Menopause is a natural part of life for the majority of women. It is diagnosed when a woman has no periods for 12 months. Periods stop due to a reduction in female sex hormones oestrogen, progesterone and testosterone produced by the ovary. This can happen between ages of 45 to 55. In most women in UK, the average age of menopause is 51.
Other conditions causing menopausal symptoms include Premature ovarian insufficiency (menopause under age 40), surgical menopause (following removal of ovaries or uterus) and following cancer treatments with radiotherapy and chemotherapy.
What is perimenopause?
Perimenopause is the time around menopause when the menstrual cycle changes, periods become irregular, with shorter or longer cycles, and may become heavier in some ladies.
Often symptoms of the menopause can present during perimenopause and can continue after the menopause.
How long will these symptoms continue for and how will I know I have been through the menopause?
On an average these menopausal symptoms can last for 2-7 years. It is difficult to predict how long these symptoms will last and a few women can continue with symptoms into their 60s and 70s.
Do I need a blood test to diagnose menopause ?
A blood tests for serum FSH (Follicular Stimulating Hormone) is not necessary to diagnose menopause over the age of 45. Diagnosis over age 45 is based on clinical symptoms and changes to periods.
Blood test for serum FSH is recommended between age 40 to 45 if women have atypical symptoms of menopause.
In all cases under age of 40, blood tests should be done to diagnose Premature ovarian insufficiency (POI). This is confirmed with undertaking 2 blood tests for serum FSH taken 6 weeks apart, and both results above 30 IU/L.
What are the symptoms of menopause ?
Vasomotor
•Hot flushes •Night sweats
Altered Sexual Function
•Lack of interest in sex •Low sex drive
Physical
•Weight gain mainly around the middle, difficult to lose weight •Fatigue, muscle weakness •Joint pains •Worsening of migraines, headaches •Burning mouth syndrome •Restless leg syndrome •Sleep disturbances, insomnia •Dry hair, hair loss, dry itchy skin •Worsening of some skin conditions like eczema, psoriasis, feeling of crawling sensations on the body
Psychological
•Low mood, irritability, feeling overwhelmed or lonely •Loss of confidence •Brain fog, lack of concentration •Worsening of low mood, premenstrual symptoms, anxiety, palpitations
Local Vaginal Symptoms
•Vaginal dryness, soreness •Recurrent vaginal infections •Recurrent urinary tract infections •Pain during sex •Increased frequency of urination •Urgency •Incontinence
I am finding it difficult to lose weight. Does HRT cause weight gain?
Weight gain in midlife is predominantly related to ageing and lack of oestrogen partly contributes to changes in body shape from pear shape to apple shape and weight gain is mainly seen around the abdomen during and after menopause.
Some women find it hard to lose weight during menopause. HRT does not cause weight gain, and you will be more motivated to exercise if you are feeling better on HRT.
Women with obesity after menopause are more prone to develop the Metabolic Syndrome which is a risk factor for heart disease and stroke. This consists of central obesity, hypertension, raised cholesterol and diabetes. It is important for you to be prescribed the right type of HRT if you have features of the Metabolic syndrome.
Can I take vaginal oestrogen pessaries or cream in addition to HRT?
Vaginal oestrogen works only locally with minimal absorption in the rest of the body. This local HRT can be taken with systemic HRT such as oral tablets, patches or gels. Vaginal oestrogen is licensed for indefinite use and symptoms of vaginal dryness and soreness commonly recur if treatment is stopped.
If you have breast cancer and vaginal moisturisers/lubricants have been ineffective, your doctor will advise you if vaginal oestrogen can be recommended. The safety of this hormone treatment remains uncertain.
What is the difference between Bioidentical and Body-identical HRT?
Bioidentical HRT is offered by some private clinics and is compounded in the laboratory based on patient’s salivary hormone levels. This kind of compounded HRT is not approved by MHRA (Medicines Healthcare Products Regulatory Agency) and is not licensed for use in UK as safety, efficacy and potency is not established . It is therefore not recommended by British Menopause Society.
Body identical HRT consists of hormones designed to be similar in structure to your own body, consisting of oestradiol and micronized progesterone. These are manufactured and prescribed in accordance with British standards for healthcare. They have undergone rigorous safety testing and are recommended by British Menopause Society.
When can I stop HRT?
Your doctor will advise you about stopping HRT depending on your medical history and risk factors. Most women can make an informed choice when they wish to stop their HRT. There is no defined time limit for taking HRT.
What are the benefits of HRT?
HRT is the most effective treatment for menopausal symptoms and improves quality of life.
Benefits for the heart: There is good evidence that HRT started within first 10 years of menopause decreases the risk of death from heart attacks, strokes lowering your cardiovascular and all-cause mortality. HRT combined with life style interventions including a healthy diet, regular exercise, reducing alcohol intake and smoking cessation will further reduce the risk of heart disease.
Prevents Osteoporosis and reduces risk of fractures.
Prevents dementia: There has been conflicting evidence regarding the risk of dementia and HRT use. Based on the current evidence, women can be reassured that HRT is unlikely to increase the risk of dementia or be detrimental to cognitive function in women initiating HRT under the age of 60 years.
What are the risks of HRT?
The safety of HRT depends on a number of factors including the dose and type of HRT you are given.
Risks need to be individualised, a benefit risk assessment is done in each case depending on your age, medical and family history and life style factors before prescribing HRT.
Healthy women under 60 should not be unduly concerned about risks with taking HRT.
Breast cancer risk: This is the biggest worry for women. The overall risk of breast cancer from HRT is low and increases with age, family history (genetic makeup) and life style factors amongst others. The risk of breast cancer also depends on type of progestogen in HRT and this risk needs to be put in perspective.
Life style factors such as alcohol intake of greater than 2 units/day, i.e. a small glass of wine or BMI>30, is associated with higher risk of breast cancer than from HRT. Risk of breast cancer from oestrogen only HRT is lower than from Combined HRT containing oestrogen and progestogen .
Blood clots and Thrombosis Risk: Oral HRT increases risk of thrombosis i.e. blood clots in chest and legs. Transdermal oestrogen (patches, gel, and spray) have no increased risk of thrombosis in most patients. This risk also depends on type of progestogen used in HRT. If you have a personal or family history of blood clots, decision to treat with HRT or Alternatives to HRT will be carefully assessed by your doctor.
Stroke risk: is increased with oral HRT especially in older women above age 60 and in women with additional cardiovascular risks factors if they are not adequately managed. Type of progestogen also has an effect on increasing this risk.
I have a surgical menopause, how will I know I am going through the menopause and can I have HRT?
Even though you have your uterus or both ovaries removed which stops your periods, you will experience menopausal symptoms mentioned above when you are going through the perimenopause and menopause.
You will be eligible for receiving HRT except in some cases where the surgery has been done for some gynaecological or breast cancers.
Can I start HRT more than 10 years after my menopause at age 60?
This will depend on your comorbidities, cardiovascular health, risk factors for blood clots and other risk factors.
A Cochrane review in 2015, showed starting HRT after 60 is likely not have a harmful effect provided you are prescribed the right type and dose of HRT.
I have medical problems, can I start HRT?
This will depend on the underlying medical condition you have and after weighing up the benefits and risks a decision will be made on starting HRT if it is considered safe.
Is there a difference in progestogens in HRT?
Different progestogens have different side effects and effects on the heart, blood clots and breast cancer risks and therefore advising the right HRT depending on your own risk factors is critical.
No one size fits all and the right progestogen will be chosen after taking a detailed history at your first consultation.
If you get side effects from HRT these can be managed with changing dose and type of HRT.
HRT and COVID?
Severity of Covid was lower in females in reproductive age group compared with men possibly due to protective effect of female hormones. If patients are hospitalised due to COVID, please inform your doctor you are on HRT, as oral HRT will need to be stopped due to risk of thrombosis or changed to a safer HRT (patches, gels or spray).
There is some evidence that patients diagnosed with Long Covid have seen their symptoms improve with HRT.
What is Premature ovarian insufficiency (POI)?
POI is menopause under age of 40 years and is seen in 1% of cases. Often no clear cause is found, but in some cases it can be auto-immune, inherited, or following surgery, chemotherapy and radiotherapy.
Women with POI should be strongly encouraged to use HRT at least until the average age of the menopause (51 years) for control of symptoms, and to prevent heart disease, osteoporosis, dementia and Parkinson’s disease.
The diagnosis can have a psychological impact and these women need counselling and help for future fertility if desired.
Do I need to use contraception?
HRT is not a contraceptive. If you are having periods when you start HRT, contraception will be required until age 55.
You do not need to use contraception 1 year after your last period if you are over 50 and 2 years after last period if you are under 50.
What are the benefits of testosterone?
Testosterone is prescribed for low sex drive which has not improved despite HRT. The decline in testosterone levels appears to be age related at least partly due to decline in ovarian function. Blood tests for testosterone are difficult to measure and do not correlate well with tissue levels.
However levels reduce markedly after removal of ovaries and in patients with Premature ovarian insufficiency. These women are more likely to see benefit from testosterone replacement for improvement of sex drive if HRT has not helped. There is anecdotal evidence that testosterone may improve mood, cognition, energy levels, headaches and bone health.
Do I need to take Calcium and Vitamin D?
You will be assessed and depending on severity, the risk factors for osteoporosis and medical history treatment will be advised.
Are non-hormonal treatments such as herbal products safe?
Many patients try these over the counter/online treatments by choice or if they cannot access menopause services. These are isoflavones in red clover, black cohosh, alpha alpha, sage. Safety and reliability is a concern for some natural treatments, and these are contraindicated in breast cancer patients and have some drug interactions. These herbal preparations should be stopped if you are prescribed HRT.
How much does HRT cost?
Following the consultation, I will send an email to your GP requesting a prescription for your HRT to be issued on the NHS which is free.
If private prescriptions are requested, cost will vary depending on the type of HRT. On an average it will cost £15 per item per month. The prescription charge of £20 for a private prescription is included in the cost of the consultation. However, if you require a private prescription in between follow up attendances an extra charge will be applied (£20).
Not all GPs are willing to prescribe testosterone cream called Androfeme® 1 cream as it is off label/unlicensed. Androfeme® 1 cream costs approximately £80 for 100 days of treatment which is going to increase to £100 very soon (ie £1 per day). Your GP may be willing to prescribe some alternatives treatments of testosterone products on the NHS (preparations used by men) such as Testogel/Testim gel/Tostran gel in lower doses following my recommendation.
This is a private Menopause Clinic run by Dr Manju Navani, a Menopause Specialist with an Advanced Certificate in menopause care, recognised by The British Menopause Society. Dr Manju Navani is regulated by the General Medical Council – No 4493617
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