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Menopause and Me:A guide for younger women

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This booklet has been written by Dr Louise Newson, GP, menopause specialist and founder of the

Newson Health and Wellbeing Centre in Stratford-upon-Avon, England.

For more information on Dr Newson visit www.menopausedoctor .co.uk

Contents

What is the menopause? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

What is POI? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-6

Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-7

Long-term health risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Treatment options for your menopause:

Hormone Replacement Therapy (HRT) . . . . . . . . . . . . . . . . . . . . . 9-11

Other treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-14

Lifestyle changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Common HRT myths busted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

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Menopause and me: menopause in younger women

Did you know? About three in four women will experience symptomsduring their menopause

The menopause can be a difficult time in the life of a woman.

Symptoms such as hot flushes, fatigue, mood changes and ‘brain fog’ can affect all aspectsof life, including home-life, relationships and careers.

And for women who go through their menopause at an earlier age, it can be anunexpected and particularly difficult diagnosis to come to terms with.

This simple guide explains what your menopause actually is, describes symptoms you mayexperience, as well offering advice on treatments and lifestyle changes that make a realdifference.

This booklet has been created for women with premature ovarian insufficiency (POI) oran early menopause. A more general booklet, Menopause and Me, has been written forolder women.

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What is the menopause?

How and when does your menopause happen?

Did you know? About one in a hundred women have prematureovarian insufficiency (POI)

Your menopause is when you stop havingperiods. It occurs when your ovaries stopproducing eggs and as a result, levels ofhormones called estrogen andprogesterone fall.

There are four key stages to be aware of:

Pre-menopause: the time in your life beforeany menopausal symptoms occur

Perimenopause: when you experiencemenopausal symptoms due to hormonechanges, but still have your period

Menopause: when you do not have aperiod for 12 consecutive months

Postmenopause: the time in your life afteryou have not had a period for 12consecutive months.

Hormones estrogen and progesteronework together to regulate the menstrualcycle and production of eggs. Estrogenalso plays an important role throughout awoman’s body, including bones, memory,mood and even hair and skin.

During your perimenopause andmenopause, hormone levels fluctuategreatly, and this imbalance can result in arange of symptoms - from hot flushes toaches, pains and mood changes.

The average age of the menopause is 51(and symptoms of the perimenopauseoften start at around 45) but this can beearlier for many women.

If your menopause occurs when you areunder 45, it is known as an earlymenopause.

Menopause in women under 40 years isusually referred to as POI.

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What is POI?

POI occurs when your ovaries stopworking properly and no longer producenormal amounts of hormone - andtherefore may not produce eggs.

This causes periods to become irregularor stop altogether and can also triggersymptoms of the menopause.

How does POI affect fertility?

Unlike menopause in older women, theovaries don’t completely stop working inwomen with POI.

In POI, ovarian function can fluctuate overtime, occasionally resulting in a period,

ovulation (when an egg is released) oreven pregnancy. This occasional release ofan egg causes around 5-10% of womenwith POI to become pregnant.

What causes POI?

About one in a hundred women under 40have POI, and it affects about one in athousand women under 30.

For most women, the underlying cause isnot known. However, it can due to one ofthe following reasons:

Cancer treatment: radiotherapy(particularly to your pelvic area) andchemotherapy can cause POI.

Surgery: An operation that removes yourovaries - known as an oophorectomy -can trigger POI. Likewise, a hysterectomy– where your womb is removed – canalso bring about POI, even if your ovaries

have not been removed. This is because itis common for estrogen levels to declineat an earlier age, after a hysterectomy.

An autoimmune disease: where yourimmune system (which normally protectsyour body from infection) mistakenlyattacks body tissues.

Genetic conditions: The most commonof these is Turner syndrome, where oneof the female chromosomes is missing.Genetic conditions causing POI are usuallymore common if you have familymembers with POI, or POI starts at a veryearly age.

How is POI or early menopause diagnosed?

If you have had your ovaries removed,then you won’t need any tests to confirmPOI.

Otherwise you will need to have a bloodtest to measure levels of a hormonecalled follicle stimulating hormone (FSH).If this is raised, then it is very likely you are menopausal. This test should berepeated 4-6 weeks later to confirm the diagnosis because your FSH levelschange at different times during your

menstrual cycle.

You may also have a bone scan (known asa DEXA scan) to check the density ofyour bones, as low levels of estrogenincreases the risk of developingosteoporosis.

If you are under 35, you may be offered ablood test to check your chromosomesto determine if a chromosomal problemis causing POI.

Symptoms of POI and early menopause

The majority of women will experiencesymptoms during their menopause, whichcan affect both their home and work lives.

The severity of symptoms variestremendously between women. Some willonly experience them for a few months,others can continue to suffer for years –even decades.

Common symptoms can include:

Changes to your periods:This is often the first sign. You canexperience a change in flow and yourperiods will become less frequent, beforestopping completely. However, for a smallminority of women with POI, periodshave never occurred at any time in theirlife.

Many women have POI or earlymenopause without realising it. If you haveirregular periods or your periods havestopped, talk to a health professional,whatever age you are.

Hot flushes:This is the most common symptom of all,affecting three out of four women. Hotflushes can come on suddenly at any timeof day, spreading throughout your face,chest and body. For some women theymay last for moments, for others severalminutes. Hot flushes can have associatedsymptoms such as sweating, dizziness oreven heart palpitations.

Night sweats:Many women find they wake updrenched in sweat and have to changetheir pyjamas or bed clothes. This can also

be a disruptive symptom for partners too.

Mood changes:Some women who suffer from moodchanges find they are very disruptive towork and home life. You may find moodchanges more common if you have hadpremenstrual syndrome in the past.

Fatigue and poor sleep:Poor sleep can be related to night sweats,but you may find you are more tiredduring the day even if your sleep is notaffected.

Brain fog:This is a collective term for symptomssuch as memory lapses, poorconcentration, difficulty absorbinginformation and a feeling your brain is like‘cotton wool’. Brain fog can not onlypresent a challenge while at work, it canalso affect the simplest of tasks likereading a book or listening to the radio.

Loss of sexual desire:It is common to lose interest in andpleasure from sex around the time of themenopause; feeling tired, having a lowmood and experiencing night sweats canall be contributing factors. There is also ahormonal reason why your libido may feelrock-bottom. Women have testosterone,as well as men, and this hormone caninfluence our sex-drive. Testosteronelevels tend to decline in women duringthe menopause.

Joint pains and muscle aches:Estrogen is very important in providinglubrication in your joints and preventinginflammation, so reduced levels of

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estrogen in your blood can leave yourjoints sore and aching.

Hair and skin changes:Estrogen helps to build collagen - theprotein that protects the structure of ourskin. Lower levels of estrogen can lead toreduced elasticity, fine lines and dryness.Some women find their skin becomesitchier, or they develop acne. Changinghormones can also make your hairthinner and less glossy, and you maynotice increased facial hair growth.

Worsening migraines:If you suffer from migraines, you may findthey become more severe and closer

together. This is due to fluctuatinghormone levels in the blood, particularlyestrogen.

Vaginal and urinary symptoms:Low estrogen can cause the tissuesaround the vagina to become thinner, dry,itchy and inflamed - known as vaginalatrophy or atrophic vaginitis. Your vaginaalso expands less easily during sex, makingsex uncomfortable or painful.

Low estrogen also thins the lining of thebladder, leading to the urge to urinatemore frequently. Some women find theyhave recurrent urinary tract infections.

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Long-term health problems which can arise from your menopause

Osteoporosis

Did you know? Women lose up to 10% of their bone-strength in thefirst five years after menopause

Osteoporosis is a condition that weakensthe bones and makes them more likely tobreak.

People with osteoporosis have anincreased risk of fractures, even with littleor no trauma – meaning that normalstresses on the bones from standing,coughing or even hugging can result infractures.

Estrogen helps keep our bones strong andhealthy but as this hormone reducesduring the menopause women are atgreater risk of developing osteoporosisthan men. Women can lose up to 10% oftheir bone density in the five years afterthe menopause.

Other factors that can increase the risk ofbone-weakening are a family history ofosteoporosis, smoking and heavy drinking.

Cardiovascular disease

This refers to conditions affecting theheart and blood vessels, such as coronaryheart disease, congenital heart disease,stroke and vascular dementia. Estrogenhelps keep our blood vessels healthy andhelps control cholesterol, so fluctuatinglevels of estrogen can increase your

chances of getting cardiovascular disease.

Other factors that can raise your risk ofcardiovascular disease include having highblood pressure, smoking, being overweightor having a family history of cardiovasculardisease.

For many women these symptoms oftenpresent after the menopause - perhapseven years after. Alternatively, some

women notice changes like these earlier,maybe even during the perimenopausalor menopausal stage.

Vaginal dryness and urinary symptoms

Did you know? Symptoms of vaginal dryness can get worse as you get older

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Treatment options for your menopause: Hormone Replacement Therapy (HRT)

Did you know? You should have a review three months after startingtreatment and a review at least once a year thereafter

There are a range of treatments availableto help manage your menopausesymptoms – and in many cases, vastlyimprove your quality of life.

Your first step after diagnosis should betalking to a health professional about theoptions available, so you can make aninformed decision about the potentialbenefits and risks of treatment.

A trusted source of information is the

2015 guidelines on menopause bymedicines regulator the National Institutefor Health and Care Excellence (NICE).

It contains information on generalmenopause and POI, including diagnosis,treatments that can help your symptoms,what sort of information you shouldexpect during an appointment with ahealth professional, and questions you canask (www.nice.org.uk/guidance/ng23).

Hormone Replacement Therapy (HRT)

Treatment for POI or early menopauseusually involves taking hormonereplacement therapy (HRT) or thecombined contraceptive pill.

HRT is a treatment that relievessymptoms by replacing the estrogen yourbody stops making after the menopause.It is available as a skin patch, gel applied tothe skin, or as a tablet.

If you still have a uterus, then you will needto take a progestogen (a synthetic type ofthe hormone progesterone) alongsideestrogen - known as combined HRT. Thisis because taking oestrogen can increasethe risk of uterine cancer, however, takinga progestogen reverses this risk.

The combined contraceptive pill alsoincludes estrogen and progestogen. Somewomen with POI take this instead of HRT,especially if they need contraception.However, there is less evidence that thecombined oral contraceptive pill lowersfuture risk of osteoporosis and heartdisease, like HRT does.

If you are diagnosed with POI or earlymenopause, then it is recommended youtake hormones until at least the age of 51– the natural age of the menopause.

HRT will replace the 'lost' hormones thatyour body would usually keep onproducing up to the age of 51 years(when hormone production wouldnormally change due to the menopause).

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HRT benefits

Your symptoms will improve. Many women find their symptomsimprove within a few months of startingHRT and feel like they have their ‘old life’back, improving their overall quality of life.

Hot flushes and night sweats usually stopwithin a few weeks of starting HRT. Manyof the vaginal and urinary symptomsusually resolve within three months, but itcan take up to a year in some cases.

You should also find that symptoms suchas mood changes, difficulty concentrating,aches and pains in your joints and theappearance of your skin will also improve.

Your risk of cardiovascular disease willreduce.There is some evidence that taking HRT,

particularly estrogen-only HRT, reducesyour risk of cardiovascular disease. Thebenefits are greatest in women who startHRT within ten years of their menopause.

Your risk of osteoporosis will reduce.Taking HRT can help prevent and reversebone loss, even for women who takelower doses of HRT, so it can reduce yourrisk of bone fracture due to osteoporosis.

Your risk of other diseases will reduce.Studies have shown that women whotake HRT also have a lower future risk oftype 2 diabetes, osteoarthritis, bowelcancer, depression and dementia.

HRT risks

For the majority of women who starttaking HRT under 60, the benefitsoutweigh the risks.

The type of HRT that is suitable for youusually depends on 4 factors:- your medical history- any existing conditions- whether you still have your womb (uterus) or not- and if you are still having periods.

If you have a womb, it will be advised thatyou take both estrogen and progestogen- known as combined HRT. This isbecause estrogen on its own can increasethe risk of developing uterine cancer,whereas progestogen helps keep thelining of the womb thin and free from the

types of cells that could turn into cancer.

There are two small risks for somewomen who take HRT - the risk of breastcancer and the risk of a blood clot. Theone that worries most women is breastcancer. Your actual risk depends on manyfactors including age, family history andyour general health and not on whetheryou take HRT alone. That is why it iscrucial you discuss your individualcircumstances with a health professional.

Studies have shown that women whotake estrogen-only HRT do not have anincreased risk of breast cancer. Takingcombined HRT (estrogen andprogestogen), may be associated with asmall risk of developing breast cancer.

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Some studies show this risk reduces if atype of progestogen called micronisedprogesterone is used, which is derivedfrom plants.

If you have a history of blood clots, liverdisease or migraine, you can still take HRTbut it is likely to be recommended as anestrogen patch or gel, as this is associatedwith no risk of clots. If you needprogestogen then this is usually still givenas a tablet or a Mirena coil can be used asan alternative form of progestogen.

Side effects of HRTThe most common side effects includenausea, some breast discomfort or leg

cramps. Side effects are most likely tooccur when you first start taking HRT andthen usually settle with time.

Different brands of HRT use differentestrogens and progestogens, so you mayfind that changing brands helps with theside effects. Switching the delivery methodof HRT – for example from tablets topatches – can also help.

Some women find that HRT patches canirritate the skin, so talk to a healthprofessional about switching brands.

Body-identical and bioidentical hormones: what you need to know

These days the NHS and privatemenopause specialists offer a moremodern type of HRT containing estrogenthat is derived from plants, such as yams.This is known as body-identical estrogen,as it has the same molecular structure asthe estrogen produced by our bodies.

However, some private clinics offer a typeof HRT known as ‘compoundedbioidentical HRT’. Like body-identicalestrogen, it is derived from plants, but thecrucial difference is that some clinics offerbioidentical treatment that is‘compounded’ or custom-blendedfollowing hormone testing.

Compounded bioidentical HRT productsare not authorised by the Medicines and

Healthcare Products Regulatory Agency(MHRA) and they are not recommendedby various medical bodies, including theBritish Menopause Society and theInternational Menopause Society.

They are marketed as naturalsupplements and do not require approvalby the MHRA. As a result, they have notbeen through the rigorous process ofdrug development, which conventionalmedicines and products undergo.

Compounded bioidentical hormoneshave not been scientifically evaluated inclinical trials for effectiveness and safety,and there is no evidence that they aremore effective than licensed types of HRT.

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Did you know? Testosterone production decreases by more than50% in women with POI

Combined Oral Contraceptive pill

Some women prefer to take thecombined contraceptive pill over HRT.Like HRT, the combined pill replaces thehormones your body has stopped making,and so will ease symptoms.

Both HRT and the combined pill easesymptoms and help protect your bonehealth, but HRT may be better for yourblood pressure than the combinedcontraceptive pill.

The pill acts as a contraception whereasHRT does not, so it could be consideredas an option for women who still requirecontraception.

You can take the combined pill up to theage of the natural menopause, but it is notsuitable if you are aged over 35 years andyou smoke, or if you have cardiovasculardisease or a history of blood clots, strokeor migraines.

Testosterone

As well as regulating sex drive,testosterone also helps with your mood,memory and concentration.

Testosterone production decreases bymore than 50% in women with POI.

Not all women will need to take

replacement testosterone but talk to yourhealth professional if you find HRT or thecombined contraceptive pill are nothelping with these symptoms.

Testosterone is given as a cream or gel, orsometimes as an implant.

Other treatments

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Treatments for vaginal dryness and urinary symptoms

To ease these symptoms, estrogen can begiven directly to the vagina in the form ofa cream, a tablet (pessary) or a silicon ringinserted into the vagina.

Using estrogen in this way is not the sameas taking HRT, so does not have the sameassociated risks. It can be safely used bymost women on a regular basis for a longperiod of time, which is important assymptoms can continue when you arepostmenopausal and they often returnwhen you stop treatment.

Another option for dryness is vaginalmoisturisers and lubricants during sex.These products can be bought over thecounter and can be used either alongsidevaginal estrogen treatments or on theirown.

Your symptoms should improve within afew weeks of treatment. See a healthprofessional if there is no improvement, asthese symptoms can be due to otherconditions.

Alternative prescription treatments

There are some alternative prescriptionmedications that can be used forsymptoms if HRT cannot be given or isnot preferred. These include

antidepressants such as citalopram orvenlafaxine - which can improve hotflushes but often have side effects, such asnausea.

Cognitive Behavioural Therapy (CBT)

It is quite common to have feelings of lowmood or anxiety following a diagnosis ofPOI or early menopause (a good source ofadvice is the Daisy Network, a charity forwomen with POI www.daisynetwork.org).

CBT is a talking therapy, recommended by

NICE as a treatment for low moodassociated with menopause. It focuses onchanging the way you think and behave,with sessions either in groups or one-to-one with a therapist. You can be referredvia your GP, but many women find it isquicker to organise privately.

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Herbal medicines

Some women consider taking herbalmedicines alongside or instead ofconventional medicines.

There is a huge market out there formenopausal symptoms, including St John’swort, red clover and black cohosh. Herbalmedicines though natural, are notnecessarily safer. There is much variety intheir effectiveness and potency. In addition,some come with side effects and caninterfere with other medicines you maybe taking.

It is also worth remembering thatalthough herbal medicines might helpsome of your symptoms, they won’taddress your hormone levels and in turnwon’t protect your bones or reduce your

risk of cardiovascular disease.

If you are considering herbal medicines,speak to a health professional.

Traditional Herbal Registration (THR)certification markThe MHRA oversees a scheme called theTHR certification mark. If you are thinkingof using herbal medicines, you should lookout for this logo, as it means it has beendeemed safe when used as intended,manufactured to set quality standards andhas reliable and accurate productinformation. The authorised usage anddosage of the medicine is based onevidence of its traditional use, but theeffectiveness of the product has not beenassessed by the MHRA.

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Lifestyle changes

Did you know? Alcohol, caffeine and spicy foods can all trigger hot flushes

Maintaining a healthy lifestyle is importantfor women of all ages, but particularlyduring your menopause.

You should be aiming to:

Eat a healthy, balanced diet: a diet rich incalcium helps protect your bones andreduce the risk of osteoporosis.

Exercise regularly: NHS guidelines stateyou should try and aim for 30 minutes ofmoderate exercise five times a week.Weight-bearing exercises, such as walkingor running, are also important to maintainbone strength.

Limit alcohol and cigarettes: alcohol caninterrupt sleep and exacerbate hotflushes. If you do smoke, try to cut downwith the aim of quitting altogether.

Get enough vitamin D: vitamin D alsoplays a part in keeping your bones strongand healthy. You should get all the vitaminD you need from sunlight and the smallamounts found in food, but you may alsowant to take a supplement.

Relax : If work is proving stressful, taketime out for yourself. Do something youenjoy that lifts your mood, such as yoga,having an aromatherapy massage or justspending time with loved ones.

Common HRT myths busted

Myth: You should wait for your symptomsto be unbearable before seeing a healthprofessional about HRTFalse. You can start taking HRT fromwhen symptoms start, even when youare perimenopausal.

Myth: HRT delays the menopauseFalse. If you experience menopausalsymptoms after stopping HRT, you wouldhave experienced them even if you hadnever taken HRT.

Myth: You should stop taking HRT afterfive years

False. There is no maximum amount oftime you should take HRT for. It dependson your individual circumstances, risksand benefits and personal choice.

Myth: HRT is not suitable if you sufferfrom migrainesFalse. If you have a history of migraine,you should opt for HRT in the form of apatch or gel rather than a tablet. Womenwho have migraines with aura (visualdisturbances such as flashing or seeingspots), have a small increased risk ofstroke when taking estrogen in tabletform, but not as a patch or gel.

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Dr Louise Newson is a GP and menopause specialist in Stratford-upon-Avon, UK.She has written and developed the website www.menopausedoctor.co.uk and is

the founder of the ‘balance’ menopause app.

The website and app contain evidence-based, non-biased information about theperimenopause and the menopause. She created both platforms to empowerwomen with information about their perimenopause and menopause and to

inform them about the treatments available.

Her aim is for women to acquire more knowledge and confidence to approachtheir own GP to ask for help and advice.

The team at Newson Health are passionate about improving awareness of safeprescribing of HRT to ladies at all stages of the perimenopause and menopause

and also offering holistic treatments for the perimenopause and menopause.

Louise is also the director of the not-for-profit company Newson Health Research and Education.

Winton House, Church Street, Stratford-upon-Avon, CV37 6HB

Enquiries: 01789 595004 | Email: info@newsonhealth.co.uk | Web: www.newsonhealth.co.uk

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