Menopause

 

The menopause is when a woman stops having periods and is no longer able to get pregnant naturally.

Periods usually start to become less frequent over a few months or years before they stop altogether. Sometimes they can stop suddenly.

The age at which women go through the menopause varies but it’s usually between 40 and 58. The average age for women to reach the menopause in the UK is 51 years.

However, around 1 in 100 women experience the menopause before 40 years of age. This is known as premature menopause or premature ovarian insufficiency.

 

Common symptoms include:

Menopausal symptoms can begin months or even years before your periods stop and last around four years after your last period, although some women experience them for much longer.

Menopausal symptoms are extremely common.

  • Vasomotor symptoms (hot flushes and night sweats) are the most commonly reported symptoms, occurring in about 75% of postmenopausal women, with 25% of these being severely affected. Symptoms may resolve in 2–5 years, but the median duration is 7 years and sometimes longer.
  • Other symptoms include mood changes, musculoskeletal symptoms, urogenital symptoms, sleep disturbance, and sexual disorders.

Treatment

Not all women need treatment for this. It really depends on the symptoms that they are suffering, their severity, past medical history – including risks of clots, heart attacks and strokes and also cancer or risk of cancer history.

There are risks associated with hrt as illustrated in the tables below.  HRT is used at a low a dose as possible for as little time as possible to minimise risk.

There are non-hormonal treatments.

https://www.nhs.uk/Conditions/Menopause/Pages/Introduction.aspx

https://patient.info/health/menopause-alternatives-to-hrt

Risks Of Hormone HRT

The tables below illustrate some of the risks. However click on this page

https://www.nhs.uk/Conditions/Hormone-replacement-therapy/Pages/Disadvantages.aspx

 

Hormone replacement therapy (HRT): further information on the known increased risk of breast cancer with HRT and its persistence after stopping

New data have confirmed that the risk of breast cancer is increased during use of all types of HRT, except vaginal estrogens, and have also shown that an excess risk of breast cancer persists for longer after stopping HRT than previously thought

Following the publication of new data, information about risk of breast cancer with HRT has been updated – see Drug Safety Update, 30 August 2019 for more information.

The table of benefits and risks provided in the article below has been superseded with an updated version and this updated version plus 2019 summary table should be used when advising women of the benefits and risks of using HRT. The advice for prescribers in this article remains an accurate reflection of the regulatory position.

Since the publication of information about hormone-replacement therapy (HRT) in Current Problems in Pharmacovigilance in October, 2004,1important new evidence has become available that affects prescribing advice.

Menopausal symptoms

HRT effectively relieves vasomotor symptoms. In most cases, 2–3 years’ therapy is sufficient, but some women may need longer—this judgement should be made on a case-by-case basis with regular attempts to discontinue. Symptoms may recur for a short time after stopping HRT.

For all women, the lowest effective dose should be used for the shortest time.

Coronary heart disease (CHD)

Randomised controlled trials have found an increased risk of CHD in women who started combined (oestrogen-progestogen) therapy more than 10 years after menopause.23 Very few randomised controlled trials have assessed younger, newly menopausal women, and some have suggested a lower relative risk in these women compared with older women. The low baseline risk of CHD in most younger women, and the very low attributable risk due to HRT, means that their overall CHD risk is likely to be low. No increased risk of CHD with use of oestrogen-only HRT has been identified to date. 2 Importantly, there are no data from randomised controlled trials to suggest a cardiovascular benefit with oestrogen-only or combined HRT.

Healthcare professionals should assess carefully every woman’s risk of CHD before prescribing HRT, irrespective of her age or time since menopause.

Stroke

In randomised controlled trials, oestrogen-only and combined HRT increased the risk of stroke (mostly ischaemic) compared with placebo.45 Although the increase in relative risk seems to be similar irrespective of age, 2 baseline risk of stroke increases with age and therefore older women have a greater absolute risk. Limited observational data suggest that this risk may depend on oestrogen dose.67

Venous thromboembolism (VTE)

Oral HRT has been associated with an increased risk of VTE (ie, deep vein thrombosis or pulmonary embolism) in randomised controlled trials and observational studies. Evidence suggests that risk is higher with combined HRT than with oestrogen-only HRT, and that these events are more likely in the first year of use.8

The level of risk associated with other routes of administration has not been clearly established, although it may be lower with transdermal HRT.9

Endometrial cancer

In women with a uterus, use of oestrogen-only HRT substantially increases the risk of endometrial hyperplasia and carcinoma in a way that depends on dose and duration.10 Addition of progestogen cyclically for at least 10 days per 28-day cycle greatly reduces the risk, and addition of progestogen every day eliminates the risk. 11

Breast cancer

The risk of breast cancer is increased in women who take HRT for several years:

  • Combined HRT has been associated with the highest risk
  • For oestrogen-only HRT, risk is lower than with combined HRT.12 Some studies have not shown an increased risk for oestrogen-only HRT 13
  • Risk increases with duration of use

HRT, especially combined therapy, may increase mammographic density, which may adversely affect radiological detection of breast cancer. In the Women’s Health Initiative trial,13 14 conjugated equine oestrogens (CEE) and CEE plus medroxyprogesterone increased the likelihood of having an abnormal mammogram that needed further evaluation.

Ovarian cancer

Observational studies suggest that long-term use of oestrogen-only or combined HRT may be associated with a small increased risk of ovarian cancer, which returns to baseline a few years after stopping treatment.15 16

Osteoporosis

HRT is effective for prevention of osteoporosis, but its beneficial effect on bone diminishes soon after stopping treatment.

Because of the risks associated with long-term use, HRT should be used for prevention of osteoporosis only in women who are unable to use other medicines that are authorised for this purpose.

https://assets.publishing.service.gov.uk/media/5d680409e5274a1711fbe65a/Table1.pdf

Old Figures Are Below

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