The Menopause and Hormone Replacement Therapy:

The menopause describes the time when a woman stops having periods. This happens at an average age of 51 years, but can occur several years earlier or later and does tend to follow a family trend, ie. if your mother has gone through the menopause at a much earlier age, it is more likely that you will also have an earlier menopause. In addition to periods stopping, there are lots of other symptoms which can occur around the time of menopause. The menopause occurs because the ovaries gradually produce less and less of a hormone called oestrogen and it is the reduction in this hormone that leads to menopausal symptoms. The severity of symptoms varies from woman to woman and some women can find it quite a distressing time. The menopause is also a time that often coincides with other life changes, such as children leaving home (the 'empty nest' syndrome) and this can contribute to the stress experienced.

What sort of symptoms can I expect during the menopause ?

As mentioned above the severity of symptoms varies from person to person and some women will barely notice the changes, whereas others will have far more significant symptoms.

Vasomotor Symptoms:

Hot flushes and/or night sweats, the so-called 'vasomotor symptoms' are a common reason for women seeking help with the menopause.

Hot flushes are experienced by roughly three quarters of women who are going through the menopause. These are very variable in severity and can last from a few minutes to over an hour. Many women notice the onset of flushes long before there is any change in their menstrual periods and some women carry on being troubled by flushes for several years.
Night sweats are also very common and can prove very troublesome, with some women waking up several times a night drenched in sweat and having to change nightwear and bed clothes.

Psychological Symptoms:

These too vary from woman to woman but the commonest symptoms experienced include lethargy, lack of energy, difficulty in concentrating, mood swings and irritability. Women also often feel that they are not coping as well with general day to day life as they did previously. Low mood or depression is also more common around the time of the menopause and can contribute to difficulties in coping with the other physical and psychological symptoms.

Other Physical Symptoms:

Several physical changes to the body are associated with the menopause in the longer term.
Irritation around the vaginal area is extremely common and can be quite distressing. This tends to happen because the vaginal skin becomes much thinner and drier when oestrogen levels fall. The poor quality of the skin around the vaginal area also predisposes women to the development of infections, such as thrush. Intercourse can also become very uncomfortable and artificial extra lubrication may be required.
Some women also notice bladder symptoms as the muscles and other tissues around the pelvic area become thinner and less supportive. These can include mild incontinence on coughing or sneezing (stress incontinence), sudden onset of an urgent need to pass urine, sometimes with resulting incontinence if a toilet can not be reached quickly enough (urge incontinence) or recurrent urinary infections and cystitis symptoms.
In addition to changes in the skin around the vagina, the skin generally can become much drier and less elastic. Some women also notice thinning of the hair and a change in its texture.
The hormone oestrogen has a protective effect on the blood vessels, but as levels drop following the menopause, women become more prone to heart disease. Healthy eating and exercise therefore become all the more important during and after the menopause, particularly if there is a family history of heart disease.
One of the main physical consequences of falling levels of oestrogen in women is osteoporosis. This occurs at different rates and to different extents in women but gradually, over a period of years, bone is lost and women become increasingly susceptible to fracturing or breaking bones. The hip, wrist and back bones are particularly vulnerable to osteoporosis and this is a major cause of hospitalisation and ill-health in elderly ladies. There are various ways you can reduce your risks of developing osteoporosis (see osteoporosis).

Is there a test to show I'm becoming menopausal ?

Because the menopause often spans several years and varies from woman to woman, it can sometimes be difficult to establish when the actual onset is. Many symptoms, such as flushes, can start some time before the periods actually stop and some women may only initially experience psychological symptoms such as mood swings and irritability. Most of the time, the onset of the menopause is based upon the presence of symptoms and/or stopping of periods. In some women, however, it may be useful to take a blood test. It is not possible to accurately measure falling oestrogen levels but various other hormone levels in the blood rise as oestrogen falls and this can be an indicator of the menopause.

Blood tests can be particularly useful in women who have previously had a hysterectomy and who therefore no longer have periods to provide reassurance that they are not, as yet, through the menopause and therefore needing to consider measures to help prevent osteoporosis. When the womb is removed before the natural menopause, even though the ovaries are left in place, women quite often go through the menopause earlier than average. If the ovaries are removed with the womb then menopausal symptoms will develop soon after operation.

What treatments can help menopausal symptoms ?

There are lots of general measures that a woman can undertake to help alleviate menopausal symptoms. A healthy diet, which of course is advisable at any age, becomes even more important during the menopause. A diet which is low in fat and cholesterol helps to reduce the risk of heart disease and calcium in the diet helps to maintain the bones. Exercise is also important. Regular, moderate exercise (such as a brisk walk every day) helps to keep the heart healthy.

The only definitive treatment for the menopause is to replace the hormones which are dwindling. This takes the form of Hormone Replacement Therapy (HRT). Several different forms of HRT are available, eg tablets, patches or implants which are inserted under the skin -usually around the abdomen - and replaced every few months. There are also various creams available which contain oestrogen and can be used in the vaginal area to help with local symptoms from thinning and dryness of the skin. Different forms of HRT are prescribed for individuals depending on the woman's own personal circumstances. Those women who have had an hysterectomy (womb removed) can safely take oestrogen alone. Women who still have their womb need to take a further hormone called progesterone in addition to oestrogen in order to protect the lining of the womb from the effect of oestrogen alone.

The majority of HRT which contains both ('combined HRT') oestrogen and progesterone leads to a monthly withdrawal bleed - to all intents and purposes, a 'period'. However, in certain circumstances, particularly in older women and those who have not had a period for more than a year, there are different forms of HRT which can be taken which do not cause periods (so-called 'period-free' HRT or 'continuous combined' HRT).

What are the advantages of taking HRT ?

The main benefit most women find is that HRT helps to alleviate physical symptoms such as flushes and night sweats as well as the psychological symptoms, eg, mood swings and irritability. Such symptoms often (although not always) improve surprisingly quickly as oestrogen levels increase - many women find that within a few weeks the flushes and night sweats subside and any vaginal dryness or irritation tends to improve. Other longer term benefits of HRT include a possible reduction in the risk of heart disease and also, very importantly, women who take HRT for at least 5 years will have a reduced risk of osteoporosis.

Disadvantages of HRT:

Although HRT has many benefits as mentioned above, there are also risks to consider. Various research studies have demonstrated a small increase in the risk of breast cancer in women taking HRT for longer than 5 years. This increased risk is very small but must be taken into consideration particularly if there is a family history of breast cancer.

Relationship of HRT to Breast Cancer Development:

Time on HRT	Breast cancers over the 20 years from 50-70 years	Extra breast cancers in HRT users	Individual risk of women over 20 years
Never	45 per 1000	-	1 in 22
5 years use	47 per 1000	2 per 1000	1 in 21
10 years use	51 per 1000	6 per 1000	1 in 19
15 years use	57 per 1000	12 per 1000	1 in 17-18

HRT has also been shown to increase the risk of clots in the veins (deep vein thrombosis). About 3:1000 women in HRT will have a problem with thrombosis compared to 1:1000 women not on HRT. There is also a very small increase in the risk of cancer of the womb lining, but this is negligible as long as progesterone is taken along with the oestrogen (see above).

Some women also experience side effects from HRT, especially when they first start it. These can include nausea, pains in the legs or leg cramps, also breast fullness and tenderness. The majority of these side effects will subside over the first month or two if treatment is continued. Occasionally headaches become more of a problem whilst HRT is being taken. Many women often feel they gain weight whilst on HRT. Research has shown, however, that HRT itself does not cause a significant increase in weight but a general improvement in wellbeing resulting from HRT reducing the distressing symptoms may lead to a 'healthier' appetite and subsequent weight gain. It's worth being aware that half of women in their menopausal years will gain weight anyway, regardless of whether they are taking HRT or not. A further side effect seen in some women using HRT patches is local irritation or redness of the skin where the patch is applied.

Can anyone take HRT ?

Most women can quite safely take HRT. However, there are a certain number of conditions in which it is not recommended. Women who have had a thrombosis or blood clot in a vein may not be able to take HRT because of the increased risk of this recurring. In some instances it is possible to perform certain tests on the blood to see how it clots and if these are satisfactory, it may be possible to prescribe HRT despite a history of thrombosis. Women who have significant liver disease should not take HRT and also those who are suffering from breast cancer or cancer of the womb. Again, each case is individual and certain women who have had their womb removed for an early cancer of the lining may still be able to take HRT. However, this is something which needs to be discussed in detail with your doctor or gynaecologist.

How long should I take HRT ?

Many women only continue HRT for a year or two until they are beyond the worst of their symptoms, eg flushing or night sweats. However, in order to gain the protective benefits against osteoporosis, HRT should ideally be taken for between 5-10 years.

What about contraception if I take HRT ?

Many women begin taking HRT in their mid- to late-40's mainly for flushing and sweats and whilst they are still having fairly regular periods. It is particularly important to remember that during this time it is possible to conceive and precautions must therefore be taken against pregnancy. There are various options available as far as contraception is concerned, such as barrier methods or a coil (IUD) and these can be safely used whilst taking HRT. It is worth having a chat with your doctor about the most suitable form of contraception for you if taking HRT. Your doctor will also be able to advise you on the appropriate and safe time to stop using contraceptive measures.

In summary, the menopause can be a very difficult time for women involving a combination of physical and psychological symptoms. HRT can help to alleviate a lot of these symptoms but it must be remembered that it is not a miracle cure and some women find it more useful than others. Many women choose to tolerate the symptoms rather than replace hormones. As mentioned earlier, a healthy lifestyle as regards diet and exercise are important measures to consider along with the possibility of HRT.

Disclaimer: This page is for informational purposes only and should not be considered as medical advice or substituted for professional advice. Always consult your doctor with your questions and concerns.