Menopause Matters Magazine
Dr Currie's Casebook
Your questions answered.
Painful sex
Q: My periods stopped about 4 years ago without any significant consequence. I had minimal flushes and generally feel well. However I have recently noticed some pain during sex and generally feel dry and uncomfortable "down below". I bought some gel which helped a little but last week I had cystitis for the first time. Could this all be menopause related?
A: The consequences of menopause are due to our bodies becoming low in estrogen. Many women experience flushes and sweats as an early sign of estrogen deficiency; the severity and duration vary hugely between women. Later consequences which are very common are effects on the vagina and bladder and usually occur a few years after our periods stop, or after stopping HRT. The lack of estrogen can cause vaginal dryness, less circulation to the genital area, less elasticity of the vagina, pain during sex, increased frequency of passing urine and increased risk of both vaginal and bladder infection. Dryness can be helped by the use of regular vaginal moisturiser and lubricants during sex. The overall problem can be treated by the use of vaginal estrogen. This is not the same as HRT since the absorption around the body is minimal; vaginal estrogen effect is concentrated in the vagina and bladder. Long term treatment is recommended.
I am a smoker but generally well and yet…
Q: "My GP says that despite my severe menopausal symptoms I am generally in good health - but I admit to being a smoker and did suffer deep vein thrombosis two weeks after a hysterectomy, which was 5 years ago now. I have been prescribed black cohosh but my symptoms are persisting. I am just 47. Would you have anything you think could help?
A: HRT is the most effective treatment for controlling menopausal symptoms. The symptoms are believed to be due to estrogen decline and deficiency. HRT aims to replace estrogen and so control symptoms. If the womb is stll present, then progestogen is taken along with the estrogen to prevent the estrogen stimulating the womb lining. Since you have had a hysterectomy, estrogen alone can be taken. Your history of deep vein thrombosis means that care should be taken about the type of HRT, since tablet form of HRT can increase the risk of deep vein thrombosis, but estrogen taken through the skin (transdermal) by a twice weekly or weekly patch, or a daily gel, can be considered. This can be discussed with your doctor. Meanwhile, it is also worth thinking about any diet or lifestyle factors which can contribute to making menopausal symptoms worse and may be able to be changed, such as stopping smoking, reducing alcohol and caffeine, losing weight and increasing exercise.
Migraines a real headache when hitting the menopause
Q: For many years I have suffered from migraines around the time of my periods. They affect me really badly. What will happen when I hit the menopause? I’m worried that they will become worse—I don’t think I could cope if this was the case. Also, if I need to take HRT will this make the migraines worse?
A: Migraines around period time (perimenstrual migraines) appear to be triggered by the fluctuating hormone levels thatoccur leading up to the period in the monthly cycle. While hormonal fluctuations continue in the perimenopause, hormone levels then gradually decline so that many women who are prone to perimenstrual migraines find that migraines decrease and may even stop after the menopause. A few women develop migraines for the first time during the menopause due to estrogen deficiency which may be helped by replacing estrogen by taking HRT. If you develop menopausal symptoms and decide to take HRT, the history of migraines is not a reason to avoid HRT - many women think that they cannot take HRT with this history because they have been advised in the past not to take the combined contraceptive pill because of risk of stroke. The hormones in the contraceptive pill and HRT are very different and are taken in different situations; the combined contraceptive pill providing high dose synthetic hormones to suppress ovarian activity, preventing egg release and so providing contraception, while HRT provides low dose natural hormones which simply replace the hormones which the ovaries no longer produce. There is no evidence of increased stroke risk with use of HRT with ah istory of stroke. Regarding type of HRT, estrogen would usualy be recommended to be taken through the skin by patch or gel; some women do find a worsening of migraines with a daily tablet because of the daily hormone fluctuations from a daily tablet but less so with a patch or gel.
Heavy bleeding on HRT
Q: I am 59 and have been on HRT, Prempak C, for about 15 years. It has suited me really well. I usually have a bleed at the end of each pack but last month the bleed was heavy and lasted longer than usual. Should I be concerned and should this be checked out?
A: Prempak C is a monthly bleed type HRT, or known as Sequential HRT meaning that it has estrogen in every day and progestogen for part of the month. The estrogen controls menopausal symptoms and the progestogen looks after the womb lining (endometrium), preventing it from becoming thickened by stimulation from the estrogen. If the bleeding on this type becomes heavier, prolonged or more frequent, then it should be investigated, since taking sequential HRT for more than 5 years is associated with a small increased risk of thickening of the endometrium. Investigation is usually carried out at a gynaecology or menopause clinic and is simple.
Anyone taking HRT should be reviewed at least once per year to discuss if HRT is still thought to be required, whether it is effective, if it is the best type, and update on new information. By the age of 54, women taking sequential HRT and wishing to continue, should be offered a period-free type, or known as continuous combined HRT. This contains daily estrogen and daily progestogen which offers better endometrial protection long term than sequential therapy.
Q: I’m 59, came off of HRT as I had fibroids and experienced a bleed. I was on tablets before – would you recommend patches because of my age and should I get back to my doctor before I reach 60? I have heard some GPs are reluctant to prescribe HRT after that age.
A: There are no arbitrary limits for duration of HRT, nor for an age at which it cannot be used. Many women continue to experience troublesome menopausal symptoms after the age of 60 and so for them, the benefits may continue to outweigh the risks. A risk that does increase with age is the risk of deep vein thrombosis, (blood clot). Because there is a small increased risk of this with tablet form of HRT, it is recommended that transdermal HRT should be considered if HRT is taken after the age of 60, and at younger ages if there are risk factors for blood clot, such as being overweight, past history, and some medical problems.
Q: I am post-menopausal, age 62 and was previously on HRT but am not any longer. My hot flushes appeared to have disappeared over the last 18 months but now appear to have returned. They are not debilitating but I just wonder why they may have returned?
A: Many factors can contribute to the presence or not of symptoms such as hot flushes. Some women may find it helpful to restart HRT if the symptoms are troublesome, but it is first of all worth considering and addressing other factors which may have led to the return of symptoms. These include change in diet or weight with increased weight and more processed, high carbohydrate intake or spicy foods affecting some women. Alcohol or caffeine intake may have changed and some find that stress can be a factor. Of course, hot weather may contribute, which we can’t control! If none of these apply, it is worth considering other medical conditions such as overactive thyroid and some medications.
Q: At 48 I am in my peri-menopause, with quite a number of symptoms, including fatigue, hot flushes and anxiety. I have not yet had my second Covid-19 vaccination as I felt awful shortly after the first one so now feel nervous of the second jab. Could it enhance or make my peri-menopause symptoms even worse?
A: We are still learning so much about both Coronovirus and the vaccine. Side effects of the vaccine are hugely variable, and unpredictable and having felt unwell after the first one does not mean that you will feel the same after the second. It has been questioned whether or not the vaccine can affect periods, which are often already changing as part of the perimenopause, but any effect, and it is not clear with no obvious scientific reason why there should be an effect, would be transient. There is no reason why any specific perimenopausal symptoms should be worsened and it is really important to go ahead and have the second vaccine for best protection.
Q: M friend is suffering with her menopause experience and as a reader of Menopause Matters I passed my copy along to her and suggest she subscribed. To my amazement she said she "did not want people to know that she was experiencing medical difficulties and that this was a private matter." Whilst I completely respect her standpoint why do you as doctor think women still seem to attach a stigma to their menopause?
A: We are all very different and it is up to each woman how she copes with and manages this phase. Many years ago it was frowned upon to even mention the word "period" and hence many other terms were used such as "my friend," "monthly," "Aunty Flo," "time of the month." We have come a long way and periods and menopause are talked about much more freely, but that doesn’t mean that everyone wants to do so. The important point is that all women have access to information so that they are prepared for the perimenopause and menopause and know what options are available to them, should they need help. Some women may prefer to make their decision privately and not discuss it, and that’s fine!
Q: Is acid reflux a side-effect of HRT by any chance? I have been on patches for about 4 months now and it started when I was two months in. Could there be a connection?
A: It is believed that HRT can affect the relaxation mechanism of the sphincter in the lower oesophagus. It may be worth reviewing the dose of estrogen that you are taking and consider trying a lower dose, which may still provide benefit of control of menopausal symptoms.
Q: What is the difference between compounded and natural bioidentical hormones?
A: Bio-identical hormones is a confusing term! There are lots of types of HRT and those that can be prescribed on the NHS are standardised and regulated and have been proven to provide benefits. The term "Bio identicals" refers to hormones that very closely resemble estradiol, estriol, estrone (all types of naturally occurring estrogen), progesterone, dehydroepiandrosterone (DHEA), and testosterone as produced by the human ovary and adrenal gland. While the message of replacing hormones which are very like the hormones that we produce ourselves until the menopause seems sensible, hormones are being provided by compounding pharmacies which are not standardised or government approved in terms of content, dose and balance between estrogen and progesterone.
What is often not realised is that both estrogen and progesterone can be prescribed as standardised, regulated, government approved HRT in ways that very closely mimic our own hormones. These preparations, which are available with NHS prescriptions could also be described as "bio identical" and are prescribed in approved forms. The difference between hormones prescribed in compounding pharmacies and those prescribed in approved forms is that while some of the basic hormones used in both settings may be the same, ie estrogen and progesterone, the amounts and balance between estrogen and progesterone are not provided in regulated, approved forms in compounding pharmacies such that the stimulating effect of the estrogen on the womb lining may not be adequately balanced by the progesterone provided. This has raised concerns about these compounded combinations leading to increased risk of endometrial cancer. In approved regulated forms of HRT, the appropriate dose and balance has been thoroughly investigated.
Q: I believe myself to be perimenopausal at age 48 and I often experience headaches around the time of my period. Can I look forward to these stopping once my periods do?
A: Headaches and other symptoms often occur around the time of a period, and are believed to be due to the fluctuation of hormones which occurs during a normal menstrual cycle in the week leading up to a period. At that time, both estrogen and progesterone are falling and the levels dropping leads to the womb lining being shed, hence the period. As our ovaries gradually have less egg cells to develop each month, they produce less estrogen, which eventually remains low and steady. Some women develop headaches as part of their menopausal symptoms, but the headaches triggered by hormonal fluctuations as described, do become less when periods stop. Hormonal treatments which suppress the menstrual cycle and level off hormonal fluctuations, such as the contraceptive pill desogestrel, can be very helpful during the perimenopause to reduce symptoms such as cyclical headaches, and can be used for non-contraceptive benefits even if contraception is not required.
Q: Can HRT really help stave off Alzheimer's Disease as seems to be being claimed recently?
A: It has been recognised for many years that more women than men are affected by dementia and Alzheimer's Disease (AD) and that female hormones have been thought to play a role. It is known that there are estrogen receptors in the brain which interact with chemical pathways and metabolism, and that women who have an untreated premature menopause may have an increased risk of developing dementia. It would seem reasonable to expect therefore, that replacing estrogen in the form of HRT may help to reduce the risk. However, studies so far have not provided conclusive evidence that HRT is protective, though the potential does exist. A review published in the British Medical Journal in 2021 showed that overall, there were no increased risks of developing dementia associated with menopausal hormone therapy. A decreased global risk of dementia was found among women younger than 80 years who had been taking oestrogen-only therapy for 10 years or more. Increased risks of developing specifically Alzheimer's disease were found among women who had used oestrogen-progestogen therapy for between five and nine years and for 10 years or more. This was equivalent to, respectively, five and seven extra cases per 10?000 woman years. This risk is very small and for women who require to continue taking HRT long term for persistent menopausal symptoms, the benefits of continuing HRT are still very likely to outweigh the risks.
Currently, the indications for prescribing HRT include the treatment of menopausal symptoms, Premature Ovarian Insufficiency, early menopause and the prevention and treatment of osteoporosis. HRT is unlikely to increase the risk of dementia or to have a detrimental effect on cognitive function in women starting HRT before the age of 65. However, HRT should not be started purely for the purpose of reducing the risk of dementia in postmenopausal women and at this time, there is not enough evidence to support prescribing HRT purely for prevention of dementia.
Reference: 1. Vinogradova Y, Dening T, Hippisley-Cox J, et al. Use of menopausal hormone therapy and risk of dementia: nested case-control studies using QResearchand CPRD databases. BMJ 2021; 375: n2182 doi.org/10.1136/bmj.n2182
Q: I'm 52 and would like to stop using contraception. I started sequential HRT about a year ago when I got hot flushes and now have irregular periods. Can I tell my partner he doesn't need to bother about a condom any more?
A: If periods stop under the age of 50, then contraception should be continued for 2 years after the last period. Contraception is needed for 1 year after the last period if this is over the age of 50. Since your periods don't appear to have stopped yet, then it is too early to stop contraception. The added complication is that the sequential HRT will likely lead to a monthly bleed and so while taking it, you will not know whether or not your own period cycle has stopped. The options are:
1. Continue using condoms until the age 55, when all women can stop contraception at that stage, even if you still have a period cycle and hence are producing eggs, it is believed that the egg quality will be so poor that conception is extremely unlikely.
2. Use another form of contraception along with your HRT, eg a daily progestogen only pill, or a Mirena coil. A Mirena coil releases progestogen directly into the womb and provides good protection of the womb lining and bleeding control, as well as excellent contraception. It can be used for the progestogen part of HRT for 5 years. With a Mirena in place, your HRT can be simplified to be estrogen only, instead of a combination of estrogen and progestogen as you are currently taking. If you chose to take a progestogen only pill along with your HRT, you would still need to take both estrogen and progestogen in your HRT since the progestogen only pill is not licensed for the progestogen part of HRT.
Q: What type of HRT is best?
I had been suffering from hot flushes as well as regular night sweats. My periods had been irregular for well over a year. There had been times where I had not had a period for 6 months and then I had a few monthly ones, and then I had no period for 9 months which was great! HRT was discussed and I was prescribed Evorel sequi patches. I had read that patches were better than tablets so this is why I asked for patches. I did not want a coil. I wasn't aware that I would have a bleed every month! I read the small print and found out that this was normal. If I had known this when I first went onto HRT, I would have thought twice about going onto it, as my periods are as heavy as they were before, and my breasts are extremely tender for about 10 days before each bleed. I then discovered that there is another type of HRT for women who have been having irregular periods, and one where you only bleed every 3 months, so I am wondering if I should have been put into this in the first place?
Also, if I still bleed while taking HRT, how do I know when I have not had a period for a year and thus started the menopause?
A: Evorel sequi is a sequential, or cyclical, HRT regimen. It provides a medium does of estrogen every day, (the main part of HRT, though we recommend starting with a low dose) and, in the second half of the monthly pack, progestogen in addition (the progestogen is to prevent estrogen stimulating the womb lining). This type sort of mimics your own cycle and leads to a withdrawl bleed (from stopping the progestogen) at the end of each pack. This type is recommended when you still have a period pattern, due to continuing ovarian function.
If it is clear that your own ovarian function, and hence periods, have stopped, you can take both estrogen and progestogen every day by tablet or patch. The daily use of both hormones is known as continuous combined, or "period-free" HRT. This does not recreate the monthly cycle, but some bleeding in the first 6 months is quite common, and only needs to be investigated if it goes on beyond 6 months, or occurs again at a later date. We know that your periods have stopped if you have had at least a year without periods, or are aged 54. By age 54, 80% of women have stopped having periods.
The long cycle HRT - which provides a course of progestogen every 12 weeks, is not used often since there are concerns that this may not be enough progestogen to protect the womb lining. So when you started HRT, it was not then clear that your periods had stopped, hence why you were offered sequential HRT. If continuous combined is taken when you still have ovarian function, it won't do any harm, but your own ovaries may still produce some hormonal stimulation to the womb lining and hence irregular bleeding may occur.
You are quite right in asking that now you are having an HRT induced monthly bleed, how will you know when your own periods have stopped. By 54 it is very likely that they have, but you may not want to wait until then. So we can bend the rules a bit! If your period was 9 months before starting HRT, and you also had 6 months between, it is very likely that a year or two later your periods will have stopped and you could try changing over then. Changing too early may just be more likely to lead to irregular bleeding which may then need to be investigated, so it may be worth waiting a little longer.
Meanwhile, to reduce the pain and heaviness, it may be worth considering a sequential preparation with a lower dose of estrogen, which may be causing breast tenderness, and a different progestogen (which may be causing the premenstrual symptoms) eg a tablet such as Femoston 1/10. Unless you have risk factors for deep vein thrombosis, such as past history or being overweight, then tablets provide many benefits and are convenient - one tablet per day.
You can see different types of HRT here and a useful fact sheet at womens-health-concern.org
Q: I have friends who are on HRT due to experiencing menopausal symptoms. At 49 I don't seem to have had any signs that I am approaching menopause as yet but I understand there could be benefits for me in later life. Would a doctor considering prescribing this to me? I know GPs are all under pressure and I don't want to waste their time.
A: At the age of 49, ovarian function may still be fairly normal. Menopausal symptoms could develop over the next few years, when options including HRT can be considered. There is no reason to start HRT before then. HRT should only be prescribed for a clear indication, such as troublesome menopausal symptoms, (the commonest indication), having an early (before the age of 45) or premature (before the age of 40) menopause, or having risk factors for osteoporosis, such as family history. HRT can also be considered for treatment of osteoporosis in women found to have osteoporosis under the age of 60. Not all women experience menopausal symptoms and if they are generally fit and healthy, there would be no indication to use HRT. There is evidence that if HRT is commenced under the age of 60, or within 10 years of the menopause, then it can reduce the risk of cardiovascular disease, but healthy diet and lifestyle can also reduce the risk in women who do not need HRT for menopausal symptoms.
Q: I am confused about doses of HRT. I feel fine taking a low dose but some of my friends seem to take a much higher dose. Is this necessary and should I ask for a higher dose?
A: The recommendation is that with HRT, the dose of estrogen should be the lowest dose which is effective. This principle applies to most areas of health; there is no need to take more than is required. As has been stated many times, all women are different in how the menopause will affect them, their requirements for treatment, and how they will respond to treatment. For many women, a low dose of estrogen, with appropriate progestogen to protect estrogen from stimulating the womb lining, will be adequate to control menopausal symptoms, and for most women starting HRT, it should be started as a low dose. Any type of HRT should be tried for at least 3 months before deciding whether or not a change in dose, type or route is needed. Some women find that symptoms are reduced quickly, others find that it can take at least 3 months to notice the full benefit. Effect is assessed by how you feel; blood tests are unlikely to be needed to assess response.
In some situations, such as for young women who have had surgery or medical treatment to induce menopause, a medium dose would be a reasonable starting point, and higher doses may subsequently be required to control symptoms due to the rapid drop in estrogen.
Some women may respond well to a low dose of estrogen in the perimenopause when they are still producing some estrogen and the HRT is "topping up" the levels, but then at a later date an increase in dose may be needed as their own ovarian production decreases and the total amount in the system has fallen. Subsequently, as symptoms gradually decrease, a lower dose can be tried.
Estradiol-approximate equivalent doses -
Oral:
Ultra low 0.5mg
Low 1.0mg
Medium 2.0mg
High 3.0mg
Patch:
Ultra low Half25
Low 25
Medium 50
High 75-100
Gel-pump:
Ultra low Half a pump
Low 1 pump
Medium 2 pumps
High 3-4 pumps
Gel-sachet:
Ultra low Half x 0.5mg sachet-0.25mg
Low 0.5mg
Medium 1mg
High 1.5-2mg
Spray:
Ultra low 1 spray
Low 2 sprays
Medium 3 sprays
It should be noted that response to any preparation is unique to each woman, some women responding well to a low dose of one preparation while not responding well to a high dose of another.
You can see different types of HRT here
Q: Could a hormone analysis be checked to identify the exact HRT suitable for me individually, rather than accept a standard HRT that is probably prescribed routinely for many women? I seem to remember reading that it is important to have hormonal analysis taken.
A: Blood tests are not recommended in women over the age of 45 to diagnose menopause, and are not at all helpful in determining the HRT which is likely to suit you best - there is no correlation between hormone levels and symptoms, need for treatment, or to indicate which type. I am concerned that some women pay for blood tests that are not required and are not helpful. There isn't a standard HRT prescribed routinely for all women, the type is determined by medical history, whether or not you are still having periods or they have stopped or had a hysterectomy, other medication, and personal preference. What's important is to keep the regimen as simple as possible and not too complicated!
Q: I'm aged 46 and in the past year I am finding that I seem to need the toilet a lot more, especially at night. Wearing tight jeans and recently even my pants have begun to feel uncomfortable. My vagina feels dry and I also seem to have a very watery discharge. Have you any advice please?
A: Estrogen deficiency of menopause often leads to significant effects on the vagina and bladder - dryness and thinning of the vaginal skin along with loss of elastic support. Vulval changes can cause irritation and discomfort from tight clothing. Changes in the bladder can lead to passing urine more often, including at night, discomfort when passing urine and urgency, along with an increased risk of urine infections. Sometimes vaginal infections may be more common due to a change in the acid level, and hence balance of micro-organisms in the vagina. These changes usually happen a few years after the menopause transition, but can start in the perimenopausal phase for some women.
Regular vaginal moisturisers can help the dryness but it is also worth considering the use of vaginal estrogen. Vaginal estrogen is available in the form of a small vaginal tablet, (inserted nightly for 2 weeks then continued long term at the maintenance dose of twice weekly) a cream (applied nightly for 2 weeks then continued long term at the maintenance dose of twice weekly), a gel, pessary or a vaginal ring which gradually releases estrogen and is changed 3 monthly.
You may find the article, GSM-genitourinary syndrome of the menopause, published in a previous article of our magazine, helpful, you can see the GSM-genitourinary syndrome article here. There is also more information about treatment options for vaginal dryness here.
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