After attending the British Menopause Society, (BMS) conference in July, followed by the Menopause Society of Ireland Conference in September, I thought readers might be interested in take-home points.
Look after yourself
As women we are bombarded by fads; best thing for sleep, energy, belly fat – you name it and someone claims to have re-invented the sliced pan in terms of a cure.
I found it refreshing to read The International Menopause Society (IMS) white paper emphasising the vital role of lifestyle medicine when navigating menopause. This puts power into the woman’s hands by pointing out the vast body of evidence showing that changes to lifestyle have a big effect on not just menopause symptoms but risk of subsequent chronic diseases like diabetes and heart disease, and enhance quality of life. It talks about the six pillars: healthy eating, exercise, mental wellbeing, avoiding risky substances, good sleep and healthy relationships.
Not rocket science, is it? Yes, HRT or other non hormone drugs help menopause symptoms but unless you are looking after yourself, all your symptoms will be worse
The heart: Coronary Heart Disease (CHD)
Dutch cardiologist professor Angela Maas, who wrote a fascinating book ‘A Woman’s Heart’, presented at the MSI conference. I mentioned in previous articles that women’s CHD is different to men’s. However, women have rarely been included in studies on cardiac drugs or procedures. There is an assumption that what works for men will work on female physiology. Angina is chest pain caused by reduced flow to heart muscle. In men, this is as a result of blockage in large arteries. Most female angina occurs as a result of narrowing of small arteries, a process called vasospasm. This vasospasm can be brought on by exercise, nicotine, but also by stress. The arteries then open again returning blood flow so symptoms are intermittent and can seem inconsistent; the same activity causes symptoms one day but not the next.
Studies have shown that 80 per cent of women after a heart attack, have a normal angiogram.
Female CHD symptoms are also different from men’s who get chest pain when exercising. Women can get chest pain, but also fatigue, back ache and low mood. The chest pain can be atypical, typical being pain brought on by exercise.
Diagnosing CHD: The treadmill test looks for ECG changes and symptoms brought on by exercise. An angiogram, when dye is put through heart arteries, looks for large artery blockage. The term ANOCA, ‘Angina with Non Obstructed Coronary Arteries’ is a relatively new term recognising that not all CHD involves large arteries.
Angiograms and treadmill tests are not accurate CHD diagnostic tests for women; negative results do not rule out CHD. Invasive coronary function tests do assess reversible vasospasm but are available in specialist centres only.
Prof Maas confessed that in her field there are still some, usually male, cardiologists who “do not believe” in female heart disease – like we are some kind of mythical creature.
Can we believe what we read and see on social media about menopause? Probably not. Findings of a study in 2024 was presented at the BMS conference, looking at accuracy of content of posts about menopause on social media platforms; whether they reflected evidence based guidance of bodies such as NICE, National Institute of Clinical Excellence, the BMS and IMS: 67 per cent did not.
Always get your female health and menopause information from reputable sources. I recommend the BMS patient facing arm of their website; Women’s Health Concerns (womens-health-concern.org).
Testosterone: We all need it, right? Wrong.
Previous studies have shown that testosterone very gradually starts to decline in both men and women from age 18. There is no sharp drop for women during menopause. Yes, the ovaries produce testosterone, but a significant amount of testosterone is produced by adrenal glands and this is unaffected by menopause. Professor Susan Davis, Head of Monash University Women’s Health Research Program Melbourne, presented the fascinating findings of a study involving over 1400 randomly-selected 18- to 75-year-old women; 500 had testosterone levels analysed.
They found the same slight, gradual decline in testosterone levels from 18 to 62, with then a rise in levels. No significant difference in testosterone levels were found between women who were pre, peri or post- menopausal. The study also found no association between sexual function and testosterone levels. I was fascinated to learn that in placebo-controlled studies on testosterone to treat reduced libido, the placebo consistently produce a 33 per cent improvement in libido. Never knock a placebo.
Studies have looked for but found no evidence that testosterone helps with other menopause symptoms such as fatigue, mood, brain fog, general energy, strength or muscle mass.
The testosterone we prescribe is for men, is not licensed for women, and risks of overdose are real, which is why regular blood tests are needed. Even when levels are kept in the female range, we can see side effects of facial hair, hair thinning/male pattern baldness, voice changes and even clitoromegaly – enlargement of the clitoris – which might be irreversible. In addition we lack safety data on use of testosterone by women for longer than 12 months in terms of effects on cholesterol and cardiovascular risk.
Bottom line, ladies; we are complex creatures. Our sexual function and desire is multifactorial. While it is tempting to think that a dab of testosterone gel every day will fix everything in the bedroom department, emerging data shows that perimenopause and menopause are not times of testosterone deficiency. Plus there are strong signals that our testosterone levels will rise over the age of 60; something to look forward to… or not? You decide.
So what/when exactly is perimenopause?
No two women are the same and neither are the symptoms experienced through menopause transition. Dare I use that term journey? Became, if it was a trip we paid for we’d all want our money back.
Professor Susan Davis presented findings of the Australian Women’s Study (AWS) looking to see what menopause symptoms women experienced and when ie in early or late perimenopause, in menopause or in post menopause. A few definitions:
A woman is said to be in the menopause if it has been more than 12 months since her last period.
Postmenopause is the time beyond 12 months after the last period.
A woman is pre-menopausal if she has a regular four-week cycle, no symptoms and no changes to her periods.
These three stages are easy to spot.
Perimenopause is not so straight forward.
We lack evidence-based or indeed any guidelines on treatment of women in perimenopause.
The global gold standard for the past 15 years defining a woman’s reproductive stages is the STRAW-10 system. In brief, it says perimenopause starts once cycles vary in length by seven or more days; ie periods become either further apart or closer together by seven or more days. That may need to be rethought.
The AWS found that women experienced typical menopause symptoms like hot flushes when their periods were still occurring at the usual interval, but what they had was a change in flow; either lighter or heavier periods.
What we do know about perimenopause is that it is a time of hormone chaos, not oestrogen deficiency. This is because some months we ovulate, others we do not. A cycle without egg release results in high oestrogen levels giving heavier, longer periods, headaches, bloating, fluid retention.
‘PMS on steroids’ is what one patient described what it felt like for her in her early 40s. Many women start to get migraines for the first time in their 40s. Anxiety is also a prominent symptom in perimenopause.
This is where social media is definitely not your friend: It is often advocated that HRT needs to be started the minute a woman starts to experience any menopause symptoms. Stop and think about that: if your hormones are all over the place, does it seem like a good idea to throw a load of other hormones in on top? That is what taking HRT in the early perimenopause will do.
HRT is a product designed and safety tested for use by post-menopausal women to treat oestrogen deficiency. What we need to do in perimenopause is stop the hormone chaos and this is achieved by switching off ovulation; HRT products will not do that. Also we have no safety data on the use of HRT starting in women as young as 43 in terms of lifelong risks of breast cancer.
What we do have is a range of very safe hormone therapies that will stop ovulation and therefore stop the chaos and get rid of the PMS. Once the hormone roller-coaster stops, anxiety symptms invariably settle. Many of these products now contain the same oestrogen you get in HRT.
New drug for hot flushes
Some readers may have come across Veoza, brand name for Fezolinetant. It acts centrally in the brain to calm the thermoregulatory system and is very effective. A sister medication, Elinzanetant has been studied in women with breast cancer, who are unable to use HRT, and it is very effective and safe.
But, it is expensive and can affect the liver. While the HSE is considering whether it might be covered by medical card or DPS, drug prepayment scheme, it is not currently and costs €80 a month. Liver blood tests need to be done before starting, a few weeks after and again six months later.
I have rheumatoid arthritis/Lupus so I cannot have HRT. Not true.
Dr Arvind Kaul, consultant rheumatologist, St George’s Hospital London gave an interesting presentation at the BMS conference, emphasising that transdermal HRT is safe to use in autoimmune disorders such as RA, Sjogrens, or Lupus.
I’ve had a clot so I cannot have HRT. Not true.
While the link between oral HRT and clots is well-established – the risk is increased two to four times – we have compelling evidence from large studies that using HRT through the skin, transdermal HRT, does not increase the risk of clots. The presentation by haematologist and clotting specialist Professor Beverly Hunt highlighted an issue we have all come across as doctors and patients; a doctor or nurse telling you that you must stop HRT before a procedure or surgery; not true. Yes, if you are on oral HRT you should stop four weeks before any operation but a safe option is to switch to transdermal HRT.
If you have questions about any if the issues raised here, please discuss with your GP.