 70 days, followed by 14 days of oestrogen plus progestogen, and finally 7 days of placebo tablets. This formulation results in four withdrawal bleeds per year.
HRT can be administered in various forms. Usually oral treatment is prescribed first-line as it is cheaper and more acceptable to women. If this is not tolerated or there are relative contraindications then oestrogen patches or gels can be tried – non-oral therapy avoids first pass liver metabolism thereby avoiding increased synthesis of coagulation factors, triglycerides, CRP and sex hormone binding globulin.3 Contraindications to the use of oral HRT include: malabsorption problems, lactose intolerance, gallstones, liver enzyme inducing drug usage, increased venous thromboembolism risk, liver disease, migraines, diabetes, hypertension, and the presence of cardiovascular risk factors. Progestogen can be either given orally, transdermally in a patch (in combination with oestrogen), in a vaginal cream, or via a levonorgestrel intrauterine system (Mirena®) – Mirena® is a good option if contraception is required, if other formulations have resulted in progestogenic side effects, or if heavy bleeding is experienced with sequential HRT.
For urogenital symptoms, topical oestrogen administered as a cream, pessary, vaginal tablet or ring is the preferred option as it provides the best symptom control. It can be prescribed either alone or in combination with systemic HRT, with about one in four women needing both therapies. Topical oestrogen will improve vaginal thickness, elasticity and blood flow which can ease superficial dysparenuia.3 When given vaginally in a low dose maintenance regimen there is minimal systemic absorption of oestrogen and hence no endometrial stimulation providing a safe option for women.
Women who have had both their ovaries removed for health reasons may present with loss of libido as a result of low testosterone levels. Tibolone is a synthetic gonadomimetic compound that breaks down into oestrogenic, progestogenic and androgenic components helping menopausal symptoms and improving sexual desire. Testosterone can also be used to help libido alongside systemic HRT. The licensed transdermal testosterone preparation for women is no longer marketed in the UK so specialists are recommending very low dose testosterone gel (Testogel®) but its use is ‘off-label’ and should ideally be initiated by a specialist.
For women in who oestrogen is contraindicated, oral progestogen can be tried. Medroxyprogesterone acetate 10mg per day may reduce flushes and sweats by 60% but again its use is ‘off-label’. Unfortunately there is no long-term data on the safety of this for women with a history of venous thromboembolism or breast cancer.
Over the last decade there has been much controversy surrounding the use of HRT after publication of the ‘Women’s Health Initiative’ and ‘Heart and Estrogen/Progestin Replacement’ studies. Recent re-analysis of the Women’s Health Initiative data along with results from other studies have clarified the benefits and risks of HRT for specific populations.3 HRT has a better safety profile when initiated within 10 years of the menopause.3 Commencing HRT around the time of the menopause may even reduce the risk of cardiovascular disease and cognitive decline.3 However if it is started 10 or more years after the last natural period these risks are increased.4
HRT should always be given at the lowest dose to alleviate symptoms and for the shortest duration of time. Most women
will use combined HRT for less than five years to avoid the increased risk of breast cancer.3
Recent data has shown that oestrogen-only HRT does not appear to be associated with any increased risk of breast cancer.3 Prolonged use is acceptable provided that women are fully informed of the potential risks.
Bone mineral density is gradually built up throughout the first 30 years of a woman’s life. Bones are constantly changing and being renewed by the process of bone remodelling. This involves osteoclast cells which break down and remove old bone, and osteoblast cells which form new bone. Until peak bone mineral density is achieved, osteoblast activity predominates. Oestrogen helps to regulate this process hence in the post-menopausal years bone loss exceeds replacement predisposing women to osteoporosis. One in three women will develop osteoporosis and 40% of women will sustain an osteoporotic fracture in their lifetime.8
To assess an individual’s risk of osteoporosis a fragility fracture risk assessment (FRAX) can be performed. This takes into account current risk factors plus bone mineral density at the femoral neck. The result of the FRAX assessment gives an accurate indication of how likely an individual is to sustain a fracture over the next 10 years. Some basic lifestyle interventions may prevent the development of osteoporosis.
Menopausal women should consume at least 700mg of calcium per day – this can be achieved by either drinking approximately one pint of milk or taking calcium supplements.8 The National Osteoporosis Society states that HRT is good at preventing fractures of the hip and spine however it is not a suitable treatment for osteoporosis in women aged over 60.9 For women who are less than 60 years HRT can still be used to treat osteoporosis if the benefits of treatment outweigh the risks.9 HRT is licensed for use in women at high risk of fractures who are unable to take or tolerate other preventive therapies.9
The Role of the Primary Care Nurse
Most menopausal women will be managed in primary care with very few needing onward referral to secondary care. The practice nurse plays an important role in initially identifying those with troublesome symptoms, for example when taking cervical cytology and can provide the necessary support for exploring solutions to embarrassing problems such as pain when having sex or urinary incontinence. Nurses are key players in motivating patients to adopt healthier lifestyles by stopping smoking and introducing weight loss initiatives. Many menopausal women derive comfort from simply talking about their physical and psychological issues – practice nurses are in an ideal position to provide a listening ear. For further medical management the woman should be referred on to her general practitioner. Once established on HRT, the practice nurse will frequently monitor the patient’s progress by seeing her three months following the initial prescription and then at six monthly/yearly intervals. The nurse will assess whether menopausal symptoms are being effectively controlled by the prescribed therapy and if there are any nuisance side effects or bleeding problems. Enquiries should be made about any changes in the woman’s medical history or medication that may potentially contraindicate the use of HRT. Finally blood pressure should be checked at each visit and all women should be encouraged to attend for routine cervical screening and mammography.
The menopause can affect women in a range of ways and management should be individually tailored. Basic lifestyle interventions are vital and can significantly improve symptoms. Women who experience an early or premature menopause benefit from taking HRT up until the age of 50 when they then will need to reassess the benefits and potential risks of HRT continuation with their physician. Following careful assessment HRT remains an effective and safe option to treat troublesome vasomotor symptoms in women of normal weight under the age of 60.3
1. Menopause symptoms. 2011. Available at: www.menopausematters.co.uk/symptoms.php
2. Rees M, Hope S, Stevenson J. Premature Menopause. 2008. Available at: www.thebms.org.uk/factdetail.php?id=1
3. Sood R, Faubion S, Kuhle C, Thielen J, Shuter L. Prescribing menopausal hormone therapy: an evidence-based approach. Int J Women’s Health 2014;6:47-57.
4. Faculty of Sexual and Reproductive Health. Contraception for women aged over 40. 2010.
5. Rees M, Hope S. Alternative and Complementary Therapies. 2008. Available at: www.thebms.org.uk/factdetail.php?id=3
6. Rees M, Hope S. Medical Alternatives to Hormone Replacement Therapy. 2008. Available at: www.thebms.org.uk/factdetail.php?id=2
7. MacLennan A, et al. Oral oestrogen replacement therapy versus placebo for hot flushes. Cochrane Database Syst Rev 2001;(1):CD002978.
8. Hodson J. Osteoporosis. 2008. Available at: www.thebms.org.uk/factdetail.php?id=7
9. National Osteoporosis Society. Hormone replacement therapy for the treatment and prevention of osteoporosis. 2010.
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