Before I begin, I want to dispel a few myths: “You are still having periods, therefore your symptoms could not be menopausal”; “You are only 45, you could not possibly be having menopause symptoms”; “Your hormone blood tests are normal so your symptoms are not menopausal”.
These statements are false.
Diagnosis
Menopause is not a line in the sand: it is a process, different for every woman both in nature and duration. Medical terminology is not terribly useful. Clinically the word menopause is used when a woman has not had a period for one year. However, starting from the age of 45, and less commonly earlier, a woman can experience menopause symptoms right up to and beyond 12 months after her last period.
Menopause is not diagnosed with a hormone blood test but by taking a detailed, careful history. I use the phrase: The Menopause Symptom Package, which I will run through. This is a term I coined, as 25 years of clinical experience taught me that women going through the menopause process have a great variety of symptoms.
Hot Flushes: I put this first to get it out of the way. We all recognise this as a menopause symptom. What we need to be mindful of as medics is not to dismiss all other symptoms as possibly being menopausal in the absence of hot flushes.
Sleep: Even without hot flushes at night, many women complain of very poor sleep, either not being able to fall asleep for hours or waking in the night and being unable to get back to sleep.
Brain Fog: A term known to most women, brain fog covers a number of brain function issues such as poor memory, loss of skills such as time management, ability to multitask, numeracy and so on. Put simply, feeling like your brain is just not working properly. This impacts our ability to function both in the home and at work. There is poor menopause awareness training and even fewer incorporated menopause policies in the workplace to support working women through menopause.
Emotional issues: In my work as a GP over the past 30 years, I have seen many women come in absolutely terrified that they had early onset dementia or Alzheimer’s disease, only to take a careful history that reveals the many other symptoms indicative of the menopause process.
Anxiety: This can be a huge problem in early menopause, either arising anew or as a worsening of pre-existing anxiety.
Irritability and mood swings: Many women describe this aspect as PMS on steroids.
Low mood, sadness: Change is a huge part of menopause, occurring across so many of our archetypal female roles: We can no longer have a baby, we change physically – no longer the hot young thing, we move into the realm of matriarch and very importantly, society regards us differently, somehow values us less. We are aware of this and it all takes processing. It is a watershed stage in our lives, as much as the year around our first period was, and I feel the emotional impact on women going through all that change is unappreciated. For some women, psychologically the menopause process also involves an element of bereavement.
Headaches: There are different types of headache but many women begin to experience migraines for the first time in their late 40s. This can herald the imminent onset of menopause or can be a really troublesome part of menopause symptoms.
Fatigue: Even when there are not sleep issues, many women feel completely wiped out in the time before and after their last period.
I pause here in going through the package to make a point. Yes, by the age of 50 most of us have a lot of good reasons to explain poor sleep, irritability, mood swings, rubbish libido, anxiety and fatigue such as running a house, the kids, the part- or full-time job, the grandparents: both sets. The children at that time are probably Junior and Leaving Cert ages and our parents are starting to crumble a bit. Just because all of the above is happening in this woman’s life does not mean she is not also going through menopause. As a clinician, I need to consider the full symptom package before reaching for the sleep or antidepressant medication.
Skin and Hair: Most of us noticed a change to skin and hair quality over the age of 50. The hair can feel more thin and brittle, the skin less plump and lustrous.
Joints: Even women without any pre-existing arthritis can have trouble with generalised joint stiffness and ache in early menopause.
Vagina: Symptoms of vaginal soreness and dryness are very common. You can get accompanying itching but not typically. As a clinician, I need to be careful not to misdiagnose and treat for thrush.
Sexual dysfunction: Reduction in our sex drive or libido is very common in early menopause. It is important to always ask how the sex life is because this is often not volunteered. Commonly I have found women tell me the vagina is not sore, only on questioning to admit she is not having sex, as that is too uncomfortable and, to be honest, she is just not interested. Not surprisingly, relationship issues can arise.
Urinary symptoms: Falling levels of oestrogen affect not only the womb and vagina but also the urethra, which is the pipe going from the bladder to its exit at the top of the vaginal opening. The results can be recurrent cystitis, which is discomfort or burning when passing urine and frequent urination. Treating the low oestrogen usually resolves the symptoms. When a woman does not want full HRT, vaginal oestrogen therapy in the form of gel or pessary will have the same effect.
Incontinence: I plan a full article on the pelvic floor, prolapse and female incontinence issues but want to mention that our pelvic floor similarly does not like falling oestrogen levels so pre-existing leaking problems can worsen or, sometimes arise anew.
While female hormone blood tests do not have a place in diagnosing menopause, it is important to rule out other causes of fatigue and check blood tests for anaemia, low thyroid and diabetes as part of the diagnostic process.
Hormone Replacement Therapy (HRT)
HRT contains two of our own female hormones, oestrogen and progestogen. If a woman has not had a hysterectomy; meaning she still has a womb, she needs both hormones. This is because the progestogen protects the lining of the womb, called the endometrium, from being overstimulated by oestrogen. If a woman has had a hysterectomy, she can have oestrogen alone. HRT can be given as a tablet or through the skin as a patch or gel.
The benefits of HRT can be categorised as short term and long term.
Short term: Usually within days, hot flushes improve and will disappear once oestrogen levels are stable. Sleep invariably improves, as do emotional issues. Urinary symptoms of cystitis and frequent urination, where due to oestrogen deficiency, will resolve. Stress type incontinence can improve a little on HRT. Libido, once oestrogen levels are adequate, can improve. Many women feel their skin and hair quality improve on HRT, as do energy levels and brain fog.
Long term benefits:
Bones: Five years of HRT reduces the risk of having an osteoporotic hip fracture by the age of 65 years by 50 per cent. After the menopause the rate of bone resorption increases resulting in higher prevalence of osteoporosis or thin bones and resultant fragility fractures in women over 60 versus men. HRT treats this condition and patients on HRT have shown improvement in and sometimes resolution of osteoporosis as measured by DEXA or bone density scans, before and two years after starting HRT.
Joints: Randomised control trials such as Women Health Initiative (WHI) study have shown significant improvements in joint aches with HRT.
Brain and Heart: Cochrane analysis suggests that HRT started below the age of 60 years is associated with a reduction in heart disease, heart attack and stroke. Other studies have shown significant reduction in all causes of death for women on HRT.
The Cons…HRT and breast cancer
There remains controversy about the risk of breast cancer diagnosis and mortality associated with HRT: it has been shown not to be as risky as was previously thought. Advice for clinicians prescribing HRT following publication in 2012 of Women’s Health Institute (WHI) study has been amended following the publication of WHI study long-term follow up data in 2020.
We can now tell women that if they have a low underlying risk for breast cancer, having combined (oestrogen and progestogen) HRT for up to five years incurs very little increased risk of breast cancer for her. Neither oestrogen alone, HRT, nor vaginal oestrogen therapy are associated with any increase risk of breast cancer.
What patients must be counselled about is the effect of lifestyle factors on their risk of breast cancer:
• Obesity increases the risk by 10 times
• Alcohol – over six units per day increases the risk by 11 times
I hope this has been useful. Related information on menopause can be found at www.womens-health-concern.org
Next month: Perimenopause.
In a future issue, I will also cover what women can take if they don’t want HRT/ have had breast cancer.
Dr Stanley welcomes emails from readers requesting women’s health topics for future articles or links to information:
drstanley@westcorkpeople.ie
We must emphasise that this is not a platform for medical advice. Phone the clinic on 028 23456 to book a telephone consultation on any women’s health topic with Dr Stanley.
