MENOPAUSE

What is menopause?

Menopause is a normal stage in a woman's life. It happens when menstrual periods stop. From this point onwards, ovaries cease to release any more eggs. Periods stop and pregnancy is unlikely.

The mean age of menopause is 52 years of age. Sometimes it is similar to the maternal age of menopause. Some women will experience menopause from their 30s- 40s already.

If menopause comes before the age of 40, then it is considered premature.

When a woman gets close to menopause, her periods might stop abruptly. But usually what happens is that periods gradually get longer whit wider spacing before completely stopping.

 

What causes menopause?

  • Natural decline of the reproductive hormones levels

Menopause is caused by a change in the woman's body reproductive hormones levels. In the time period that precedes menopause, called peri-menopause, estrogen levels fall and ovaries cease releasing an egg (ovum) every month. Either way, the ovarian egg reserves gradually decline and this process accelerates after the age of 40.

  • Hysterectomy

Hysterectomy is the surgical removal of the womb. In the type of hysterectomy that only the womb but not the ovaries are removed, menopause does not appear right away. Despite not having periods, the ovaries will still release eggs and produce the female hormones estrogen and progesterone.

If during the surgery both ovaries and the womb are removed (total hysterectomy and bi oophorectomy) then menopause ensues straight away with no intermediate time period. That means that the period stops appearing and you may probably experience menopausal symptoms like hot flashes and others. The symptoms may be quite intense since these changes happen abruptly rather than over several years.

  • Chemotherapy and radiotherapy

These kind of cancer treatments may cause menopause causing symptoms like hot flashes during or shortly after the treatment. Menstrual period stopping (and fertility as well) is not always permanent after chemotherapy, therefore you should also think about contraception if you want to avoid a pregnancy.

  • Primary (or premature) ovarian insufficiency

Approximately 1 in 100 women will enter menopause before the age of 40 (premature menopause). Menopause can be caused by the so called premature (or primary) ovarian failure that happens when ovaries fail to produce the normal amount of the female reproductive hormones. The commonest explanations are genetic causes, specific infections or autoiummune diseases. Frequently, no specific cause can be identified. For these women, we recommend that they take hormone replacement therapy until the normal age of menopause to protect the heart and brain vessels and to prevent from osteoporosis.
 

What are the menopausal symptoms?

The fall of the estrogen hormone levels causes both emotional and physical changes in a woman's body, like:

  • Hot flashes

  • Night sweats

  • Mood changes

  • Vaginal dryness

 

When does a woman need to seek help for the menopausal symptoms?

When a woman enters menopause, a discussion with the gynecologist about the changes happening is always helpful. This way one can be better prepared about this stage of her life. There are cases, however, that this discussion should not be postponed. This is when symptoms become annoying and disturbing. You may seek help because there are very efficinet ways of relief of the menopausal symptoms.

 

How is menopause diagnosed?

For women younger than 50 years of age, it would be wise to wait for 24 months without a period before the diagnosis is made. For women older than 50 years of age, 12 months without a period is sufficient time to tell that menopause has arrived.

There is no such thing as a specific test to diagnose menopause. We can check a hormone, FSH (follicle stimulating hormone). In menopause, FSH levels usually are >40 IU/ ml. Nevertheless, the test result usually does not alter the management.

 

What are the options for treating menopause?

When menopausal symptoms, caused by lack of estrogen, appear around the normal time of menopause, treatment is not always needed. Most women deal with the mild symptoms that may appear with simple lifestyle and dietary changes. These simple changes (see below) are usually enough to relieve from symptoms.

Nevertheless, for those women that have more intense symptoms that interfere with daily activities and affect quality of life, we could discuss the need for administering treatment to provide relief from the symptoms.

Hormone replacement therapy (HRT) is one of the main therapies used in menopause. It helps alleviate the menopausal symptoms by replacing the missing estrogen. It can also strengthen the bone structure that begins to weaken much faster when menopause comes. HRT can be administered as tablets, cream, gel, skin patch or as an implant.

Additionaly, vaginal lubricants can be used to counteract the vaginal dryness that happens after menopause.

In some cases, drugs that are classified as antidepressants can help treat hot flashes. Please read below for more information on HRT.

 

What can I do to help myself when menopause comes?

Every woman that enters menopause can help herslef by doing some simple changes in her lifestyle and her dietary habits. This will iprove, a great deal, symptoms caused by menopause.

For example, following a balanced, healthy diet nad exercising regularly you can avoid the weight gain that is common after menopause.

A healthy diet that includes food from all dietary groups can help keeping your bones strong and healthy. By combining aerobic activities, such as walking for example, together with strength and flexibility exercises you can maintain your bone and muscle mass.

 

I would like more information about hormone replacement therapy (HRT)

Estrogen and progesterone are the female hormones responsible for multiple roles in a woman's body. When falling, a series of symptoms may present, both phsyical and psychological ones. Amongst others, got flashes, mood swings and vaginal dryness present in variable intensity.

The purpose of hormone replacement therapy (HRT) is to restore the female hormone levels so that normal body function returns.

 

How do estrogen and progesterone work?

Estrogen

Estrogen helps to release the eggs from the ovaries. It also helps to regulate periods and to achieve conception.

Estrogen also plays a role in controlling other functions of the female body. For example, it can regulate bone density, skin temperature and vaginal lubrication. It is the very decline in estrogen levels that causes most of the symptoms associated with menopause, such as:

  • hot flashes

  • night sweats

  • vaginal dryness

  • loss or decrease of sexual desire (libido)

  • stress incontinence (loss of urine with cough, laughter or sneezing)

  • bone weakening (that can lead to osteoporosis and fractures)

Most of these symptoms are temporarily, even though vaginal dryness will probably get worse unless treated. Stress incontinence will probably persist and the risk of osteoporosis will increase with age.

Progesterone

Progesterone's main role is to prepare the womb for pregnancy. Additionally, it helps protecting the inner lining of the womb, called endometrium.

If progesterone levels fall, the body is not affected in the same way as with estrogen levels fall. However, if you are on HRT with estrogen only, the risk of a womb cancer called endometrial cancer is higher.

This is why, usually, a synthetic form of progesterone (progestin) is combined with estrogen in HRT. However, if you have done hysterectomy (a procedure where the womb is removed), you do not need to take any progestin and you can safely only take estrogen as hormone replacement treatment.

 

How is HRT administered?

Pills, patches or implants are needed only if you have intense menopausal symptoms, for example hot flashes, and we have previously discussed with you the benefits and risks of treatment.

Since there are several HRT treatment combinations, it is preferable to discuss together beforehand what suits you better and what kind of treatment you should have.

There are several ways to take HRT, including:

  • tablets taken from the mouth

  • an adhesive patch that is applied to the skin

  • an estrogen implant that is placed under local anesthesia under the tummy, thigh or buttock skin (not available in Greece)

  • an estrogen gel that is applied to the skin to be absorbed.

Local estrogen for vaginal dryness

If your only concern is vaginal dryness, then you can try applying estrogen gel in your vagina.

Since the gel is only applied locally, the dose is minimal, does not have any impact on the rest of your body, not even the uterus and therefore you do not need the protecive administration of any progestin. Local estrogen does not have the same risks as the combined regiments that are usually given as HRT.

Local estrogen can come in several forms:

  • pessaries that are inserted into the vagina

  • vaginal ring

  • vaginal cream

 

When should I stop taking HRT?

Most women will stop taking HRT when menopausal symptoms dissapear. This happens after two to five years after they show up.

What we usually recommend is gradually decreasing the dose rather than stopping it alltogether at once. Sometimes, after discontinuing HRT symptoms relapse but even so, they dissapear after a few months. In case this is not the case, we might have to continue administering HRT, probably in a lower dose.

After stopping HRT, you might need treatment for vaginal dryness and osteoporosis prevention.

 

For which women is HRT appropriate?

We can start treating with HRT as soon as you start noticing menopausal symptoms. After excluding pregnancy we will take your medical history to find out if there is any of the following:

  • history of breast, ovarian or endometrial cancer

  • history of blood clots

  • history of cardiac disease or stroke

  • high blood pressure without any treatment. You have first to control blood pressure and then begin taking HRT

  • liver disease

If you have any of the above, then HRT might not be appropriate for you.

If you have irregular periods this should also be investigated before HRT is used. If HRT is contraindicated, then we can discuss about HRT alternatives.

 

What are the alternative to HRT treatments?

Lifestyle changes

  • Regular exercise

  • Keep your body cool at nights

  • Reduce caffeine, alcohol and spicy foods intake

  • Try to reduce stress levels

  • Stop smoking

 

Tibolone

Tibolone is a synthetic hormone that can be used in menopausal women that still have their uterus. Tibolone has a mixed estrogen- progestin action.

If there are any medical reasons not to take HRT (for example if you have a history of breast cancer or heart disease) we would not advise you to take tibolone either.

Additionally, tibolone is not suitable for women that show menopausal symptoms earlier than the actual menopause or if less than a year has passed since your last period.

 

Antidepressants

Certain antidepressants can help a lot against hot flashes appearance, although they are not officially licenced for this indication. Such drugs are venlaxafine and citalopram. Since antidepressants have contraindications and side effects, discussion is needed before prescribing them.

 

Clonidine

Clonidine is a medication that is used in high blood pressure treatment but has also been found to be beneficial in some menopausal women. As every drug, clonidine as well has some side effects that you need to be aware of before starting treatment with it. There can be a test administration of the drug for a few weeks to evaluate its effectiveness. If it does not work for you, or has side effects that you cannot tolerate, then it can be stopped.

 

What are the HRT side effects?

Hormones used in HRT can have side effects, such as:

  • fluid retention

  • swelling

  • breast tenderness or swelling

  • headaches

  • indigestion

  • depression

 

What are the benefits and risks of HRT?

Over the years, many researches have been done in order to investigate the benefits and risks of HRT treatment.

The main benefit of HRT is that it is very effective in controlling and relieving from menopausal symptoms. Indeed, HRT can make the difference as far as a woman's quality of life and well- being are concerned.

Moreover, HRT can reduce the risk of osteoporosis and large intestine (colorectal) cancer. Nevertheless, long term administration is not indicated and bone density will quickly be reduced once HRT is stopped.

Combined HRT slightly increases the risk of breast, endometrial and ovarian cancer as well as stroke. Moreover, HRT increases the risk of deep vein thrombosis and pulmonary embolism (pulmonary artery obstruction). You have to know that there are other available drugs that can treat osteoporosis without carrying the same risks.

Most of the field experts agree that if HRT is used for a short period of time (not more than five years) benefits overwhelm risks. If, for any reason, a woman takes HRT for more than ten years, a thorough discussion needs to be made to discuss the associated risks and arrange closer follow up.