Menopause symptoms and treatments, including HRT
By Joanna Pearl
Article 1 of 2
Menopause symptoms and treatments, including HRT
We explain the signs and symptoms of menopause, including perimenopause, treatment options and how to get help from your GP.
Menopause happens when your ovaries stop producing the hormone oestrogen and therefore stop producing eggs. This usually happens to women aged 45 to 55, with an average menopause age of 51.
Menopause is usually diagnosed when your periods have stopped for a year. Most women don’t need hormone testing or other tests to make the diagnosis.
Some women may experience early menopause (sometimes called premature ovarian insufficiency). Menopause is classed as premature if it affects you before the age of 45. It can also happen if you’ve had one or both of your ovaries removed during a hysterectomy.
What is Perimenopause?
This is essentially a pre-menopause phase. For some time before you have your final period and the menopause starts, your oestrogen levels gradually fall and your periods become less regular and sometimes heavier.
Perimenopause typically starts in the mid to late 40s and lasts four to five years
It is still possible to get pregnant while perimenopausal so you should continue to use contraception. If you are trying to conceive, and have perimenopausal symptoms, consult your doctor.t
Menopause symptoms are caused by fluctuating and decreasing levels of oestrogen. The most common symptoms are:
- hot flushes and night sweats
- joint and muscle pain
- vaginal dryness
- low mood or anxiety
- loss of libido (lack of interest in sex).
You can experience menopause symptoms if you’ve had a hysterectomy.
Other effects of menopause
Menopause can exacerbate certain age-related conditions, such as osteoporosis, heart disease and loss of muscle strength.
Getting help with menopause symptoms
These can really vary from woman to woman in their severity and impact on your life.
If you are struggling with menopause symptoms, there are treatments available, the most popular of which is hormone replacement therapy (HRT).
Here's a rundown of the different treatment options by symptom, with more detail below the table:
|Hot flushes and night sweats||
HRT or bioidentical hormone treatment
Prescription medication, such as Clonidine and Gabapentin
Herbal remedies such as black cohosh, isoflavones (soya products/red clover), St John's wort
Lifestyle changes such as dietary/exercise changes for weight loss and cooling techniques
|Low mood or anxiety||
Cognitive Behavioural Therapy (CBT)
Mindful-based stress reduction
|Lack of interest in sex||
Vaginal oestrogen (pessary, cream or ring)
Vaginal moisturisers or lubricants
|Joint or muscle pain||HRT|
Hormone replacement therapy (HRT)
The best-known menopause treatment is hormone replacement therapy (HRT). This involves taking synthetic hormones to replace those in the body and can limit the severity of more troubling symptoms, such as hot flushes, as well as helping across the board.
HRT is available in a variety of formats, including oral tablets, skin patches, injections, body gels or sprays, vaginal rings, and as a cream or pessary. You'll need to discuss the best format for you with your doctor.
Usually, HRT will contain oestrogen and progestogen (a synthetic form of progesterone) if you have a uterus, and just oestrogen if you don’t (or you are getting your progestogen in another way, such as a Mirena contraceptive coil).
If HRT is not suitable for you – for example, there's something in your family history such as breast cancer or deep vein thrombosis (DVT) – your GP should discuss other treatment options with you. See our guide to discussing menopause with your GP for more on this.
Is HRT safe?
The effects of HRT have been studied worldwide and, according to the Royal College of Obstetricians and Gynaecologists, the latest research shows that for most women HRT works and is safe.
A research study in 2002 caused alarm when it was cut short due to concerns about increased incidence of breast cancer, heart disease and blood clots in women taking HRT. However, when the study was re-analysed with age taken into account, it was found that the benefits outweighed the risks in the target market of women under 60.
Your doctor should discuss your own particular medical history with you before you start to take HRT and any factors that may influence this decision, such as a history of breast cancer.
Other possible effects of HRT
It was thought that HRT caused weight gain, but a Cochrane review of clinical research trials found no evidence that HRT had any effect on body weight, over and above that usually gained at the time of menopause (many women gain weight naturally during menopause).
Treatment options for common menopause symptoms: in detail
Hot flushes and night sweats
HRT is the usual treatment offered after discussion of benefits and risk with your GP.
Nonhormonal medical treatments, which would need to be prescribed by your doctor include Clonidine (a high blood pressure medication) or Gabapentin (an anti-epileptic drug) for hot flushes.
If you would rather not have HRT, or it is isn't suitable for you, you can ask your doctor about these alternatives. There is limited evidence that Clonidine works, and further work is being done to determine whether Gabapentin is effective. They can have unpleasant side effects, too, such as dry mouth, tiredness, fluid retention and depression (Clonidine).
Some women find that supplements such as black cohosh and isoflavones can reduce their hot flushes and night sweats. However, the ingredients of these products may vary and their safety is unknown. They may also interfere with any other medicines you are taking. For more see our guide to HRT alternatives.
Possible treatments for emotional symptoms of menopause such as sadness, anxiety and mood swings include HRT and CBT (cognitive behavioural therapy).
HRT is an effective treatment. CBT – a psychological treatment that can include education, paced breathing, relaxation, stress control, and understanding and challenging beliefs about menopause and its symptoms – has also been found effective
Low mood as a result of the menopause is different from depression. Antidepressant drugs, such as SSRIs and SNRIs, haven't been shown to help if you haven't been diagnosed with depression.
Lack of interest in sex
Some women have less interest in sex during menopause, and HRT containing oestrogen and/or progestogen can help. But if HRT doesn't help you, you might be offered the hormone testosterone which can help with low libido in both men and women.
Testosterone isn't currently licensed for use in women, but it can be prescribed by a doctor if their assessment concludes that it's necessary for the needs of the individual patient. This would of course take into account the safety and efficacy (effectiveness) of the drug.
During and after menopause, the skin of your vagina and vulva (the area around your vagina) becomes thinner and you can experience dryness and discomfort or pain during sex.
Vaginal oestrogen (put directly into the vagina as a pessary, cream or ring) can help with this, even if you’re on HRT. Other forms of HRT can also help, as can moisturisers and lubricants.
Risks and benefits of HRT
Similar to the contraceptive pill, HRT can slightly increase your risks of some illnesses, and decrease others. This depends on any pre-existing conditions you have, what type of HRT you take, and what age you start to take it.
Risks associated with HRT: the facts
Heart disease and stroke
HRT doesn’t increase your risk of heart disease if you start taking it before you're 60, and it doesn’t increase your risk of dying from cardiovascular disease. But, HRT tablets (not patches or gels) can slightly raise the risk of stroke (which is already very low in women under 60).
If you already have heart disease, talk to your GP as it’s possible you may be able to use HRT, but it depends on your individual circumstances.
Oestrogen-only HRT causes little or no change in the risk of breast cancer.
HRT containing both oestrogen and progestogen may increase breast cancer risk, and this may be higher if you take HRT for longer, but the risk reduces once you stop taking it.
There is some concern about HRT tablets (not patches or gels) and the increased risk of blood clots either in the lungs or presenting as deep-vein thrombosis, especially among women who are obese or have other risk factors for clotting.
Women at high risk of blood clots may be referred to a haematologist (doctor specialising in blood disorders) before starting HRT.
Benefits of taking HRT
Reduced risk of osteoporosis
Menopause increases the risk of osteoporosis (an age-related condition where your bones break more easily), as when your ovaries stop making oestrogen your bones become thinner. HRT can help to lower this risk.
Bear in mind that even for women around menopausal age the risk of breaking a bone is low. HRT just reduces this risk further. This benefit only lasts while you are taking HRT, but it may last longer if you have taken HRT for a long time.
Preventing loss of muscle strength
HRT may help to prevent age-related decline in muscle strength, but it’s also up to you to stay as strong and fit as possible through daily activity.
Does HRT increase your risk of getting type 2 diabetes?
HRT does not increase your risk of developing Type 2 diabetes, and is unlikely to affect your blood-sugar control.
Those with existing Type 2 diabetes should discuss individual risk and the need for specialist advice with their GP.
If you have health problems because of your diabetes, your GP might refer you to a specialist for advice before giving you HRT.
Does HRT affect your risk of dementia?
As the population ages and there is more concern about dementia in old age, there have been questions about whether HRT could have a beneficial effect on your future risk of getting dementia.
This is currently unknown, but the National Institute for Health and Care Excellence (NICE) has recommended more research into this area.
How long can you use HRT for?
There's no set timescale, and your doctor or healthcare professional should discuss your individual circumstances with you.
You can stop HRT gradually or suddenly, but one shouldn't affect the chances of your symptoms returning more than the other.
Symptoms such as hot flushes tend to reduce over time (usually two to five years, although some women may need longer), so your GP may encourage you to consider stopping treatment at this point.
You may need topical (vaginal) oestrogen long term, but some women do stop it successfully.
Menopause symptoms can vary from mild to severe, but if they’re making your day to day life difficult, you should see your GP.
Your GP should be able to diagnose perimenopause or menopause based on your age, symptoms and how often you have periods.
If you're under 45 you're more likely to be offered blood tests to confirm the diagnosis. These measure a hormone called FSH (follicle-stimulating hormone) which is found in higher levels during menopause.
Your GP should give you information about:
- stages of the menopause, ie perimenopause, menopause and post-menopause
- common symptoms and how menopause is diagnosed
- changes you can make in your lifestyle that will help with symptoms
- menopause treatments – such as HRT – and their risks and benefits
- the likely effect of menopause on your future health, such as your bone health and the risk of osteoporosis
- alternative treatments and what you should know before you try them.
Some women find that alternative treatments such as red clover and sage help, but your GP should explain that the evidence they work is not compelling, and that the quality of the products vary. For more information and advice, see our guide to alternative menopause treatments.
If you’re about to have treatment that will cause menopause (such as a hysterectomy), your GP should talk you through what to expect and the likely effect on your fertility. They should also refer you to a healthcare professional specialising in menopause, as well as offering you support themselves.
Referral to a menopause specialist
If the treatments you try don’t help or cause unwanted side effects, or it's not clear which is the best treatment for you, your GP should refer you to a healthcare professional specialising in menopause. They should be able to discuss alternative options for you.
Further reading: the National Institute for Health and Care Excellence (NICE) publishes comprehensive guidelines on menopause diagnosis and management, which you may also find helpful.