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Options for helping women through the menopause

Victoria Goldman
BSc MSc
Medical Journalist
Editor
Menopause Exchange Newsletter

A s women approach the menopause, their oestrogen levels fall, their ovaries release fewer eggs and their periods gradually stop. All women go through the menopause, but their experiences vary greatly.(1) Primary healthcare professionals have an important role in educating women about the management options available and ensuring that those on hormone replacement therapy (HRT) comply with the treatment programme.

The menopause
Medically, the "menopause" means the last menstrual period, but the term is now widely used to describe the changes that lead up to this time. These changes don't usually take place overnight but can last several years (see Box 1). Most women notice changes in their periods as they enter their late 40s, with their last period occurring at an average age of 52. If the menopause occurs before the age of 40, it is known as a premature menopause. About one in every 100 women will experience a natural premature menopause, which is often caused by an autoimmune disorder. However, a premature menopause can also be brought on by surgery (both ovaries are removed), radiotherapy/chemotherapy or several other factors.(2)

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Signs and symptoms
During the menopause, a woman's monthly periods may become more frequent or irregular and may get heavier and last longer. She may experience spotting between them, until they eventually stop completely. The most common symptoms of the menopause are the vasomotor ones, the hot flushes and night sweats. Other short-term consequences of the menopause (ie, symptoms) are listed in Box 2. Hot flushes may occur several times a day. When a woman has a flush, she may suddenly feel hot and sweaty, her heart may beat faster and she may feel faint or dizzy. Night sweats can cause a loss of sleep.(3)
The long-term consequences of the menopause are due to a prolonged lack of oestrogen, which can affect the bones and heart and lead to osteoporosis (brittle bones), cardiovascular disease and cerebrovascular disease. One in two women over the age of 50 will break a bone, usually due to osteoporosis.(4) The Royal College of GPs' clinical guidelines for the prevention or treatment of osteoporosis recommend that a dual- energy X-ray absorptiometry (DEXA) bone density scan should be available to anyone at a high risk of breaking a bone because of the condition.

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How to cope with the menopause
Menopausal symptoms can be troublesome enough to warrant treatment. Women need to find an approach that suits them. When considering HRT, women and the health professionals advising them need to take into account the woman's age, type, severity and duration of symptoms, individual life circumstances (eg, relationships or work), medical history, medical family history, and the pros and cons of HRT (in relation to themselves).

HRT benefits
HRT, which replaces lost oestrogen, can make menopausal symptoms less severe. There is well-documented evidence that HRT can reduce hot flushes and night sweats, ease vaginal dryness, improve libido and relieve urinary symptoms.(5) Oestrogen-only HRT also improves mood. In the long term, HRT reduces the risk of hip and spine fractures, and HRT containing oestrogen and progestogen reduces the risk of colon cancer.
Controversy concerning the use of HRT stems from various clinical studies, including the randomised Women's Health Initiative studies, the observational Million Women Study and the HERS study.(6-8) The current medical opinion is that to relieve moderate-to-severe menopausal symptoms HRT should be prescribed in the lowest dose possible for the shortest period of time. In the UK, most women who take HRT use it for symptom relief and take it for less than five years.(5) Obviously any contraindications to HRT need to be taken into account before prescribing it, and the type, form and dose should be tailored to each woman's needs.

HRT side-effects and risks
Most of the side-effects associated with HRT use disappear after two to three months. The most common short-term side-effects include:

  • Fluid retention.
  • Leg cramps.
  • Breast tenderness.
  • Nausea.
  • Dyspepsia.
  • Headaches/migraine.
  • Mood swings.
  • Depression.
  • Acne.

In the long term, the use of HRT increases the risk of developing venous thromboembolism and also increases the risk of developing gall bladder disease. HRT causes a small increase in the risk of breast cancer, depending on the type of HRT used.(1) For most women with menopausal symptoms affecting their quality of life, the risk of breast cancer is so small that it is outweighed by the benefits of HRT's short-term use. The only women who can't take HRT are those who are currently pregnant or currently have breast cancer, endometrial cancer or a deep vein thrombosis. Women with a previous history of breast cancer, deep vein thrombosis or heart disease should discuss going on HRT with their GP.

Types and forms of HRT
Although HRT replaces lost oestrogen, women who still have a uterus need progesterone as well (called "combined HRT") to protect their uterine lining from endometrial cancer.(5) Progesterone balances the effects of the oestrogen and causes a withdrawal bleed, which is scanty and predictable and usually lasts for four to five days each month.
Sequential combined products cause a monthly withdrawal bleed, while quarterly bleed products cause a withdrawal bleed every three months and benefit women who have erratic periods. Continuous combined HRT involves taking oestrogen and progesterone in one tablet every day, does not cause a withdrawal bleed and is designed for women who have not had a period for 12 months.
Forms of HRT include: oral tablets; patches; implants; skin gels; the intranasal spray (for postmenopausal women) and vaginal preparations. For the pros and cons of these forms, see Box 3. Some women are prescribed the intrauterine system (Mirena; Schering Health Care). Others may be prescribed testosterone implants (50-100mg) to help sexual function.

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Alternatives to HRT
If women can't or don't want to take HRT, there are some prescription alternatives (eg, clonidine, anti-depressants and gabapentin), but the side-effects of these drugs restrict their use. Women experiencing vaginal dryness may benefit from over-the-counter vaginal products, such as the Durex "Play" Range, KY Liquid, Replens MD and SYLK.(9) Some women find that complementary therapies, such as homeopathy and herbal medicine, help their symptoms, although there is limited research on these treatments.
There is some evidence that soya isoflavones (found naturally in foods such as beans and pulses and the herb red clover) can help to ease hot flushes, lower cholesterol levels and strengthen bones.(10) However, more research is required. Women with oestrogen-dependent breast cancer (or a history of the disease), or who are at a high risk of breast cancer, should not eat more than one to two servings a day of phyto-estrogens or take phytoestrogen supplements. If women are taking thyroxine for an underactive thyroid, their thyroxine levels need to be monitored if they increase their phytoestrogen intake. Similarly, care needs to be taken if women are on anticoagulants.
For osteoporosis prevention, women should do weight-bearing exercise, such as tennis, aerobics, jogging, weight training, dancing and skipping. This should be carried out at least three times a week.(11) Women with low bone density should not do vigorous exercise because of the risk of fracture.
Menopausal women should also be encouraged to eat a healthy diet rich in calcium (eg, dairy products and green leafy vegetables), as it strengthens the collagen framework of bones. They should aim for at least 700mg of calcium a day if they are over 50 years. If they have osteoporosis, they may need to boost their calcium intake to around 1,200mg a day.(12)

References

  1. British Menopause Society. HRT and breast cancer factsheet. Available from: http://www.the-bms.org
  2. British Menopause Society. Council consensus statement on premature menopause. 10June 2006. Available from: http://www.the-bms.org
  3. Mullin N. Coping with sleeplessness. The Menopause Exchange Newsletter 2004;23:5.
  4. National Osteoporosis Society. All about osteoporosis factsheet. Available from: http://www.nos.org.uk
  5. British Menopause Society. Council consensus statement on HRT. 10 June 2006. Available from: http://www.the-bms.org
  6. Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA 2002;288:321-33.
  7. Million Women Study Collaborators (MWSC).Breast cancer and hormone replacement Therapy in the Million Women Study. Lancet 2003;9382:419-27.
  8. Hulley S, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/ progestin Replacement Study (HERS) Research Group. JAMA 1998;280: 605-13.
  9. Abernethy K. Coping with vaginal dryness. The Menopause Exchange Newsletter 2006;28;6.
  10. Nachtigall L, et al. Complementary and hormonal therapy for vasomotor symptom relief: a conservative Clinical Approach. J Obstet Gynaecol Can 2006;28:279-89.
  11. Brockie J. Exercise for women in the early postmenopause years. J Br Menopause Soc 2006;12(3):125-7.
  12. National Osteoporosis Society. Calcium rich foods and bone health information sheet. Available from: http://www.nos.org.uk


Resources

British Menopause Society
W: www.the-bms.org

National Osteoporosis Society
T: 01761 471 771
Helpline: 01761 472 721
W: www.nos.org.uk

The Menopause Exchange
PO Box 205, Bushey
Herts WD23 1ZS.
T: 020 8420 7245
E: norma@menopause-exchange.co.uk