What is the menopause?

Strictly speaking, the menopause is the last menstrual period. However, most women think of the menopause as the time of life leading up to, and after, their last period. It is often called the change of life. It occurs because as you get older your ovaries make less oestrogen (the main female hormone). The average age of the menopause in the UK is 51. However, it may be sooner or later than this. For example, you may have an early menopause if you have a hysterectomy.

What are the possible symptoms and problems of the menopause?

The menopause is a natural event. You may have no problems. However, it is common to develop one or more symptoms which are due to the low levels of oestrogen.

Short term symptoms:

• Hot flushes occur in about 3 in 4 women. A typical hot flush lasts a few minutes and causes flushing of your face, neck, and chest. You may also perspire (sweat) during a flush. Some women become weak, faint, or feel sick during a hot flush. The number of hot flushes can vary from the occasional flush, to fifteen or more times a day. Hot flushes tend to start just before the menopause, and typically persist for 2-3 years.
• Sweats commonly occur when you are in bed at night. In some cases they are so severe that sleep is disturbed and you need to change bedding and night clothes.
• Other symptoms may develop such as headaches, tiredness, palpitations, being irritable, difficulty sleeping, depression, anxiety, aches and pains, loss of libido (sex drive), and feelings of not coping as well as before. It can be difficult to say whether these symptoms are due to the hormone changes of the menopause. For example, you may not sleep well or you may become irritable because you have frequent hot flushes, and not directly because of a low oestrogen level. Also, there may be other reasons why these other symptoms develop. For example, depression is common in women in their middle years for various reasons.

• Skin and hair. You tend to lose some skin protein (collagen) after the menopause. This makes the skin drier, thinner, and more likely to itch. You may have less underarm and pubic hair. Some women have an increase in facial hair.
• Genital area. Lack of oestrogen tends to cause the tissues in and around the vagina to become thinner and drier. These changes can take months or years to develop.
• Osteoporosis (brittle bones) may develop after the menopause. As you become older, you gradually lose bone tissue. Oestrogen helps to protect against bone loss. When the oestrogen level falls, the rate of bone loss increases. If you lose a lot of bone tissue, then this is called osteoporosis. It may cause no symptoms. However, if you have osteoporosis the bones are less dense and are more likely to break. You may break a hip or wrist quite easily after a fall or minor injury. Not all women develop osteoporosis after the menopause. See separate leaflet called 'Osteoporosis' for more detail.

What is HRT?

All types of HRT contain an oestrogen hormone. If you take HRT it replaces the oestrogen that your ovaries no longer make after the menopause. HRT is good at preventing hot flushes, vaginal dryness and related vaginal symptoms, and may help to improve sleep if your sleeping pattern is affected by the menopause. Long-term use of HRT also has a small benefit in helping to prevent osteoporosis and bowel cancer. However, there are risks in taking HRT. See separate the leaflet called 'Menopause and HRT' for more detail. The rest of this leaflet discusses some other treatment options for menopausal symptoms.

Non-HRT treatments for hot flushes and night sweats

Lifestyle

There is some evidence that women who are more active tend to have fewer symptoms of the menopause. However, not all types of activity lead to an improvement in symptoms. High-impact exercise done now and then may even make symptoms worse. The best activity is regular sustained aerobic exercise, such as regular swimming or jogging.

Wearing lighter weight clothing, sleeping in a cooler room, and reducing stress may reduce the number of hot flushes. Some women find that things such as spicy foods, caffeine (in tea, coffee, cola, etc), smoking, and alcohol may trigger hot flushes. Avoiding these things may help in some cases.

SSRIs and SNRIs

Selective serotonin reuptake inhibitors (SSRIs) are a class of antidepressant drugs. They include: paroxetine, fluoxetine, escitalopram and citalopram. Several years ago it was noticed as a side-effect that menopausal women who took these drugs for depression had fewer hot flushes. Since then, research trials have confirmed that several SSRIs stop or reduce hot flushes in some (but not all) menopausal women. That is, whether they were depressed or not. A similar antidepressant drug called venlafaxine has also been shown to have this effect. Strictly speaking, venlafaxine is classed as a selective noradrenaline reuptake inhibitors (SNRI). How SSRIs and SNRIs work to help hot flushes is not clear.

When it works, an SSRI or SNRI provides relief from hot flushes almost immediately. A 1-2 week trial is usually enough to find out whether it is going to work or not. If symptoms improve, a longer course may then be prescribed. The main drawback with these drugs is that they may cause side-effects in some women, such as nausea (feeling sick), reduced libido and reduced sexual response.

Clonidine

Clinical trials have shown that flushing symptoms in some women can be eased by taking a drug called clonidine. However, it frequently causes side-effects such as dry mouth, drowsiness, dizziness, and feeling sick. It is therefore not commonly used, but may be worth a try if other treatments do not help. Clonidine is thought to work by interfering with a body chemical called noradrenaline which is involved with the process of flushing and sweating.

Gabapentin

Gabapentin is drug that is usually used to control epileptic seizures and pain. However, research has shown that it eases menopausal flushing symptoms in some women. More research is needed to confirm the place of gabapentin in the treatment of menopause.

Note: strictly speaking, SSRIs, SNRIs, and gabapentin are not licensed for treating menopausal symptoms. However, many doctors are willing to prescribe one of these treatments, with the patient's consent, to see if it works.

Complementary and alternative treatments

Because of recent concerns about HRT, some women have turned to complementary and alternative treatments. For example, the following have been marketed for menopausal symptoms: black cohosh, red clover, dong quai, evening primrose oil, ginseng, soy, and kava. However, just because a product is labelled 'natural' does not mean that it is automatically safe and free from potentially damaging chemicals. A recent national guideline from Clinical Knowledge Summaries (reference at the end) states that "CKS does not recommend the use of complementary therapies". The reasons include:

• They have not been shown convincingly to work very well.
• There is very little control over the quality of the products available, which may vary.
• Some of these treatments (ginseng, black cohosh, and red clover) have oestrogenic properties and should not be used in women who should not take oestrogen (for example, women with breast cancer).
• Long-term safety (for example, effects on the breast and lining of the uterus) have not been assessed.
• Some may have serious side-effects. For example, severe liver damage has been reported with black cohosh and kava. Kava has been withdrawn from the UK market because of concerns over safety.
• Dong quai and some species of red clover contain chemicals called coumarins, which make them unsuitable if you take anticoagulants (such as warfarin).

A consensus statement from the British Menopause Society (reference below) also states:

"This guidance regarding alternative and complementary therapies is in response to the increased use of these strategies by women who believe them to be safer and more 'natural'. The choice is confusing. Evidence from randomized trials that alternative and complementary therapies improve menopausal symptoms or have the same benefits as hormone replacement therapy (HRT) is poor. A major concern is interaction with other treatments, with potentially fatal consequences. Some preparations may contain estrogenic compounds, and this is a concern for women with hormone-dependent diseases, such as breast cancer. Concern also exists about the quality control of production."

Non-HRT treatments for vaginal dryness

You can buy vaginal lubricants and moisturisers from pharmacies, which can help ease vaginal dryness. Some women only notice dryness when they have sex. In this situation, placing a small dose of lubricant inside the vagina before having sex will usually help.

(Note: you may not be aware that there are oestrogen creams which ease the vaginal symptoms of the menopause. Strictly speaking, they are a form of HRT, but have less risk than taking HRT tablets. See separate leaflet called 'Atrophic Vaginitis' for more detail.)

Non-HRT treatments for preventing osteoporosis

In the past, HRT was heavily marketed as a preventer of osteoporosis. The results of the recent large trials of HRT showed that the protective effect of HRT on bones is actually quite small. You can probably do more to prevent osteoporosis by:

• Doing regular weight-bearing exercise. This means exercise such as brisk walking, aerobics, dancing, running, etc. For older people, a regular walk is a good start. Exercise helps because the pulling and tugging on the bones by the muscles helps to stimulate bone-making cells and strengthens the bones.
• Eating a diet that includes foods rich in calcium and vitamin D. If you eat 1,000 mg of calcium each day you have a reduced risk of hip fractures. Ask your practice nurse for advice about diet. Briefly, you can eat 1,000 mg calcium most easily by:
  • Drinking a pint of milk a day; plus
  • Eating 60 g (2 oz) hard cheese, such as Cheddar or Edam, or one pot of yoghurt (125 g), or 60 g of sardines.
  White bread, and calcium-fortified soya milk are also good sources of calcium.
• Taking dietary supplements of calcium and/or vitamin D tablets if you do not get enough in your diet and you are at increased risk of developing osteoporosis. A dietary supplement of vitamin D is recommended for all people over the age of 65.
• Stopping smoking if you smoke.
• Cutting down on alcohol if you drink heavily.

If you develop osteoporosis, there are drugs which can help to restore some lost bone, and help to prevent further bone loss. See leaflet called 'Osteoporosis' for details.

Treating other symptoms

Various other symptoms may occur around the menopause (depression, anxiety, sleeping difficulty, etc). As mentioned above, these are not likely to be directly related to a low level of oestrogen. If any of these symptoms persist, it is best to see your doctor. Treatment for these symptoms is much the same for women going through the menopause as for any other age group. There are separate leaflets for each of the above-mentioned problems.

Lack of sexual desire after the menopause

There is some evidence that treatment with testosterone (patches and implants) may help to improve a lack of sexual desire (lack of libido) that may occur following the menopause. Testosterone is a hormone but very different to oestrogen. If recommended, it is usually given at the same time as oestrogen-based HRT. This is because there is a lack of research to say that testosterone alone is safe. Further research may determine if testosterone is safe to have alone without the oestrogen-based HRT.

Further help and information

Women's Health Concern

Web: www.womens-health-concern.org
A charity providing help and advice on a wide variety of women's health issues.

References

• Alternatives to HRT for management of symptoms of menopause, Royal College of Obstetricians and Gynaecologists (September 2010)
• Non-estrogen based treatments for menopausal symptoms, British Menopause Society Consensus Statement (March 2008)
• Alternative and Complementary Therapies, British Menopause Society Consensus Statement (June 2007)
• Menopause, Clinical Knowledge Summaries (January 2008)
• Nelson HD, Vesco KK, Haney E, et al; Nonhormonal therapies for menopausal hot flashes: systematic review and meta-analysis. JAMA. 2006 May 3;295(17):2057-71. [abstract]
• Hubayter Z, Simon JA; Testosterone therapy for sexual dysfunction in postmenopausal women. Climacteric. 2008 Jun;11(3):181-91. [abstract]
• Freeman EW, Guthrie KA, Caan B, et al; Efficacy of escitalopram for hot flashes in healthy menopausal women: a JAMA. 2011 Jan 19;305(3):267-74. [abstract]
• Toulis KA, Tzellos T, Kouvelas D, et al; Gabapentin for the treatment of hot flashes in women with natural or Clin Ther. 2009 Feb;31(2):221-35. [abstract]