Hormone treatment for the menopause is now much more complex than simply giving oestrogens for hot flushes, sweats and vaginal dryness as there are many new developments to deal with specific problems and to improve acceptability and continuation therapy.
The menopause occurs because the ovaries of a woman are no longer able to produce hormones, oestrogen being the most important. As a result, the periods stop and the loss of oestrogen leads to a variety of symptoms has long term health consequences, with an increased risk of heart disease, osteoporosis and dementia.
The average age of the menopause is 51. However the ovaries may produce reduced quantities of oestrogen in the years leading up to the menopause when the woman may still be experiencing regular periods, though very often the periods can become irregular at this time. This is sometimes referred to us the peri-menopause or menopause transition.
Sometimes the symptoms are most troublesome in the peri-menopause but may not be recognised as being due to oestrogen deficiency because the woman feels she is too young or because she is still having periods.
Symptoms of the menopause
The symptoms experienced vary from woman to woman; the main symptoms are listed below.
- Hot flushes and nights these are the most common symptoms of the menopause. 80% of women will experience hot flushes and on average last for about 5 years but in some women can last for much longer. They may be relatively minor or very severe area and can disturb sleep when they occur at night,
- Sleep disturbance may be associated with hot flushes and night sweats but quality of sleep can be disturbed even without these associated symptoms,
- Depression and mood changes these can be the most difficult symptoms of the menopause and often not recognised as being menopausal. Patients may therefore not be offered HRT but prescribed antidepressants instead, which do not always help and can exacerbate symptoms such as tiredness.
- Tiredness is common symptom of the menopause and may be exacerbated by sleep disturbances.
- Headaches, headaches tend to become more frequent around the time of the menopause
- Forgetfulness many women experience forgetful and say that they less able to concentrate, which can lead to difficulties in coping with work.
- Vaginal dryness can occur due to thinning of (atrophy) of the vaginal tissue
- Frequency of micturition - caused by atrophy of the urinary tract.
- The skin can become thinner, dryer and loose some of its elasticity as a result of the menopause.
Long term effects of the menopause
Osteoporosis - The bone density declines in both men and women but in women there is a marked increase in the rate of loss of bone density leading following the menopause leading to osteoporosis or brittle bones. This can result in fractures particularly of the hip bone and vertebrae (spine) which can lead to curvature of the spine, sometimes referred to as dowagers hump, loss of height and back pain.
The risk of heart disease increases in women after the menopause because oestrogen is thought to have a protective effect. Women who have a premature menopause are particularly at risk of heart disease.
Benefits of HRT
Oestrogen replacement can help alleviate the symptoms of the menopause improve quality of life, and reduce the risk of developing, osteoporosis, heart disease and possible dementia.
Types of HRT
There are many types of HRT and careful assessment of an individual woman's needs and medical back round will determine the most appropriate type for her. There is no one form of HRT that is suitable for all.
Oestrogen be given orally as tablets but we favour transdermal route using oestrogen gels, patches or implants because this is safer because it avoids the excess risk of thrombosis that occurs with oral oestrogen.
Women taking oestrogen also need to take a second hormone, progestogens for 7-14 days every month to ensure regular monthly bleeds and prevent overthickening of the endometrium or lining of the womb and thereby reduce the risk of endometrial cancer of the womb.
Oestrogen alone will usually alleviate the symptoms of the menopause but sometimes symptoms such as tiredness low moods and loss of libido may persist. In such cases the addition of testosterone can be very helpful.
Risks of HRT
HRT is safe but a number of recently published studies that have been flawed have received much attention in the media and has lead to many women discontinuing HRT. Some of these studies have suggested that HRT can increase the risk of breast cancer and Heart disease but these studies were on women who started HRT for the first time when they were over 60 years of age and up to twenty years after the menopause. More recent studies in women who were in their fifties and within a few years of the menopause indicate that these risks do not apply and there may be reduction in the risk of breast cancer and heart disease especially in women who have had a hysterectomy and only take oestrogen and not oestrogen plus progestogen. This is very important because most women who start HRT do so before the menopause or soon after as this is when the symptoms are most troublesome. It is very unusual for a woman to start HRT for the first time after the age of 60. Some times women do need to start HRT when they are in their 60s and in this cases a lower dose is required.
The symptoms of the menopause can be very troublesome and last for many years. HRT is effective in controlling these symptoms improving quality of life as well as preventing the long-term effects of the menopause. HRT is safe and the benefits far outweigh any risks. However the type of HRT needed should be tailored to the individual woman.