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Condition
Menopause

Class
Women's health

Description
Menopause is the term used to describe the ending of menstruation. Strictly speaking 'menopause' refers to one date, the last day of the final period, but the term is commonly used to refer to the time before, during and after this event. It is a time when women may experience many physical and emotional changes, so the menopause is often called ‘the change of life’ or ‘the change’.

On average, the menopause occurs naturally at around age 50, but in some women it can occur as early as age 40, in others it may occur as late as age 55.

Causes
The menopause is not a disease, but is simply a natural stage in every woman's physical and emotional development. It is a time when her body ceases to be fertile because ovulation stops, a time when levels of the hormones oestrogen and progesterone decrease, and monthly periods end. The decline in the level of the hormones, in particular oestrogen, is responsible for most of the symptoms of the menopause.

Symptoms
In the time leading up to the menopause, a woman’s periods do not stop suddenly but become less regular, less frequent before finally stopping. As with menstruation, the menopause is a very personal experience. Many women sail through the time, seemingly not affected. For others, the ending of periods has a marked psychological effect as they realise that they can no longer have children and think that they are becoming ‘old’.

The fall in the level of oestrogen not only stops ovulation, but is also responsible for a whole range of other symptoms. The most common of which are:

  • Hot flushes
  • Fatigue
  • Heart palpitations
  • Night sweats
  • Irritability
  • Vaginal dryness
  • Headaches
  • Weight gain
  • Insomnia
  • Pain in the joints
  • Poor concentration/memory
  • Incontinence
  • Urinary tract infections


Hot flushes, night sweats and palpitations are thought to be experienced by 70% of women for a year. Around 30% suffer for five years and 5% to 10% of women find the symptoms persist for 10 years.

Long term effects of the menopause are osteoporosis (a loss of bone strength with an increased risk of fractures), and an increased risk of heart attacks and strokes.

Treatment
HRT - Hormone replacement therapy
Hormone replacement therapy (HRT) involves the medical replacement of oestrogen for the short term treatment of menopausal symptoms, in particular hot flushes, mood swings and vaginal dryness. Preparations are available in a wide variety of formulations including tablets, patches, pessaries, intra-uterine devices and creams.

Oestrogen preparations may be used alone or in combination with a synthetic progesterone. For women who have had a hysterectomy (removal of the uterus), oestrogen preparations may be used alone.

For women who have not had a hysterectomy, a synthetic progesterone must be used together with the oestrogen to reduce the risk of cancer of the uterus developing. When the synthetic progesterone is taken after the oestrogen, the process is called ‘sequential combined HRT’. Women on such therapy will experience vaginal bleeding that resembles a period, but it is not a real period. When the synthetic progesterone is taken at the same time as the oestrogen, the process is called ‘continuous combined HRT’. Women on such therapy will not experience vaginal bleeding.

Concern over an increased risk of breast, endometrial and ovarian cancer associated with the long-term use of HRT, and because of an increased risk of heart attacks, strokes and thrombosis, has lead to the recommendation that HRT is only used to treat menopausal symptoms that affect the woman’s quality of life. In such circumstances, it is also recommended that HRT is used at the lowest effective dose for the shortest possible time.

HRT does not prevent heart disease or protect against a decline in mental function and so it should not be taken for these uses.

HRT should not be used for the long-term prevention of osteoporosis in women over the age of 50 unless other treatments are ineffective or should not be used. The need for continued HRT should be reviewed each year and the woman should be encouraged to have her breasts and cervix examined regularly.

Drugs affecting bones
To prevent osteoporosis and reduce the risk of hip and spinal fractures, drugs known as bisphosphonates have become the first choice treatment. These drugs inhibit the break down of bone tissue and, in some cases, stimulate the production of new bone tissue. Bisphosphonates include alendronate, etidronate, ibandronate and risedronate, and are available in a variety of formulations from tablets or capsules that are taken daily, weekly or monthly to injections that are given every 3 months. Women receiving bisphosphonates should also take calcium and vitamin D supplements to help the bones make new tissue.

Denosumab is a human monoclonal antibody that also inhibits the breakdown of bone tissue. It is used for the treatment of postmenopausal osteoporosis in women at increased risk of fractures who are unable to take bisphosphonates.

Strontium stimulates bone formation and reduces bone break down. It is licensed for the treatment of postmenopausal osteoporosis when bisphosphonates cannot be used in women with a previous fracture and low bone mineral density who are at risk of further fractures.

When to see your pharmacist
If your doctor has prescribed HRT and you have any questions about the treatment, talk to your pharmacist. HRT comes in such a wide variety of different forms that it can be extremely confusing. Your pharmacist will explain the various types of product available and will advise you as to how they should be used. If your pharmacist considers that a different form of HRT would be more suitable, it may be suggested that you visit your doctor to have it changed.

If you prefer to manage your symptoms through the use of supplements, many of these are available through your local pharmacy without the need for a prescription.

When to see your doctor
Visit your doctor if you find that your menopausal symptoms are interfering with the quality of your life. Your doctor will explain to you the risks and benefits of the various types of treatment and will take into account other factors such as your age, your state of health, your life-style and your family medical history. If HRT is prescribed, your treatment will be reviewed at least once per year, allowing a decision to be made whether or not to continue treatment.

If your doctor thinks that you are at risk of developing osteoporosis, either through an early menopause or because of a family history of the condition, a bisphosphonate may be prescribed.

Living with the menopause
Women who decide not to take prescribed medicines to cope with menopausal symptoms have other choices. Non-medicinal actions, such as improving nutrition and lifestyle can be very beneficial. Eating well balanced meals rich in fresh fruit and vegetables and taking regular exercise will help you feel better and reduce the risk of many other diseases such as heart problems and cancer developing.

There is also a variety of other alternative therapies available such as acupuncture, reflexology, homoeopathy, herbalism, acupressure, aromatherapy and osteopathy. If you decide to try one of these methods, find a reputable practitioner by contacting the association representing the natural therapy.

Many women have found supplements to be beneficial. Some women may wish to tailor their intake of additional natural vitamin supplements while others may find it more convenient to take a balanced all-in-one formulation. Supplements contain many nutrients including vitamin E, which may be of benefit in normalising hot flushes, mixed B vitamins, which may help contribute to a normal balance of nutrients and vitamin D, to help maintain calcium levels in the body.

Plant oestrogens, called phyto-oestrogens can help relieve symptoms of the menopause. These natural substances, similar to oestrogen, are found in more than 200 plants. Some good plant sources are linseeds, soya proteins and clover extracts.

If you do use HRT, remember to see your doctor at least once each year to have your treatment reviewed, and ensure that you attend any appointments for breast examinations and cervical smear tests.

Further information
The British Menopause Society is a registered charity dedicated to advancing education in all matters related to the menopause. Although the Society is intended for those in the medical professions, its website has some very useful fact sheets on the various treatments for the menopause, including alternative and complementary therapies, and the risks and benefits of each.

www.thebms.org.uk


Reviewed on 5 April 2011


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