The menopause is medically defined as the point 12 months after a woman’s last menstrual period.1 However, hormones can fluctuate and fall in the years leading up to this time; this is the perimenopause and can lead to a variety of unpleasant symptoms and consequences to health due to a lack of oestrogen.
Nearly all women will experience perimenopausal/menopausal symptoms. As a healthcare practitioner, you ideally want to pick up on problems early on and provide the right treatment to alleviate symptoms and prevent health worsening with time.
When should you consider the perimenopause?
Many HCPs associate the menopause with women around the age of 50, and although 51 years is the average age of menopause in the UK2, symptoms usually start years before this. One in 100 women enters menopause before the age of 40, and for one in 1,000 this happens before they reach 30 – this is premature ovarian insufficiency menopause.3 It is not unusual for women to experience symptoms in their early 40s or even late 30s.
How many women are affected by perimenopausal symptoms?
Around 80% of women will experience symptoms and a quarter of cases these will be severe. Some may only have one or two symptoms, others will experience many. These can last a few months or persist for years or even decades.
Every woman’s experience is unique and there are no generalities that can be made in terms of how long symptoms might last or how severe they will get if left untreated.
Joining the dots with symptoms
Imagine a woman has increasing knee pain and she sees her GP, who treats it as a musculoskeletal problem. A few weeks later she sees another doctor about increasingly low mood and she is prescribed an antidepressant, then a couple of months later she sees a nurse for cervical screening but finds it too uncomfortable to complete the exam due to vaginal dryness.
The following year she sees a GP about persistent tinnitus, then has a dermatology referral for severely dry and itchy skin, and further down the line is referred to physiotherapy for pelvic floor assessment and treatment after episodes of urinary incontinence. She hasn’t had a period for six months but puts this down to tiredness and stress, and has not mentioned this to any of the HCPs, none of whom has asked about her periods.
Would anyone from the practice join the dots and begin a conversation with this patient about her hormones?
What are the signs and symptoms to look out for?
Other symptoms of perimenopause include palpitations, anxiety, insomnia, allergies, migraine and worsening headaches, muscle aches and stiffness, irritability, loss of confidence, low or absent libido, dry eyes and sore gums.
You may wonder why hot flushes and night sweats (vasomotor symptoms) have not been mentioned. Although these are common, many women do not experience them. It’s really important to know about the wide variety of possible symptoms – every cell in the body has oestrogen receptors, so a lack of this important hormone can affect every system in the body.
HRT: the ‘gold standard’ treatment
HRT is the most effective treatment for perimenopausal symptoms. It usually involves replacing the hormones oestrogen and progesterone (if the woman still has a womb). A beneficial third hormone is testosterone, which is also produced by the ovaries – its levels fall sharply around the perimenopause and menopause.4 Replacement testosterone can help ease symptoms of fatigue, poor concentration and low libido, but it has to be prescribed off-licence as it is still not authorised for women in the UK.
Oestrogen is best given through the skin as oral oestrogen carries a small risk of clotting. Transdermal oestrogen is not associated with a risk of clot or stroke5 and is available as a patch, gel or spray.
Progesterone is required to counteract the effects of oestrogen on the womb lining, to keep it thin and the cells healthy. It can be taken orally – the safest type is micronised progesterone, branded as Utrogestan in the UK – or it can be received as a low-dose progestogen via the Mirena IUS.
Perceived risks of HRT
Research has shown that HRT reduces the risk of heart disease, osteoporosis, type 2 diabetes, bowel cancer, depression, and dementia.6 So there are many benefits beyond easing menopausal symptoms. Unfortunately though, HCPs and women alike often associate HRT with perceived risks rather than benefits, and this is compounded by the MHRA issuing warnings based on misleading reviews of the evidence.7 This stigma is misleading, outdated and must be corrected.
Many women worry about breast cancer risk yet most types of HRT do not actually increase this risk. Indeed, oestrogen-only HRT has been shown to lower women’s future risk of breast cancer compared with women who don’t take HRT. 8 Some studies have shown that taking combined HRT (containing oestrogen and a progestogen – a synthetic progesterone) may be associated with a very small increased risk of breast cancer. The risk is related to the type of progestogen in the HRT, not the oestrogen. Taking micronised progesterone has not been shown to be associated with a statistically significantly increased risk of breast cancer.9
Transdermal oestrogen and micronised progesterone (known as body-identical HRT) is also safe for women who have migraine or a history of a clot or stroke, and also for most women who have had cancer or have a family history of cancer. 10
Hormonal preparations for symptoms related to vaginal dryness
There are many vaginal hormonal preparations that can work really well to improve symptoms related to genitourinary syndrome of the menopause (GSM). This affects around 80% of women yet only around 8% currently receive treatment.10 The majority of women who have smears that are uncomfortable will have GSM and these symptoms will worsen without treatment. Some women with GSM will not necessarily experience other menopausal symptoms.
Vaginal hormonal preparations are available as vaginal tablets, pessaries, creams, gels and a ring.10 These are not absorbed in the body and can be used by all women, including those with a history of breast cancer.11 They can also be given to women who take HRT.
As nearly half of your patients will experience perimenopause/menopausal symptoms, perimenopause should be the first thing to consider and not the last when seeing all women. Be that person in your practice who joins those dots and thinks ‘hormones!’
(All links accessed on 25 June 2021)
- NICE. Menopause: diagnosis and management. NG23. London, NICE, 2019.
- NHS. Menopause: overview, 2018.
- European Society of Human Reproduction and Embryology. Guidelines Management of POI . Belgium: ESHRE, 2015.
- Davis S et al. International Menopause Society global position statement on the use of testosterone therapy for women. Climacteric 2019;22(5):429-434.
- Olié V et al. Risk of venous thrombosis with oral versus transdermal estrogen therapy among postmenopausal women. Curr Opin Hematol 2010;17(5):457-63.
- Lobo R et al. Prevention of diseases after menopause. Climacteric. 2014;17(5):540-56. Epub 2014 Jun 27. PMID: 24969415.
- Medicines and Healthcare products Regulatory Agency. Hormone replacement therapy (HRT): further information on the known increased risk of breast cancer with HRT and its persistence after stopping. London: MHRA, 2019.
- Chlebowski R et al. Association of menopausal hormone therapy with breast cancer incidence and mortality during long-term follow-up of the Women’s Health Initiative Randomized Clinical Trials. JAMA 2020;28;324(4):369-380.
- Stute P et al. The impact of micronized progesterone on breast cancer risk: a systematic review. Climacteric. 2018;21(2):111-122.
- Newson L et al. British Society for Sexual Medicine position statement for management of genitourinary syndrome of the menopause (GSM). Staffordshire: BSSM, 2021.
- Temkin S et al. The role of menopausal hormone therapy in women with or at risk of ovarian and breast cancers: misconceptions and current directions. Cancer. 2019;125(4):499-514.