Updated 21 July 2014

Dr Davey answers menopause questions

Weight gain, hot flushes, HRT treatments and the risk of osteoporosis - here are the questions and answers by Dr Mike Davey.

Dr Mike Davey, president of the South African Menopause Society (SAMS), answers some of your questions about menopause:

How can one practically deal with hot flushes without using medication, and approximately how long do symptoms like hot flushes persist – does it eventually go away?
25% of women do not experience significant hot flushes in the menopausal years. In the majority of those women who do experience flushes they last between 2 and 5 years. There is a group of about 8-10% of women where they last for many years longer than this.

Dietary interventions such as limiting caffeine intake, avoiding refined carbohydrates, and limiting alcohol intake are important. Smoking significantly increases hot flushes. Exercise helps to reduce flushes. Try and exercise 4 to 5 times weekly for 40 to 50 minutes per session. The exercise must be brisk. Stress significantly worsens flushes and therefore activities that decrease stress such as yoga may help.

Why do women with peri-menopause and menopausal women struggle with disturbed sleep patterns, and how can one deal with it?
The major reason for the sleep disorder is the presence of flushes and sweats that are often more frequent at night. They are often accompanied by a feeling of agitation making it difficult for a woman to get back to sleep. It should however be realized that advancing age, in both men and women, does result in an increase in sleep disorders.

Is it safe to use an oestrogen cream to counteract vaginal dryness, or are there better options?
Vaginal oestrogen can be given in the form of creams or tablets, and is generally used on a twice weekly basis. This results in low doses of oestrogen being administered. Although there is a small amount of absorption, when given in these low doses blood levels are not significantly affected and remain in the post menopausal range. It is therefore considered safe. There are however no long term studies showing safety in women who have previously been diagnosed with an oestrogen receptor positive breast cancer. The only other alternative is to use a good lubricant.

How long can one take a low dosage oestrogen-only HRT before it becomes risky?
Low dose oestrogen-only therapy cannot be considered safe in women who have not had a hysterectomy as it may result in an increase in endometrial carcinoma. It must be used with some form of progestin to protect the endometrium. Ultra-low dose therapy (0.25 mg estradiol daily or a 14µg oestradiol patch 2x weekly) was shown to be safe for the endometrium in one small study. It is not effective in controlling hot flushes at this ultra-low dose in most women. It does however protect against bone loss. If used this way, the endometrium must be monitored every 6 months by ultrasound or biopsy.

In women who have had a hysterectomy, estrogen only therapy is the treatment of choice as studies have shown no increase in breast cancer for up to 7 years.

Is osteoporosis inevitable for menopausal women, and is there any way to prevent it?
Osteoporosis is not inevitable, but it is common with 40% of women expected to experience an osteoporotic fracture if measures are not taken to prevent it.

Ensuring an adequate amount of calcium and vitamin D intake, exercising frequently and regularly and the avoidance of risk factors such as smoking and excessive alcohol will help to prevent bone loss. A family history of osteoporosis, particularly if it was a hip fracture, is a particularly high risk factor for osteoporosis.

Other high risk factors are any personal history of a hip or vertebral fracture. Any fracture that occurs where the trauma would not usually be considered sufficient to have caused that fracture should be considered to be an osteoporotic fracture until proved otherwise. A Bone Mineral Density assessment should be done in all high risk situations and, if done in early menopause, may help to find women at high risk for osteoporosis. Any women who has had a spontaneous or low trauma fracture should be considered for osteoporosis treatment even if the bone density is not in the osteoporotic range

What can menopausal women do to strengthen their bones?
As explained in the question above, the most important factors are exercise and correct diet. Exercise that is weight bearing or high impact is better at increasing bone strength. Exercise also increases muscle strength, flexibility and balance which helps prevent the falls that predispose to fracture. It is important to exercise four to five times weekly.

Adequate calcium and vitamin D intake is extremely important. Many women get very little sunlight exposure (the main source of Vitamin D) or use sunscreens due to concerns about skin cancer. An intake of 1000 mg of elemental (absorbable) calcium and 800IU Vitamin D is considered sufficient. Dairy products will provide some calcium. A glass (250 ml) of skim milk provides 300mg elemental calcium and 125 ml low fat yoghurt provides 200mg.

Does menopause actively impact on metabolism, is weight-gain inevitable?
Weight gain is not inevitable. There is however an age related slowing of metabolism in men and women that results in a tendency to weight gain in middle age. There are also social issues such as a tendency to less exercise. In addition, the loss of oestrogen at the time of the menopause does result in a small increase in insulin resistance that can result in a redistribution of fatty tissue to the central part of the body- “Pears turn into apples “.

(Dr Mike Davey, November 2009)


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