Menopause – quick recap
Menopause is natural time in a woman’s life, typically over the age of 45 years, where she has not had her periods for 12 months. This is in the absence of anything artificially stopping your periods.
Perimenopause is the time leading up to menopause. This varies in women – some may have perimenopause lasting for years, whereas, some for a few months. It is characterised usually by changes in periods (i.e., your periods may be lighter, shorter duration, closer together or further apart) and can be accompanied by menopausal symptoms.
Post-menopause is the time after your menopause.
These changes leading to perimenopause, menopause and post-menopause are due to decreasing oestrogen levels and since there are many areas in the human body that oestrogen impacts, you may experience a range of symptoms. The commonest symptoms tend to be:
- Changes in periods
- Hot flushes
- Night sweats
Slightly more infrequent symptoms may be:
- Mood changes
- Hair and skin changes
- Poor sleep
- Brain fog
- Memory problems
- Vaginal and urinary symptoms
- Lack of libido
- Joint pains
- Muscle aches
- Dry eyes, dry mouth
Diagnosing menopause is based on your symptoms, changes in menstrual cycle pattern and your age. You usually do not need any blood tests or investigations.
Treatments available for menopause
First and foremost, each and every woman going through menopause has a different experience. There are many factors impacting the nature and severity of your menopause. These include your socioeconomic, education and socio-cultural background, other existing physical and medical conditions, such as smoking, dietary habits, activity levels and body mass index (BMI).
It is thus extremely important to approach menopause in a holistic and individualised manner, especially when considering treatment.
Many women who experience troublesome menopause symptoms may be able to positive influence their symptoms by lifestyle modifications, whereas some may require medications or alternative therapies. Your doctor will discuss this with you thoroughly and advise accordingly.
In this article, we highlight some of the common treatments for perimenopause / menopausal symptoms and the up-to-date evidence behind them.
Hormone replacement therapy (HRT)
Hormone replacement therapy (HRT) is the first line recommended treatment for perimenopausal / menopausal symptoms. It has been shown to be most effective in managing vasomotor symptoms (hot flushes), low mood/anxiety. The aim of HRT is to replace the hormones that the body ceases to produce during menopause, mainly oestrogen.
HRT can be given as oestrogen alone or together with progestogen, known as ‘combined HRT’. Only women who have had complete hysterectomy (removal of the whole womb including the cervix) are suitable for oestrogen alone therapy.
HRT can be given in many different ways – orally as a tablet, transdermally as patches or gel, subcutaneously as an implant injected under the skin to provide slow release over several months. Furthermore, for women mainly affected by vaginal or urinary symptoms, they can be prescribed oestrogen as a small vaginal tablet, cream or vaginal ring. This ‘local’ application of oestrogen can be used for as long as symptoms are present.
Your doctor will have an in-depth and individualised discussion with you about the decision to start HRT, how long to take it for and the required dose. They will help you understand the short- and long-term benefits and risks of HRT.
Apart from the benefits of HRT for controlling menopausal symptoms, research has shown HRT can improve quality of life and have a positive effect on cardiovascular health and bone health for women. There is also evidence to show HRT can be protective against diabetes, colon cancer, possibly dementia and mental health problems.
The risk of HRT and breast cancer has been widely discussed. Essentially, oestrogen alone is associated with little or no change in the risk of developing breast cancer. Whereas, the combined HRT can be associated with slight increase in the risk of breast cancer. However, this risk is still very low and comparable to other risk factors, such as smoking, alcohol intake and obesity. Furthermore, there has not been any study to show that there is an increase in mortality when taking HRT.
There is also an associated increased risk of developing blood clots and possible stroke with oral HRT. This increased risk is only with oral HRT. Transdermal HRT (patches, gels) do not carry this increased risk and are safe to use in women who may be at a higher risk of developing blood clots or stroke.
The risk and benefits of HRT should be contextualised to the individual depending on their age, personal and medical background, family history and type of HRT given.
Testosterone replacement in menopause
Many women believe that testosterone is a ‘male’ hormone. However, premenopausal women produce both testosterone and oestrogen.
As we age, like other hormones, testosterone levels tend to decline as well. But this does not mean that testosterone needs to be replaced in every perimenopausal / menopausal woman. Research has shown that many women with systemically low testosterone levels do not have distressing low libido or other related symptoms.
Recent guidance recommends that once a complete biopsychosocial assessment of women with low sexual desire has been completed and conventional HRT has been tried, a trial of testosterone supplementation may be beneficial. There are associated side effects to testosterone therapy, such as excess hair growth, acne and weight gain. Most of these side effects usually stop with a reduction in dose or stopping the medication altogether. There is currently not enough data to assess the long-term effects of testosterone on cardiovascular health and breast disease.
Many women often ask about ‘bioidentical’ hormones and often consider these as a safer alternative to HRT.
The term bioidentical hormones mean hormones that have a similar chemical structure to the hormones produced by human ovaries. The benefit of taking these over non-bioidentical or synthetic alternatives is that they have a more neutral effect on the risk of blood clots and a lower risk of breast cancer. These ‘bioidentical’ hormones are available in the form of estradiol and certain types of progesterone in HRT and these can be prescribed as part of HRT therapy. These hormones are subjected to rigorous scrutiny by regulatory bodies.
These hormones must be distinguished from compounded ‘custom-made’ bioidentical hormones, which are often promoted as being matched to an individual’s requirements after hormone testing. However, such hormones do not go through stringent safety and regulatory checks. There is no evidence to support the safety or efficacy of these products and their use is not supported by most Menopausal societies.
If you do prefer to opt for bioidentical hormones, please discuss this with your doctor who can advise you the best form of medication most suited and appropriate for your use.
Complementary & alternative therapies
There are several complementary and alternative therapies that may help women with bothersome menopausal symptoms. These include acupuncture, aromatherapy, herbal treatments, homeopathy, yoga and reflexology.
Some women find these useful, especially if they do not wish to take HRT or are unable to take HRT. However, more research is needed to assess the effectiveness of such therapies.
Furthermore, alternative therapies may not be a safer alternative to HRT. Similar to compounded bioidentical hormones, there is often a concern for the quality, purity and constituents of some herbal products. Products containing phytoestrogens contain oestrogenic properties and hence, the risks associated, with breast cancer for example, are unknown.
Several herbal products, such as St John’s wort, have significant interactions with other medications you may be taking. Therefore, a thorough discussion of such therapies should be undertaken together with your doctor.
Non-hormonal medications for menopausal symptoms
If a woman does not wish to or is unable to take HRT, there are a few other medications that can be used to relieve menopausal symptoms. These include such as SSRIs / SNRIs (selective serotonin reuptake inhibitors / serotonin noradrenaline reuptake inhibitors) and other pain-modulating medications (gabapentin, pregabalin).
These medications may be useful in helping women with hot flushes, night sweats and improving sleep quality. However, they are not as effective as HRT and have their own side effects profile.
Cognitive Behaviour Therapy (CBT)
Hot flushes, night sweats and hormone changes have an inter-twined and complex relationship with stress, anxiety, low mood and sleep disturbances.
Cognitive behaviour therapy (CBT) has been shown to improve anxiety, low mood and sleep disturbances for perimenopausal, menopausal and postmenopausal women.
CBT has also been found to be effective in the management of hot flushes and night sweats in three clinical trials and it is recommended as a non-hormonal treatment option for hot flushes and night sweats.
CBT can be performed by using self-help books with some guidance and through a licensed therapist as well.
Menopause is a natural and normal event in every woman’s life. While some women may not find their symptoms bothersome, others may have a completely different experience. Approaching menopause and the care of menopausal women needs a very personalised and individualised approach. We, at Osler Health International, understand this and pride ourselves in delivering this bespoke care to each one of our patients.
- NICE Guidelines Menopause (published November 2015, updated December 2019)
- The British Menopausal Society
- Women’s Health Concern
- Women’s Health Initiative
- Royal College of Obstetricians & Gynaecologists UK (RCOG) Menopause guidelines
- Hamoda H, Davis SR, Cano A, et al. BMS, IMS, EMAS, RCOG and AMS joint statement on menopausal hormone therapy and breast cancer risk in response to EMA Pharmacovigilance Risk Assessment Committee recommendations in May 2020. Post Reproductive Health. 2021;27(1):49-55.
- Langer RD, Hodis HN, Lobo RA, Allison MA. Hormone replacement therapy – where are we now? Climacteric. 2021 Feb;24(1):3-10.
- Shan D, Zou L, Liu X, Shen Y, Cai Y, Zhang J. Efficacy and safety of gabapentin and pregabalin in patients with vasomotor symptoms: a systematic review and meta-analysis. Am J Obstet Gynecol. 2020 Jun;222(6):564-579.e12.