The word menopause is derived from the Greek words “menos” which means month and the word “pausos” which means an ending. Menopause literally refers to the cessation of the monthly fertile cycle of ovulation and menstruation in the female body. It marks the end of a woman’s reproductive years. A woman is considered post-menopausal if she has not had a period for 12 months. The cessation of menstruation can happen naturally and spontaneous or it can be induced by treatments such as radiotherapy, chemotherapy or by a surgical procedure such as the removal of both ovaries. In the UK the average natural age of menopause is about 52. Some women have no or only very few physical problems when going through the menopause and they embrace positively the new freedom they experience including no longer having periods and not having to worry about contraception. However, about 70% of women in the Western cultures experience hot flushes and night sweats. Other debilitating physical and psychological symptoms women report during the menopause are:
- vaginal dryness, soreness, itching
- urinary symptoms such as recurrent bladder infections, incontinence
- depressive symptoms, anxiety, low mood, mood swings, anger
- low libido
- sleep problems/night sweats
- fatigue and lack of energy
- dry skin, skin crawling sensation
- muscle and joint aches and pains
- pain during intercourse
- memory problems, word finding problems
- brain fog
Menopausal symptoms can have an adverse effect on all aspects of a woman’s life: her work, her relationship or marriage as well as family life and general ability to enjoy life and her “joie de vivre”. Hormone replacement therapy (HRT) has been shown to be a safe and effective treatment for most of these symptoms. Hormonal health can be complex. A careful and individual assessment can help identify the main problems and the underlying cause. Occationally blood tests may be required to confirm the diagnosis, when treatment isn’t working and to exclude other conditions.
The perimenopause is the transitional phase between the onset of the first menopausal symptoms until 12 months after the last menstruation. Ovarian function starts to decline around the age of 35. Although most women may not feel any different at that age, some women may start to have mild menopausal symptoms from the age of 40. Initially these symptoms may be more psychological such as increased irritability, mood swings, sleep problems or low libido, but they can later also manifest in a physical way with irregular periods and hot flushes. HRT can be an effective treatment option for these symptoms. it is a common myth that periods need to stop before HRT can be started. This is not the case. Women can start HRT during the perimenopause, even when periods are still regular.
When menopause occurs between the age of 40 to 45, it is called “Early Menopause”. Women in this age group who’s periods stopped for 12 months or more and have had tests to exclude other underlying causes, have a very high risk of developing cardiovascular disease and osteoporosis. The recommendation is that these women should be prescribed Hormone Replacement Therapy, unless there is a contraindication, such as breast cancer.
There are certain conditions such as endometriosis, large fibroids, ovarian cysts etc. which require surgical interventions. Women who are not post-menopausal, but have their ovaries removed at a younger age, will experience menopausal symptoms soon after surgery. Even women who only had a hysterectomy and still have their ovaries left in situ, often experience menopausal symptoms due to a drop in their sex hormone levels.
Premature Ovarian Insufficiency
If a woman is menopausal before the age of 40, it is called Premature Ovarian Insufficiency POI). The underlying cause for this condition ought to be established and women in this age group need to be on HRT to reduce the risk of osteoporosis and cardiovascular disease later in life.
Premenstrual Syndrome (PMS)
Up to 80% of women in their reproductive years experience some physical, mental or cognitive symptoms during the week before their period: bloating, cramps, low mood, anxiety, anger or fatigue. Whilst having PMS can affect the quality of life, it would not stop most women from functioning completely and they can still continue with their daily activities. PMS symptoms often start or get worse during the perimenopausal years.
About 3-8 % of women are extremely hormone sensitive and have particularly debilitating symptoms, which can stop them from functioning completely. They may feel severely depressed and even suicidal for the 7-10 days before their periods, but they tend to feel almost immediately better as soon as their period starts and they feel absolutely fine and have no mood related symptoms during the rest of the month. If symptoms are severe and so debilitating that it stops women from carrying out their normal day to day activities, then this condition is no longer classed as PMS, but would be called Premenstrual Dysphoric Disorder (PMDD). The hormonal fluctuations during the second part of the menstrual cycle can trigger a severe response in the brain of the affected women and can make them feel very unwell. Whilst there is no definitive cure, there are various effective hormonal and non hormonal treatment options available for both PMS and PMDD.
Please note: I don’t currently offer appointments for patients with severe PMDD, particularly if cyclical mood exacerbations are associated with recurring self harm, suicidal plans or ideation. I also currently can’t support anyone with severe PMDD who also has an existing eating disorder or problems with ongoing alcohol or substance abuse.
Prior to a consultation for PMS or PMDD, it would be very useful to keep a symptom diary for 2-3 months, so that the cyclical pattern of the symptoms can clearly be identified and confirmed. The symptom diary can be downloaded via this link: Symptom-Diary
Testosterone Replacement (women only)
Testosterone is not an exclusively male hormone. In women, testosterone is made in the ovaries and the adrenal glands. Once a woman is menopausal, she can lose 50% of her circulating testosterone. This can cause fatigue, brain fog and lack of energy and motivation. Reduced levels of testosterone also frequently contribute to Hypoactive Sexual Desire Disorder (HSDD), also commonly known as low libido. While many women may feel great on oestrogen/progesterone based HRT alone, some may need some testosterone as well. It is good practice to check blood levels of the free androgen index (FAI) (available on the NHS), before starting treatment and 3 months after starting the treatment. There is currently no licensed testosterone product available for women in the NHS. Privately, we can prescribe a licensed testosterone cream, which is imported from Australia and which is specifically formulated for women. Testosterone replacement is often the ‘missing link’ when it comes to HRT. Many women report that it gives them their ‘mojo’ back and they feel more like they used to feel.
Vulvo -Vaginal Atrophy (VVA)
Almost every postmenopausal woman will experience a degree of vaginal dryness and vulval irritation. Intercourse can become very painful or even become impossible. Many women also experience incontinence symptoms or recurrent bladder infections. Vaginal atrophy is the result of a thinning of the vaginal wall and reduced glands which used to make lubrication. Systemic HRT often helps with vaginal symptoms, but many women also need to use topical treatments. There are now many effective options available to treat this debilitating condition. Topical treatments are very safe and can be used without systemic HRT, also in women in whom systemic HRT is contraindicated.
Some women get migraine type headaches very frequently at the same time every month, either during the week before their period is due to start, during their period or in the first week of the cycle. If migraines appear to be cyclical in nature and very closely linked to periods, it is possible, that hormonal fluctuations are the trigger for these migraines. Stabilising the hormonal fluctuations can sometimes help to prevent these migraine attacks or reduce the severity and frequency. Lifestyle changes and certain supplements can also be beneficial. Prior to a consultation for hormonal migraines, it would be very useful to keep a symptom diary for 2-3 months, so that the cyclical pattern of the headaches can clearly be identified and confirmed. The symptom diary can be downloaded via this link: Symptom-Diary
Review of current Hormone Replacement Therapy
If you already take HRT, but you don’t feel well on it, or are not sure if it is the right type for you, then I can discuss other available options with you and help you to optimise your current HRT or switch you to a different type. You may take HRT already and feel well on it, but would like to receive more in depth information about long term health risks and benefits.
What I don’t treat
I will not see women who have been diagnosed or suffer from the following problems:
- breast cancer, if still receiving active treatment – unless as part of a multidisciplinary team in conjunction with the breast surgeon and oncologist. I do not routinely prescribe HRT to women with a history of breast cancer.
- I don’t offer hormone implants
- I don’t fit Mirena coils, but I can refer you to a private GP colleague for this service
- Severe PMDD which is associated with self harm, suicidal plans or ideation and/or ongoing alcohol and substance abuse