We’re living longer than ever before which means we’ll spend about ONE THIRD of our life as a menopausal woman! It’s so important to know about it to empower yourself to live your best, healthiest life. I hope I our lifetime that being a “menopausal” woman can take on a powerful and positive meaning. It’s a stage in life where a woman has accomplished and experienced a lot, risen through ranks of her career, raised her children and has a wealth of life experience. It’s a time to thrive on take some time for herself. So here’s everything you need to know…
What is menopause?
The main hormonal change seen in menopause is a decline in oestrogen but levels of testosterone and progesterone decline too. Menopause has officially occurred after one year of no periods. This can be tricky as we’re not sure that it’s happened until after the fact! The average age is about 51 but perimenopause can start a few years before that.
Perimenopause
“Peri” means around so perimenopause means the time leading in to or “around” menopause; it’s the transition from reproductive years to menopause. It’s characterised by symptoms of menopause, which we’ll dive in to below, coupled with lengthened menstrual cycles, skipped periods and then missed periods. A good way of predicting when you’ll go through it is asking your mom or grandmother when she experienced it as our age-of-menopause has a genetic component.
Early Menopause and Premature Ovarian Insufficiency
Some women may go through menopause before 45; this is early menopause. Premature ovarian insufficiency is when it occurs before 40. Women can experience POI from teens onwards. Reasons for POI or early menopause include autoimmune disease, bilateral oophorectomy (surgical removal of both ovaries) or a past history of chemo- or radio- therapy. Tubal Ligation (“tubes tied”) may also result in slightly earlier menopause due to disruption of blood supply to the ovaries.
Symptoms
There are a long list of symptoms of peri- and post- menopause but the cardinal three categories to look out for are:
- Hot flushes; these are often the most distressing and have a major impact on quality of life. They can disrupt sleep, performance at work and even day-to-day tasks like doing the groceries or school run.
- “Genitourinary Syndrome of Menopause”. This basically means vaginal dryness, painful intercourse, painful, thinning vulval skin (“atrophic vaginitis”) and recurrent urinary tract infections.
- Mood changes like depression, anxiety, lack of confidence at the workplace or short temper in family life. The hormonal changes can occur in waves meaning a woman may experience some month where symptoms feel worse; this often leaves women in their late 40s wondering if they’re experiencing PMS or perimenopause. Keeping a diary of periods and symptoms can be helpful here.
Other symptoms include brain fog, headaches, reduced libido, joint aches and pains, fatigue, dry skin and hair loss.
DIAGNOSIS
Diagnosis is made on careful history taking with your doctor or nurse i.e. discussing your symptoms with them. In women over age 45 with the cardinal symptoms of menopause associated with menstrual cycle changes, a working diagnosis of peri or post menopause can be made and treatment can be started. Blood tests to support the diagnosis can be done but aren’t necessary to make the diagnosis in this age group. The blood test we do is FSH (follicle stimulating hormone). This is high in menopause. However, we can also make the diagnosis even if FSH is normal if there’s strong clinical suspicion of menopause. Long story short? FSH is a piece of the puzzle. It doesn’t paint the full picture and often isn’t needed to make the diagnosis.
In women under age 45, investigations must be done to assess for reasons for her symptoms. We must rule out other causes of symptoms e.g. could it be thyroid disease?
Home Testing
I hope by now it’s clear that I don’t recommend home menopause tests? Why? Because they test for urinary FSH. As outlined above, a raised FSH alone is not how we diagnose menopause. Many women with symptoms who need treatment do these tests but the results are normal so they delay seeking appropriate healthcare. Remember, FSH does not have to be high to make the diagnosis and start treatment.
TREATMENT
Oestrogen
The gold standard of treatment is Menopausal Hormonal Therapy (MHT) – formally and commonly referred to as HRT. Oestrogen is the first and most important hormone to replace. Whilst oestrogen tablets are available, transdermal (through the skin) formulations are safer from a side effect profile; they have a lower risk of causing clotting. Gels, sprays and patches are available; patches are usually twice weekly which a lot women find handy.
Progesterone and Womb Protection
If a woman still has her uterus she will need to also take progesterone. Taking oestrogen alone in this cause will increase the risk of uterine cancer ; we give progesterone to balance the oestrogen exposure and protect against this. Progesterone is given cyclically for women still experiencing periods whilst it’s given continuously for women who have stopped periods. It can be given in the form of an oral tablet or via The Mirena Coil too.
Women who’ve had an hysterectomy won’t need added progesterone. Oestrogen only will suffice in this case. However, there is one exception to this rule; women with endometriosis who’ve had an hysterectomy, may still have endometrial like tissue in the pelvis and in other parts of the body too. So women with a past history of endometriosis and hysterectomy will still progesterone for “hormone balancing” and to protect this endometrial like tissue from the effects of unopposed oestrogen.
Mirena
The added bonus of using The Mirena for hormone balance and womb protection is that it also functions as contraception! Remember that MHT is not contraception! For contraception purposes, Mirena lasts 8 years in women under 45. If it’s inserted after age 45, it provides contraception until age 55. With that said, when used for endometrial protection it’s still only licenced for 5 years.
COCP
Some women may opt for the combined oral contraceptive pill to deliver their MHT as it has both oestrogen and progesterone. Whilst we do need to be more mindful of the clotting risk associated with the combined pill, it may still be appropriate and safe even in some menopausal women if they don’t have risk factors like high blood pressure.
Vaginal Oestrogen
We rarely say “everyone” in medicine but I think it’s safe to say that every peri and post menopausal woman should use vaginal oestrogen. Our genitourinary tract, think bladder, vaginal, urethra (where we urinate from) and vulva, needs healthy oestrogen levels to function optimally. Oestrogen supports collagen formulation so keeps our genitourinary tract and vulva supple and hydrated. But when levels declines, the area becomes dryer, less moisturised and less functional. This results in The Genitourinary Syndrome of Menopause as discussed above. The best way to stop these symptoms is to use vaginal oestrogen whether in the form of a pessary or a cream. All menopause consults should discuss vaginal oestrogen. Sometimes it’s the only form MHT women need.
It's quite common for women in their 40s or 50s to find themselves in a never ending cycle of antibiotics for recurrent UTIs or using Canesten or steroid creams again and again for painful vulval skin. If this sounds like you, look in to vaginal oestrogen; it’s very likely to stop those cycles in their tracks! Vaginal oestrogen can also improve symptoms of urinary incontinence and pelvic organ prolapse. Using it in the two weeks before cervical screening tests can make the procedure more comfortable too!
Contraindications to Hormonal Therapy
Some health conditions such as liver disease, clotting disorders and a past history of breast cancer may result in a woman being advised by her doctors to avoid hormonal treatment . With that said, this is very much assessed on a case-by-case basis. If you have a condition that “excludes” you from MHT but you feel you would benefit from it, request specialist opinion from a Complex Menopause Clinic. Some women with a past history of breast cancer still opt to avail of MHT, with the guidance of their oncologist, because their symptoms are having such a negative impact on their quality of life. In this case, based on risk assessment, the women and doctor may conclude that the benefits to quality of life outweigh the potential risks associated with hormonal therapy.
Breast Cancer Risk and HRT
This is probably the biggest concern most women have when starting HRT. Per 1000 women in The UK aged 50-69 there will be 23 cases of breast cancer. When combined HRT i.e. oestrogen and progesterone is add, there will be 4 more cases per thousand. For oestrogen only HRT, there will be 4 fewer cases. To put this in to context, there will be FIVE additional cases in women who drink 2 or more units of alcohol a day. Bottom line? There is a small increased risk of breast cancer in women who take combined HRT but alcohol use poses a bigger risk. And interestingly, you can “undo” this increased breast cancer risk associated with HRT by getting 150 minutes of brisk exercise a week!
Non-hormonal Treatments
With that said, there are non-hormonal medications such as oxybutynin, venlafaxine, clonidine and gabapentin that can help too. Cognitive Behavioural Therapy has been shown to be useful for hot flushes and sleep disturbance.
CONTRACEPTION
As mentioned above, Menopausal Hormonal Therapy is not contraception! There is still potential to conceive. One of the best options is Mirena as it address two issues: 1. Uterus protection and 2. Contraception. Discuss vasectomy with your partner if your family is complete. The “mini pill” (progesterone only) is commonly used during menopause and, as mentioned above, the combined pill (with oestrogen and progesterone) may be appropriate for some women; again, it can address two issues: 1. Contraception and 2. Provide oestrogen and progesterone replacement negating the need for additional MHT (HRT).
CANCER SCREENING
Make sure you’re register with Breast Check for your mammograms from age 50-69 and Cervical Check from 25-65. Women with a family history of breast cancer will need to start screening earlier; discuss referral to a family history breast clinic with you menopause care provider.
The free HSE colorectal cancer screening home testing starts at age 59 and ends at 69. You may be advised to start bowel cancer screening earlier i.e. have a colonoscopy, if you have a family history of colorectal cancer so again, discuss a referral with your healthcare provider.OVERALL HEALTH
Heart Health
Oestrogen is “cardioprotective” i.e. protects us from heart disease so , as oestrogen levels decline, women are at high risk of heart disease and heart attack. We so often think about our risks of diseases like breast and ovarian cancer but we are more likely to suffer from heart disease; it’s the leading cause of morbidity and mortality in peri and post menopausal women. So how do we protect ourselves? By knowing and addressing our risk factors. These include:
- High blood pressure. Check your BP at home yourself (your local pharmacy will likely sell automated home BP check devices), at your pharmacy, or with your practice nurse or GP.
- High cholesterol: Have your level checked by blood test with your GP or practice nurse.
- Family History of Heart Disease
- Smoking: check out www.quit.ie for support in quitting
Female Specific Heart Disease Risk Factors:
- A past history of endometriosis, pre-eclampsia (high blood pressure during pregnancy) or gestational diabetes (high blood sugars during pregnancy). If you have any of these risk factors for heart disease you will need closer monitoring of your blood pressure, cholesterol and blood sugar levels.
- PCOS
- Early Menopause
- Premature Ovarian Insufficiency
- Endometriosis
- Autoimmune disease (more common in women)
- Premature delivery of a baby or stillbirth
- Interestingly, and sadly, I learned at a cardiology conference recently that domestic violence also increases risk of heart disease in women.
- Women who experience severe hot flashes are at higher risk of heart disease than women who have milder symptoms
We can reduce our risk by maintaining a normal blood pressure, a normal cholesterol level, getting regular cardiovascular exercise and eating a balanced diet. If you have high blood pressure or cholesterol, it would be worth linking in with a registered dietitian to speak with them about specific dietary measures to address these concerns.
Bone Health
Osteopenia (weak bones), sarcopenia (muscle “wasting”) and osteoporosis (brittle bones) may creep in during peri and post menopause. Whenever I talk about this I feel like it falls on deaf ears. I guess because we can’t see our bones? It’s hard to care about and conceptualise a problem when we can’t visualise it. But it’s SO important to take care of your bones and muscles. Having osteopenia and osteoporosis puts us at increased risk of falls and fractures. This sounds pretty benign but a fall later in life is often life threatening; I’ve seen it all to often in my work as a junior doctor. Older adults often fall at home, can’t get up due to weakness, may be discovered days later. This “long lie” must be psychologically agonising. Once in hospital, recovery is often long, requiring weeks of rehabilitation, particularly in the case of hip fractures. Some older adults never make it back home due to never recovering to their baseline agility. It’s not uncommon for patients to require transfer to nursing home care after a severe fall and fracture.
Ok, that’s the extreme end, but what about the less extreme end? A wrist fracture after a fall on an outstretched hand. This won’t result in hospitalisation but it will certainly curtail your independence and day to day functioning! Then there’s the kyphosis or hunching over of the spine and loss of height that can occur in osteoporosis of the spine.
Now that I’ve hopefully convinced you to care about your bones matter, how do you mind them? Firstly, get weight bearing exercise in to your routine. Take Vitamin D and ensure you’re getting enough calcium in your diet. Also speak with your doctor about getting a DEXA scan. I had mine done last year at age 37. Maybe a but too early but those years as a registrar on the Care of The Older Adults team left a lasting impression of the importance of bone health on me!
Other important measures for bone health include reducing alcohol intake and quitting smoking. People who are on long term oral steroids are at higher risk so will need earlier monitoring.
Exercise
Incorporating movement in to our routine is important at all stages of life but during and after menopause it’s particularly important. Cardiovascular exercise can help to reduce blood pressure and thus lower risk of heart disease associated with menopause. Maintaining a normal blood pressure is one of the single most important things women can do to improve life expectancy. It can help to reduce risk of a type of dementia called vascular dementia too.
Resistance training can strengthen muscles and bones, reduce sarcopenia (muscle wasting), osteopenia (weak bones) and osteoporosis (brittle bones) all of which contribute to increased risk of falls and fracture (I won’t get in to my falls and fractures rant again!).
Exercise also helps to prevent constipation, improves our mood and sleep. It’s win win win! Bonus points for exercising with a friend of family member as friendships, relationships and connection are also key for our longevity.
As mentioned above, 150 minutes of brisk walking a week can offset the increased risk of breast cancer associated with combined HRT.
Supplements
Check out our Menopause bundle for the best supplements to take to support your healthy journey through the menopause, these are Omega 3 Fish Oils, Magnesium and Vitamin D3.
