The menopause can be a difficult time for women with a variety of symptoms perpetuating from hot flushes to mood swings and depression. This article answers frequently asked questions regarding the menopause such as 'What can I do to prepare for the menopause?' and 'Why do I need Hormone Replacement Therapy?'
- What is the menopause?
- What can I do to prepare for the menopause?
- Is there a link between depression and menopause?
- Why do I need Hormone Replacement Therapy?
- How would I know if HRT might be the best option for me?
- What are the best treatments for these symptoms?
- Isn’t testosterone a male hormone?
- Who is HRT best for?
- Is HRT a cosmetic treatment / are there other benefits?
- When is it best for me to start taking HRT?
- What else can I do to prevent the symptoms of menopause?
- Should I see a gynaecologist or a psychiatrist to treat depression?
- What do I do if my GP advises against HRT?
- What about reported side effects?
The menopause is a term that merely refers to the cessation of periods, for most women this occurs around the age of 51. The first important time is the five or ten years around the time of the menopause when the worst of the symptoms occur. This is known as the ‘transition’ years leading up to the cessation of periods. After the transition years there are then often problems of vaginal atrophy, painful sexual intercourse (dyspareunia) and of course loss of bone tissue (osteoporosis).
There is a lot that you can do including making sure you have good advice on the various symptoms over these years, be careful with your diet, stop smoking, take less alcohol and have an annual physical check-up including pelvic ultrasound and cytology. If you feel you need hormone therapy, you may need to go to see a specialist. The local GP may disagree with Hormone Replacement Therapy (HRT) (see my comments below), and will often not want to take on the commitment.
There certainly is a link between hormones and depression in the years before the menopause, which can be successfully treated with oestrogens. This occurs as worsening pre-menstrual depression with age as well as a background of peri-menopausal depression which is associated with loss of energy, loss of self-confidence, loss of libido and an increase in general anxiety.
There is no evidence that depression occurs more commonly after the cessation of periods and if there is depression it does not normally respond to oestrogens. Of course, if there is insomnia and exhaustion due to night sweats or marital problems due to painful intercourse or loss of libido, HRT and a relief of these symptoms will clearly make things better.
There are two important reasons to take HRT, these are:
- For the relief of symptoms associated with the menopause.
- To increase low bone density and to avoid bone fractures (osteoporotic fractures) ten or twenty years down the line.
The most common symptoms of oestrogen deficiency around the time of the menopause are hot flushes and night sweats which produce insomnia and tiredness together with headaches. However vaginal dryness and painful intercourse is another highly characteristic symptom of hormone deficiency. There are other symptoms which are disputed by some doctors but would in my view include tiredness, loss of libido, anxiety and depression. This depression may be somewhat cyclical before the periods stop and be a mixture of premenstrual depression and perimenopausal depression. Sometimes women just feel below par, tired, anxious, and grumpy with a poor sex drive and possible marital problems. Low bone density is another metabolic symptom and needs checking using a DEXA bone density scanner.
HRT is an excellent option. Many of these symptoms can be treated with oestrogens, sometimes with the addition of a small dose of testosterone. It is vital to match the hormone treatment type and dosage to meet individual needs.
It should be understood that testosterone is a normal female hormone and present in ten times the amount as oestradiol in normal young women. It is not just a male hormone although men (hopefully) have higher testosterone levels than women.
HRT will be good for patients with the sorts of symptoms described. HRT should not be given to women who do not have these symptoms and who do not have low bone density. Some women like to be proactive and want to delay the maturation process, but HRT is not appropriate for this.
HRT is not a cosmetic treatment although it is fair to say that after the menopause women will lose collagen from the skin resulting in the thin and inelastic skin of the older women. This lost collagen from the skin, the tendons, the nails, and the hair and of course the bones can be replaced with oestrogen therapy.
The best time to start HRT is when symptoms occur. If the HRT removes the symptoms then it would be sensible to continue for several years.
It is sensible to be proactive about your health around the time of the menopause. This would include careful diet, adequate exercise, absolutely no smoking and only moderate amounts of alcohol. HRT should not be seen as a substitute for the usual lifestyle healthy disciplines.
The problem of depression is a highly controversial one. There is no doubt that depression is more common in women than in men but whether it is due to hormonal changes or social or environmental factors is debatable. However, there is a whole syndrome which we should call “reproductive depression” in women where depression occurs following abrupt changes in hormone levels. This is most spectacularly seen with postnatal depression but also premenstrual depression every month and towards the menopause as perimenopausal depression during the transition phase to amenorrhoea. These three types of depression are effectively treated with transdermal estrogens which are in my view much more effective and safer than the use of antidepressants. I have no doubt that women with premenstrual depression should see a gynaecologist/endocrinologist rather than a psychiatrist and the same would apply to the perimenopausal depression and even the more dangerous postnatal depression.
A lot of GPs now refuse to prescribe HRT because of outdated advisory statements or merely because it is easier not to bother. You can insist but you still may not receive HRT. You can find another GP or a consultant gynaecologist although I appreciate that a new GP is often hard to find and a gynaecologist in private practice may be expensive. In my opinion there should be a menopause clinic in every hospital.
Unfortunately most of the reported side effects arose in 2002 from a large American study which selected an inappropriate group of patients (they were too old) and gave them the wrong type of HRT (too high a dose of oestrogen along with continuous progestogen). The results showed an increase in heart attacks, stroke and breast cancer. This has naturally influenced opinion amongst GPs. The investigators from this study have subsequently retracted most of the bad news as it is very clear that these complications do not appear in women who start taking appropriate HRT before the age of 60. It does appear that the probable cause of the serious side effects reported is due to the progestogen component not the oestrogen.
Women who start oestrogen therapy before the age of 60 can be reassured that this form of HRT is safe.
For further information on the author of this article, Consultant Gynaecologist, Professor John Studd, please click here.
The time of a woman’s life when her ovaries stop releasing an egg (ovum) on a monthly cycle, and her periods ceaseFull medical glossary