ENTERING PERIMENOPAUSE IS a natural event for most females. If we live into our 40s and 50s we will all experience an inevitable decline and then loss of our ovarian function; no more eggs, far less hormone.
This is not to forget those of us who have been unlucky and have had to go through ovarian failure too soon – either spontaneously or as a result of treatment such as radiotherapy, chemotherapy, ovarian hormone-suppressing medication and surgical removal of the ovaries and/or womb.
So yes, menopause is a natural and inevitable event for most of us. But does that mean it is always a good thing? Sometimes yes, sometimes no. Sometimes a bit of both – it is not black and white.
If you suffered painful or heavy periods and had not responded to or been able to tolerate treatments, you might be delighted to welcome the last day of your final menstrual period. Other disorders like Endometriosis and premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD) usually improve significantly after the last ever period and that can be liberation for those sufferers. So some people welcome this natural transition and God bless them.
Others however do not do well as they enter the menopause transition and might find that their quality of life can start to blow up as they go through this ‘natural process’. The word natural is a little loaded, too.
Lots of things are natural and inevitable for people who age. Heart disease, strokes, diabetes, dementia, broken bones, etc. – these are all natural consequences of getting older for many of us.
Does that mean our doctor or nurse will sit idly by and watch while our quality of life and possibly our longevity implodes? Well of course not. We try to help. That is medicine. And we try to address all the aspects of these situations. Remember just because something is natural doesn’t mean you have to put up with it.
Do we just offer pills and patches for menopause? Not always – we also try to educate and intervene in an effort to improve lifestyle – or at least as much as our patient can cope with.
Some patients are warned to avoid hormone therapies – esp if they have been diagnosed with breast or ovary cancer – so there is more to menopause than writing a prescription. Of course, we DO prescribe hormones – in accordance with accepted guidelines – it just isn’t a one size fits all situation.
Classic symptoms of peri-menopause (the time before your periods stop altogether) and post-menopause (the time after your periods have stopped altogether) are fairly well known by now.
Symptoms of peri-menopause do not hit everyone in the same way but more than 25% of sufferers describe their symptoms as severe. One study looked at the menopausal vasomotor symptoms over the menopause transition. It found that hot flushes and night sweats occur in 80% of patients – this often causes sleep disruption. Joint or muscle pain and stiffness are also pretty common.
Mood changes such as new onset or worsening anxiety, low mood, irritability, depression and rage have all been reported.
Cognitive issues such as poor memory skills and decreased concentration with a possible decline in work performance are not unusual. Urinary frequency, urgency, recurrent UTIs, vaginal dryness, irritation, itch or pain and uncomfortable sex are not uncommon all of which can lead to loss of libido – which may happen even in the absence of these physical problems as testosterone decline in females has been linked to low sex drive.
Weight gain and a tendency to shift from gluteo-femoral fat to the more sinister centrally deposited fat are also common.
Did I mention headache and migraine, burning mouth syndrome, palpitations, dry eyes, formication (crawling sensation of the skin) and tinnitus?
Do not panic though – many people get through this midlife transformation with minimal symptoms- or can manage their symptoms quite well with some lifestyle changes – not everyone needs to be on HRT!
Hormone replacement Therapy refers to the use of oestrogen (always) progestagen (usually) and testosterone (sometimes) in pills, creams, patches, sprays, pessaries and the like to balance out ovary hormone fluctuations or, in later life, replace the ovarian hormone. It can really help.
HRT is the most effective treatment for sweats and flushes associated with menopause (and most of the other menopause-related symptoms) and is a proven treatment agent for osteoporosis.
Testosterone as a form of HRT is very much in the public eye at the moment and the debate rages on among clinicians about its effectiveness as an additional treatment for women in menopause. Currently, it is recommended that Testosterone therapy for menopause is limited to people complaining of Low libido or ‘HSDD’ (hypoactive sexual desire disorder).
But HRT is not a magic wand and is not necessarily going to fix everything that ails you. HRT is just hormones and they are not without risk. Overprescribing of any medication is not wise and every consult needs to be taken as it comes. It might seem as if every female over 40 is having severe menopause symptoms and wants HRT. Well, that is worth discussing and exploring.
The current recommendations say no. We do not have enough data to say all females should keep their estrogen/progestogen/testosterone levels high as they age. We still have lots of unknowns or ‘not too sures’ surrounding what the real risks of long-term use of HRT might be for people who do not need it for control of symptoms.
HRT is not for everyone and is certainly not to be used as a salve for people who know they ought to move more, eat better, drink less and stop smoking.
But, if an individual patient is struggling, if they are not well and if THEY are likely to get more benefit from using HRT than risk, they can consider HRT.
I would suggest that this recent upswing in HRT popularity might be a natural pendulum shift away from the historical narrative in which we ignore women, particularly middle-aged women. Maybe the current interest in HRT is payback for the last 20 years when HRT was a dirty word and only small pockets of healthcare seemed to have any knowledge about it.
The aftermath of the now somewhat outdated ‘Women’s Health Initiative’ HRT study created a black hole of ignorance among some medical professionals which in turn opened the door to unnecessary suffering and preventable illness. That publication created a concern that the use of HRT could cause breast cancer. It didn’t then, it doesn’t now but there is a link and that needs to be teased out in a menopause consultation with each patient.
The fear associated with HRT use caused some people to be too afraid to seek the help that they needed and those fears were often validated when medics refused to prescribe them HRT. Those days are more or less gone.
Our guidelines for prescribing are straightforward. People under 60 without certain medical issues (hormone-related cancers mainly) CAN almost always try HRT if they like. If it doesn’t help, they stop. If it does you can choose to carry on. You should also be trying to tweak those modifiable risk factors too – and your GP or nurse can help with that. Prescribers should give you balanced information, point you toward quality resources and then let you decide. You accept the benefits; you accept the risks – as with any medication.
We are urged to use a menopause consult as an opportunity to highlight health screening (when was YOUR last smear test?) and chat about modifiable risks such as smoking, drinking, being inactive, tackling obesity, etc, as well as discussing a patient’s eligibility for HRT.
Everyone is an individual and every menopause consultation is unique.
Deirdre Lundy is a doctor working in general practice who is a specialist in sexual and reproductive health. She runs the NWHIP-funded Complex Menopause Service at the National Maternity Hospital in Holles St. Dr Lundy will speak at the sold-out inaugural National Menopause Summit supported by M&S which takes place in The Round Room at The Mansion House in Dublin City on Thursday, 23 March.
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