Last partial update: January 2018 - Please read disclaimer before proceeding

 

What is menopause?

Many women find the changes to their body that accompany menopause distressing. Menopausal changes occur due to the normal reduction in the production of the hormone oestrogen from the ovaries. This process usually occurs gradually over a period of several years. Menopause is said to have occurred when the woman has had no menstrual periods for 12 months. This reflects an almost complete cessation of hormone production by the ovaries. Symptoms or menstrual period irregularities usually commence several years prior to the actual menopause and occur for about four to six years. On average in Australia, menopause occurs at 51.5 years, but the normal range is between 45 years and 55 years.

At puberty, women have about 400,000 eggs. With each cycle about 20 to 50 are used up (although only one egg is released) and there is also considrerable general attrition of this number throughout reproductive life. Menopause occrs when the egg supply becomes exhausted.

Premature menopause: Premature menopause is defined as menopause occurring before the age of 40 year. It occurs spontaneously in about 1% of women and in about 5 to 8% of women as a consequence other disease, mostly the treatment of cancers but also rarely in association with autoimmune diseases. In about half of the women with spontaneous premature menopause, some return of ovarian function does occur and they can become pregnant. Thus, all these women still need to consider taking contraception if needed.

Menopause symptoms

The symptoms of menopause vary greatly and are not easy to assess for two reasons. Firstly, there are many symptoms and individual symptoms affect women differently. Secondly, menopause symptoms are often vague and women may therefore not attribute them to menopause. To help overcome these problems, a list of twenty symptoms typically experienced by oestrogen deficient women has been included in the table below. The severity of each of these 20 symptoms can be rated from nought to three depending on the severity felt and adding the scores together. (Nought for no symptom ranging up to three for a severe problem.) The overall severity of menopause symptoms can then be assessed by adding the scores together, giving a range of scores from nought to sixty.

Menopause Symptom checklist

 

Symptom

Score*

Hot flushes

 

Light headaches/ dizziness

 

Headaches

 

Feeling of crawling under the skin

 

Sleeplessness / altered sleep pattern

 

Irritability

 

Depression

 

Feeling of being unloved / unappreciated

 

Anxiety

 

Mood changes

 

Backache

 

Joint pains

 

Muscle pains

 

New facial hair

 

Dry skin

 

Unusual tiredness

 

Less sexual feeling

 

Uncomfortable intercourse

 

Dry vagina

 

Passing urine more often

 

Total score*

 

Each of the above symptoms is rated from 0 to 3, depending on the severity felt by the woman. (0 for no symptom up to 3 for a severe problem.) The scores for all 20 symptoms are then added. A score of over 15 indicates significant menopausal symptoms.

Source: Royal Australian College of General Practitioners ,  CHECK PROGRAM - HRT,  September 1998 .          

 

A score of over fifteen indicates oestrogen deficiency is causing a significant problem for the woman and that treatment of this oestrogen deficiency is likely to give considerable symptom relief. This treatment is almost always a course of hormone replacement therapy.

It is important to realise that menopause symptoms vary in the length of time they persist. Up to 50 per cent of women with significant menopauseal symptoms will not have significant symptoms a year later. In others they will last several years. In all about 65% of women complain of hot flushes (with 25% have them severely); and in over 80% of these women they last for longer than 12 months. Managing menopause is, in the end, all about managing these symptoms. Some women may elect to wait and see how their symptoms progress before deciding to take medication that may cause its own side effects; others will need treatment at the onset of symptoms.

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Treatment options for menopause

Lifestyle modification

Hot flushes can be helped by initiatives such as the use of fans, layering of clothes, avoiding foods that can trigger hot flushes suc as alcohol caffeine and spicy foods. Reducing life stresses and stress management techniques such as meditation and yoga can also be beneficial. Lubricants can reduce pain with intercourse and vulval irritation can be reduced by wearing cotton underwear.

Osteoporosis and cardiovascular disease both increase after menopause and women should be assessed for their risk of developing these conditions and treated if necessary. (See sections on these conditions.)

 

Medication - Hormone replacement therapy

 What is hormone replacement therapy (HRT)?

Hormone replacement therapy (HRT) is simply the replacement of this naturally occurring oestrogen with administered oestrogen supplements. It is given with the aim of relieving the symptoms of menopause in women who are suffering significantly from these symptoms and has been shown to significantly reduce hot flushes in 80% of women suffering from with this problem compared with placebo. It is usually administered with progesterone. (See section on HRT administration.) About 20% of women going through menopause would benefit significantly from taking HRT. While HRT may be beneficial for cardiovascular disease or osteoporosis, it s not recommended as a treatment for these conditions.

Women who have premature menopause should be offered HRT up till the age of 51 years, the average age of menopause onset, unless it is otherwise contraindicated.

HRT and evidence from the Women’s Health Initiative (WHI) Trial

In the past long term HRT has been advocated and used for the prevention of other illnesses such as osteoporosis and heart disease. However, there is now good evidence that such long term uses offer no overall benefit. This evidence came mostly from the findings of the Women’s Health Initiative (WHI), which initially found that taking HRT caused a slight increase in the incidence of breast cancer, cardiovascular disease and clotting problems and that such harms outweighed any benefits gained. (The main benefit is a reduction in osteoporosis.) However longer term review of this study and other subsequent studies have shown these findings to be incorrect.

In fact, women who take HRT within 10 years of menopause have a significantly reduced short term mortality from catrdiovascular disease and no change in their mortality from breast cancer. (Obviously breast cancer is still a common condition in this age group and some women who are taking HRT will develop breast cancer). Importantly, their all-cause mortality rate is not affected by taking HRT.

 

Another health benefit of HRT - Prevention of osteoporotic fractures

Bone density in maximum at the end of adolencence and then declines gradually. This process accelerates after menopause and increases the risk of osteoporotic fractures. A healthy woman at age 50 has a two per cent chance of fracture in the next five years while a woman of 70 with normal bone density for her age has a 9 per cent risk. These fracture risks are much higher if the woman has increased risk factors for osteoporosis.

HRT, even in very small doses, reduces fracture risk by between 20% and 35% (depending on the type of fracture) and it may be useful in for this purpose in a select group of women at increased risk of osteoporosis. The problem is the other adverse side effects mentioned below and there other osteoporosis treatments available. To minimise cardiovascular disease risk associated with taking HRT to prevent osteoporosis, its use is usually restricted to women under the age of 60 years or within 10 years of the start of menopause. Other measures that help reduce osteoporotic fractures in postmenopausal women, such as stopping smoking, regular exercise and vitamin D / calcium supplements, are discussed in the comprehensive section on osteoporosis. (See section on Fracture Prevention.)

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Contraindications to using short term HRT

Women who have had or have an increased risk of the following medical problems need to discuss these issues with their doctor before commencing HRT.:

As stated above, it should not be commenced in women who are 10 or more years past menopause.

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Disadvantages / health risks of HRT

Breast cancer, stroke and cardiovascular disease - There is no increase in mortality from these conditions in women who commence HRT within 10 years of menopause

As stated above, the initial findings of the Woman’s Health Initiative (WHI) study showed that HRT slightly increased the incidence of cardiovascular disease, breast cancer and stroke. However, re-examination of the evidence after a longer period has confirmed that there is no increase in mortality from these conditions and no increase in all-cause mortality. In fact, there is a quite significant decrease in the incidence of early death in women who start HRT at menopause.

Slight ‘period’ bleeding:

In women with a uterus, HRT will usually cause light periods. These will vary according to age and the dose of progesterone given (as well as individual variation). In the time around menopause, oestrogen is given continuously (every day) with a course of progesterone being added for 10 to 14 days each month. Initially this will be associated with a slight withdrawal bleed that lasts for a few days and occurs for a few days after each course of progesterone is ceased. This will hopefully reduce with time.

Once a woman has been on HRT for about one to two years, their uterus is less hormone-sensitive and the program can be changed to giving both oestrogen and progesterone every day. Slight break-through bleeding often occurs in the first six months of this combination and then bleeding usually ceases. If it continues, the woman needs to consult her doctor. (Unfortunately, if this combination is given around menopause, it leads to more significant and inconvenient irregular break through bleeding.)

Slight increase in the incidence of deep venous thrombosis:

The incidence of clots forming in deep veins (deep venous thrombosis) is increased to about two times normal in women taking HRT and is greater in women on combined osetrogen-progesterone HRT. (The most common form of this disease is clots in the large veins in the legs.) This is a similar incidence to that caused by taking the oral contraceptive pill.

As the overall risk of such events is very small in women aged 50 to 60 years, this is not a major consideration unless the person has an increased risk of clotting. This includes women with a past history or family history of clotting diseases. It may also be wise to take precautions such as wearing support stockings to reduce the risk of clotting during long plane flights etc. It is worth noting that increased clotting is not a in HRT administered via patches.

Oestrogen side effects, including breast tenderness:

Oestrogen symptoms include breast discomfort and enlargement, headaches, abdominal bloating, pelvic discomfort and nausea. These symptoms are often transient and can usually be reduced or prevented by adjusting the dose of oestrogen given.

Other minor disadvantages:

These may include a slightly increased risk of developing gallstones, dry eyes and a worsening of migraines and autoimmune diseases if you already have these problems.

There are several conditions that have been incorrectly attributed to HRT. HRT does not cause an increase in blood pressure, an increased risk of diabetes, an increased  risk of uterine cancer (as long as it is given with progestin), or an increase in weight. If any weight gain does occur, it is no more than the normal average for the age group.

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HRT is NOT effective as a form of contraception.

Contraception needs to be used in some form for one year after the last natural period. (A low dose combined oral-contraceptive pill may be a good alternative to HRT for women who need contraception and are able to take ihis medication.)

 

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How is HRT administered and for how long?

Replacement oestrogen is given every day, either as tablets, as patches applied to the skin. Oestrogen implants were previously available but have now been withdrawn from sale in Australia. The lowest dose that is effective should be given.

Use with a progestogen: In women with a uterus, oestrogen should always be given with a progestogen. This is because if the oestrogen is taken alone, there is an increased risk of cancer of the uterus. This also applies to women who have had an endometrial ablation operation. It needs to be emphasised that when oestrogen and progestogen are taken together, there is no increased risk of uterine cancer. The progestogen is taken either oraaly or is included in the HRT skin patch.

The progestin is usually taken in tablet form or as skin patches and can be taken either:

Oestrogen can also be used locally in the vagina to relieve the vaginal symptoms of menopause, such as dryness, which may lead to painful sexual intercourse. When used in this manner alone, the oestrogen only affects the vaginal area and does not assist in reducing other menopausal symptoms.

Contraception is an important issue around this time and needs to be used in some form for at least one year after the last natural period.

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When should a women stop HRT?

The only major indication for taking HRT is for the treatment of menopause symptoms. As menopausal symptoms have a natural history of resolving in a couple of years in many (but not all) women, women taking HRT should be taken off it at regular intervals (yearly) to see if their remaining symptoms warrant the continuation of HRT. About 50% of women will have a recurrence of hot flushes when they initially go off HRT and some will want to extend treatment. Most women choose to take HRT for no more than a few years but symptoms can go on for much longer and and it can safely be used for up to seven years. Women can choose to stop HRT either abruptly or to wean themselves off HRT over a couple of months.

The minimum effective dose should be taken and this best achieved by starting off on a small dose and increasing it gradually until symptoms are relieved. (The effective dose of oestrogen is often about a quarter of that taken in a low dose oral contraceptive pill.)

Women with premature menopause should continue to take HRT until the age of 50; the normal age that menopause occurs. This will help prevent osteoporosis in these women.

HRT will provide benefit with regard to osteoporosis prevention while it is taken.

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Other treatments for menopause symptoms

There are several other treatments for menopausal symptoms for those women who cannot take HRT or do not wish to do so.

Treatments for women who have not had a hysterectomy (i.e. still have a uterus).

  • First line treatments
    • HRT that includes both an estrogen and a progesterone
    • Tibolone
    • A tissue sensitive estrogen complex (a combination of an estrogen plus a selective estrogen receptor modulator (SERM))
  • Second line treatments
    • Oestrogen implant plus a progresterone

Treatments for women who have had a hysterectomy (i.e. do not have a uterus).

  • First line treatments
    • HRT that includes an estrogen (patches or oral) but not a progesterone
    • Tibolone
  • Second line treatments
    • Oestrogen implant without a progesterone

Low dose oral contraceptive pill

Some women get menopause symptoms before their periods start to decrease in frequency and HRT is poorly tolerated in this situation. Also HRT does not provide contraception which will still be required in this situation. In these women a low-dose oral contraceptive pill (20 micrograms of oestrogen) may be a more suitable choice, as long as there is no contraindication to its use (e.g. smoking, high blood pressure).

Tibolone

Tibolone is a selective tissue oestrogenic activity regulator. Once in the body, tibolone breaks down into several steroid compounds that interact with body hormones to produce effects on various body tissues similar to that of traditional HRT. It reduces menopausal symptoms including hot flushes, night sweats, dizziness, fatigue, sleeplessness, irritability, mood problems and vaginal symptoms such as dryness.

Tibolone also has the advantage of not having oestrogen-like effects on the breasts and thus does not cause breast soreness. It is, however, associated with an increase in break-through bleeding in peri-menopausal women (i.e. around menopause) and thus it is more suitable for women past their menopause. 
It is as effective in preventing bone loss as oestrogen-based HRT and there is some evidence that it is effective in preventing fractures.

This medication does have a slight ‘male hormone’ (androgenic) effect. While this may benefit mood and libido, it may also cause a reduction in ‘HDL cholesterol’, increasing vascular disease risk.

There is an increase in the risk of stroke in older women similar to that occurring in older women using HRT. Otherwise, little data exists regarding its effect on cardiovascular, breast cancer, or thrombosis risk. There is evidence that it increases the risk of breast cancer recurrence in women with a past history of breast cancer and thus it should not be used in this group of women.

It is likely to be most useful in women who have depressed mood / libido or those who develop breast soreness on conventional HRT.

Antidepressants: SSRIs and SNRIs

These drugs have been shown to reduce hot flushes and are particularly useful in women with significant symptoms who are unable to take hormone therapy. They are usually effective in doses that are much smaller than the amount required to treat depressive illness. Two that are sometimes used are Venlafaxine and Paroxetine.

 

Treatments and medications that have been shown to be of little or no benefit or that are not recommended

Numerous medications / treatment have been used for treating menopause symptoms that have been found to give little or no benefit. These include:

Phytoestrogens: There is little good evidence that phytoestrogens is of much benefit in reducing symptoms associated with menopause and certainly they are nowhere near as good as HRT. A significant problem with phytoestrogens is that there are numerous types and there is not enough evidence to sort out which ones are most beneficial. Also, there is little information regarding appropriate dosages or the side effects of taking larger doses than those contained in our normal diets.
In general, if any menopausal therapy is going to be successful, it should show definite signs of benefit by six weeks of treatment.

Bioidentical hormones: These are hormones that are identical to those produced by the ovaries and are usually delivered via troches. Many people feel these are more natural and thus safer than HRT but this is not the case. Oestrogens delivered in this manner have similar effects regarding breast cancer as HRT and there is evidence that progerterones delivered via troches are not well absorbed and thus they do not prevent the endometrial hyperplasia that accompanies oestrogen therapy in women with a uterus. (Preventing this hyperplasia, which can occasionally lead to cancer of the uterus, is the reason women with a uterus need to add progesteron to the oestrogen in their HRT.) These compounds are thus not recommended.

 

 

 

Further information

Australasian Menopause Society  
www.menopause.org.au

International Menopause Society  
www.imsociety.org

North American Menopause Society 
www.menopause.org

The Sydney Health Decision Group, School of Public Health, the University of Sydney.
www.health.usyd.edu.au/hrt/questions/index.php
A good source of information about using HRT.

  

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