Some women start to experience perimenopause with symptoms including hot flushes, sweating (especially at night), disrupted sleep, mood changes, poor sex drive, irritability, rage, anxiety, poor memory, and cognitive decline.
As women move deeper into the perimenopause, issues to do with declining collagen levels arise – for example, weakness of the pelvic floor (and incontinence), and skin, hair and nail quality may also be affected. The elasticity of the vaginal wall may disimprove (vaginal atrophy) as time goes on, so that exercise and sex are less comfortable.
Britain’s National Institute for Health and Care Excellence (NICE) guidelines (available at www.womens-health-concern.org) affirm that the diagnosis of perimenopause is primarily a clinical one.
Sex-hormone blood tests are only supported for women under 40-45 years of age when a diagnosis of premature ovarian failure is suspected, or for women over 50 years of age to help identify the end of contraceptive need.
Many women experience perimenopausal symptoms long before their final menstrual period, so it is not uncommon for women to still be having menstrual cycles while going through perimenopause. The one does not exclude the other. It is clearly no picnic – and some women suffer much worse than others.
The worst of the symptoms usually ease off by a woman’s late 50s, but some women continue to have menopausal symptoms well into their mid-60s and beyond. The most efficient and appropriate way to combat the disruptive symptoms brought on by all this menopausal hormonal fluctuation, and then decline, is to medically supplement and stabilise ovarian hormones. This is hormone replacement therapy or ‘HRT’.
There has been much anxiety about the use of HRT and the impact that it might have on the development of breast cancer – as well as the development of thrombosis – but much of the fear was unwarranted. Risks of HRT use were not presented in an accurate way, either by the popular media or even by some of the medical publications.
HRT – why all the fuss?
HRT involves using small doses of usually quite physiological types of ovarian hormones (usually an oestrogen and a progestogen), which supplement and stabilise the fluctuations that occur during perimenopause. Certain symptoms, notably low libido, will require the additional of supplemental testosterone replacement therapy too.
HRT is produced by pharmaceutical laboratories – the higher-quality oestrogens are frequently derived from natural sources, such as soya or Mexican yam. One brand of oral oestrogen is derived from an extract of pregnant mare’s urine, namely, Premarin.
The higher quality oestrogens come in oral tablets, transdermal gels, patches and sprays, and there is even an intranasal oestrogen spray. Progestagens are available as oral tablets, vaginal pessaries, in a transdermal patch, or via the 52mg levonorgestrel intra-uterine device, Mirena.
HRT was prescribed liberally in the western world from 1970s, and users derived great benefit from it. The situation changed in 2002 though, when a study from the USA created concern about a possible link between using HRT and increased breast cancer.
The Women’s Health Initiative (WHI) was commissioned by the US Government’s National Institute of Health (NIH) and explored strategies to prevent morbidity and mortality in older women. They were particularly keen to see what factors affected heart disease and cancer rates.
In excess of 16,000 women were recruited to the HRT arm of the study. These were almost all over 55 (median age was 63), and they were either offered oestrogen alone (Premarin) if hysterectomised; Premarin plus 2.5mg of medroxyprogesterone acetate (MPA) – known as Prempro – if they had a uterus; or a placebo.
Initially, no difference in breast cancer detection was seen within the three groups but, after the first five years, a slight increase was noticed in the number of breast cancers found in the women on the Prempro product versus the placebo and the Premarin. The Premarin-alone group actually reported a reduction in breast-cancer diagnosis after five years.
The extra numbers seen in the oestrogen plus progestagen (Prempro) arm were small, and did not reach statistical significance. The reported relative risk increase in breast-cancer detection was quoted as 1.26 times background – which is about the same increase in breast-cancer detection associated with women who drink one large glass of wine a day, and almost half the relative risk increase associated with women who are overweight or obese.
There was no suggestion that the HRT was creating new cancers. The authors chose to halt the Prempro arm of the study until more information was gathered but, sadly, things took an unfortunate turn when some of the authors published the data relating to breast cancer without discussing it with other lead authors.
Their article in the Journal of the American Medical Association was very alarming in its tone (attracting much criticism), reporting “a marked increase in breast cancer” among the HRT-using group. The popular newspapers picked up their story and terrifying headlines quickly appeared in most major publications, causing hundreds of thousands of women to abruptly stop their HRT.
Some women coped well without the hormones, but others saw their symptoms return with a vengeance and were too scared to seek help. Even when they did ask for advice, they didn’t know who to believe. No matter how much some clinicians tried to reassure patients about the real relationship between HRT and breast cancer, there were just as many other doctors warning patients to avoid it at all costs!
Other associations explored by the Women’s Health Initiative (WHI) study looked into the impact of oestrogen on women with established ischemic heart disease. WHI data seemed to suggest an early increase in ischemic event risk – particularly heart attack and stroke – but once a patient was established on HRT for approximately 6-12 months, the incidence of heart attack and stroke was reduced (implying protection from the HRT).
We now understand that this is linked to the use of oral oestrogens principally, which can promote blood clotting and may destabilise plaques. We know from more recent studies that transdermally delivered oestrogens, when used in modest doses, do not have this impact.
In 2015, NICE published a review of menopause care and HRT, which reaffirmed what menopause doctors had been saying all along: if your patient is suffering and needs HRT to control troublesome perimenopausal symptoms, she should feel confident to use it, and you should support her in her choice.
They pointed out that most women who need HRT are well under the age of the subjects in the WHI study; the products we are encouraged to use now are much more physiological in effect; and, in most cases, the benefits outweigh risk. An individualised approach to prescribing was encouraged, and many GPs enjoyed an increased confidence in offering HRT.
We have also noticed an increasing number of women willing to talk about their symptoms and consider HRT use since the NICE guidelines were published. Having said that, not every woman with menopausal symptoms will choose to use HRT – it is entirely discretionary.
Alternatives to HRT
Women who won’t or can’t consider HRT may use over-the-counter vitamin and mineral supplements to help alleviate symptoms. None are proven to be as effective as prescription HRT, but they may help some individual patients.
Alternative therapies for vasomotor symptoms include alpha-agonists, such as Clonidine (an old-school high-blood-pressure medication), the overactive bladder medication Oxybutynin, or one of the SSRIs/SNRIs (selective serotonin reuptake inhibitors/serotonin and norepinephrine reuptake inhibitors), such as Prozac or Effexor. Sadly, relief with these treatments appears to be short-lived, and none is actually licensed for menopausal symptom relief.
Mood problems can be addresses by antidepressant medications, of course, but antidepressants are not the treatment of choice for menopause-related mood disorder, according to NICE. HRT, however, is recommended by NICE for menopausal mood changes.
Vaginal moisturisers and lubricants are available that may help improve the symptoms of vaginal dryness and discomfort that plague some menopausal women, but prescription vaginal oestrogen preparations are also readily available, and are extremely safe to use – no studies have ever shown vaginal oestrogen to have any effect on breast-cancer rates.
Menopause at work
The number of older women in employment is higher than ever before and employers would do well to address the changing needs of their employees going through ‘the change’. Simple awareness on the part of human resources can make a big difference.
Hot flushes and sweating will be harder to cope with in an office environment where the temperature is set too high or personal fans are prohibited. Heavy menstrual bleeding and flooding will be tricky to negotiate when your workplace limits toilet breaks, and so on. There are many companies offering menopause awareness training for staff and employers.
Look it up
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