Menopause

Menopause is the time when menstruation permanently ceases.  Menopause rarely occurs suddenly. The months preceding are typically associated with irregular menstrual periods of differing severity and duration. Heavy bleeding is not uncommon. Other symptoms are hot flushes, sweating, vaginal dryness, forgetfulness, loss of sexual libido, emotional lability, irritability and lowering of the mood. At the menopause the fall in oestrogen is associated with a reduction in the density of the bones (which can result in osteoporosis).

Why does this occur?

This is due to failure of the ovaries to produce ‘eggs’ (follicles). The process of egg loss (known as ovarian follicle atresia) actually begins before birth (when the female baby is in the womb) and continues relentlessly throughout adult life until there are few functional follicles remaining at the time we recognise as the menopause. This usually occurs at the average age of 52 years but in some this can be much earlier (known as premature menopause) and some later (delayed menopause).

Yes. The doctor can measure the level of the female hormone oestrogen which is low and the hormone FSH which is elevated.

There are three major forms of medication;
1. Hormone-Oestrogen replacement e.g. HRT
2. Medication specifically for symptoms e.g. tibolone
3. Selective oestrogen receptor modulation (SERM)

Hormone replacement therapy or HRT, as the name suggests, is a means of continuing to provide oestrogen (the female sex hormone) after its production by the ovaries has started to fail.

There is currently a bewildering range of HRT products available. Numerous brands of this type of medicine are available and in a variety of forms (tablets, patches, gel) but essentially HRT can be classified into three basic types. These are:

. 1. Preparations which contain oestrogen-only; these include:

Preparations which contain oestrogen-only are appropriate for women who have undergone a prior hysterectomy (surgical removal of the womb). If however the womb (or uterus) is intact, it is necessary to give a second hormone in addition to oestrogen called a progestogen. Progestogens prevent the tendency for oestrogens to cause the uterus to enlarge which in turn is thought to be associated with a slightly increased risk of cancer of the womb.

2. Preparations which contain an oestrogen plus sequential progestogen; these include:

Preparations which contain an oestrogen plus sequential progestogen are favoured for women around the time of the menopause. They are intended to produce a "more natural" cycle of oestrogen and progestogen production and so predictably they will cause bleeding similar to a regular period. This may not be acceptable for older women for whom preparations which contain an oestrogen plus continuous combined progestogen may be preferred. The latter are often used for women who have not had a "natural" period for at least one year. A switch from sequential to continuous combined HRT is usually possible after 1-2 years or after the age of 54 years.

3. Preparations which contain an oestrogen plus continuous combined progestogen; these include:

HRT can be taken as tablets by mouth on a cyclical or continuous basis or applied to the skin every 3-4 days in the form of adhesive patches from which the medicine is gradually released, or if oestrogen-only is appropriate, as a gel which is massaged into the skin. Given the huge range of products that is available it is usually possible to find one that will suit most people and this is the basis on which they are chosen. It is not possible to describe each product in detail here but all are accompanied with easy to follow instructions and the package insert should always be consulted when commencing HRT. If in doubt, seek advice from your Pharmacist.

Besides reducing the symptoms of menopause especially the flushing and vaginal dryness, HRT prevents the normal post-menopausal reduction in bone density which can result in osteoporosis. HRT will reduce the risk of fractures in such circumstances.  It can cause problems in women who already have heart disease and therefore may need to be used with caution in such patients.  However one must emphasise that HRT does not substitute for other healthy lifestyle measures such as exercise, weight control, healthy diet and non smoking all of which prevent cardiovascular disease in women. HRT may also delay the age of onset of the dementing disease Alzheimer Dementia in those who may be susceptible to this condition.

This has been a very controversial issue ever since the use of HRT became widespread. Although it is accepted that HRT does increases the risk of blood clots forming in the veins compared with non-users of HRT, it is estimated that this is likely to account for only 1 extra case per year of deep vein thrombosis for every 5,000 HRT users. Clearly other factors which increase the risk of blood clots such as obesity, immobility and smoking must also be taken into account when assessing the overall risk. If there has previously been a case of thrombosis this will be of concern but there is no evidence that the presence of varicose veins (which are very common) should prevent anyone taking HRT.

The risk of deep vein thrombosis and therefore blood clots on the lung has been the subject of recent research where the combined oestrogen/progesterone HRT pill was associated with an extra 8 serious blood clots for every 10,000 women treated for 5 years.

Withdrawal bleeding apart (which occurs with sequential combined products, see above), there may be unexpected bleeding or spotting when other HRT preparations are first used. Only occasionally does this persist or is seen as a problem in which case an alternative HRT product can be tried. In any event your Doctor should be informed so that he or she can investigate further, if necessary. It is a good idea to keep a diary of such events so that your Doctor can assess the problem from time to time.

This has received a great deal of publicity in the media in the past and women are understandably concerned given the incidence of breast cancer in the United Kingdom. Large studies which have been undertaken in an attempt to assess the risk of breast cancer in women who take HRT have failed to confirm anything other than a slightly increased risk after 5 or more years of continuous use. The risk would appear to be an extra 8  women develop breast cancer out of 10,000 when treated with the combined pill for 5 years. There is therefore a need for regular breast screening including self-examination of the breasts for the appearance of lumps. However breast lumps are much more common than breast cancers and your doctor will frequently be able to re-assure you should you find them. You should pay special attention to regular breast checks if you have had problems with breast lumps in the past.

Although the risk of breast cancer continues to receive a great deal of publicity in the press and on television, what is often overlooked is the considerable benefits that HRT brings in relation to reducing the risk of bone fractures.

This is not uncommon in users of HRT and will often go unnoticed. It is not an indication of any underlying problem but if you have kidney or heart problems or suffer from high blood pressure, your doctor may wish to keep a close check on these conditions from time to time.

Recent evidence suggests that HRT does not prevent heart disease and may actually increase the risk in the first year of use. In the 5 year study of treatment of 10,000 women with the combined HRT pill an extra 7 women developed heart disease than would be expected for their age, an extra 8 had a stroke BUT 6 fewer developed colorectal cancer a 5 fewer suffered a hip fracture.

Stomach upsets including nausea, vomiting, abdominal pain and liver problems have been encountered and may be a reason for switching from tablets to patches. Breast tenderness or breast engorgement may also occur. Skin conditions may occur or deteriorate if already present.

It is stated in Patient Information Leaflets which accompany HRT products that conditions such as multiple sclerosis, systemic lupus erythematosus, porphyria, melanoma, epilepsy, migraine and asthma may worsen on HRT. Some of these conditions are rare but if you suffer from them you will be all too aware of what they are. The important point is to recognise that HRT is a replacement for oestrogen which is a natural hormone anyway and there is no known reason why such conditions should get worse. Do not therefore assume that your condition will be affected but do consult your Doctor if you believe that this has happened. It may be necessary to discontinue treatment in some cases.

An adjustment of anti-diabetic medication may be required when HRT is commenced. Occasionally a change in glucose tolerance (your diabetes control) may occur.

It is likely that if you have fibroids in your womb or endometriosis that HRT will cause further problems. Seek medical advice if you are uncertain about this.

It is stated in Patient Information Leaflets which accompany HRT products that conditions such as multiple sclerosis, systemic lupus erythematosus, porphyria, melanoma, epilepsy, migraine and asthma may worsen on HRT. Some of these conditions are rare but if you suffer from them you will be all too aware of what they are. The important point is to recognise that HRT is a replacement for oestrogen which is a natural hormone anyway and there is no known reason why such conditions should get worse. Do not therefore assume that your condition will be affected but do consult your Doctor if you believe that this has happened. It may be necessary to discontinue treatment in some cases.

An adjustment of anti-diabetic medication may be required when HRT is commenced. Occasionally a change in glucose tolerance (your diabetes control) may occur.

It is likely that if you have fibroids in your womb or endometriosis that HRT will cause further problems. Seek medical advice if you are uncertain about this.

The effectiveness of HRT in tablet form may be reduced by concurrent use of some anti-epileptic medicines including barbiturates, phenytoin (EpanutinÒ ) and carbamazepine (TegretolÒ ) all of which may increase its metabolism (breakdown) by the liver. Your Doctor or Pharmacist can advise you.

HRT preparations should be kept in the packs in which they are supplied i.e. tablets in blister calender packs, patches in individual sachets. The dosing instructions are set out in detail for combined (oestrogen plus progestogen) preparations. If you forget to take your tablets on any one day, ignore these and continue your treatment according to the calender pack on the following day. All products are stored at room temperature.

Conventional medicines for relief of symptoms are clonidine (DixaritÒ ) and Tibolone (LivialÒ ). Clonidine acts centrally to reduce hot flushes but may not be effective in some women. Tibolone combines oestrogenic and progestogenic activity with weak androgenic activity and is used specifically for the treatment of the vasomotor i.e. flushing type symptoms associated with the menopause as well for the prevention of osteoporosis. It is given continuously. Side effects include weight change, ankle swelling, dizziness, headache, vaginal bleeding, gastrointestinal symptoms, some increased facial hair, depression, joint pains and in some an allergic rash.

The major medication available is Raloxifene (EvistaÒ ). Raloxifene is a selective oestrogen receptor modulator (SERM) with oestrogen like beneficial activity on bone preventing the development of osteoporosis due to the lack of oestrogen at the menopause. Raloxifene reduces cholesterol concentration and may reduce the risk of heart disease.  Raloxifene does not stimulate the endometrial womb lining and is thought to pose no threat of womb cancer. Also raloxifene possesses anti-oestrogenic effects on the breast and not only prevents but actually decreases the risk of breast cancer in those who have an inherent susceptibility. However, raloxifene does not appear to relieve the vasomotor (flushing) symptoms of menopause or relieve vaginal dryness, so is not used for this purpose. Indeed after starting Raloxifene there may be a period of time where flushing symptoms get worse.  Some authorities use HRT for the first 5 years to relieve the menopausal symptoms and then switch to SERM to reduce the risk of breast cancer.

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Ó NHS Tayside; 2006; version 1.0

Disclaimer; no liability whatsoever is accepted for information given and all such information, especially with regard to drug usage (UK version provided), must be checked with a person’s health provider.