Understanding the Menopause: More Than Just a Life Stage
Understanding the Menopause: More Than Just a Life Stage
Menopause is a natural biological transition that marks the end of a woman's reproductive years but for many, it remains misunderstood or surrounded by stigma. Despite affecting half the population, conversations around menopause are often limited, leaving many women unprepared for the changes they may face.
In this blog, we’ll explore what the menopause really is, when it typically occurs, and why recognising and managing symptoms early can make a significant difference to your patient's health and wellbeing as well as different treatment options available.
What is the menopause?
The natural process of the menopause can take place at any age but in the UK this takes place on average around the age of 51. Menopause is officially the term given when a woman is one year after her last menstrual period. In women over the age of 45, the diagnosis is made based on the symptoms alone and NICE guidelines advocate that FSH measurement is not needed in this scenario. It is also important to note that many women develop symptoms may years before their periods change and in this scenario a trial of HRT can be both diagnostic and therapeutic.
The signs and symptoms
The typical symptoms range from
- Hot flushes
- Night sweats
- Poor sleep
- Mood changes
However, it can sometimes present in obscure ways, for instance
- Palpitations
- Severe joint pains (in the absence of any other explanation or symptom)
- New onset anxiety
These symptoms can be crippling, and women in leading roles in their careers often resort to reducing their hours, leaving work or suicidal ideation due to the overwhelming nature of the symptoms.
On average symptoms affect women for more than 7 years although this can be longer in a subset of women.
What are the treatment options?
- Lifestyle change
This is easily overlooked but a powerful treatment option. A diet low in saturated fat and salt as well as rich in calcium and vitamin D is essential. Increasing unsaturated fats such as olive oil, avocado, nuts, seeds and oily fish has beneficial effects on lipids.
Natural sources of phytoestrogens such as soya, chickpeas, lentils and flaxseeds can reduce symptoms. Between October and early March, it is recommended that all adults take a 10 microgram vitamin D supplement.
Smoking cessation advice is worthwhile as smoking can increase the risk of an earlier menopause and can trigger hot flushes. Alcohol and caffeine reduction can reduce hot flushes, anxiety and poor sleep.
Regular exercise and weight resistance training has been shown to reduce the severity and frequency of hot flushes.
2. Complementary and alternative therapies
This includes yoga, acupuncture, reflexology and aromatherapy as well as herbal remedies like black cohosh or red clover.
Cognitive Behavioural Therapy (CBT) can be particularly helpful for both mood disorders and menopausal symptoms. Prescribable alternatives for women with contraindications or who wish not to take hormones include medications like antidepressants or medications for an overactive bladder which can take the edge off some of the symptoms.
The latest addition to this treatment group is the invention of the neurokinin 3 receptor antagonist, which is only available privately at present but has been shown to reduce the frequency and intensity of hot flushes.
3. Hormone replacement Therapy (HRT)
The mainstay of treatment is hormone replacement therapy (HRT). There are a number of ways that HRT can be given, taking into consideration if the woman has a uterus, or whether she is pre- or postmenopausal, and whether contraception is required.
Transdermal oestrogen does not increase VTE or stroke risk at standard doses and comes in a
- Gel
- Patch
- Spray
This is especially a good option for migraine suffers due to the steady hormone release, or women with absorption or thyroid issues. Lower risk women who have no significant medical history and have a normal BMI could also consider oral oestrogen options, which is also better at controlling irregular vaginal bleeding compared to transdermal options.
The Hormonal Coil
For the progesterone element, an excellent option is the hormonal coil, as this delivers contraception, minimises irregular vaginal bleeding which is a common presentation with hormonal changes, and provides excellent endometrial protection even at higher doses of oestrogen. The latter point has been under scrutiny of late due to the limited data supporting the efficacy of micronised progesterone for endometrial protection at higher dosages of oestrogen.
A combined patch is another great option for women who work shifts or who forget to take tablets regularly. The key is personalising the treatment option to the woman’s needs and medical history.
What are the benefits and risks of HRT?
The main risk that people fear is that of breast cancer but putting this into context for the patient helps to reduce anxiety around this risk. Being overweight or drinking just 2 units of alcohol daily poses more risk of breast cancer than HRT itself, and if there is significant concern then the use of micronised progesterone or dydrogesterone is deemed to be the most breast friendly option. Whilst a considerable focus is placed on risks, it is worth remembering the significant hidden benefits of HRT to long term health including protection to the cardiovascular system and the reduced risk of developing osteoporosis, diabetes or bowel cancer.
What is Genitourinary Syndrome of Menopause (GSM)?
Commonly women also experience vaginal soreness or dryness due to thinning of the vulvovaginal skin as a result of the lack of hormones. This is not routinely volunteered by women but a simple direct question on this subject can help women feel heard. This can be treated easily with vaginal moisturisers and lubricants, as well as localised oestrogen therapy in the form of
- Creams
- Tablets
- Pessaries
- Vaginal rings
These are very effective and can be life-changing and can be used in most women long term. Latest NICE guidance supports the use of topical oestrogen in breast cancer survivors too in conjunction with advice from the patient’s specialist, and in this scenario lower dose oestrogen options can prove to be very helpful.
When to refer?
Menopause is a significant milestone in a woman's life and, with the right support, it can be navigated confidently and comfortably. For many women, symptoms can be effectively managed in primary care with a personalised approach to treatment, including the use of HRT where appropriate. However, it’s important to recognise when a more specialist opinion is needed, particularly in complex cases or when treatment options are unclear such as:
- There are menopausal symptoms and contraindications or risks of HRT
- There is uncertainty about the most suitable treatment option
- Patients with premature ovarian insufficiency
- Women considering the use of testosterone replacement for poor libido
Final Thoughts
Understanding these nuances is crucial for supporting women through this significant life stage with the care, knowledge, and options they deserve.
By staying informed, following clinical guidance, and knowing when to refer, healthcare professionals can ensure women receive the best possible care throughout the menopausal transition and beyond.
Empowering women with knowledge and access to appropriate treatment is key to improving quality of life during this important life stage.
Author - Ramiya Al-Alousi, Menopause specialist and GP with specialist interest in women’s health