This article was included in issue 51 (Winter 2011/12) of The Menopause Exchange newsletter.

Insomnia has a rather wishy-washy definition: ‘Repeated difficulty in getting to sleep, staying asleep or getting enough good quality sleep, despite adequate opportunity, which leads to some form of impairment of performance or wellbeing during the daytime.’

The problem is that people vary so much in their normal sleep requirement. I function on seven hours sleep a night, but my husband needs eight hours or he’s grumpy. Margaret Thatcher and Bernard Levin both famously needed about four hours sleep a night and excelled in their careers because of it: they did four hours of extra work per day than the rest of us.

So it’s not how long you sleep, but whether it’s upsetting you that counts and whether it’s a change from the ‘normal’ you. In medical research papers, there is an ‘Insomnia Severity Index’ rating scale that is often used and has been proven to be valid for self reported insomnia.

Causes of insomnia

Excitement, misery, depression, physical pain and lying awake waiting to hear a teenage daughter safely coming home from a party at 3am are all causes of insomnia.  Women sleep less well around the time of their period because of the physical discomfort of bloating or cramping pain. At the menopause, hot flushes may wake women up during the night and their partner’s snoring may be so loud that they can’t get back to sleep again. Bladders are less resilient to an overnight load of urine as pelvic floors droop with a lack of oestrogen, so women wake up to wee more at night, also affecting their sleep patterns.

Osteoarthritis of the neck, spine, hips and knees gets worse as people age and the pain wakes them up. Restless legs syndrome is where your legs feel crampy and painful as soon as you relax. If you experience this, ask your GP to check for iron deficiency; several medicines (e.g. quinine) can help with restless legs.

Snoring and sleep apnoea are both sleep disorders that need a referral to secondary care. Sleep apnoea is when you actually stop breathing in the night, and then often wake yourself with a terrifically tough gasping rasping snore, designed to make you breathe and re-oxygenate your brain. There are sleep clinics that can diagnose this.

People often say they can’t sleep as a way of expressing their level of anxiety or depression. In the dark, problems seem much worse and you have no one to chat to; you may drop off just as dawn makes you feel that things might be ok. Menopausal women are often in the centre of a support ring: we may be worrying about frail elderly parents or in-laws, plus coping with our partner’s mid-life crisis and our children’s problems, or friends who are unwell.

Find a network of support for yourself, as stress makes hot flushes worse. It becomes a vicious cycle of worry and menopausal physical symptoms. Remember you are not alone. In one study of American women aged 40 to 60, 20% reported insomnia.

Treatment options

The first thing to do is to decide why you are having sleepless nights and treat the underlying cause. If you are in pain, for example, find out if something can be done to help your symptoms or the underlying cause (e.g. simple painkillers, steroid injections, surgery). If you suffer from bladder weakness, do you need pelvic floor physiotherapy to improve your bladder tone? There are also medications to help some bladder problems in men and women.

Think about whether you are actually depressed and need help from your GP. If things are getting too much, try to think of solutions (e.g. just saying ‘no’ to extra burdens works surprisingly well and people won’t hate you for it). Self-help books can provide information on problem solving, allowing yourself treats and saying ‘no’ nicely. Alcohol is not the answer. It may make you go to sleep, but you get rebound wakefulness at about 3am, which is worse.

Your GP may be able to direct you towards ‘mindfulness therapy’ classes. In a randomised control trial, mindfulness therapy was shown to give significant improvements in quality of life in menopausal women with insomnia.

Phytoestrogens are plant molecules that when eaten sit on oestrogen receptors and weakly act as stimulants. They are known to reduce hot flushes, but a recent paper found them particularly effective for anxiety, irritability and insomnia. Aim to take 60 mg of isoflavones a day (try red clover supplements or beans, peas, lentils, soya or chickpeas). Some women with severe menopausal flushing find hormone replacement therapy works for them, but combined oestrogen and progesterone doubles the risk of breast cancer.

Some women find that complementary therapies reduce their insomnia. Find a reputable hypnotherapist to teach you ‘self hypnosis’: how to go into a hypnotic trance (deep relaxation). This relaxes you and you drift off to sleep. Even if you don’t sleep, you feel better than tossing and turning. In Taiwan’s Institute of Traditional Medicine, a study found that auricular acupressure therapy could contribute to total sleep duration.

Herbal remedies such as valerian may help as well. In a randomised controlled trial from Tehran, women were given 530mg of valerian or placebo and the treated group were 30% better than the control group after four weeks.

Medical help

If the herbal remedies and alternative therapies don’t work, see your GP. Usually GPs don’t like prescribing sleeping tablets, as all the benzodiapines are addictive, so these are only prescribed for getting over a crisis in the short term. Your GP may offer antidepressants as these may have a double function of helping your depression and stopping your mind ruminating at night. Your GP will be able to offer to refer you to counsellors (e.g. cognitive behavioural therapy or mindfulness therapy). They should also offer you help for physical problems that interfere with your comfort and prevent sleep.

About the author

Dr Sally Hope FRCGP DRCOG is a principal in general practice in Woodstock, Oxfordshire and an honorary research fellow in the women’s health department of Primary Health Care, University of Oxford.

Created Winter 2011/12

Copyright © The Menopause Exchange 2012

References:

• Polo-Kantola P. Sleep problems in midlife and beyond. Maturitas. 2011 Mar;68(3):224-32. Epub 2011 Feb 3.

• Taavoni S, Ekbatani N, Kashaniyan M, Haghani H. Effect of valerian on sleep quality in postmenopausal women: a randomized placebo-controlled clinical trial. Menopause. 2011 Jul 14. Epub ahead of print.

• Agosta C, Atlante M, Benvenuti C. Randomized controlled study on clinical efficacy of isoflavones plus Lactobacillus sporogenes, associated or not with a natural anxiolytic agent in menopause. Minerva Ginecol. 2011 Feb;63(1):11-7.

(Individual UK membership entitles members to quarterly issues of The Menopause Exchange newsletters, quarterly fact sheets, use of our information service and use of our ‘Ask the Experts’ panel).

Membership: http://www.menopause-exchange.co.uk/join_us/index.htm

This article was included in issue 51 (Winter 2011/12) of The Menopause Exchange newsletter.

If you think the biggest killer of women is the big C, especially breast cancer, you wouldn’t be alone. But you would be wrong. Heart disease is the single biggest killer of women in the UK and kills three times more than breast cancer. The good news is that it’s largely preventable. If you’re going through the menopause, now is a particularly good time to take action. This is because women’s hormones may give them some protection against heart disease before the menopause, but afterwards their risk rises.

What is heart disease?

Heart disease is caused by a build up of fatty deposits in the lining of the coronary arteries (the arteries that supply the heart muscle with blood and oxygen). This narrows your arteries, meaning your heart has to work much harder and can result in angina (pain or discomfort in the chest). A blood clot forms if some of the fatty deposits leak, which blocks the artery, stopping blood flow to that part of the heart muscle. This causes a heart attack.

Heart checks

Women over 40 can have a free health check at their GP surgery. This involves a blood pressure, cholesterol and weight check as well as talking through other risk factors for heart disease, such as smoking and your family’s health history. The doctor or nurse will advise on whether you need to make any lifestyle changes or take medication to reduce your risk.

Smoking

Smoking is a major risk factor. Kicking the habit is the single best thing you can do to improve your heart health. Within just one year of stopping, your risk of heart disease falls by about half. Getting support is vital, so if you want to quit, ask at your GP surgery for details of local smoking cessation services.

Blood pressure

High blood pressure (hypertension) is known as a silent threat because there are usually no symptoms, and the only way to find out is to have your blood pressure measured. To help prevent or reduce high blood pressure, stay active, keep to a healthy weight, cut down on salt and alcohol and eat more fruit and vegetables. If your blood pressure remains high, your GP can prescribe medicines to reduce it.

High cholesterol

High cholesterol is also a risk factor for heart disease. This is particularly the case if you have high levels of ‘bad’ cholesterol (‘Low Density Lipoprotein’) and low levels of ‘good’ cholesterol (‘High Density Lipoprotein’), which can help protect the heart.

Sometimes high cholesterol is caused by a genetic problem, but the main reason is that people eat too much saturated fat. You can help reduce your cholesterol by cutting down on fatty foods like cakes, biscuits and sausages. Swapping products like butter for margarine or full fat milk for skimmed can also help, as can using healthier cooking oils, such as olive, corn, sunflower or rapeseed oil. Prescribed drugs called statins can lower cholesterol.

Being overweight

Being overweight, particularly carrying weight around the middle, is another risk factor. Women should aim for a waist size of 31.5 inches (80cms) or less. While we can all enjoy an occasional treat, it’s important to eat a healthy, balanced diet with lots of fruit and vegetables. Eating fish twice a week, including one portion of oily fish (e.g. salmon or mackerel) can also help protect your heart.

Sedentary lifestyle

You should aim for 30 minutes of physical activity at least five days a week to stay healthy. This doesn’t mean turning into a gym bunny though because activities such as taking a brisk walk or doing the gardening also count.

Diabetes

Having diabetes makes you more likely to develop heart disease. The condition, which means your body can’t produce enough insulin to control glucose levels in your blood, is much more likely if you are overweight, not physically active or have a family history of diabetes. Your ethnicity can also be a factor; Black Caribbean and Pakistani women in England are 2.5 times more likely to get diabetes than other women in England. If you have diabetes, it’s even more important to do more physical activity, eat a healthy balanced diet and control your weight.

Alcohol

While there is some evidence that moderate drinking (one or two units a day) may help protect your heart, there are much healthier ways to do this. And drinking too much alcohol can lead to damage of the heart muscle, high blood pressure, stroke and some cancers so moderation is absolutely key.

Stress

Research is currently being carried out on how stress may link to heart disease. What we know for sure is that stressful situations often lead people into unhealthy habits, such as smoking and drinking or eating badly and not exercising. These behaviours can increase the risk of heart disease, so it’s important to find ways of coping with stress. For example, try a relaxation technique, a yoga class, getting a breath of fresh air or talking to a friend. Your GP can also offer advice.

Family history

Your risk of heart disease is increased if your father or brother developed cardiovascular disease (an umbrella term for all diseases of the heart and circulatory system) before age 55 or if your mother or sister developed cardiovascular disease before age 65. Ethnicity can also play a role, with South Asian women in England more likely to develop heart disease than other women. You can’t change your ethnicity or family history, but you can still reduce your risk by tackling the other risk factors outlined above.

For more information

For medical information and support relating to heart disease, contact the British Heart Foundation (BHF) on 0300 330 3311 (Mon-Fri, 9am to 5pm). Or visit the BHF’s website at www.bhf.org.uk

Created Winter 2011/12

Copyright © The Menopause Exchange 2012

Does life begin at 50? Well, it certainly did for me. When I reached 51, the average age of the menopause, I changed direction and achieved new goals. Having worked as a pharmacist for several years, I obtained a Master’s degree in health promotion. I then began giving talks and seminars on all aspects of the menopause to both women and healthcare professionals. In 1999, I founded The Menopause Exchange, which is an independent organisation for anyone with an interest in menopausal issues.

I am highly attuned to the concerns of women facing the menopause and their families and friends. I enjoy meeting women at the talks that I present, interacting with them and hearing about their menopausal experiences. I am often interviewed by journalists for newspapers, journals and magazines.

Since I founded The Menopause Exchange, my life has become more hectic than ever. I am married with two daughters and three grandchildren, so I also enjoy spending time with my family.

Going through the menopause certainly hasn’t stopped me enjoying life. And I hope my story will inspire and encourage women to ‘have a go’ and take opportunities as they arise.

I am postmenopausal. I would like to do as much as possible to prevent problems with my teeth and gums. Which foods should I eat to make sure I am getting the correct nutrients?

This question was answered by Angie Jefferson, consultant dietitian.

The menopause can increase the risk of teeth and gum problems. Good dental hygiene (brushing and flossing), a healthy balanced diet and limiting sugary drinks and foods between meals should help to keep teeth in great shape. Teeth are essentially similar to bone so it’s important to eat calcium-rich dairy foods (milks, yoghurts, custard, cheese etc.), and foods containing vitamin D (e.g. oily fish and vitamin D-enriched breakfast cereals and breads) daily. Drinking tea (without sugar) has been linked to good dental health, possibly due to increasing the intake of fluoride from water or from the antioxidants contained in the tea leaves. Vitamin C and antioxidants help to keep gums healthy, so eat plenty of fruits and vegetables. Fibre-rich foods help to stimulate saliva flow, so choosing high fibre will improve dental health.

I am going to be having a blood test to see if I am going through the menopause. Will this measure my levels of FSH and LH? Are the results reliable?

This question was answered by Kathy Abernethy, senior nurse specialist.

It’s not usually necessary to measure hormones to see if you are going through the menopause. A combination of your age (45 to 58), your symptoms (usually flushes and sweats, but others too) and a change in your periods all indicate that you are likely to be going through the change. If however you are younger than 45 or if you have had a hysterectomy so have no periods as a ‘marker’, you will be offered blood tests. The hormones commonly measured are oestradiol (oestrogen) and follicle-stimulating hormone (FSH). Even when these are measured, they don’t reliably diagnose menopause and you may need more than one test. After the menopause, oestrogen levels fall and FSH levels rise but during the ‘menopause transition’ they fluctuate wildly making them fairly unreliable as a single test.

I am 47 and I am going through the perimenopause. I have just had my first bout of cystitis. Is there anything you can recommend that women can buy from a pharmacy to help this?

This question was answered by Lila Thakerar, community pharmacist.

The symptoms of cystitis are caused by bacteria in the urine that make the urine more acidic. The aim of over-the-counter treatments is to make the urine less acidic (i.e. more alkaline). You can buy various alkalising salts in the form of sachets (eg Canesten Oasis, Cymalon, Cystocalm, Cystopurin sachets). It’s important to start treatment with these sachets as soon as the symptoms begin, and to continue treatment after the symptoms have subsided. With these sachets, drink as much fluid as possible to flush out the bacteria. If your symptoms persist after treatment with these sachets, consult your doctor.

Should HRT be stopped suddenly or reduced slowly?

This question was answered by Dr Sarah Gray, GP.

This depends on which type of HRT you are taking. If it’s one of the very low strength vaginal preparations, ask yourself why you want to stop as they have a very good safety profile and the problems that they are dealing with are likely to return when you stop. If you’re using tablets, patches or gel for more general problems, most experts would reduce the dose progressively. If symptoms return and are troublesome, it may be better to use the lowest dose that works for a year or so longer before trying again. Implants wear off slowly and this takes over two years from the last implant. Regardless of the method used, as you reduce the oestrogen dose it’s important to check how much progesterone you need to ensure that you have adequate protection for your uterus if you still have one.

Copyright © The Menopause Exchange 2012

This article was included in issue 50 (Autumn 2011) of The Menopause Exchange newsletter.

If you’re not careful, the menopause is the time of life that can herald significant weight gain. In fact, research has shown that, on average, women going through the menopause gain 2 to 2.5 kg (4½ to 5½ lbs) over a period of three years. Metabolic rate is the rate at which your body burns energy (calories) to keep your organs (e.g. heart and lungs) working efficiently. There is evidence that as women reach the menopause, their metabolic rate declines and they need fewer calories. This is probably because they are less active and there will be a decline in their lean muscle tissue.

The extra weight put on during and after the menopause is more likely to be deposited around the tummy area. This is associated in particular with an increased risk of raised LDL (‘bad’) cholesterol, lowered HDL (‘good’) cholesterol, high blood pressure and diabetes.

Weight risks

It is important to keep your weight gain down for health reasons, as well as to save you having to buy a whole new wardrobe when you hit the menopause. In general, carrying excess weight is linked to several health risks, for example:

• it can exacerbate painful joints

• it can increase the risk of developing high blood pressure

• it can increase the risk of heart disease and certain cancers such as breast and colorectal cancer.

• it can exacerbate hot flushes and night sweats, especially if the weight is carried around the middle of the body. In one study in 2010, research found that for every 5kg of weight lost, there was a 30% improvement in hot flushes.

Changing lifestyles

To offset your falling metabolic rate, you shouldn’t need to eat as much as you did during your younger days, unless you are very active. It’s important to stay as physically active as possible because as well as burning up more calories, physical activity is associated with fewer menopause symptoms. This may also help to reduce your chances of gaining fat around the middle of your body, even if you lose little weight overall.

Food choices

Research has shown that following a diet low in saturated fat is the best way to combat rising cholesterol levels. A recent study showed that combining a soy isoflavone supplement of 40mg alongside a Mediterranean diet and increasing exercise had the combined effect of preventing the onset of weight gain and diabetes in postmenopausal women.

Research shows that fad diets don’t work and those that promote rapid weight loss usually lead to rapid weight gain once you come off the diet. Avoid the Atkins diet or any other diet that restricts carbohydrates. Although a diet with a modest amount of protein can keep you from feeling too hungry, avoid high protein diets as these can put too much stress on your kidneys.

As mentioned above, the Mediterranean diet is backed by good evidence to show that it works well to achieve weight loss. It also has lots of other health benefits, especially during the menopause. This diet is made up of plenty of fruit and vegetables of all different colours, as well as beans, nuts, seeds, fish (including oily fish like salmon or mackerel), some olive oil and a modest drop of wine.

The best rate of weight loss is 1 lb a week. It would be harder to lose any weight faster than this without having to restrict calories too much and also lead to falling energy levels as well as resolve!

Exercise matters

Weight loss with dietary changes should always be accompanied by increased levels of exercise or physical activity. Aerobic exercise (where you get slightly out of breath and a bit warmer) is important, and 30 minutes on five to six days a week is the minimum recommendation for good health. People who have lost weight and do about 60 minutes of moderate physical activity a day have been shown to manage to keep their slimmer figures on a long-term basis and not regain the weight.

Resistance exercises (where you use weights or you resist against something else such as push ups from the wall or floor) are also important. These can help increase muscle mass, which tends to decline, especially in the upper body, after the menopause. There is little evidence that exercise alone can bring about weight loss, so you need to combine it with a diet that is about 500 to 600 calories less than you actually need so that you start using up your own fat reserves.

Get some support

If you find it hard to lose weight on your own, remember that the well known commercial slimming groups, such as Slimming World (contact 0844 897 8000 or visit www.slimmingworld.com) and WeightWatchers (contact 0845 345 1500 or visit www.weightwatchers.co.uk) have been approved by most of the medical profession as offering sensible weight loss advice. Unfortunately, weight loss is often regained a year on from losing the weight, so make sure you get support on how to maintain your weight loss too.

Being underweight

A low bodyweight (losing too much weight) can also carry health risks. It can lead to an increased rate of calcium loss from the bones due to very low levels of circulating oestrogen.

After the menopause, some oestrogen is still produced in the body’s fat cells, but if there is very little fat, then little extra bone-protecting oestrogen will be made in the body. In fact, weight loss of as little as 5% of body weight is associated with an increased loss of calcium from the bones.

Women who embark on weight loss programmes should therefore ensure they consume a bone-healthy diet (e.g. calcium-rich foods) combined with some high impact exercise, if possible, to try to minimise bone loss.

About the author

Gaynor Bussell BSc (hons) RD RPHNutr is a registered dietitian, public health nutritionist and writer who specialises in obesity and women’s health.

Created Autumn 2011

Copyright © The Menopause Exchange 2012

References

• Davidson, M.H., Maki, K.C., Karp, S.K., Ingram, K.A. (2002). Management of hypercholesterolaemia in postmenopausal women. Drugs Aging. 19(3), 169-78.

• Huang, A.J., Subak, L.L., Wing, R., West, D.S., Hernandez, A.L., Macer, J., Grady, D. (2010) An intensive behavioral weight loss intervention and hot flushes in women. Arch Intern Med. 12;170(13), 1161-7.

• Llaneza, P., Gonzalez, C., Fernandez-Iñarrea, J., Alonso, A., Diaz-Fernandez, M.J., Arnott, I., Ferrer-Barriendos, J. (2010). Soy isoflavones, Mediterranean diet, and physical exercise in postmenopausal women with insulin resistance. Menopause. 17(2), 372-8.

• Mastorakos, G., Valsamakis, G., Paltoglou, G., Creatsas, G. (2010) Management of obesity in menopause: diet, exercise, pharmacotherapy and bariatric surgery. Maturitas. 65(3), 219-24.

• Polotsky, H.N., Polotsky, A.J. (2010) Metabolic implications of menopause. Semin Reprod Med. 28(5), 426-34.

• Seo, D.I., Jun, T.W., Park, K.S., Chang, H.., So, W.Y., Song, W. (2010)  12 weeks of combined exercise is better than aerobic exercise for increasing growth hormone in middle-aged women. Int J Sport Nutr Exerc Metab. 20(1), 21-6.

• Whiteman, M.K. (2003) Smoking and Obesity Increase risks of severe Hot Flashes. Obstet Gynecol 101, 264-272.

Cognitive Behavioural Therapy – an alternative treatment to help women to manage menopause symptoms for women going through natural menopause and for women who have had breast cancer treatments.

Two new studies show that cognitive behavioural therapy (CBT) is an effective treatment for women experiencing hot flushes and night sweats (HFNS) – the main symptoms of the menopause. The studies, both led by Professor Myra Hunter at the Institute of Psychiatry at King’s College London, suggest that CBT may be a safe and effective alternative in treating symptoms of the menopause.

Hot flushes and night sweats (HFNS) are commonly experienced during the menopause transition and are problematic for approximately 20-25% of healthy women, causing discomfort, embarrassment and sleep disturbance. However, following breast cancer treatments, HFNS tend to be more severe, affecting 65-85% of women, and HRT is often either undesirable or contraindicated.

The first study (MENOS1), published in The Lancet Oncology followed 96 women who had problematic HFNS after breast cancer treatment in a randomised controlled trial (RCT) over 26 weeks. The authors found that group CBT significantly reduced HFNS problem rating at 9 weeks compared with usual care. These improvements were maintained at 26 weeks. The authors conclude that group CBT could be incorporated into breast cancer survivorship programmes and delivered by trained breast cancer nurses.

The second study (MENOS2), published in Menopause: The Journal of the North American Menopause Society, followed 140 healthy women in an RCT over 26 weeks and found that both group and guided self-help forms of CBT led to significant improvements in how problematic women rated HFNS. In both studies there were additional benefits to mood, sleep and aspects of health related quality of life.

Professor Hunter says: ‘Cognitive behavioural therapies are brief, effective, non-medical treatment options for menopausal women that can be delivered by trained health professionals. Our finding that self-help therapies can be as effective as group therapies is very exciting as we are keen to increase access to these kind of psychological therapies.’

Professor Hunter is currently working on a study to develop a CBT online strategy, with colleagues in the Netherlands, and will be publishing a self-help book for women next year. The research group is also investigating whether CBT helps men who have these symptoms following certain prostate cancer treatments.

References:

Mann E, Smith MJ, Hellier J, Balabanovic JA, Hamed H, Grunfeld EA, Hunter MS. Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment (MENOS 1): a randomised controlled trial. Lancet Oncology. 2012;13(3):309–318.

Ayers B, Smith M, Hellier J, Mann E, Hunter MS. Effectiveness of group and self-help cognitive behavior therapy in reducing problematic menopausal hot flushes and night sweats (MENOS 2): a randomized controlled trial. Menopause. 2012 Feb 14. PMID: 22336748.

MENOS 1 was funded by Cancer Research UK. MENOS 2 was supported by the National Institute of Health Research (NIHR) Biomedical Research Centre for Mental Health at the South London and Maudsley NHS Foundation Trust and the Institute of Psychiatry at King’s College London.

This article was included in issue 50 (Autumn 2011) of The Menopause Exchange newsletter.

At the menopause, women may suffer from hot flushes and night sweats, often accompanied by emotional or mood difficulties, erratic bleeding, vaginal dryness and low libido. Women with poor quality of life will see their doctor for advice and may be offered Hormone Replacement Therapy (HRT) after a risk-benefit evaluation.

There are different types of HRT formulations available in the UK. In the last issue of The Menopause Exchange newsletter, we discussed ‘no bleed’ or continuous combined HRT, which is suitable for postmenopausal women. These women have stopped having monthly periods or bleeds for a year or over. In this article, we discuss oestrogen only and ‘bleed’ HRT formulations.

Oestrogen-only HRT

When a woman has had a hysterectomy and both of her ovaries have been removed as well, she will go into a surgical menopause. As she doesn’t have a uterus (womb) after this type of surgery, the woman can safely use oestrogen-only HRT. Oestrogen-only HRT is available in different forms, including tablets, patches, gels and implants.

Patch formulations include ones where the patch needs to be replaced twice a week or just once a week. All preparations need to be used correctly to ensure good symptom control, for example taking a tablet daily or ensuring the patch is changed as directed on the packaging. Gels need to be applied over a large surface area to ensure good hormone levels in the bloodstream.

The dose needed will be determined by the healthcare professional but, generally speaking, the lowest dose that gives reasonable control will be used. Younger women with a surgical menopause may be offered their oestrogen as an implant, which involves a small incision in the groin area so that a pellet of oestrogen can be implanted. Women who are given implants need to have blood tests two weeks before an implant review appointment, to ensure that their blood oestrogen levels are low. Otherwise with frequent repeated implants, there is a risk of tachyphylaxis. This is a condition where the blood oestrogen levels are very high but the brain doesn’t register these high levels and the woman suffers all the symptoms associated with low oestrogen levels, including hot flushes and night sweats.

If a woman has a hysterectomy but one or both ovaries has been conserved, she probably won’t be given oestrogen-only HRT immediately after surgery. This is because her ovary or ovaries may continue to function for some time and she won’t immediately have menopausal symptoms. Women who have had a surgical menopause for a condition called endometriosis may initially be given combined oestrogen and progestogen HRT, rather than oestrogen-only HRT.

‘Bleed’ HRT

‘Bleed’ HRT is suitable for women who are going through the menopause and haven’t stopped having periods, but where the pattern of bleeds is erratic. These women are classified as being in the perimenopause phase; they are going through the menopause but still have some internal cycling of oestrogen and progesterone, the hormones that regulate the menstrual cycle in women.

Women who are perimenopausal will be offered a monthly bleed type of HRT. This involves taking oestrogen daily (for 28 days with each pack), and a progestogen course is added in for around 12 to 14 days of the month. This type of HRT causes a monthly bleed profile, with the woman having a bleed towards the end of the progestogen course once they are settled on their HRT.

There is also one HRT formulation that provides three-monthly bleeds, with oestrogen taken continuously for three months and the progestogen course added in for two weeks at the end of each three-month pack. This product is suitable for menopausal women who have infrequent bleeds, usually more then three months apart. There have been some safety concerns linked with uterine lining (endometrial) protection and women may also suffer heavier bleeds with the three- monthly HRT.

There are different types of oestrogen and progestogens used in different HRT formulations, and your healthcare professional will advise on which one is the most suitable for you. HRT is available as tablets, patches or a combination of tablets and patches. Women who find that their bleeds are very heavy may be offered their daily oestrogen as a tablet or patch, and be given the progestogen embedded in an intra-uterine system (IUS) called Mirena. With Mirena, the woman has inbuilt contraceptive cover as well as getting her progestogen from the IUS. When a woman is first put on HRT, she will be advised that HRT doesn’t offer contraceptive cover (unless she is using the Mirena coil as her progestogen in HRT). She will be asked to keep a bleed diary for her review appointment so that her healthcare professional can decide on whether there is a need to adjust the HRT doses or change the formulation.

Summary

Women going through the menopause who suffer from hot flushes and night sweats that affect their quality of life need an individualised risk-benefit evaluation before being offered HRT.

In women who have had a hysterectomy (with one or both ovaries removed), an oestrogen-only form of HRT is suitable. In women with an intact uterus who are experiencing menopausal symptoms and have an erratic bleed pattern, a monthly bleed type of HRT would be more suitable. Occasionally these women may be offered the three-monthly bleed HRT regimen instead.

About the author

Dr Nuttan Tanna is a pharmacist consultant. She runs the menopause and osteoporosis medication management clinics at Northwick Park Hospital, Harrow, Middx. Her research interests include new NHS service models to improve patient care.

Created Autumn 2011

Updated March 2012

Copyright © The Menopause Exchange 2012

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