Menopause – the facts!

18 August 2016

Menopause – what is it?

Menopause is when the number of eggs left in your ovaries is very small.   This means that fertility sharply decreases and the levels of oestrogen in the body drop.   The declining oestrogen levels often cause menopausal symptoms.  The average age for women to experience menopause is 51 years.   If women become menopausal before the age of 40 years then the term used is “premature menopause” or “premature ovarian insufficiency”.   

What are menopausal symptoms?

Most (75%) of menopausal women will have some/all of the following:
                       -  
menstrual cycle becomes longer, heavier, more infrequent and then ceases
                       -   
flushes and night sweats
                       -   
poor sleep quality
                       -   
vaginal dryness, intercourse uncomfortable
                       -   
itchy skin, crawling sensation
                       -   
changes in mood, more anxiety, memory poor
                       -   
weight gain

All women will have different experiences.  Some women have no symptoms, some have mild symptoms, some have severe symptoms, yet the hormone changes are the same.  Women who have their ovaries removed (“surgical menopause”) nearly always have more severe symptoms.  The natural history of all menopausal symptoms is to improve with time.  The exception is vaginal dryness, which typically worsens over time.   On average symptoms last about 7 years.

What should I do?

If you are older than 45 years and find symptoms are not particularly affecting your quality of life you do not need to do anything.  If periods stop at an earlier age you should talk to your doctor and have some hormone tests.  If you find symptoms are affecting your quality of life you should talk to your doctor. 

What can I do to manage my symptoms?

There are lots of lifestyle measures you can try that may help manage your symptoms.  Maintain a normal weight.  Stop smoking.  Identify any triggers to hot flashes and try to avoid them.  Explore relaxation techniques and mindfulness.  Keep up your exercise on most days.

 In addition, don’t forget your regular health checks: mammogram, cervical smear, blood pressure, cholesterol and diabetes risk assessments.

Are there any supplements that treat menopausal symptoms?

The medical evidence does not support relief of menopausal symptoms from any over the counter product.  Some women have temporary relief from mild symptoms with some products.  Medication to treat menopausal symptoms has a high placebo response rate.   There is no safety data for the over the counter products. 

What about prescribed medicines?

Yes, there are hormonal and non-hormonal options.   Hormone replacement therapy (HRT) contains oestrogen and often progesterone.  HRT will help about 95% of women with menopausal symptoms.   Risks of HRT are very individual and should be discussed with your doctor.  HRT should be strongly considered for all women with premature ovarian failure. 

Vaginal dryness can be easily treated with vaginal oestrogen, which is a safe option for most women.  Vaginal oestrogen can be used for as long as necessary. 

Non-hormonal medicines that have been shown to be effective in treating menopausal symptoms include SSRIs and gabapentin. SSRIs (selective serotonin reuptake inhibitors) are the most commonly used medicines and improve menopausal symptoms in up to 70% of women. Gabapentin is another medicine that has been shown to be effective in treating flushes and sweats associated with menopause.  Gabapentin is not currently funded  in New Zealand for treating menopausal symptoms.   

In Summary

If menopausal symptoms are affecting your quality of life please talk to your doctor or specialist.   We have effective options that may be helpful for managing your symptoms.   If you are less than 40 years old and your periods have stopped you should discuss this with your doctor regardless of symptoms.   

More information can be found at - http://www.menopause.org.au/

For General Practitioners:

What are the appropriate hormone tests for investigating a woman with menopausal symptoms?
If a woman less than 45 years old presents with amenorrhoea, we suggest measurement of FSH and oestradiol.  To exclude other causes for her amenorrhoea, measurement of TSH, prolactin and testosterone is necessary. 

In women over 45 years old who present with menopausal sweats and menstrual change, appropriate testing includes TSH, prolactin and metabolic testing (HbA1c and lipid profile). 

Are any other tests required?

Measurement of blood pressure and body mass index help with risk assessment.  If your  patient has not had one, then consider a mammogram. 

Can I start treatment?

For many women HRT is a very low risk option that is extremely effective in treating often debilitating symptoms.  If you feel comfortable starting HRT (or a non-hormonal medicine) and there are no contraindications to use, then a trial of therapy could be considered.

Practice Point: Remember that lowered mood/ increasing anxiety associated with oestrogen deficiency can often respond well to treatment with HRT.  

When should you refer?

Refer women who have potential contraindications to therapy, and women not responding to first line treatment.  Some practitioners will also prefer to have a specialist involved in initial decision making.

Please refer any woman for whom you have concerns about HRT use or if you feel uncomfortable using medication to treat menopausal symptoms.    Refer any woman who is not responding as anticipated to a trial of treatment.

Dr Megan Ogilvie, Dr Stella Milsom, and Dr Susannah O'Sullivan are Endocrinologists at Fertility Associates Auckland.