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Womens Health FAQ
What is menopause?
Pre-menopause – This is the time in your life following your periods starting, during which most women will have regular periods.
Perimenopause – This is when those cycles start changing; often becoming longer or less regular
Menopause – This is defined by the time when your periods have completely stopped for 12 months or more
Why does the menopause happen?
We are each born with a finite number of eggs – these eggs are producing oestrogen, and we are supposed to ovulate these eggs each month. In the menopause, we get to a point where we have run out of the ability to ovulate, so periods stop and oestrogen levels decline.
Surgery to remove the ovaries will also cause menopause, though a hysterectomy doesn’t as eggs will still be released and hormones produced by the ovaries.
Can you test for perimenopause?
During the perimenopausal period, your hormone levels are constantly fluctuating – the reduction in oestrogen is not completely linear. Hormone levels will fluctuate not just week by week, but can vary throughout a day too. Therefore, testing for hormone levels is not reliable to enable a diagnosis of perimenopause. The British Menopause Society state that blood tests shouldn't be used to diagnose people that are aged 45 and over. The average age of menopause in the UK is 51.
The jury is still out on DUTCH tests. They’re not evidence based and the results from them are difficult to interpret. Hopefully, they may lead to more reliable tests in the future.
How do you diagnose perimenopause?
We give any woman that’s aged 45 or over a diagnosis of perimenopause based purely on their symptoms.
For those getting symptoms before age 45, we may consider a blood test. This tests for Follicle Stimulating Hormone (FSH). FSH levels increase as you approach menopause, as it tries to stimulate the ovaries to produce eggs. Due to fluctuating hormone levels, we would require at least two raised FSH levels, 6 weeks apart, to confirm a diagnosis before age 45.
There is no correlation to FSH levels and how severe your symptoms are.
We would advise any woman in her 40s who begins to notice any symptoms, to track them using a diary or online symptom tracker. This doesn’t have to be changes in your period, as some forms of contraception will prevent this.
In the first instance, we would recommend you make some lifestyle changes to see if these have an impact. If things don’t improve then speak to your GP. It can be difficult to definitively say if symptoms are due to perimenopause, but your doctor can talk through things with you to help reach a diagnosis and manage your symptoms.
How do you diagnose menopause?
As this is defined by not having a period for at least 12 months, this can only be diagnosed retrospectively.
What are the symptoms of perimenopause / menopause
There are many different symptoms, and some people experience most of them, whilst others don’t experience any.
Common symptoms are:
- Irregular periods
- Hot flushes
- Night sweats
- Mood changes
- Irritability
- Joint aches
- Brain fog
- Poor sleep
- Reduced sex drive
- Vaginal dryness
- Incontinence and bladder problems
It’s often tricky to unpick which symptoms are directly caused by the menopause or whether they are related to other physical or mental health conditions. Do speak to your GP about your symptoms for further assessment.
How to manage perimenopause / menopausal symptoms?
Hormone Replacement Therapy (HRT) – This is the most effective treatment that we currently have for managing menopausal symptoms. HRT replaces the oestrogen levels that are declining. It can help with symptoms that are being caused by low oestrogen, so we would support women to trial this to see if it benefits them. It can also help with long term health consequences of menopause - for example by reducing the risk of osteoporosis, and it can help maintain heart health if started within 10 years of the menopause under the age of 60.
Don’t expect HRT to be a cure all. It can help to manage symptoms but may not resolve all issues. If you trial it and it doesn’t work, then stop it after 3-6 months. You can always try again in the future if needed.
Exercise – During the perimenopausal period, exercise is excellent for both mental and physical health. Reducing oestrogen levels correlate with a significant increase in the risk of heart disease and reduced bone density. Regular exercise helps you to maintain a healthy weight, which reduces the risk of heart disease, and strength training is particularly good at reducing the risk of bone thinning and osteoporosis.
Diet – Keep things simple, breaking things down into macro nutrients:
- Have ¼ of your plate as protein, ¼ of your plate from fats (saturated fat is needed to create oestrogen) and ½ your plate from complex carbs (multigrain seeded breads, sweet potatoes, beans and lentils etc).
The guidance recommends 20g a day of omegas 3 and 6 for good heart, brain, hair and skin health. These can be found in oily fish, nuts, seeds, avocado, red meat and olive oil. Calcium rich foods are also required to help maintain good bone health. These can be found in milk, yoghurt and cheese.
Lifestyle – Smoking, excess alcohol and high intakes of caffeine should all be avoided. Women who smoke tend to have an earlier menopause than non-smokers and we know that alcohol and caffeine can increase hot flushes and night sweats. Reducing your intake of these could help better manage symptoms.
Sleep – Sleep can be affected during menopause, particularly with stress and night sweats. Good sleep hygiene is key, so try to maintain a regular sleep schedule, avoid excessive caffeine and blue light. Try some relaxation techniques prior to going to bed.
CBT – Menopause specific CBT can be helpful in regulating mood and managing anxiety. It has also been shown to reduce the impact of hot flushes and sweats.
Supplements – There’s mixed opinion about whether supplements are helpful or not, especially as we should be getting most of the nutrients through a balanced diet. Vitamin D is the only dietary supplement that is currently an evidence-based recommendation for all women in the perimenopause. This should be 10 micrograms or 400 international units per day.
Magnesium is currently very popular and there is some limited evidence that aiming for about 250 milligrams of magnesium supplements a day might help to prevent bone loss. You can also take omega-3 supplements if you’re not having enough in your diet.
Do be aware of any interactions with other medications that you’re taking. Your local pharmacist should be able to help with this.
Other treatments – There are lots of other treatments available for women who can’t take HRT, to help manage some of the symptoms of menopause. We often use drugs that were developed for other reasons, but these are given in very specific situations, so have a discussion with your GP.
What are the risks of using HRT?
HRT is suitable for almost all women, but the exception might be those with certain cancers, e.g. breast or womb cancer, or if they’ve had previous blood clots.
For breast cancer:- For those who take combined HRT over a period of 7-8 years, an extra 4 women in every 1,000 may be diagnosed with breast cancer, compared to those who didn’t take combined HRT. This is a similar increase in risk for those taking combined hormonal contraception. Your risk can be lowered through exercising at least 2.5 hours per week, reducing alcohol to 2 or less units per day, giving up smoking and maintaining a healthy weight.
For blood clots, oestrogen can make the blood sticky, so if you have an increased risk, we advise taking transdermal oestrogen rather than tablets, which is safer.
The safest time to take HRT is within the first 10 years of having menopausal symptoms, as the risk goes up with age.
You also need to consider other medications that you are taking for conditions such as epilepsy or if you’re using medicines such as Mounjaro (Tirzepatide). Again consult with your GP making them fully aware of any medications that you are taking.
Whilst oestrogen is the hormone that combats the symptoms of perimenopause, if you have a womb, you will also be given progesterone alongside this. This is to protect the womb from becoming over stimulated and the womb lining thickening. This can lead to problems with bleeding, and in some cases, abnormalities such as womb cancer. Therefore, for women with a womb, it’s imperative that you take a form of progesterone alongside your oestrogen, to mitigate this risk.
Contraception during perimenopause
HRT is not a form of contraception. You will need to continue with an alternative form of contraception right up until you get to the menopause stage (12 months post periods) to avoid pregnancy. The Mirena coil can be used for both HRT and contraception, so is an excellent choice for many women.
Some contraception can camouflage the effects of perimenopause on your periods. But if you’re having any of the other symptoms then you should try to rule out other causes first. It’s also good to try to make some lifestyle changes to see if these have an impact. If things don’t improve then speak to your GP and discuss your options.
The oestrogen in the combined pill may also offer some protection against perimenopausal symptoms – although the combined pill can only be continued until aged 50, so you may need to switch to a different form of contraception then.
What HRT should I take?
Oestrogen can be given as an oral tablet or through the skin. The preferred option is through the skin, using patches, sprays or gels, as it is considered safer for women with certain medical conditions, such as high blood pressure, overweight, increased risk of blood clots or heart disease.
Progesterone can be given as oral tablets, a combined patch with oestrogen, as the Mirena coil, or off label as a vaginal tablet.
Testosterone - the ovaries also contribute to the production of testosterone. Currently, testosterone replacement is only prescribed for women with persistent low libido. There is a tablet form that has a combination of oestrogen, progesterone and testosterone that's given to those that are post-menopausal. If there’s no benefit after a trial of 6 months, then this should be stopped.
There is a cream which is licensed for use in women in the UK, but this is only available on private prescription. It is also only offered to women using systemic oestrogen treatment, and we’d want to ensure that you’re on the maximum or optimum amount of oestrogen before offering a trial of testosterone, because upping the oestrogen may help, without the need for testosterone.
There is also a testosterone gel, but in the UK, this is only licensed for use in men. We can offer a smaller dose to women under specialist advice.
There is no one size fits all solution to HRT
Have a discussion with your GP and don’t be afraid to ask to switch if one option doesn’t seem to work for you.
If you don’t have symptoms that are impacting your life, then don’t feel that you must take HRT. It’s not necessary for everyone and other approaches may be better to manage your symptoms.
When should I stop taking HRT?
There’s no set duration on how long a woman should stay on HRT. The average duration of perimenopause / menopause symptoms is about 7 years. Most women will stay on HRT for this period and then trial gradually coming off, to ensure that symptoms aren’t returning. We generally encourage thinking about stopping HRT from the age of 60, as this is when some of the risks may start to outweigh the benefits.
However, this is a personal decision, and some people will trial coming off HRT earlier or later, depending on their circumstances.
Can I take HRT if I suffer from migraines?
Some women find that their migraines get better in the perimenopausal or menopausal stages and some find that they get worse. We do take migraines into consideration when prescribing HRT, and we would recommend transdermal oestrogen, as migraines can be associated with other cardiovascular risk factors. Do let you GP know if you suffer from migraines so that they can help you decide if HRT is suitable for you.
Do I have to take HRT?
You do not have to take HRT! It’s helpful for many women but lots of women don’t need it, and can manage their symptoms with other approaches. Do speak to your GP about this.
Is family history an indicator for how you will experience menopause?
There isn’t evidence for experiencing the same symptoms, but there is evidence that you are likely to have a menopause at a similar age to your mum.
Are there menopause specialists at the practices?
All GPs in our practice undertake consultations around the perimenopause and menopause. This is both male and female GPs. We often discuss this topic in our clinical meetings. You have a right to request a specific GP if you prefer, or would like a second opinion.
Vaginal and bladder health
It’s quite common for women to experience genito-urinary symptoms during perimenopause and menopause. This can be soreness in the vulva and vagina, with itching, burning or dryness. Some women may get recurrent urine infections or symptoms that mimic urine infections.
If you experience any of these symptoms, please raise them with your GP. There are treatments that can help- including a localised oestrogen for the vagina, which can ease many symptoms. This can be used long term without additional risks associated with it. There are also moisturisers and lubricants that can be used to ease symptoms.
A good approach to vulval health in the 40s and 50s has a big impact. This includes using emollients to wash with rather than shower gels; not letting shampoos and shower gels run through the vulval area; making sure you don’t stay in your gym kit or damp clothing too long; wearing clothing that is breathable.