Dr Tobie de Villiers, gynaecologist and committee member of both the South African Menopause and International Menopause Societies, clears up some of the confusion surrounding menopause and treatment.
1. Please explain menopause for dummies?
TdV: The word menopause is derived from a Greek word meaning ‘‘the last period’’. In modern times however it has come to mean the transition phase after a woman has experienced her last menstruation.
Worldwide the average age for the onset of menopause is 51 but it can begin at any age between 45 and 55. A small number of women experience premature menopause before they reach this age. This is abnormal and is treated differently. The stage leading up to menopause (called perimenopause) usually begins after the age of 45 and is characterised by missed or irregular periods. In general, treatment is not necessary at this stage.
At the end of the 19th century the average age for the onset of menopause was 51 – as it is today. But female life expectancy then was just 40 years and women often died before menopause. Today women living in First World countries can expect to live well into their eighties.
Periods end because the ovaries no longer release eggs for fertilisation every month. As a result production of the female hormone oestrogen stops. In normal circumstances egg-cell production stops when the number of eggs a woman was born with has been exhausted or their quality has deteriorated.
2. What will the first symptoms be?
TdV: The sudden absence of oestrogen has a huge impact on a woman’s body and emotions. One of the first things to become seriously mixed up is the temperature-control centre in the brain, and that’s the reason you keep feeling hot. In the beginning hot flushes, night sweats (nocturnal hot flushes), insomnia, mood swings and joint pains are the most common symptoms. These are followed by the thinning of the vaginal wall which can lead to sexual discomfort. There is also a greater risk of heart disease and osteoporosis. Forgetfulness is often a symptom. Your skin and hair gradually thin and you have a greater chance of developing a belly.
3. What’s the best treatment for the symptoms of menopause?
TdV: The only treatment that results in a dramatic improvement of all the symptoms is hormone therapy (HT). HT involves either only oestrogen hormone therapy (EHT) or a combination of oestrogen and progesterone therapy (EPT).
Women don’t all experience the same symptoms in the same way. However no woman should have to suffer because oestrogen therapy, whether on its own or with progesterone, really works.
Your hot flushes and night sweats (which are actually hot flushes at night) should stop within14 days after starting HT. You’ll also sleep better and be less moody and your quality of life will improve.
HT also reduces the possibilities of osteoporosis and heart disease if you start the therapy as soon as possible after menopause. Because hot flushes and the other unpleasant menopausal symptoms don’t usually last longer than five years your doctor will interrupt the treatment after that time to see if you still need it.
If HT is used to treat or prevent osteoporosis the treatment could last longer, with a specialist’s approval. But women older than 60 should preferably use a skin patch, which releases a lower dose.
If you’re a suitable candidate for EHT the sooner you start using it the more effective it’ll be. It’s available in pill form, as a patch and in gels.
4. Should all menopausal women have HT?
Remember, hormone therapy isn’t suitable for everyone. But for those who can use it it’s a safe option – and it works. Every patient has the right to make an informed decision but it’s important to remember HT isn’t a fountain of youth.
TdV: No! Firstly only one or two in every five women experience symptoms so severe they need treatment. Secondly not all women are suitable candidates for EHT. It’s important to remember that while menopause can be uncomfortable it isn’t a disease. It’s a physiological reality all women go through. Many women say they feel more relaxed, wiser and more at peace with themselves once the uncomfortable bit is over.
In fact, menopause is an excellent opportunity for women to pay attention to their overall health. Take a look at your eating habits and weight. Get fitter and try to stress less. Go for the tests your doctor recommends, including cholesterol, blood glucose, thyroid function and bone density tests. Also have a mammogram done.
5. Why have doctors changed their tune about HT the past few years? Is the treatment safe or not?
TdV: Forget about researchers’ interpretations of the Women’s Health Initiative (WHI) findings. The WHI writers owe women and doctors around the world an apology for the confusion. They’ve exaggerated the dangers of HT. Hormone therapy is perfectly safe, provided it’s used correctly.
These are the risks
A slightly higher risk (47 in 10 000 instead of 45 in 10 000 women) of breast cancer as time goes on, but only when oestrogen and progesterone are used together (as is the case with women who still have a womb). It doesn’t occur among women who use only oestrogen.
The risk of blood clots is higher among patients older than 60 – 34 in 10 000 instead of 16 in 10 000 women. The risk is small and increases with age but is at its greatest during the first year of treatment.
There is a slightly greater risk of a stroke if you start HT after 60 – 29 in 10 000 instead of 21 in 10 000 women. Unlike blood clots the risk remains the same after the first year of treatment.
Higher risks end with the treatment – but so does the protection against osteoporosis and colon cancer.
6. What about natural and herbal remedies?
TdV: Unlike HT alternative remedies don’t have to conform to the strict requirements of the SA Medicines Control Council before they’re made available to the public.
Research has proved beyond all doubt HT works, and works well. Unfortunately that can’t be said for alternative remedies. Some researchers believe plant oestrogen in the herb black cohosh and in soya (but not in soya tablets) can relieve hot flushes.
Although some women swear by them a new American study by the National Institutes of Health has once again proved plant oestrogen is nothing more than a placebo.
People often assume medicines derived from plants are safe but there’s no proof this is really the case. Some herbal medicines can have serious side-effects, such as damaging your liver. They also interfere with the effects of other medication. Talk to your doctor before you start using them.
During menopause the ovaries cease to produce oestrogen but precursor hormones released by the adrenal gland remain in circulation. These hormones are transformed into oestrogen in fat cells, which is why overweight women who have many fat cells have more oestrogen for longer than thinner women.
It’s ironic: people who want to use natural remedies avoid EHT yet all oestrogen prescribed by doctors has a natural origin (either plant or animal). The oestrogen is adjusted slightly so it corresponds exactly with the oestrogen naturally produced by the human body. It’s so natural the female body can’t distinguish between its own oestrogen and EHT.
7. Who shouldn’t use HT?
TdV: HT isn’t suitable for patients with a personal or family history of blood clots, strokes or breast cancer. It should also not be used for the first time if you’re older than 60.
Women with wombs are treated with a combination of oestrogen and progesterone. Although oestrogen alone is slightly safer the combination treatment is also very safe and highly effective, provided it isn’t used for more than four years and not by women older than 60.
It’s definitely not worth having a hysterectomy to benefit from the minimal advantages of oestrogenonly treatment.
8. What about women who don’t want to use HT or natural remedies?
TdV: Try to use common sense to manage your symptoms. It’s only when this practical approach doesn’t help that medical treatment should be considered. This also applies to women who can’t use HT because of its annoying side-effects such as bloating, tender breasts and mood swings.
9. Can you offer some practical tips to survive the symptoms?
This is the most common symptom, experienced by 75 to 80 per cent of menopausal women. A hot flush usually lasts about five minutes but some women experience a hot flush every 15 minutes. These get worse in the late afternoon, when it’s hot, after hot drinks, after hot or spicy food and when you’re stressed. They decrease after about two years.
It’s a good idea to dress in layers so you can take off or put on clothing as needed. Sit in front of a fan at home or at the office.
Avoid hot drinks and spicy food and drink cold water. Although hot flushes can occur during exercise regular exercise can help beat flushes and relieve insomnia. Low dosages of certain antidepressants can also help relieve hot flushes.
Wear light pyjamas. Have a brief shower if you wake up drenched.
Half an hour’s exercise every day will help insomnia as long as you don’t exercise late in the afternoon or at night. Avoid smoking, heavy meals, coffee and alcohol after 4 pm and don’t work late. Make sure your room is dark and cool.
These can be a problem particularly for women with a history of premenstrual syndrome or post-natal depression. HT can help – and be assured, mood swings aren’t the same as depression.
Use over-the-counter internal creams (such as K-Y® Jelly) or oestrogen cream.
You’re not alone if you’re feeling absentminded. This too will pass. Make sure you get enough sleep and exercise every day.