Getting up to speed with the menopause

Registered nurse and clinical educator Ruth Devlin provides an overview of the menopause, including key facts, the underlying biology and principles of symptom management

Menopause is an area of women’s health that has historically lacked consistent treatment and advice. However, the situation has improved significantly in recent years, and especially since 2021. In Scotland, the Women’s Health Plan was published last August, while the Women’s Health Strategy is expected to be published in England this year. There is also improved education provision for healthcare professionals to bring their knowledge up to date.

The menopause is a natural hormonal transition in a woman’s life that every woman will go through. A small percentage of women will experience an induced menopause, as a result of surgery or as a reaction to treatments like chemotherapy and radiotherapy.

Many women will not even seek help for the symptoms of menopause, which can be for a number of reasons. They may not want to consider they are at that stage of their life, or they may not be aware anything can be done, or lack confidence in their healthcare professional (HCP). Some women may have been put off by sensationalist and inaccurate media stories. Half of all women will go through the menopause without consulting a HCP, even though their symptoms may impact their quality of life at home and also at work. Fifty percent of women report that their symptoms negatively affect their sex life.¹

On a positive note, there are many clinicians who specialise in this area of women’s health, who have worked tirelessly to not only actively treat women but also regularly contribute to research and provide education. These clinicians collate valuable resources for the general public as well as HCPs, all of which are regularly reviewed and updated, for example on the British Menopause Society (BMS) website.²

Primary care nurses are well placed to provide menopause care, information and support, so should ensure they are up to date with information available on this important topic.

Facts about the menopause

Approximately 75% of women will experience symptoms to varying degrees.
The average age at which women experience menopause is 51 years.
Women have oestrogen receptors throughout their bodies, which is why so many different body processes are affected when oestrogen levels start to decline during perimenopause, and why over 34 different symptoms are associated with the menopause.
Symptoms could also be a result of other medical issues which should first be excluded.
Other factors affect how women not only experience symptoms but how they cope with them – for example, lifestyle choices, diet, exercise.
Menopause is established when there have been 12 consecutive months of no bleeding following the last menstrual period (LMP), after which a woman moves into the postmenopausal years.³

Causes and symptoms

Symptoms of the menopause are caused by levels of oestrogen declining. Other factors such as fluctuating hormones also contribute to an overall hormonal imbalance that can, for some women, result in debilitating symptoms. Varying levels of progesterone and testosterone, and stress hormones like cortisol, along with lifestyle behaviours that impact on hormone levels, can contribute to menopausal symptoms.

The symptoms associated with the menopause range from vasomotor symptoms like hot flushes and night sweats, to joint aches, weight gain and bloating. There are also the well-known psychological and emotional symptoms such as mood swings, poor concentration, anger and anxiety, all of which can be extremely debilitating. In addition, there may be long-term symptoms such as genitourinary problems including: vaginal atrophy; vaginal or vulval irritation and dryness, and related lack of libido; increased urinary frequency, urgency or leakage; and nocturia.

Additional potential long-term conditions related to menopause to be aware of include osteoporosis and cardiovascular disease. Preventing these conditions is always better than firefighting.

Premature menopause or premature ovarian insufficiency

Premature menopause, also known as premature ovarian insufficiency (POI) is when the menopause occurs under the age of 40 years. It affects approximately 1% of women. Anyone presenting with symptoms of POI should be referred to a specialist for adequate support and care.⁴

Perimenopause

The perimenopause is the most symptomatic stage of the menopause and is the stage from the beginning of experiencing menopausal symptoms to the start of the postmenopause.³

Women should be encouraged to seek advice and support during this stage if their symptoms are impacting on the quality of their lives. Explanation of why symptoms are occurring, the various ways to cope with symptoms and how they can help themselves should all be explained to them. Giving each patient a moment of your time can save a lot of distress for them and can reduce the need for repeat appointments further down the line.

Diagnosing the menopause

For the majority of women diagnosis should be possible through taking a full medical history and discussing how symptoms are impacting their lives. It can be helpful to have a symptom checker to hand and for patients to focus on how their symptoms are impacting their lives by keeping diaries of symptoms, even for a short time – for example, sleep, food, urinary and hot flush symptoms.⁵

The follicle-stimulating hormone (FSH) blood test should only be offered to women who are suspected to have POI, or those age between 40 and 45 years with symptoms, to diagnose menopause.⁵ FSH tests need to be done accurately; at least two tests need to be done four to six weeks apart and preferably around the third to fifth day of the cycle. Some women can become very frustrated not knowing exactly which stage they are in, but it is not always possible to accurately establish this. Taking time to explain this can be reassuring. It is also important to explain that various forms of hormonal medication, such as the combined oral contraceptive pill, can mask symptoms.⁵

Managing symptoms

Lifestyle choices. One of the most important messages to get across to women is that they can really help to manage their symptoms themselves, by taking a good look at their lifestyle choices. Regardless of whether medication might be required these lifestyle choices should always be discussed. Symptoms can sometimes be successfully managed by having a nutritious diet, keeping well hydrated, reducing caffeine and alcohol levels, taking regular gentle exercise and addressing poor sleep patterns. This might not always be welcome advice, but is important to give as it encourages self management and helps with good quality long-term health.

Alternative remedies. Herbs and supplements are easy to access and have historically been used to help with symptoms. However, this industry is largely unregulated as herbs and supplements are treated as food supplements. Patients should be advised to consult qualified herbalists who have sound knowledge of what will interact with other medications and what will help to treat specific symptoms. Women who self treat should also be advised to be cautious – choices between alternative remedies can be confusing, and the strengths, constituents and importantly the quality of contents can vary considerably between brands. Nonetheless, herbs and supplements can be helpful for some women who find their symptoms are impacting on their lives and who either prefer not to take HRT or cannot take HRT for various reasons.

Hormone replacement therapy

Accessing accurate, up to date information on hormone replacement therapy (HRT) is paramount. Encourage patients to avoid reading sensationalistic headlines and direct them to recognised resources, such as the fact sheets from Women’s Health Concern (WHC), which is the patient arm of the BMS.⁶

Replacing oestrogen restores the natural hormonal environment so helps to alleviate the short-term symptoms, as well as prevent long-term complications by supporting bone, cardiovascular and cognitive health.

HRT is a valid option to consider for the majority of women. The benefits outweigh the risks but, as with any medication, each patient needs to be assessed individually. The risk of breast cancer has to be put into perspective alongside the far greater risks of being obese (a body mass index above 31) or drinking more than two or three units of alcohol a day. It can be helpful to show patients easily understood infographics on risk, which can be downloaded from either the BMS/WHC websites.⁷

As a HCP, it is important to explain and discuss all the different routes available such as oral, transdermal and intrauterine system.^8,9 Make sure a follow-up appointment is organised for three months and then annually. As well as systemic HRT, remember that vaginal oestrogen can be prescribed and is the best treatment for all genitourinary symptoms.

Any patient diagnosed with POI should be referred to a specialist and encouraged to be on HRT, if there are no contraindications, at least up until the average age of menopause, or 51 years. There are no arbitrary limits for duration of treatment.¹⁰

Physiotherapy

There are exercises that women can do to improve genitourinary function and control symptoms such as urinary urgency or leakage, including pelvic floor exercises. You can signpost patients to resources such as the squeezyapp and the pelvicroar physiotherapy website.^11,12

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is an invaluable option to consider and a recognised alternative to HRT to manage low mood or anxiety symptoms of menopause.¹³ It is non-invasive and anyone can learn simple CBT tools. These strategies can be used alongside other treatments without fear of interaction, making it an excellent option for breast cancer patients to consider.

The main focus of CBT is to reduce anxiety and stress levels. Simple tools such as paced breathing have been physiologically proven to reduce stress levels. Stress exacerbates any symptom.

It can also help with sleep, hot flushes and night sweats. Tools, once learnt, are valuable throughout life and help to give a sense of control back. It can sometimes be hard to access a therapist but patients can be encouraged to access self-help resources, such as this guide on managing menopause symptoms from BMS experts.¹⁴

Conclusion

All women should be encouraged to seek help and advice about the menopause. This should not be viewed as a taboo topic, but one that is openly discussed and taken as seriously as any health condition. It is important to understand that symptoms can for some be incredibly debilitating and life changing. As nurses, you are in a position to easily help many women by simply listening, assessing their needs, advising them of all options available to them and directing them to accurate resources.

To complete relevant women’s health CPD modules on Nursing in Practice Learning, click here.

References

1. British Menopause Society Fact Sheet. Information for GPs and health professionals. https://thebms.org.uk/wp-content/uploads/2020/09/BMS-NationalSurvey-SEPT2020-B.pdf [Accessed 26 January 2022]

2. British Menopause Society. https://thebms.org.uk/ [Accessed 26 January 2022]

3. Menopause Matters. What and when is menopause? https://www.menopausematters.co.uk/menopause.php [Accessed 26 January 2022]

4. The Daisy Network. What is POI? https://www.daisynetwork.org/about-poi/what-is-poi/ [Accessed 26 January 2022]

5. NICE. CG23 Menopause: diagnosis and management. 2015. Diagnosis of perimenopause and menopause. https://www.nice.org.uk/guidance/ng23/chapter/Recommendations#diagnosis-of-perimenopause-and-menopause

6. Women’s Health Concern. Factsheets and other helpful resources. https://www.womens-health-concern.org/help-and-advice/factsheets/

7. Women’s Health Concern. Understanding the risks of breast cancer. https://www.womens-health-concern.org/wp-content/uploads/2019/10/WHC-UnderstandingRisksofBreastCancer-MARCH2017.pdf [Accessed 26 January 2022]

8. British Menopause Society. Tools for clinicians. https://thebms.org.uk/publications/tools-for-clinicians/ [Accessed 26 January 2022]

9. Hazell, T. Top tips on prescribing HRT. 21 June 2021 https://www.nursinginpractice.com/clinical/womens-health/top-tips-on-prescribing-hrt/

10. British Menopause Society. HRT Guide https://thebms.org.uk/wp-content/uploads/2020/07/04-BMS-TfC-HRT-Guide-JULY2020-01D.pdf [Accessed 26 January 2022]

11. Squeezy for women. https://www.squeezyapp.com

12. Pelvicroar website. https://www.pelvicroar.org

13. NICE. CG23 Menopause: diagnosis and management. 2015. Managing short-term menopausal symptoms https://www.nice.org.uk/guidance/ng23/chapter/Recommendations#managing-short-term-menopausal-symptoms

14. Hunter M, Smith M. (2020). Managing hot flushes and night sweats. A cognitive behavioural self-help guide to the menopause. Routledge

Further reading and resources

British Menopause Society.HCPs with an interest in this area can join the British Menopause Society to receive regular updates on recent research and notification of learning/educational events.

Menopause Matters – decision tree: https://www.menopausematters.co.uk/tree.php

NICE guidelines on menopause: www.nice.org.uk/guidance/ng23

Primary Care Women’s Health Forum: https://pcwhf.co.uk/resources

Royal College of Nursing – Menopause and mental health pocket cards: https://www.rcn.org.uk/professional-development/publications/pub-007813

Faculty of Sexual and Reproductive Health: Contraception for over 40s: https://www.fsrh.org/standards-and-guidance/fsrh-guidelines-and-statements/contraception-for-specific-populations/aged-over-40/

RCGP: Women’s health e-learning module and podcast – open to all clinicians: https://www.rcgp.org.uk/clinical-and-research/about/clinical-news/2020/january/womens-health-new-e-learning-module-and-patient-podcast.aspx

Patient resources

Women’s Health Concern fact sheets: www.womens-health-concern.org

Menopause Matters: www.menopausematters.co.uk

NICE guidelines on menopause: www.nice.org.uk/guidance/ng23

Let’s Talk Menopause: www.letstalkmenopause.co.uk

Squeezy app: www.squeezyapp.com