What is menopause?
Menopause marks the end of menstrual cycles caused by a change in the balance of the body’s sex hormones, which occurs as women get older. It is diagnosed when a woman has not had a period for 12 months. The ovaries stop producing the sex hormones oestrogen, progesterone and testosterone and no longer release an egg each month. Most women go through the menopause between the ages of 45 and 55. The average age of menopause in the UK is 51. Factors that can impact the age of menopause include family history, personal medical history, and lifestyle.
What are the symptoms of menopause?
Women’s experience of the menopause varies widely – the symptoms and how severe they are is fairly unpredictable. It is, therefore, important to be aware of how menopause may present itself and to chat with us if you think you may be experiencing symptoms.
Symptoms of menopause can be grouped by the hormone deficiency which causes them:
- Oestrogen deficiency can cause hot flushes, night sweats, palpitations, reduced skin elasticity, itchy skin, dry/gritty eyes, vaginal dryness, low libido, and urinary symptoms like recurrent cystitis.
- Progesterone deficiency can cause anxiety, low mood, irritability, poor quality of sleep, and increased inflammatory processes such as joint pain, achiness, bloating and breast tenderness.
- Testosterone deficiency can cause low libido, reduced muscle tone, reduced self-confidence, and reduced focus and concentration.
What is perimenopause?
Perimenopause is the term used to describe the time prior to the menopause. Women can start experiencing mild to moderate symptoms of hormonal imbalances a few months or even years before they reach menopause. For the majority of women, perimenopause will start in their 40s, and their periods will start to change. Progesterone levels start declining quicker than oestrogen, such that sleep patterns and mood are often affected first.
Fluctuations in progesterone and oestrogen are at their peak during perimenopause, making this a very unpredictable and often difficult time for women. Historically, many women will endure symptoms in silence, but it is important to come and see us as there are numerous treatment options we can offer to support you.
How is the menopause and perimenopause diagnosed?
The diagnosis is symptom-led, so please do chat with one of our doctors to discuss what you are experiencing. Blood tests are a good guide to hormone levels but can vary each month, so they are not the most reliable diagnosis method. Your blood levels of the hormones can guide us as to what dose of HRT we could start you on. Depending on the hormone we are measuring, we often try and time the blood test to the relevant day of your cycle – so please discuss timings with us, and we can advise you when is best.
Transvaginal ultrasound scans are sometimes used for irregular bleeding if heavy or prolonged, although some irregularities in the cycle are expected for all women.
What is HRT?
HRT is the abbreviation for hormone replacement therapy. The aim of HRT is to replace the hormones that the body is missing. Oestrogen and progesterone are the main components, and testosterone is sometimes used depending on the woman’s symptoms.
Body-identical versus synthetic HRT
There are two main types of HRT: Synthetic and Body-identical. At Sloane Street Surgery, we most often prescribe body-identical hormones, which are molecularly identical to what is naturally found in the body. The hormones are plant-derived from a yam. Body-identical hormones are thought to have a lower risk of cancer and fewer side effects compared to synthetic hormones, but no long-term studies have been done to confirm this clinically.
The oestrogen found in most HRT preparations is body identical – doctors rarely prescribe synthetic oestrogen nowadays.
Body-identical progesterone is prescribed in the form of an oral capsule called Utrogestan. Synthetic progesterone – called progestogen, is sometimes still prescribed in the form of combined HRT patches or combined tablets. The Mirena coil can be used for the progesterone component of HRT – it contains synthetic progesterone but has minimal side effects compared to patches or tablets, as it only acts locally in the womb.
What is the difference between bio-identical and body-identical hormones?
Body-identical hormones are regulated and have been studied in large-scale trials. Bio-identical hormones are unregulated and have not been evaluated in trials.
You may have heard of bio-identical or compounded hormones being prescribed as ‘bespoke HRT’. The clinics that offer this have their own labs and make oestrogen and progesterone creams of different doses depending on the patient’s hormone level. While this may sound promising, their labs are unregulated and are not held to the same stringent standards as the larger drug companies.
The different ways to take HRT
The safest way to take oestrogen is through the skin – either a patch, a spray or a gel. These are body-identical; if taken this way, there is the lowest risk of blood clots and stroke. It is often personal preference as to whether the gel, spray or patch suits a woman. The spray and gel can take a few minutes to dry and can be messy and harder to travel with. The patch needs to be changed twice a week, so it can be tricky to remember.
As mentioned above, body-identical progesterone comes in a capsule, which is taken every evening before bed. This can cause side effects such as bloating and nausea. If oral progesterone is not tolerated, we can suggest taking this capsule vaginally, but this is not licensed. If neither of these suits the woman, we often suggest having the Mirena coil inserted, which supplies enough progesterone and only releases it in the womb so it can be better tolerated.
Body-identical testosterone comes in the form of a gel. This is applied to the inner thigh. It rarely can cause side effects such as hair growth in the area applied, hair loss from the scalp and acne. At Sloane Street Surgery, we like to use an Australian brand of testosterone called Androfeme, as it is the only testosterone that is licensed for females.
What are the benefits of HRT?
- HRT helps to control the symptoms associated with declining levels of hormones, therefore allowing women to continue their day-to-day life without the negative effects of menopause.
- HRT can help prevent osteoporosis and maintain strong bone health.
- HRT has been shown to help with muscle strength.
- There is some evidence to show that HRT can reduce the risk of dementia.
What are the risks of HRT?
The risk of breast cancer is slightly increased with HRT. However, most of the concern stems from a study done on synthetic hormones. The risk is thought to be lower with body-identical hormones. Clinical guidance states ‘HRT that contains oestrogen and progestogen may increase breast cancer risk. This risk may be higher if you take HRT for longer but falls again when you stop taking HRT.’
The risk we are referring to is very small. It has been shown that being overweight (BMI of 30+) or drinking more than two units of alcohol a day increases the risk of breast cancer more than HRT does. Most recent research shows that the benefits of HRT outweigh the risks for most women.
It is important to note that for women who reach menopause at a younger age than 51, HRT doesn’t increase the risk of breast cancer at all, as it simply replaces hormones that your ovaries would have released until the average age of menopause.
We recognise that for many years, breast cancer was splashed across the media as a major concern for all patients on HRT. We want to change this narrative – the risk is much lower than we originally thought. We now use body-identical hormones, and the benefits to women’s mental and physical health of being on HRT are becoming more and more apparent.
When should I see a doctor?
If you notice your periods are changing, if the symptoms above describe how you are feeling, or if you just want to be armed with more information about the menopause and HRT, then please do come and chat with us.
It is never too early or too late to discuss the treatment options available to you. In the past, menopause has not been talked about openly, and we at Sloane Street Surgery are on a mission to change that. This stage in life can be very difficult for women, but with guidance and support, we aim to make it seamless to allow you to continue your action-packed lives!
References:
https://thebms.org.uk/wp-content/uploads/2023/01/WHC-Infographics-JANUARY-2023-BreastCancerRisks.pdf
