Treating menopause

By the time you reach menopause, the ovarian production of oestrogen and progesterone stops.

Whether you choose to use menopause hormone therapy (MHT) for symptoms like vaginal dryness, hot flushes or mood changes depends on the extent to which these menopausal symptoms interfere with your quality of life and your perception of self.

Not all women who are menopausal need to use MHT, which is why it’s important to discuss the pros and cons with your doctor. If it looks like you can benefit from MHT, your doctor can prescribe it at the lowest, most effective dose to manage your specific symptoms.

It’s often argued that menopause is a physiological, normal life event and that it shouldn’t be treated as an illness – in other words, with medication. While this is true, it’s also worth considering that women now live for many years beyond the menopause and that these changes in life expectancy are relatively recent.

Researchers now know that there are some risks associated with living for many years with low levels of oestrogen in the body (oestrogen is involved in more than 300 processes in the body), and that the bones and heart are most at risk. For example, oestrogen influences how the body uses calcium. Without it, your risk for osteoporosis increases.

Menopause isn’t managed according to a formula; every woman should be evaluated on an individual level. The type of intervention will depend on your symptoms, needs, stage of menopause, and whether you’ve had a hysterectomy or not.

1. Follow a healthy lifestyle
In general, strive towards following a healthy lifestyle, which includes stopping smoking, exercising daily, controlling your weight and managing your stress levels. Stress-reduction techniques such as massage, yoga and meditation may help to reduce some symptoms.

Following a healthy diet is extremely important, as it helps to reduce the risk of osteoporosis and heart disease. Adopt a low-fat, high-fibre diet rich in fruits, vegetables and whole grains, and make sure you consume adequate vitamin D and calcium for strengthening your bones. Eat calcium-rich foods (such as dairy products) or take a calcium supplement, so that your daily intake is 1,000 milligrams per day.

Eating foods high in plant oestrogens (phytoestrogens) may ease menopausal symptoms and lower your cholesterol levels. Good sources of phytoestrogens are lima beans, soybeans and soy products (such as soy milk, roasted soy nuts, soy burgers and tofu), nuts, seeds, fennel, celery, parsley and flaxseed oil.

Daily exercise, in turn, will help you to keep your weight down, improve sleep, help ease hot flushes and lift your mood. Weight-bearing exercises such as walking and jogging may help to prevent osteoporosis, while stretching exercises will help you to remain flexible.

Also continue to look after your skin, as this will also be affected by a drop in oestrogen levels. Use adequate sun protection (SPF 30+), stay hydrated and keep your skin moisturised.

Being attuned to your bodily changes helps to make this time in your life less confusing. Monitoring your menstrual cycle for several months, and keeping track of your symptoms in a diary, will give you a greater sense of control and provide useful information to discuss with your doctor.

Along with a good understanding of your body and the changes it’s going through, a positive attitude is important for dealing with any difficulties it may bring.

Treat specific symptoms as follows:

Hot flushes 

  • Keep your home and workplace cool.
  • Use a light blanket or sheet at night.
  • Wear light, loose clothing in layers that are easily removed. Choose natural fibres.
  • Drink plenty of fresh, cool water.
  • Eat smaller meals, which will help to regulate your body temperature better.
  • Avoid caffeine, alcohol, hot drinks and spicy foods if they bring on hot flushes.
  • Exercise daily to help stabilise insulin levels and boost endorphin levels.
  • Relax by practising stress-reduction techniques (e.g. meditation, yoga).

Vaginal dryness
Short-acting, water-based vaginal lubricants (such as K-Y Jelly) can be used immediately before sexual intercourse to supply moisture (avoid petroleum-based products such as Vaseline). However, these lubricants don’t offer a long-term solution or help with strengthening the skin.

You could also consider using a local oestrogen vaginal cream or vaginal ring twice weekly. The twice-weekly local oestrogen vaginal pessary, a small soluble block that’s inserted into the vagina, is an over-the-counter preparation (schedule 2). It can be used long term by women who would normally have been excluded from oestrogen use because of hormone-dependent cancers, severe liver disease or previous deep-vein thrombosis. Talk to your doctor about the treatment that’s right for you.

Interestingly, it may help to have more sex: intercourse helps to maintain vaginal elasticity and lubrication. Try new positions to find the ones that are most comfortable.

Mood changes
Discuss problematic symptoms with other women or perhaps a therapist, and ask you partner for support. Ask others for consideration and understanding during this period of transition.

Decreased sexual desire
The primary cause of a lowered libido should be identified and treated. A decreased libido and uncomfortable sex may be linked to physical changes (such as vaginal dryness), low self-perception and/or lifestyle factors.

Urinary incontinence
Urinary incontinence can often be improved by doing regular Kegel exercises (pelvic muscle-strengthening exercises).

Contract your pelvic muscles as if trying to close the vaginal opening. Hold the contraction for a count of three, and then relax. Wait a few seconds and repeat. Fast Kegels (squeezing and relaxing muscles as quickly as possible) can also help. Performing several Kegels per day (aim for 50) can improve bladder control and may enhance sexual pleasure.

2. Hormone therapy
If the above steps don’t offer enough relief, prescription medication in the form of menopause hormone therapy (MHT) may be required.

MHT involves taking low dosages of oestrogen (oestrogen therapy, or OT), or of both oestrogen and progestin (combined OPT), to relieve short-term symptoms. It may also help to reduce the risk of some of the long-term diseases associated with menopause.

There are benefits and risks associated with taking OT and OPT, which may differ for each woman. The decision to use hormones, as well as dosages, routes and duration of use, must be based on your individual risk-factor profile.

Your doctor will take your personal and family medical history, particularly of certain cancers, heart disease, stroke and osteoporosis, into consideration.

Oestrogen-only therapy, for example, doesn’t increase the risk of breast cancer and may decrease the risk for heart disease, but it’s only an option for women who don’t have a uterus or for women who have had a progestin-releasing intra-uterine device (Mirena) fitted. This is because oestrogen-only therapy increases the risk of endometrial cancer (cancer of the lining of the womb).

The hormone testosterone is sometimes prescribed when menopause has a negative effect on sex drive, particularly in the case of surgical menopause (i.e. when you’ve had a hysterectomy).

MHT includes one or more of three hormones:

  • Oestrogen. This is the main component of hormone therapy, which controls hot flushes and night sweats, improves sexual function, increases bone density and decreases heart-disease risk in younger women. 
  • Progesterone or progestin, a synthetic version of naturally-occurring progesterone. This is prescribed in combination with oestrogen in women who still have their uterus. It helps to protect the lining of the uterus (a thickened lining can increase your risk for cancer).
  • Androgen (testosterone). This hormone may be given under certain circumstances where libido is decreased, particularly after removal of the ovaries.

The hormones in MHT can be delivered in a number of ways:

  • Oral (a tablet taken by mouth)
  • Across the skin (transdermal) as gels or patches
  • As implants under the skin 
  • In a hormone-impregnated intrauterine device (IUD)
  • Via the vagina as creams, pessaries or oestrogen-impregnated rings

Oral preparations
This is the most common and best known form of MHT, and the method for which there is the most clinical experience.

Advantages of oral preparations:

  • Relatively inexpensive
  • Easy to take
  • A wide choice of different preparations
  • Oral progestin can be given at the same time
  • Oral oestrogen raises levels of HDL, the “good” form of cholesterol

As with any drug, there are disadvantages:

  • You must take your tablet every day for it to work effectively.
  • You’ll need to take a relatively high dose of the active ingredients. This is because some of the oestrogen is lost when the drug is broken down in the liver.
  • If you have a gut disorder, absorption will be poor. 
  • The functions of the liver enzymes are altered.
  • Levels of triglyceride (the major form of fat stored by the body) can be raised.
  • All the tablets contain lactose, which can be a problem if you’re lactose intolerant.
  • MHT is associated with an increased risk of deep-vein thrombosis (DVT) – when a blood clot forms in a vein located deep inside your body, usually in the legs. It’s a serious condition because blood clots can break loose and lodge in your lungs, blocking blood flow. This is called a pulmonary embolism.

Oestrogen gels
Oestrogen gels are a popular choice of MHT among some women. The amount of oestrogen delivered depends on the amount of gel used, which makes it easier to use a dosage that’s just right for you and to adjust it over time. It usually has to be applied daily and the risk for skin reactions is low.

Note, however, that these gels contain only oestrogen. If you still have your uterus intact, you might also have to take progesterone to lower your risk for endometrial cancer.

Oral oestrogen preparations pass through the liver, which inactivates 35-50% of the absorbed oestrogen. Non-oral oestrogen has the advantage that it bypasses the liver, which means that more oestrogen is delivered where it’s needed. This is where patches come in.

The original patches were called matrix patches and were alcohol-based, which caused skin reactions in some women. The new-generation patches deliver oestrogen as effectively as the original ones, but don’t contain alcohol. Progestin-containing combination patches are also available.

Most patches need to be replaced twice a week (remember to apply them to clean, dry skin). A patch that only needs replacing once a week is also available.

All skin preparations (patches and gels) may suit women who:

  • Are lactose intolerant.
  • Have a history of blood clots (there’s no evidence of an increased risk for deep-vein thrombosis with patches and gels).
  • Have experienced problems with oral MHT.
  • Have difficulty with hot flushes and other symptoms of menopause, despite the use of oral MHT.
  • Have diabetes.
  • Have high triglyceride levels, particularly if they’re overweight. (Triglycerides are a type of fat found in the blood. High levels may raise the risk of coronary artery disease.)
  • Suffer from vascular headaches such as migraines.
  • Have liver disease.

Vaginal oestrogens
Oestrogen is also available as vaginal creams, pessaries (small, soluble blocks that are inserted into the vagina), and low-dose vaginal rings.

The vaginal route of administration is particularly useful for women who can’t use oral oestrogen, skin creams, gels or patches.

The vaginal ring, in particular, delivers a very low dose of oestrogen over a period of a month, with very little absorption in the rest of the body. This is useful where the main postmenopausal complaints are related to thinning of the vaginal wall and problems with the urinary tract. The oestrogen that’s made available to the tissue from the vaginal ring can counteract vaginal dryness and constant urinary tract infections (UTIs).

Implants of oestrogen have been around for a while, but are controversial. These oestrogen-containing pellets are surgically implanted under the skin – usually in the upper arm, abdomen or buttocks. The hormones are broken down and delivered to your system at variable rates.

The main problems with this method of delivery are as follows:

  • A surgical procedure is needed.
  • The effects of the oestrogen can become weaker with time, while the implant needs to be replaced frequently – usually every six months, or when the oestrogen falls below certain levels (you’ll start to experience symptoms again).
  • Some women experience a rapid decrease in response to the hormones (a syndrome called tachyphylaxis).
  • Implants aren’t suitable if you still have an intact uterus. Oestrogen-only therapy increases the risk of endometrial cancer – the oestrogen from the implants can stimulate the endometrium, leading to excess growth. This cannot be easily controlled, even when the implant is removed.

Tibolone is a synthetic steroid hormone derived from the Mexican yam. It works by mimicking the activity of the female sex hormones, oestrogen and progesterone, and also has some male hormone (testosterone) effects.

Tibolone is effective for preventing bone loss and treating hot flushes and vaginal dryness. It also seems to have a positive effect on libido. Because it isn’t an oestrogen, it doesn’t have any negative effects on the endometrium (i.e. it doesn’t lead to excess growth). In fact, it causes the endometrium (the lining of the uterus) to decrease in thickness. It may also have protective effects against breast cancer.

The main disadvantage of tibolone is that it tends to reduce HDL, the “good” form of cholesterol, in the short term. But just how much effect this has on coronary artery disease isn’t known.

The main advantage is that women seldom bleed while taking the drug, but this is only true if it’s started at least one year after the final menstrual period.

Who can benefit from MHT?
Not all menopausal women need MHT. Only one in four experience symptoms so severe that they need treatment. Secondly, not all women are suitable candidates.

You may be one of the women to benefit from MHT if:

  • Your menopause started recently, you’re younger than 60 years, you suffer severely from hot flushes and/or other menopausal symptoms, and you’re at risk for hip fractures. You may benefit from taking MHT, either on its own or combined with anti-osteoporosis drugs.
  • Your menopause transition starts relatively early (before 45 years of age). Treatment is used to stall the changes that occur due to a lack of hormones. Studies show that this prolonged exposure to hormones doesn’t increase breast cancer risk or any other risks (besides clots). Once the natural age of the menopause is reached, the risks are the same as for any other woman.

You may not be able to take MHT if you:

  • Have a personal or family history of breast cancer.
  • You’re older than 60 and haven’t taken MHT before. 
  • Have a family or personal history of or increased risk for heart disease, stroke, deep-vein thrombosis, blood clots and/or hypertension.
  • Have elevated cholesterol or lipid levels. Talk to your doctor about statins, as studies show women are undertreated in this regard.

How safe is MHT?
Rational analyses of the Women's Health Initiative Study results, as well as subsequent studies, have proved that MHT is perfectly safe when used correctly and by the right women.

Effective MHT is dependent on your individual profile. Age is the most important determinant when it comes to assessing the benefits and risks. It’s recommended that MHT is used as soon as possible after menopause starts and not, for instance, only years later.

In general, when using approved hormone-replacement therapies, the American Food and Drug Administration (FDA) and healthcare professionals recommend using the lowest possible dose for the shortest possible period of time.

The benefits of MHT
If MHT is used correctly, it can improve your quality of life, reduce menopause symptoms and increase your bone density. In some women, there’s also a reduced risk for heart disease.

Possible side effects of MHT
As with all drugs, there are side effects and risks associated with MHT. These are usually reversed when MHT is stopped.

Common side effects include:

  • Breast tenderness and bloating. This can often be dealt with by altering the dose or route of delivery.
  • Vaginal bleeding: Some women who are taking combined oestrogen and progestin therapy may experience light, irregular vaginal bleeding during the first six months of treatment. Likewise, postmenopausal women who are taking a cyclic hormone regimen (oral oestrogen and a progestin added for 10-12 days per month) may experience some vaginal bleeding similar to a menstrual period for a few days each month. Postmenopausal women who experience heavy or prolonged vaginal bleeding while on hormone therapy should always see a doctor to rule out more serious causes. Less frequent but serious causes of vaginal bleeding in postmenopausal women include endometrial cancer and hyperplasia (overgrowth of the endometrium, which can be precancerous).
  • High blood pressure: Oestrogen usually causes no changes in blood pressure. In fact, in some women it lowers blood pressure. Others, however, have an unusual reaction to the oestrogen in MHT and develop hypertension. This is rapidly reversed when MHT is stopped. It may also be possible to alter this effect by changing the dose and the way in which MHT is delivered (e.g. via the skin instead of an oral preparation).

Effects of MHT on the body
The effects of MHT can be summarised as follows (+ and - signs indicate positive and negative effects):

+ MHT relieves symptoms associated with menopause such as hot flushes, night sweats and vaginal dryness. In fact, MHT is the only treatment that results in a dramatic improvement of all the symptoms of menopause. You’ll also sleep better, and your quality of life will improve.

+ MHT can provide the tissues of the urogenital tract with enough oestrogen to improve its function. In this way, it also helps to prevent vaginal dryness and recurrent urinary tract infections.

+ MHT reduces the risk of developing osteoporosis. Oestrogen-related drugs, though, may be prescribed as chronic medication for the prevention of post-menopausal osteoporosis.

+ Large studies indicate that MHT may prevent type 2 diabetes. The reduction may be linked to a lower risk of weight gain around the abdomen, reduced insulin resistance and/or other unknown factors. MHT is also associated with an improvement in insulin resistance in post-menopausal women. However, there isn’t evidence to recommend MHT as the sole or primary indication for the prevention of type 2 diabetes in menopausal women.

+ Combined oestrogen-progestin therapy (OPT) decreases the risk of cancer of the endometrium. In the past, MHT was administered only as oestrogen with no addition of progestin. Women who still had their uterus intact, had the risk of developing cancer of the endometrium (the lining of the uterus). By adding progestin to the MHT regimen, this risk is prevented. In general though, MHT isn’t recommended for women with a history of endometrial cancer.

+ MHT reduces the risk for colorectal cancer.

+/- Evidence is mixed concerning the effects of MHT on mood. Several small, short-term trials suggested that MHT improves mood. Other trial results showed no change.

MHT isn’t an antidepressant and shouldn’t be prescribed to treat depression. It’s interesting to note, however, that SSRI antidepressants may alleviate hot flushes in some women.

Progestin in combined MHT may worsen mood in some women, particularly those with a history of premenstrual syndrome, premenstrual depressive disorder or clinical depression.

+/- MHT may protect younger women against heart disease, but may increase the risk for older women.

Careful analysis of studies indicate that MHT may reduce the risk for heart disease – if MHT is initiated within two to three years after the onset of the menopause in woman aged 50 - 59.

However, indications are that MHT, when initiated more than ten years beyond menopause in women older than 63 years, may increase the risk for coronary heart disease. These are indications, not absolutes.

Experts conclude that MHT should not be prescribed to primarily reduce the risk of heart disease. The correct treatment options for women with an increased risk for heart disease include anti-hypertensives (for high blood pressure), cholesterol-lowering drugs and other medication aimed at decreasing the specific risk factors.

- MHT may increase the risk for stroke. Results of studies of the risk of stroke with MHT have been inconsistent. Some studies, including the very large Nurses’ Health Study (NHS) and the Women's Health Initiative Study (WHI), indicated an increased risk of ischaemic stroke (that occurs as a result of an obstruction within a blood vessel supplying blood to the brain). Other studies showed no effect on stroke risk.

Experts conclude that MHT isn’t effective in reducing stroke among women with established cardiovascular disease, or for the prevention of a first stroke. It may even increase the rate of first strokes, particularly in women who started using MHT after the age of 60.

- MHT increases the risk of blood clots and deep-vein thrombosis (DVT). The risk of developing blood clots is higher among women older than 60. There’s no evidence, however, that this increases the risk of death as a result of the clots. In fact, the risk is less than half of that during normal pregnancy. Women who have already had venous thrombosis have an increased risk of suffering further clot formation if they take oestrogen orally. However, according to observation, this seems to be diminished if they use transdermal patches.

Experts conclude that women with a prior history of deep-vein thrombosis, or women who possess a specific clotting gene (Factor Leiden V), are at increased risk for DVT with MHT use.

- MHT may increase the risk of breast cancer slightly, especially after five or more years of MHT (particularly combined OPT) use. Despite the increase in breast-cancer incidence, the mortality rate remains unchanged. It seems that breast cancer is detected earlier in women on MHT because of increased awareness and annual mammography screening.

The use of OT in breast-cancer survivors is still controversial. There’s still no proof that OT use in breast cancer survivors is safe.

Remember, the risk varies widely among women, so individual risk factors need to be evaluated carefully before starting MHT. It’s also worth remembering that deaths from coronary artery disease among women outnumber deaths from breast cancer, so the relative risk of both conditions needs to be assessed as well.

- MHT may increase ovarian cancer risk after longer use. Data on the role of both OT and combined OPT and the risk of ovarian cancer is conflicting. Many studies show either no association or a slight increased risk with MHT use.

- MHT use in older smokers may promote lung cancer. Overall, data suggest that combined OPT, when initiated in older women with a history of smoking, may promote the growth of existing cancers. All smoking women in any stage of their life should be encouraged to stop smoking.

- MHT doesn’t protect against Alzheimer’s disease.

3. Over-the-counter medication and natural remedies
Unlike MHT, alternative remedies don’t have to conform to the strict requirements of the SA Medicines Control Council (MCC) before they’re made available to the public. They’re not registered with the MCC, and purity and testing are unknown. Research has proved beyond all doubt MHT works, and works well. Unfortunately, that can’t be said for all the alternative remedies out there.

Some researchers believe plant oestrogen in the herb black cohosh and soya (but not in soya tablets) can relieve hot flushes. Although some women swear by them, an American study by the US National Institutes of Health has once again proved plant oestrogen is nothing more than a placebo.

People also often assume medicines derived from plants are safe, but there’s no proof that this is really the case. Some herbal medicines can have serious side effects, such as damaging your liver. They can also interfere with the effects of other medication.

Black cohosh has been documented to cause liver damage in some women. In America all black cohosh therapies have a “black box” warning about potential liver toxicity. Studies have also shown that high amounts of soya in the diet is effective to treat some menopause symptoms, but that phyto-oestrogen extracts from soya supplements are not.

Other herbals that may be effective in providing some relief from menopause symptoms are Dong Quai (Angelica sinensis), liquorice root (Glycyrrhiza glabra) and chaste berry (Vitex agnus-castus).

The bottom line: Some natural remedies do relieve some symptoms of menopause, but they don’t act like MHT and generally aren’t as effective. Plus, they can have dangerous side effects and interact with other medication.

Keep in mind that:

  • Approved hormone therapies are available on prescription only.
  • Bio-identical hormone therapy (BHT) products will have the same risks as the products they're identical to – namely a heightened risk of breast cancer and serious heart problems. There may be other, as-yet-unknown risks as well.
  • Beware of claims by pharmacists or BHT manufacturers that they can make customised bio-identical compound hormone products based on hormone levels measured from a woman's saliva sample. Hormone levels fluctuate constantly and saliva tests aren't specific enough to determine drug dosages.
  • No drug containing the hormone estriol (the weakest of the three oestrogens produced by the body) has been approved by the MCC.

Reviewed and updated by Dr Carol Thomas MBChB (UCT) FCOG (SA) MMed (O&G) (UCT), specialist gynaecologist in private practice, Cape Town, President of the South African Menopause Society and Director of the WomanSpace and iMobiMaMa. March 2017.

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