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Managing women’s health in the menopause

Key learning points

 

  • Women’s experience of the menopause is variable
  • Nurses should be able to provide information and education
  • NICE provides a good guideline on the management of menopausal women

The menopause is a complex time in a woman’s life that can span many years and have an impact on the health, social and psychological aspects of a woman’s quality of life. Nurses are in a prime position to help.

All women will experience the menopause. What is different is the ways in which women experience it, from minimal symptoms and cessation of periods to severe hot flushes. The woman’s age, the symptoms and other conditions will impact on whether women need to interact with health professionals at this stage of their lives. This article aims to look at the issues in the menopause and the support that nurses can give.

Menopause is complex and the information on it is confusing. Hormone replacement therapy (HRT) was in vogue from the 1980s until the 1990s, with a sharp decline after the publication of many studies in the 1990s.[1,2,3,4] Since then, the data have been re-evaluated, and have shown HRT in a more positive light. In 2015, NICE published guidelines for the menopause.[5] This has given a more balanced view.

All women should be able to access advice on the menopause and how to optimise their health. The nurse’s role is key here, to signpost women to this information. Depending on the level of practice and competency, this may also involve giving holistic and individualised assessments and possibly prescribing HRT. 

Menopause has many different stages and meanings. Menopause itself is an all-encompassing term for the changes that occur in a woman at this stage of her life. In the UK, the current age of menopause is 51-52 years old,[6] with a range of 45-55 years old. The menopause is now a midlife event, as women will on average live 30 years plus in the post-menopausal state,[7] with the time leading up to this and the last menstrual period (LMP) called the perimenopause. This can start in the 40s and is characterised by changes in the hormone levels, which can lead to some symptoms and irregular periods. This ends with the last period and from then on, the women are postmenopausal. 

Postmenopausal is when a woman has not had a period for a year and it is a retrospective event, which cannot be predicted. The stages can be seen further with the classifications seen in the Stages of Reproductive Aging Workshop (STRAW).[8] Biological changes that occur around this time are the decrease in ova so follicle-stimulating hormone (FSH) is produced in greater levels to try to trigger ovulation. This leads to greater concentrations of FSH and luteinising hormone (LH) and lower levels of oestrogen until there are no follicles left and the process stops, with no periods, high levels of FSH/LH and low oestrogen.[9]

The condition of premature ovarian insufficiency (POI) is classified as reaching menopause before the age of 40. This can have a devastating effect on women, both in terms of physical and psychological impact and the loss of fertility. POI affects 1% of women [10] and can be natural or because of medical intervention, such as surgical removal of ovaries, chemotherapy and radiotherapy. In cases like these, the symptoms can be more sudden and more intense. 

Signs and symptoms of the menopause

There is a wide range of symptoms that women can experience. These can be minimal and the menopause passes with little impact. However, in some, the symptoms can have a debilitating effect. Symptoms can be variable in length. For most women, they last a few years but in some, they can last 10 years or more.[11]

Many women will want to know if they are in the menopause or when the menopause will finish. If women are over 45 with menopause symptoms, no blood test is needed,[5] as the hormone levels fluctuate during this time making the levels unreliable. The question of when this will subside is one that currently cannot be answered by looking at clinical symptoms or blood tests. Research is currently in progress looking at the genetics behind menopause, which will eventually be able to answer those questions.[12]

Symptoms can be divided into short-term and long-term. However, short-term can be misleading as the symptoms can last 10 years or more. Long-term consequences of the menopause are osteoporosis and cardiovascular disease. These are especially of concern in women who have POI.

The main symptoms of menopause that most women are aware of are vasomotor. These include hot flushes and night sweats and occur in 75% of women, with 25% causing significant problems.[7] They are periods of inappropriate heat loss, related to changes in the hormone levels and norepinephrine and serotonin and lead to a narrowing in the thermoregulatory zone, which leads to increases in core temperature,[13] but the cause of them is not completely understood. Women might feel hot on the face or sweat, which can soak through the clothes and bedclothes at night and can be associated with palpitations, shivering, tachycardia and nausea. Both hot flushes and night sweats impact on quality of life and night sweats can impact on sleeping, which in time can have negative consequences on mood, fatigue and self-esteem.

Another symptom is changes in periods. Periods can be more or less frequent, or there might be a change in flow.

Other symptoms of menopause include:

  • Problems sleeping.
  • Fatigue and difficulty in concentrating, mood changes, confusion, poor memory, irritability.
  • Genito-urinary symptoms.
  • Vaginal dryness occurs in up to 50% of women in the post-menopausal period and generally gets worse over time.[14] This can lead to pain and bleeding with intercourse, vaginal itching, dysuria and urinary urge and frequency.
  • Decreased libido.
  • Joint pain.
  • Weight gain and bloating.
  • Migraine.

Role of the nurse

Nurses should advise and inform women about the symptoms of the menopause. Nurses should all be able to recognise women with menopause and give education to maintain health into longer life, regardless of symptoms. This can be general health advice, in relation to reducing the risks of cardiovascular disease and decreasing the risks of osteoporosis, by looking at diet and exercise and basic strategies such as decreasing alcohol and smoking.

Important in this age group is offering advice on contraception. Women need to continue contraception for two years from their last period if they are under 50 and one year if they are over 50.[15]

Women are often confused by the information in the press on menopause and HRT. The nurse should be able to give well-founded information, and signpost women to reliable sources of evidence. Nurses are often the best placed to give information on HRT alternatives and discuss the pros and cons of each. 

In addition, nurses may initiate conversations with women who are not presenting with menopause symptoms, such as when undertaking cervical screening, asking about dryness and giving basic advice.  

Another group of women who require advice are those who are going to undergo procedures that are likely to lead to the menopause.[16]

Nurses can have many different roles when looking after women with menopause. These can range from providing basic information through to becoming a specialist in menopause with
a certification via the British Menopause Society (BMS). The role for nurses has been opened with the publication of the National Institute For Health and Clinical Excellence (NICE) guidelines,[5] which suggest referral to a specialist. But there is no definition of who the specialist is and where the specialist is situated in primary or secondary care.

Menopause and work

As well as impacting on personal life, menopause symptoms can also impact on working life. They can cause problems with performance and lead to a lack of confidence. As a large proportion of the NHS workforce is women, this issue affects staff as well as patients. Nurses who manage staff need to be aware of this and the guidance issues. 

Specialist services

There are some women who may need to be referred for specialist help when they have menopausal symptoms. These have been defined as women who fall outside the NICE guidelines. Generally, women who need referral to specialists are:

  • Women with complex comorbidities.
  • Previous venous thromoboembolism (VTE). 
  • Women with hormone-dependent cancer.
  • Women with a history of thrombosis.
  • POI.
  • Multiple treatment failures.

Treatments for the menopause 

 - General lifestyle

Women can find certain foods make their symptoms worse. These can be caffeine, spices and alcohol. Women can be advised to monitor food intake and modify their diet accordingly. Some of this lifestyle advice can help with symptoms and will also promote a healthier lifestyle. For example, smoking can increase flushes and stopping will help with this and help cardiovascular disease (CVD) and bones.

Weight gain is common during the menopause in women on or off HRT. Women with a higher BMI can have more symptoms and obvious health risks. Reducing weight can help with symptoms, decrease the risk of breast cancer and CVD.[19]

 - HRT

HRT is divided by content and mode of delivery. HRT can be oral or transdermal, such as patches or gel. NICE states that transdermal HRT has less risk of thrombosis and should be used in women who have additional risk factors.[5] In simple terms, if a woman has a uterus then she needs to have both oestrogen and progestogen. These can be given sequentially so that bleeds continue until the women is postmenopausal, when they can be given continuously together so that there is no bleeding. 

The NICE guidance [5] gives a good summary of the risks and benefits of HRT and the indications for use. One of the most common questions women ask is about the risks of developing breast cancer. The data on HRT do show an increase in breast cancer after taking combined HRT for five years or more,[5] which leads to one of the most common questions from women – when should they stop HRT? Some guidance suggests using the shortest duration and the lowest dose, but what does this mean for the women in a practical sense?

As discussed, symptom durations can vary and the only way to know if a woman no longer needs HRT is to stop. Nurses can help wean women off HRT by decreasing the dosage.[10] Women who have been started on HRT will need support and advice, especially within the first few months when they may experience side-effects, such as bloating, nausea and breast tenderness and bleeding.[5]

Cardiovascular protection can be gained from HRT if it is started before the age of 60 or within 10 years of the menopause.[14]

Women with POI should be encouraged to use HRT or the combined oral contraceptive pill (COC) to prevent long-term consequences of POI and also early mortality.[5,10,17]

Vaginal oestrogen may be used in women with urogenital symptoms. This can be as pessaries, cream or a local vaginal ring. NICE suggests long-term use without monitoring as the amount that is absorbed is minimal.[5]

 - Alternatives

Many women will use alternative and complimentary medicine (CAM), sometimes without much evidence to back it up. In the USA 36% of women use CAM.[18] There is a belief that these preparations are natural and harmless so do not need to be discussed with health professionals. Nurses should always ask women about any CAM that they are taking as some are harmful, some have interactions with other prescribed medications and some do not work. Many do not have research-based evidence behind them but anecdotal evidence of some benefit on symptoms. 

There is some evidence that phytoestrogens may help with hot flushes, but the quality of the research is suboptimal [19] and they have no impact on cardiovascular or bone health. 

Cognitive behavioural therapy is recommended by NICE for mood problems and anxiety associated with the menopause but can also be used by women who cannot take HRT. There is some research to suggest that it can help with management of hot flushes and night sweats – especially for women with breast cancer.[6]

Acupuncture has limited, mixed evidence, while black cohosh can help with vasomotor symptoms, but not mood and can interact with medications. St John’s wort helps with vasomotor symptoms,[6] but may interact with other medications. Vaginal moisturisers and lubricants can be used for women with vaginal dryness with or without using vaginal HRT. Moisturisers can be used long term, whereas lubricants are used with intercourse.

 - Prescribed alternatives

There are three main prescribed alternatives to HRT for menopausal women, for which only clonidine is licensed for menopausal flushing. The others have been used mainly in women with hormone-dependent cancers who cannot take HRT. However, evidence is limited. The alternative drugs to HRT are:

  • Clonidine – used for flushes and originally developed as an anti-hypertensive,[7] this works in around 30% of women. A possible side-effect is dizziness. 
  • Selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) – used in lower dosage than for depression and the reduction of vasomotor symptoms is a side-effect, but these drugs can cause significant GI disturbances and a decrease in libido. Paroxetine can interact with tamoxifen.
  • Gabapentin.
  • Testosterone – women who have issues with libido may respond to testosterone. This is especially true of women who have had a surgical menopause. Androgen-like properties make tibolone the only HRT licensed for treatment of libido. Other options for women are testosterone gels, which are off licence and used at one fifth of the dosage stated in the British National Formulary. Testosterone is also good for general wellbeing and mood and tiredness that does not respond to standard HRT.[5]

Further reading and support

References

1 Rossouw JE, Anderson GL, Prentice RL et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. Journal of the American Medical Association 2002;288:321-33.

2 Women’s Health Initiative. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy. Journal of the American Medical Association 2004;291:1701-12.

3 Beral V, Bull D, Reeves G. Million Women Study Collaborators. Endometrial cancer and hormone-replacement therapy in the Million women Study. Lancet 2005;365:1543-551. 

4 Beral V, Million Women Study Collaborators. Breast cancer and hormone-replacement therapy in the Million Women Study. Lancet 2003;326:419-27.

5 National Institute for Health and Care Excellence. Menopause: diagnosis and management. Clinical guideline No 23. NICE, 2015 London.

6 Ginsberg J. What determines the age at menopause? BMJ 1991;302:1288-9.

7 Sassarini J, Lumsderm M. Hot flushes: are there effective alternatives to estrogen? Menopause international 2010;16:81-8.

8 Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging: menopause. The Journal of The North American Menopause Society 2012;19:387-95.

9 Rees M, Purdie D, eds. Management of the Menopause. The Handbook, 4th edition. Royal Society of Medicine Press, 2006. 

10 Faubion S, Kuhle C, Shuster T et al. Long term health consequences of premature or early menopause and considerations for management. Climacteric 2015;18:483-91.

11 Avis N et al. Duration of menopausal symptoms over the menopause transition. JAMA 2015;175:531-9. 

12 Laven J et al. Menopause: Genome stability as a new paradigm. Maturitas 2016;92:15-23.

13 Pinkerton JV. Dose is important for non-hormonal therapy for hot flashes. BJOG 2016;123:1744.

14 Hamoda H et al. 2016. The British Menopause Society and Women’s Health Concern recommendations on hormone replacement therapy in menopausal women. Post-Reproductive Health 2016;22:165-83.

15 The Faculty of Sexual and Reproductive Healthcare. Guidance on contraception for women over 40 2010. tinyurl.com/op99xta (accessed 24 January 2017).

16 Lyons J. Advice given to women undergoing gynaecological surgery in relation to menopause, symptoms and hormone replacement therapy: could and should we improve the service we provide. Menopause international 2011;17:59-62.

17 ESHRE guideline on the management of premature ovarian insufficiency 2015. eshre.eu (accessed 24 January 2017). 

18 North American Menopause Society. Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of the North American Menopause Society. Menopause 2015;22:11.

19 Franco O et al. Use of plant-based therapies in menopausal symptoms.
A systematic review and meta-analysis. JAMA 2016;315:2554-63.