Menopause is defined as being 12 months after the last menstrual period with the average age of menopause being 51 - the range 45-55.
Natural menopause occurs due to loss of ovarian follicles, follicular development and thus hormone production, resulting in
estrogen and progesterone withdrawal.
Surgical menopause refers to menopause because of bilateral oophorectomy (removal of both ovaries). Menopause may also be bought on early due to treatment for cancer.
Peri-menopause is the transition towards menopause that lasts approximately ten years. It is characterised by hormonal fluctuations, irregular menstrual cycles. In addition to menopausal symptoms such as hot flushes, vulvo-vaginal dryness, sleep disturbance, night sweats, joint pain, itchy skin, fatigue, and brain fog, menstrual periods for some can become very heavy with risk of anemia due to blood loss.
Over 25% of women will have moderate to severe symptoms that will impact their quality of life.
Up to 80% of women will have hot flushes and sweats that may last on average 7 years, and in 1 in 3 women these can be severe.
Over 10% of women will stop work due to menopausal symptoms
Women make up 51% of the population in Australia, with the median age being almost 40. Hence a quarter of the population are peri-menopausal or menopausal. :
This means almost 7 million are peri-menopausal or menopausal
Up to 1 million women ceasing work due to menopause.
Up to 2 million women with moderate to severe symptoms impacting quality of life.
Over 5 million women with hot flashes lasting at least 7 years and over 2 million women with debilitating hot flashes.
Let’s hear that again. Almost 7 million women in Australia are peri-menopausal or menopausal. And worldwide, the mind boggles as to how many women are impacted!
For the best part of the past two decades women have largely been denied treatment due to the 2002 Women’s Health Initiative (WHI) study that erroneously reported that hormone replacement therapy (HRT), specifically the combination of estrogen and progestin together, increased the risk of blood clots, stroke, breast cancer and heart attacks.
The WHI consisted of three clinical trials and an observational study. It was conducted to address major health issues causing morbidity and mortality in postmenopausal women. The study was stopped early by the researchers due to cost, and they concluded that the risks of HRT outweighed the benefits. Subsequently, most women and their doctors abandoned HRT as therapy for menopause.
Additional research over the past 10 years has found shown that the level of risk with HRT, now called MHT (menopausal hormone therapy), depends on the individual woman, her health history, age, and the number of years since her menopause began. Overall, for most women, the benefits far outweigh any risk.
These statistics are terribly sobering, and many women are mad! However, women now, needing help with symptoms are finally starting to get the help they deserve.
You cannot go anywhere now without hearing something about menopause. The WHI was debunked over 10 years ago, but its only in the past couple of years that its being talked about openly, with confidence to treat it safely. Unfortunately, we have a generation of doctors that are not adequately trained in prescribing for menopause.
Thankfully this is changing. There has even been an Australian senate inquiry about menopause and included in its key recommendations, are studying the economic implications of menopause, increasing education of health professionals, and guaranteeing that menopausal hormone therapy is made both affordable and accessible to all women who need it.
How do you treat menopause?
Some women have minimal symptoms and do nothing different. Some women make alterations to their lifestyle, such as dietary changes and doing regular exercise. Some women have success with complementary medicines. Other women with symptoms that affect their quality of life might choose to use prescription medicine such as menopausal hormone therapy (MHT).
What is menopausal hormone therapy (MHT)?
MHT was previously known as hormone replacement therapy (HRT). It is the same thing. MHT is the medical replacement of female hormones estrogen and progesterone, and sometimes testosterone.
Estrogen is the main hormone prescribed to relieve menopausal symptoms. If a woman has a uterus (versus not, due to surgical removal i.e. hysterectomy), estrogen and progesterone are used together, as progesterone reduces the risk of endometrial cancer (cancer of the uterus).
Without a uterus often estrogen alone is prescribed. Testosterone may also be used in some cases.
Estrogen is a hormone group that covers estrone, estradiol, and estriol
Estrone (E1) is the form of estrogen that is made after menopause, largely in adipose (fat) tissue
Estradiol (E2) is the most potent form of estrogen made during reproductive years, mostly produced by the ovaries, plus some made by the adrenal glands and fat tissues
Estriol (E3) is a form of estrogen made by the placenta during pregnancy
MHT estrogen is typically in the form of estradiol - a body identical form. MHT progestogens are either synthetic or body identical. Body identical progesterone is prescribed as a capsule taken orally. Synthetic progestins are more widely available and are less expensive but are more likely to have side effects. MHT can be prescribed in different dosages and methods, including tablets, transdermal patches applied weekly or biweekly, or gel applied to skin daily.
Intrauterine devices (IUD) may also be considered to help with symptoms, particularly for management of heavy periods and contraception in peri-menopause.
Vaginal estrogen cream or pessaries are frequently used alongside MHT or independently to help manage GSM (genitourinary syndrome of menopause – more on that later). Estrogen applied to the vulva and vagina exerts a localised effect only i.e. it doesn’t impact the whole body. In contrast MHT exerts a systemic effect but is not typically enough to remedy vaginal dryness and atrophy of tissues.
Women using hormone therapies may need to try different dosages or methods to find the right combination. A doctor must supervise this process.
What are the benefits of MHT?
Menopausal symptoms are what women typically try and remedy, whether it be via MHT, complementary medicines or lifestyle changes. And may include the following:
Hot flushes (feeling waves of heat)
Sweating at night
Trouble sleeping
Joint and muscle pains
Heart beating quickly or strongly
Brain fog (difficulty concentrating)
Forgetfulness
Less or loss of sexual desire
Vaginal dryness
Painful intercourse
Vaginal infections
Mood changes - Anxiety, depression, irritability
Itchy skin
Allergies
Tiredness/fatigue
Urinary issues – incontinence, urgency, frequency, UTIs
Irregular periods
Weight gain
Dizziness, vertigo, loss of balance
Headaches and migraines
Reduction in skin and hair health
Some women don’t get symptoms of great significance or may not choose to medicate or seek help. However, menopause is also associated with adverse metabolic, organ, and bone changes leading to an increased risk of cardiovascular disease, type 2 diabetes, osteoporosis, endometrial cancer, colon cancer, dementia, frozen shoulder, and cataracts. MHT is a way that women can potentially reduce risk of these conditions.
What are the risks of MHT?
Recent comprehensive reviews of evidence on MHT found it is an effective and safe treatment for the relief of menopausal symptoms. Data shows that MHT has low risks for women aged between 50 and 60 years, however, more research is needed. The risks of hormone therapy depend upon type, dose, when started and for how long, and what forms. It is not currently recommended you start MHT if you are older than 60 years or if you’ve been postmenopausal for 10 years or more.
Your doctor may advise you not to use MHT if it could increase your health risks. E.g. if you have cancer such as breast or uterine, undiagnosed vaginal bleeding, or heart disease.
Everyone responds differently to MHT. Some women experience no side effects, while others may have nausea, fluid retention, bloating, breast enlargement and discomfort, vaginal bleeding, or weight gain. Most symptoms settle within the first three months and may require adjustment of dose and/or delivery.
How long do you need to take MHT?
You can take MHT at low doses for as long as you need. Many women have symptoms for around eight years and one in four women have symptoms into their 60s and 70s. The benefits of MHT far outweigh the risks in healthy women within 10 years of reaching menopause.
When using MHT in midlife it is recommended to start low, go slow, and review often – it can take 6 months to get it just right. Once you’ve found an MHT that works for you, it’s important to review it with your doctor each year. If you have premature menopause, your doctor will prescribe a higher dose of MHT until the age of expected menopause.
How can allied health practitioners help women in Peri-menopause and Menopause?
Many symptoms and conditions women experience are musculoskeletal in nature such as:
joint and muscle pain
osteoporosis
vertigo
headaches
migraines,
loss of strength and balance.
Manual therapies (hands on therapies such as massage and joint mobilisation) can help to relieve pain. Prescribed exercise programmes also play a very important role in managing these aspects of health by maintaining and building muscle mass, weight bearing exercise for optimising bone density, specific programmes for tendon rehabilitation, management of frozen shoulders and balance rehabilitation. Exercise also plays a vital role when it comes to optimising sleep and mood.
Genitourinary syndrome of menopause (GSM)
Vaginal atrophy (atrophic vaginitis) is thinning, drying, and inflammation of the vaginal walls and vulval tissues that may occur when your body has less estrogen. Vaginal atrophy not only makes intercourse painful but can also lead to distressing urinary symptoms. Given the condition causes both vaginal and urinary symptoms, the term genitourinary syndrome of menopause (GSM) is used these days to describe vaginal atrophy and its accompanying symptoms – which may include:
Vaginal dryness
Vaginal burning
Vaginal discharge
Genital itching
Burning with urination
Urgency with urination
Frequent urination
Recurrent urinary tract infections
Urinary incontinence
Light bleeding after intercourse
Painful intercourse
Vaginal infections
Pelvic organ prolapse
Decreased vaginal lubrication during sexual activity
Shortening and tightening of the vaginal canal
Vaginal dryness symptoms in particular, range from mild to debilitating. Studies have found that 50% of women aged 50–60 years report symptoms, increasing to 72% in women aged older than 70 years, but only 4% associated their symptoms with loss of estrogen at menopause, and it's estimated that only 7% of women are treated.
GPs, gynecologists, urologists, and Women's health physiotherapists are all trained to treat genitourinary syndrome of menopause and many women don’t seek help not knowing how much help there is!
Women's Health Physios are trained in vulva and vaginal examinations and can identify pelvic organ prolapse, vaginal atrophy, and tight or weak pelvic floor muscles. Management may include pelvic floor strength exercises, pelvic floor relaxation and stretching, bladder training strategies, TTNS for overactive bladder, support pessary fitting for prolapse, vulva and vaginal moisturiser and lubrication advice, vaginal microbiome optimisation, safe exercise prescription, post-operative gynae rehabilitation, and collaboration with GPs and specialists such as recommendations for vaginal estrogen, suggesting testing for UTIs or other infections, or specialist referral.
At Balance Health we have Casey Cleeland and Kristine Miles trained in this area. Casey specifically is trained in fitting support pessaries and Kristine in the vaginal microbiome.
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