Perimenopause & Menopause Q&A
Let's start with some definitions
Perimenopause is the period of time leading up to menopause when women start to experience the effects of fluctuating oestogen levels. Menopause is the last day of the last menstrual period. As such we can't diagnose it until enough time has passed that we can be sure that periods have stopped completely. This is generally accepted to be a year without a period for women over the age of 50 and 2 years without a period in women age 50 and under.
Post-menopause is the period of time from after the menopause until the end of a woman's life. The average age of menopause is 51. A 'normal' age for menopause is from age 45 until age 55. Menopause under the age of 45 is considered early, while menopause in women age under 40 is called Premature Ovarian Insufficiency.
What is the role of oestrogen?
At the end of the fertile years women's oestrogen levels are on an overall decline but day-to-day and even hour-to-hour they can fluctuate considerably. It is this fluctuation that can cause the symptoms of perimenopause and menopause. When we use hormone replacement therapy (HRT) we are simply bringing the oestrogen levels up to where to a point where the fluctuations are evened out, thus minimising the symptoms.
There are oestrogen receptors almost everywhere in the body and that is why symptoms can effect almost all systems.
What kind of symptoms can I expect?
First of all, the degree of symptoms varies widely from person to person. Some women sail through perimenopause and menopause with minimal symptoms, while some women can have horrendous symptoms that affect their ability to function and go on for decades. Most women will fall somewhere between these two extremes.
Often the earliest symptoms are the psychological ones such as anxiety, irritability, less ability to cope and take things in your stride. Brain symptoms can appear too - women will often report 'brain fog' or lack of mental clarity, word-finding difficulties, forgetting plans and names and less ability to focus on a task. These features can be distressing and even affect a woman's ability to perform her job.
Then can come the vasomotor symptoms - these are night sweats and hot flushes. Night sweats can be mild to drenching. Hot flushes can come on suddenly with a wave of warmth passing through the body and the face can become flushed. They usually pass within a few minutes, but in some women can be frequent and debilitating.
Other symptoms include, but are by no means limited to, joint pains, muscle aches, poor sleep (this can very much be affected by night sweats), palpitations, skin and hair changes and vaginal dryness.
The other obvious change that happens at this time is a change in a woman's periods. They can become heavier or lighter and more frequent or less frequent. But ultimately, they will become less frequent and eventually stop.
If I'm not getting periods because I'm on the pill or have a Mirena coil, how will I know that I've reached menopause? Is there a blood test that can tell me where I am?
I mentioned above that if you go two years without periods under the age of 50, or one year from age 50 that we can diagnose menopause, however, if you are on a hormonal contraceptive this can affect your bleeding pattern and may even cause you to get no periods. This muddies the waters a bit. You will eventually get other perimenopausal symptoms and this can give you a good indication. If you are on a combined contraceptive pill, the oestrogen in it may be alleviating the symptoms but it won't prevent menopause from happening. There is blood test that can be done in certain cases - such as early menopause and premature ovarian insufficiency. This is called FSH (follicle stimulating hormone). The problem with FSH as a test for menopause is that it fluctuates considerably day to day and even hour to hour - so it could be normal today and raised tomorrow. So if the level is raised it can be a good indication that you are in perimenopause at least, but if it's normal it doesn't mean you're not. That's why we rely more on what the woman is telling us about her symptoms to make the diagnosis.
It is also worth noting that if a woman is taking oestrogen in the form of a combined pill or HRT, then the FSH test is of no value as it affects the result.
When can I safely stop using contraception?
No one needs contraception from the age of 55.
If you are using a progesterone-only contraceptive such as the mini-pill, Depo-Provera injection, Implanon subdermal implant (the 'bar') or Mirena / Kyleena / Jaydess hormonal coils and you are age 50 or older you can use the FSH blood test to help you decide whether it is ok to stop. If the FSH is raised, continue using contraception for a year and then stop. If the FSH level is normal, continue for a year, then repeat the test. If the repeat test is raised, continue for another year, then stop. If the FSH is still normal, continue for another year and then repeat the test again, and so on. Combined oestrogen and progesterone contraceptives are contra-indicated from the age of 50 as the risk of a clot in the leg is too high.
From age 45 to 49 it is better to continue using contraception if needed, even if you are experiencing peri-menopausal symptoms as there is still some chance you may be ovulating sporadically.
If early menopause or premature ovarian insufficiency has been confirmed, it is also possible to get spontaneous ovulations years after periods have stopped. Therefore we often use a combined oestrogen and progestogen contraceptive at this stage as it provides contraception and the oestrogen may alleviate menopausal symptoms thus acting like HRT (as long as there are no contraindications to it). More on HRT in the next section.
Should I use HRT? Does every woman need it? Is it safe?
As previously mentioned, HRT can be used to alleviate symptoms of perimenopause or menopause by keeping oestrogen levels on a more even keel and stopping the fluctuations. It can very effective for many women, and life-changing for some. But it's not necessary for every one. Women with mild symptoms may find they can manage them with some lifestyle changes such as stress management and regular exercise, and that's absolutely fine. While it has other benefits such as protecting the bones from osteoporosis and protecting the heart, it wouldn't be prescribed just for these benefits in the absence of menopausal symptoms. The situation is different in women with premature ovarian insufficiency who need their estrogen replaced until at least the average age of menopause.
HRT had a bad reputation for 20 years following the publication of a couple of studies in the early 2000s. The desing of these studies was poor and the results of these were mis-reported, and it has since been shown that HRT is safe for most women. There are very few reasons someone can absolutely not take HRT - one such example would be breast cancer. There is a small increased risk of breast cancer in women taking HRT - no more risk than drinking 2 units of alcohol a day for example. Check the Resources section if you want to read more about risk.
What are the different types of HRT?
Hormone replacement therapy involves taking oestrogen to help symptoms. If a women still has her womb she also needs to take a progestogen to protect the lining of the womb (as oestrogen can stimulate it to overgrow).
Oestrogen can be given as an oral tablet, or through the skin as a patch, gel or spray. Oestrogen delivered through the skin is safer in terms of risk of causing a clot as it doesn't get processed by the liver where the clotting factors are made.
Progestogen may delivered in the form of a tablet taken at night, or a Mirena hormonal coil. The tablet is given at least 12 days a month for women who are still having periods, or every night at a lower dose in women whose periods have stopped for a year or so.
Oestrogen may also be used locally in the vagina for genitourinary symptoms of menopause such as dryness, in the form of a pessary or cream.
Testosterone is also a female hormone. It is sometimes given to women with significant low libido. There is no licensed product formulated for women in Ireland, but we can use a gel designed for men, just at a much lower dose.
When will menopause symptoms end?
If on HRT, when can it be stopped?
There is no straightforward answer to this question, unfortunately. As mentioned, oestrogen levels fluctuate widely during peri-menopause and menopause but are on an overall downward trend. They eventually reach a plateau at a low level, and symptoms will usually reach an end at this time. But this isn't always the case - a small proportion of women will continue to be symptomatic well into their 60s.
All women's oestrogen requirements should reduce - so as a general rule a 60 year old woman will need a much lower dose of oestrogen to alleviate her symptoms than a woman in her 40s needing HRT. At some stage it is reasonable to lower the dose and if there are no ill effects, to continue to lower it and eventually stop. If the symptoms return, then the woman can simply go back on it.
What are the alternatives to HRT for managing menopausal symptoms?
If appropriate, lifestyle changes can make a significant difference to symptoms - such as stopping smoking, increasing exercise, a healthy diet, improving sleep and reducing stress.
There are many multivitamins and minerals that are aimed towards menopausal women which one may wish to try. In general we recommend vitamin D during winter months to protect the bones and folic acid if there is any chance of pregnancy.
Some herbal supplements such as black cohosh and red clover have anecdotal evidence for symptoms relief but don't have the same scientific evidence as prescribed medications. There is also the risk of interaction with other medications.
There are non-hormonal medications which can help in women who don't wish to use HRT, or who can't due to breast cancer for instance. SSRIs such as fluoxetine which are usually used for depression can actually alleviate hot flushes and night sweats. Clonidine is another medication which can be used for hot flushes.
Cognitive behavioural therapy has also been shown to provide benefit.
For genitourinary symptoms such as vaginal dryness, recurrent urinary tract infections, vulval and vaginal irritation and discomfort, topical oestrogen in the form of a pessary or cream can be hugely beneficial. Vaginal moisturisers and lubricants for every day use and during intercourse can give added benefit.