What is the menopause?
The Menopause is officially defined as the last day of your last menstrual period, but most people use the word “menopause” when they talk about the symptoms that can occur in the months or years when a woman’s fertility is winding down. During this time, our bodies transition from producing large amounts of reproductive hormone to almost none. Some women start to feel the beginning of this transition with symptoms such as hot flushes, sweating (especially at night), poor sleep, mood changes and more. Other women are fortunate and don’t experience too much disruption during this time but for some it can be an awful process. Sleep disruption particularly can be devastating and will affect all aspects of wellbeing. The most efficient way to combat disruptive symptoms brought on by menopausal hormonal fluctuations/ decline is to supplement levels with hormone replacement therapy or HRT. In recent years there has been a lot of anxiety over the use of HRT and how it might affect the development of breast cancer but most of that information was not presented in an accurate way and caused enormous, unnecessary fear. It might be helpful to know where all this furore came from!
Firstly, how do you know you’re in the menopause?
Menopause symptoms are so varied and there are no blood tests that confirm the diagnosis, so it can be a tricky consultation. In the main, early symptoms include flushes, night sweats and sleep disturbance. Some women are more troubled by emotional and cognitive issues like low mood, poor sex drive, irritability or anxiety, poor memory and/or a cloudiness in their thinking. As some women move deeper into the transition issues to do with declining collagen levels arise, so weakness of the pelvic floor with incontinence can worsen. Skin, hair and nail quality declines as collagen levels drop even further. The elasticity of the vaginal wall usually disimproves as time goes on and that can make things like exercise and having sex less comfortable for some women. It is clearly no picnic and some ladies suffer much worse than others. The worst of the symptoms usually tail off by the late 50’s but some women continue to have troubles well into their 60’s and beyond. While blood tests are often taken during a menopause visit, they will be looking more for other causes of symptoms (thyroid hormone, iron levels, etc) and not reproductive hormones. The diagnosis does not need any confirmatory blood tests.
What is HRT & why all the fuss?
HRT stands for Hormone Replacement Therapy. It involves taking small doses of ovary- type hormones (usually; estrogen and progestagen) in order to supplement the fall in these hormones that occurs in mid-life. They are usually produced in a pharmaceutical laboratory & often derived from natural sources such as soya extracts. They can come in tablets, gels, creams & patches; there is even a version that is sprayed into the nose! The original HRT products were gathered from the urine of pregnant horses! These somewhat infamous versions of HRT raised concerns about the welfare of the pregnant mares as well as the impact an equine hormone might have on a woman. While these products are still available-they lead market leader in the USA- we in Europe almost never use them anymore and prefer the human variety of hormones.
HRT was prescribed liberally in the western world since the early 1970’s and users derived great benefit from it. The situation changed in 2002 though when a study from the US was published that created concern about a possible link between using HRT and finding breast cancer. The study was called the Women’s Health Initiative (WHI) and it was commissioned by the US government to look at many different aspects of the health of older women. They were particularly keen to see what factors affected heart disease and cancer. The ladies in the study were almost all over 55 (most participants were in their early 60’s in fact) and they were all offered a daily HRT tablet to take- some of them were given real HRT (in the form of horse urine Estrogens (as mentioned above) with or without a balancing progestagen hormone) and some were taking an identical pill that had no hormones in it at all (a placebo). In the first 5 years of the study there was no difference in breast cancer detection in the two groups but after those 5 years went by, a slight increase was noticed in the number of breast cancers found in the women on the real HRT vs the women taking the placebo. The extra numbers were small and there was no suggestion that the HRT was creating new cancers. The actual increase in breast cancers being found was quoted as “relative risk of 1.26”. That was the official report; this is about the same extra number of breast cancers we see in women who drink one glass of wine a day. The information derived from that study did not suggest or prove that HRT caused breast cancers to develop, only that there was a slight association in some older women over time, but they chose to halt that part of the study until more information was gathered which was sensible. Sadly, things took an unfortunate turn at that stage when some of the authors of the study wrote a paper about HRT and breast cancer without discussing it with some of the other authors. Moreover, their article in the medical journal was worded in a very alarming tone (they continue to receive much criticism for this even today). The popular papers picked up their story and we were seeing terrifying headlines saying HRT causes breast cancer; without any actual data to support this. It was so sad for Irish patients during those years. Droves of Irish women, as well as millions of women in the US and Europe, stopped their HRT abruptly. Some were fine, but some got their symptoms back with a vengeance & were too terrified to seek help. Even when they did ask for advice they didn’t know who to believe. No matter how much we tried to reassure patients about the real relationship between HRT and breast cancer there were just as many other doctors who hadn’t read all the information and were still warning patients to avoid it at all costs!
Other issues identified by the WHI study relate to the safety of HRT use for women with established ischemic heart disease. We know and accept from the WHI study that HRT use must not be considered in women with established angina of history of heart attack but oddly may prevent both if begun before those diseases begin.
Another important piece of data from the WHI study is the link between HRT use and VTE (thrombosis in the veins). Women are slightly more at risk of blood clots when they have extra estrogen in their blood (as seen in pregnancy or while on the pill). To a much lesser extent the use of HRT also increases that risk but only, it seems, if the hormones are swallowed. Patch, gel and cream HRT’s don’t appear to have any impact on blood clot risk and so are considered better for women already at higher risk of clots.
Things stayed this way for decades until finally in 2015 a publication from the UK slowly started to reverse the fear mongering of the last 15 years. In Britain there is a government agency known as the National Institute for Health & Care Excellence (NICE). They are charged with making recommendations and formulating guidelines for doctors and nurses in the UK. In November 2015 they published a review of Menopause Care & HRT which reaffirmed what menopause doctors had been saying all along which is; if your patient is suffering and needs HRT to control troublesome menopause 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 young (well under the age of the women in the WHI study) and are probably only going to need it for a few years anyway. This has slowly started a rising confidence in many GP’s about menopause care & HRT prescribing and we have thankfully noticed an increasing number of women willing to talk about their symptoms and seek advice.
HRT will combat most if not all of these symptoms and it is always worth educating yourself before deciding. Wonderful information can be found for patients and health workers alike on the NICE website. Additionally, some excellent agencies in the UK offer clear advice and information e.g. www.womens-health-concern.org and www.menopausematters.co.uk among others. While HRT is worth considering there are also many non- HRT remedies that NICE and other health agencies recommend.
Risks vs Benefits of HRT
The use of HRT may have an impact on the risk of finding a breast cancer if you use it for more than 5 years after you turn 50 yoa but there is no data to suggest the HRT causes breast cancer. It can have a promoting effect though; on breast cancers that have hormone receptors on them. So, a woman who has had a hormone receptor + breast cancer in the past is not usually allowed to try HRT. There can also be problems for women who use of HRT and have also had angina, a heart attack or stroke. For these ladies the use of HRT is not permitted. Paradoxically, HRT can help prevent heart disease if started early in the menopause (under 60) in someone who is still well! Women with coronary artery disease risks (family history, obesity, smoking, drinking, high cholesterol) may do well to consider HRT use in the early years to help prevent health changes.
Another significant benefit of HRT use is the effect it can have on preventing and treating osteoporosis and fracture. As estrogen levels fall in the menopause, the balance between bone loss and bone creation is lost and many women lose bone quality. This can lead to hip & spine fractures which are one of the major causes of death and decreased quality of life for older ladies. HRT use delays the onset of osteoporosis and can help reverse it if used early enough. Sadly, when HRT is stopped the bones quickly decline and women at high risk of osteoporosis should be offered alternative therapies.
Some women who won’t or can’t consider HRT will use over the counter vitamin and mineral supplements to help alleviate symptoms. None are as effective as actual HRT, but they may help. For example, some women have tried blood pressure medicine to relieve flushes and sweats with good results. Some of the newer anti-depressant medications (SSRI’s SNRI’s) have been shown to give relief from flushes too even when used in very low doses. Mood problems can be helped by these drugs too. Vaginal moisturisers and lubricants are available that may help improve the symptoms of vaginal dryness and discomfort that plague some women.
Compounded/ “Bio identical” HRT
One alternative to standard HRT that is not recommended by NICE is the use of “compounded” or “bio-identical” HRT products. These are hormone containing pellets or creams that are produced in private laboratories and as a result are not subjected to the same quality standardisation as conventional HRT that you buy with a prescription from the pharmacy. They will not have a “CE” mark on the containers and may be very expensive. These products do in fact help with menopause symptoms because in many cases they are much stronger than conventional HRT. There are many prescription HRT brands that are composed of bio- similar/ bio- identical ovary hormones; as it happens, and GP’s are advised to favour them when starting a lady on treatment. These are usually quite affordable and are covered by the medical card. Private patients can expect to pay about € 20-30 per month for the typical HRT products as recommended by NICE.
Another common symptom of the menopause is dryness and loss of collagen in the vagina. Estrogen is essential for healthy levels of collagen. As hormone levels drop the walls of the vagina can become very thin and lose its usual elasticity. This can lead to uncomfortable sex, recurrent bladder infections and loss of bladder control (incontinence). Unlike other symptoms of the menopause, this issue does not eventually improve. Sadly, women who experience bladder and vagina issues of the menopause tend to get worse as they continue to age, and many will be desperate for relief. There are a variety of hormone replacement products that work specifically on the vagina wall and pelvic floor. Local estrogen pessaries (vaginal pellets) or creams can have a wonderful effect on these symptoms. As they do not enter the blood stream (like conventional HRT) the connection between these products and breast cancer is likely to be minimal and can be used by almost everyone without anxiety.
Self-Care at the Menopause
There is a lot more to maintaining good health during the menopause than HRT! It is important to be aware of and take charge of any health issues that might be a problem for you now and later on. Consider treating yourself to a mid- life medical check-up. Mind your blood pressure and weight. Eat well and exercise. Don’t smoke or at least cut down- same goes for alcohol! Consider exploring one the many different mind-body-spirit therapies that can help improve well- being and contentedness and lastly, perhaps the best advice of all, be more kind to yourself and seek help if you need it.