What are the common symptoms and complications of the menopause?

Oestrogens are responsible for producing feminine features, whereas androgens, although present in all women, promote masculine features such as facial hair. The symptoms of menopause result from the reduced level of oestrogens and the increased level of androgens and include:

The reduced levels of oestrogens can also cause long-term effects on the body including:

Osteoporosis

Osteoporosis, a reduction in bone mass and density leading to increased risk of fracture, back pain, weight loss, and curvature of the spine, results in about 60,000 hip fractures a year in the UK, 90% of which are in people over 50 and 80% of which are in women. There are also some 50,000 wrist and 40,000 clinically diagnosed fractures a year from osteoporosis.

Identifying Patients at Risk of Fractures Due to Osteoporosis

Those who are at increased risk of osteoporosis and therefore of fracture are those with:

Post-menopausal women and men with one or more fragility fractures need assessment to rule out secondary osteoporosis (see below) and must then be offered the option of treatment to prevent further bone loss and fractures. This is an important opportunity to target therapy to those at highest risk of future fractures but is often ignored.

Bone Density Measurement

DEXA results are reported as T scores (comparison with the young adult mean) and Z scores (comparison with reference values of the same age). The T score relates to absolute fracture risk whereas the Z score related to the individual’s relative risk for their age. The table below shows a simple classification of DEXA results and guidance for management:

T score (WHO standard reference) Fracture Risk Action
Normal T > -1.0 Low Lifestyle advice
Low bone mass (osteopenia) T –1.0 to –2.5 Above average Lifestyle advice. HRT especially in women aged 50 – 60 years. Calcium and vitamin D supplementation.
Osteoporosis T< -2.5
Treat 
High Lifestyle advice Calcium and vitamin D supplementation
Established osteoporosis T < -2.5 plus one or more fractures Very high Lifestyle advice. Pain control. Exclude secondary causes. Treat (see below). Calcium and vitamin D supplementation. Consider referral.

Osteoporosis notes

Exclude Causes of Secondary Osteoporosis and Other Conditions

Before initiating therapy it is important to:

This can be achieved by carrying out the following investigations:

X-ray of thoracic or lumbar spine if needed to confirm vertebral deformity.  Exclude obvious bony secondaries; proceed to bone scintography if doubt.
Urea and electrolytes  Exclude renal osteodystrophy
Liver function tests Elevated in alcohol abuse 
 
ESR If elevated plasma electrophoresis to exclude myeloma
Calcium, phosphate and alkaline phosphatase Abnormal in osteomalacia and bony secondaries 
Thyroid function tests Exclude hyperthyroidism and hypothyroidism

 

Osteoporosis prevention and treatment

Lifestyle Measures

Target all those with a risk of developing osteoporosis

Calcium Males 11 – 18 yrs 1,000 mg daily 
Females 11 – 18 yrs 800 mg daily
Adults 19+ yrs 700 mg daily
Vitamin D  400 iu daily

  One pint of semi-skimmed mild or four ounces of cheddar cheese contain 700 – 800 mgs of calcium. If these levels cannot be achieved with diet alone consider supplements.

Drug therapy options for prevention

Further therapies such as raloxifene (a selective oestrogen receptor modulator) are under evaluation and if appropriate further guidance will be issued.

Drug therapy options for treatment

Referral for specialist opinion

The principal reasons for referral are for patients fulfilling criteric for DXA measurement where open access to this investigation is not available and when assistance is required in confirming the diagnosis or initiating management.

Other reasons for referral include:

Osteoporosis Support Groups

These organisations can provide further information on all aspects of coping with the disease for both health care professionals and patients.

Treatment for the menopause

Self Care Action Plan

All women will go through the menopause but a self-care action plan can help prevent the complications of the menopause. This involves:

Hormone Replacement Therapy

Rational for Use

Additional benefits may be:

Choosing a regimen

HRT compliance can be a problem because of side-effects and fear of an increased risk of cancer. Therefore treatment options and the long term benefits of HRT need to be fully discussed with patients. First line therapy is normally oral owing to lower cost and patient preference.

For those women who have had a hysterectomy, the addition of a progestogen is not needed when taking HRT. Therefore unopposed oestrogen can be given.

Women who have a uterus have had an endometrial ablation or who have had a sub-total hysterectomy still need cyclical or continuous progestogen with continuous oestrogen to prevent endometrial hyperplasia with its associated risk of endometrial cancer. Care must be taken to explain the necessity of progestogen to women especially if using preparations where there are separate tablets.

The following dosages are approximately equipotent and provide protection against osteoporosis when given as unopposed oestrogen replacement.

However, when using a continuous combined HRT only 1 mg estradiol is required to provide osteoporosis protection.

Sequential HRT preparations

Over 28 days continuous oestrogen is given with 10 – 12 days of progestogen

Minimum daily progestogen doses for a sequential regimen to prevent endometrial hyperplasia are:

Bleeding should occur at a regular time each month. However, the onset may vary between preparations. Absence of bleeding occurs in approximately 5 – 10% of women and requires no further investigation providing symptoms are controlled and there is no irregular bleeding.

Long cycle HRT

The only licensed preparation is Tridestra using 20 mg medroxyprogesterone acetate for 14 days each 3 month cycle. It produces four withdrawal bleeds per year and may cause initial irregular bleeding but this tends to settle.

Endometrial hyperplasia has been reported when lower doses of progestogens are used for 10 days, every 84 days.

Continuous combined HRT (CCHRT)

Continuous oestrogen is given with a continuous progestogen to induce endometrial atrophy.

Side effects with HRT

Women tend to gain weight at the menopause with the redistribution of body fat causing an increase in abdominal fat. There is no evidence that HRT causes additional weight gain.

Absolute contra-indications

There is no absolute contra-indicationg to the prescribing of HRT in post-menopausal women. Extra caution may need to be exercised in the following situations:

Breast Cancer

Every women is at risk of developing breast cancer and that risk becomes greater with age. For women not on HRT aged 50, 45 in 1,000 will be diagnosed with breast cancer by the age of 70. For women who start using HRT at 50 an extra 2 in 1,000 breast cancer cases will be diagnosed after 5 years on HRT and an extra 6 in 1,000 after 10 years on HRT. The risk still remains small but it is up to each individual woman to decide if the benefits of HRT are greater on balance for her than the risk of breast cancer. What all women over the age of 50 should certainly do is have regular breast screening whether or not they are taking HRT.

Deep Vein Thrombosis

As with breast cancer, all women have a very small risk of developing blood clots in the leg or deep vein thrombosis, whether or not they take HRT. The risk for women not on HRT is 1 per 10,000 women. For women on HRT, there are an additional 2 cases per 10,000. All women can try to reduce their risk even further by not becoming overweight, not smoking and taking regular exercise.

Alternative therapies for controlling menopausal symptoms

There is currently no convincing evidence that oil of evening primrose decreases menopausal symptoms and limited information suggesting natural progesterone cream may be of benefit.

Some practical points

Diagnosing the menopause

Menopause and contraception

Women using the combined oral contraceptive PILL (COC)

Contraception in women using HRT

Duration of therapy

A number of women may wish to continue HRT long term (more than 10 years) particularly if they have risk factors for osteoporosis. This decision should be based upon clear, unbiased information leading to an informed choice once the short and long term benefits have been weighed against any risks.

Women who are at least one year past their menopause may benefit from taking a continuous combined HRT preparation:

Myths and misconceptions

HRT is not natural:

Not true. The oestrogens used in HRT are natural and some are identical to the ones that your own body produced before the menopause. These are different to the hormones that are used in the contraceptive pill which are not natural and which can cause different sorts of problems.

HRT is the elixir of youth:

Not true. HRT cannot make you young again or slow down the normal ageing process. What it can do is to help prevent the problems that are caused by the loss of oestrogen after the menopause. Many of these are ones that we associated with age, such as tiredness, poor concentration and memory, loss of bladder tone and changes in the quality of hair and skin. HRT can help to prevent the health problems that these changes can cause.

HRT is not suitable for women …

… who had problems on the contraceptive pill

Not true. The hormones used in HRT are natural and are different from those in the pill which are synthetic. If you had problems on the pill it does not necessarily mean that you will have problems with HRT. However, it is important to discuss any problems that you had with your doctor or nurse.

… who smoke

Not true. Smoking does not mean you cannot try HRT, but you should attempt to stop to improve your health.

… who have high blood pressure

Not true. Your blood pressure should be treated by your doctor before you start HRT but this is not a reason for not taking HRT.

… who have fibroids

Not true. Fibroids are an overgrowth of the muscle of the womb. They are not malignant and do not cause cancer. They may cause heavy or painful periods or may cause no problems at all. Fibroids may grow larger when you replace oestrogen after the menopause. If you know that you have fibroids or your doctor thinks that you may have them you should be monitored regularly while you are on HRT.

… who have varicose veins

Not true. Having varicose veins (or phlebitis) does not mean that you cannot take HRT but you should discuss this with your doctor. If you have had a deep vein thrombosis (blood clot) this may put you at a slightly increased risk of having a clot with HRT but again, if you are monitored regularly, you may still be able to take it.

… who are overweight

Not true. This is not a reason for not taking HRT although if you are very overweight you may have a higher risk of some problems with HRT. You should discuss this with your doctor. Being overweight does increase your risk of other illness and so you should try to lose weight to benefit your overall health.

… who are still having periods

Not true. Some women start to get menopausal symptoms while they are still having fairly regular periods. These symptoms occur because your own oestrogen levels are falling but are still high enough to produce periods. HRT can be given to add to the oestrogen that your body is still producing to relieve symptoms.

… who are too young or too old

Not true. HRT can be given whatever age you are when you go through the menopause. It is particularly important for young women who have had an early menopause either naturally or as a result of surgery.

If you have had a hysterectomy with removal of your ovaries, you should start taking HRT immediately. If your ovaries were not removed they may stop working earlier than they would have done if you had not had a hysterectomy.

… who are diabetic

Not true. Having diabetes does not mean that you cannot have HRT. Diabetic patients have a higher risk of having raised cholesterol. HRT might be especially useful for such patients as, by lowering cholesterol, it can reduce the risk of arterial disease.