The Menopause & HRT

The menopause literally means the end of periods and occurs when the ovaries stop producing oestrogen and progesterone. Ovaries naturally fail to produce these hormones when there are only a few eggs left within the ovaries. The menopause also occurs if the ovaries have been damaged by treatment such as radiotherapy or chemotherapy and when they are surgically removed.

The average age of the natural menopause is 51 years and women may experience infrequent periods and intermittent menopausal symptoms for several years before their final period. Menopause occurring before the age of 45 is called an early menopause and before the age of 40 a premature menopause. When women have BSO, removal of the ovaries and fallopian tubes there is a very abrupt fall in the level of oestrogen and progesterone with a sudden onset of menopausal symptoms, and these often are more severe than experienced by women having a natural menopause.

 Symptoms of the menopause

Oestrogen acts throughout the body, especially affecting the brain, heart, bones, skin and genito-urinary systems and the lack of oestrogen can give rise to a wide range of symptoms including:

  • Hot flushes and night sweats
  • Uncharacteristic tiredness, anxiety and irritability
  • Disturbed sleep
  • Vaginal dryness and discomfort during intercourse
  • Joint and muscle pain
  • Memory and concentration problems
  • Depression
  • Reduced sex drive

Hot flushes

Hot flushes and sweats (vasomotor symptoms) are the commonest symptoms of the menopause and occur in 75% of women.  They can last for several years after the menopause and some women report having hot flushes even in their 80s.

It is worthwhile considering whether there are foods that trigger hot flushes such as spicy food, alcohol or caffeine that you can choose to avoid.

Hot flushes are described as a sudden feeling of heat which seems to come from nowhere and spreads upwards through the body, chest, neck and face. This can be associated with facial redness which is often embarrassing and can reduce self confidence.

Night sweats can result in sleep being disturbed by tossing and turning and waking up soaking wet. Some women find that they need to get up and change night clothes or their bedding.

Depression

It is not uncommon to experience a wide range of emotions at the time of the menopause or after BSO. Many women experience mood swings or mild depression which will settle with time. However depression and anxiety can be more severe and interfere with normal living and tends to be more common in women who have previously experienced depression and in women with a premature menopause. If you are feeling depressed it is worthwhile discussing a three month trial of anti- depressants (such as paroxetine) with your doctor.

Vaginal discomfort

Lack of oestrogen causes the tissues of the vulva and the lining or the vagina to become thinner, drier and less elastic making them more susceptible to injury, tearing and bleeding during intercourse. Vaginal secretions are reduced resulting in decreased lubrication and the vagina becomes less acidic, and some women can suffer from more frequent episodes of cystitis.

Before the menopause the vagina has a thicker lining, with many folds allowing it to stretch with intercourse. When a woman doesn’t have intercourse on a regular basis following the menopause, her vagina becomes shorter and narrower so continuing to have regular sexual activity through the menopause helps keep the vaginal tissues thick and maintains the vagina’s length and width.

Cognitive function

Oestrogen influences the area of the brain responsible for short term memory, organizing information and maintaining concentration. In addition depression and poor sleep patterns can affect your ability to focus.  Some researchers have compared the symptoms of “menopausal brain fog” to attention deficit disorders common in children.

Studies have shown that the adverse effects of the menopause on cognitive function in women under 40 are much greater and may not be completely reversed with hormone replacement treatment. There has been concern that older women taking HRT may have an increased risk of developing dementia but studies have shown that in women with a premature menopause HRT reduces the risk of dementia in later life.

In addition to treatment with HRT, symptoms of depression, anxiety and the problems with memory and concentration can be helped with anti-depressant treatment. Low dose paroxetine (Seroxat) has been shown to help and may be particular helpful for women for whom HRT is contra-indicated.

Fatigue and loss of libido

Losing interest in sex can be common at the time of the menopause but for a women who has also had risk reducing breast surgery the loss of libido may have more complex issues than just a fall in hormone levels. HRT can often help but decreased libido and profound fatigue can be the result of decreased levels of testosterone.

Testosterone is the male sex hormone which is also produces in small amounts by the ovaries in women and replacement therapy can help restore sex drive. It’s not currently licensed for use in women, although it can be prescribed by a doctor if they think it might help.

In addition to these symptoms the lack of oestrogen in women with an early or premature menopause is associated with an increased risk of cardiovascular disease, stroke, dementia, osteoporosis and death from all causes unless hormone replacement is given.

Hormone replacement therapy (HRT)

The main component of HRT is oestrogen which treats the menopausal symptoms especially hot flushes, night sweats, vaginal dryness and prevents osteoporosis.

For women who have not had a hysterectomy HRT treatment will also include progesterone to prevent thickening of the lining of the womb, known as endometrial hyperplasia which can also lead to endometrial cancer.

About ten years ago several large studies suggested there was an increased risk of breast cancer and cardiovascular disease and there was a marked reduction in the number of women prescribed HRT. Many of these studies included women aged 50-70 years old and the results do not reflect the use of HRT in women under 50 years.

 Risk of breast cancer

In the general population, women who take combined HRT (oestrogen and progesterone) for more than five years are advised that their risk of breast cancer is 1.5 – 2.5 times greater but that when they discontinue treatment the risk  will slowly reduce.

The good news is that for women who have had a hysterectomy and therefore only require oestrogen replacement there is no increased risk of breast cancer.  For this reason, women who have a BRCA mutation and have no plans to have bilateral risk reducing mastectomies should consider having a hysterectomy at the time of their BSO.

HRT after breast cancer

For women with a past history of breast cancer HRT may not be suitable. HRT cannot be taken by women taking treatment such as tamoxifen or anastrazole for an oestrogen receptor positive breast cancer. If you are experiencing severe menopausal symptoms that do not respond to non-hormonal management it is worthwhile discussing your risk-benefit balance with doctors at the BRCA or HRT clinic. For women who have had a triple negative breast cancer, HRT can be considered but it may be recommended to delay starting treatment for at least two years after diagnosis and after the woman has had bilateral mastectomies.

Vaginal oestrogen is suitable for all women with a history of breast cancer even during treatment.