Focus on women's health: The menopause
The ‘change of life’ can be a taxing time for women, but practice nurses can provide a valuable source of evidence-based advice on when and if hormone replacement therapy might be considered
As the average lifespan increases for both sexes, more and more women are living over a third of their lives post-menopause. The average age for menopause is 51-52 years in the UK and the average age at death for women is around 80; this means that many women will have around 30 years of post-menopausal life. The menopause is associated with a decline in oestrogen levels, which – as this hormone is important for many different functions in the body – can result in a variety of symptoms of oestrogen deficiency, including hot flushes, mood swings, genitourinary symptoms, sleep disturbance and generalised aches and pains.1
PHYSIOLOGICAL CHANGES
After the mid-30s the number of eggs in the ovaries reduces and oestrogen and progesterone levels start to decline. As a result, luteinising hormone (LH) and follicle stimulating hormone (FSH) levels rise in an attempt to stimulate further ovulation. Eventually, however, ovulation and menstruation cease. The term menopause refers to the time when menstruation stops; this is usually diagnosed retrospectively after the woman has not menstruated for a year, although in women under the age of 50 menopause is diagnosed after 24 months without a period.2 Hormone levels do not decline gradually but instead the ovaries go through fits and starts of producing more or less hormone until the levels are too low to facilitate ovulation. This variation in hormone levels makes it hard to accurately diagnose the menopause with a blood test. Although levels of FSH can be measured as an indication of how hard the body is working to encourage ovulation, these levels can vary enough to make blood test results unreliable.3 In common with any other diagnosis, it is usually the history that gives most of the information required to diagnose the perimenopause. Changes in the menstrual cycle in terms of frequency and flow are indications that the woman is experiencing the perimenopause; vasomotor symptoms such as hot flushes also tend to start around this time.4 The family history is often useful, as age at menopause may be similar in other female family members. Factors that may contribute to an earlier menopause include nulliparity and hysterectomy. Women who have their ovaries removed at hysterectomy will go through an ‘overnight’ menopause and will require hormone replacement therapy post-operatively. Premature ovarian failure is said to occur when menstruation ceases before the age of 40.5
Common symptoms associated with the menopause include vasomotor symptoms (VMS) such as hot flushes and night sweats, sleep disturbance, mood swings and urogenital symptoms. For many women, it is the vasomotor symptoms that bring them to the surgery. Women may suffer VMS for many years; on average they last for around 4 years and the majority of women will have them for no more than 7 years. However 15% of women will suffer VMS for 15 years or more.6 There also appears to be a link between VMS and mood changes in that they both appear to exacerbate each other.7
The menopause has been shown to affect several of the modifiable risk factors for cardiovascular disease (CVD).8 Women who have a premature menopause are at significantly increased risk of a cardiovascular event compared with women who reach the menopause in their 50s.9 This would suggest that the hypoestrogenic state has the potential to increase cardiovascular risk in post-menopausal women. Cardiovascular risk assessment should be carried out in all menopausal women and the NHS health checks system, which targets everyone aged 40-74, would cover women in this age bracket. Many women think breast cancer is the biggest risk to their health, but in reality, the biggest risk comes from heart disease.10 Around the time of the menopause, changes can be measured in blood pressure, cholesterol levels, blood sugar levels and abdominal circumference – all of these changes being to the detriment of the woman’s cardiovascular health.11 Lifestyle interventions that are known to improve the metabolic and cardiovascular risk profile should be recommended: these include dietary changes, weight reduction, smoking cessation and maintaining alcohol levels within recommended guidelines.
TREATING OESTROGEN DEFICIENCY
There is evidence to show that the menopause can cause a reduction in quality of life for women irrespective of age, social status or ethnicity so hormone replacement therapy (HRT) can offer symptom relief and improved quality of life.12 However, it is also important to note that not all symptoms experienced at this time of life are due to the menopause and clinicians should be aware of the need to consider differential diagnoses such as type 2 diabetes, depression and thyroid disorders. Most women who request HRT do so for the relief of symptoms and the role of HRT in this respect is clear.
If oestrogen replacement is required for a woman whose uterus is intact, progestogen is required to oppose the effect of oestrogen on the endometrium and protect it from hyperplasia and malignant change. Women who have had a hysterectomy can safely take unopposed oestrogen, and this may offer the best overall risk:benefit profile.13 HRT can be taken cyclically or continuously, depending on how long it is since the last period. Contraception is required through the perimenopause and for between 1 and 2 years after the last period, depending on the woman’s age. HRT can be taken orally or applied topically, for example through transdermal patches, creams or pessaries. HRT relieves vasomotor symptoms by returning oestrogen to premenopausal levels. Genitourinary syndrome of the menopause (a term encompassing vulvovaginal atrophy and symptoms including dyspareunia, dysuria, and urinary urgency) can be treated with topical oestrogen preparations such as creams, pessaries and vaginal rings.14 Measurable improvements have been seen in depression scores in women taking HRT.15 HRT can also help to prevent and treat osteoporosis, improving both bone density and fracture risk.16
Some patients – and clinicians – may be concerned at the prospect of starting HRT following adverse publicity over recent years. The main concerns around the cardiovascular risks associated with HRT came from the Women’s Health Initiative study, which reported an increased risk of cardiovascular events (CVE) in women who were taking combined (oestrogen and progestogen) HRT.17 However, further analyses of the WHI data by Rossouw et al,18 and Shifren and Schiff19 have gone some way to addressing these concerns and confirmed that although a slight increase in cardiovascular risk might occur, this increase was seen predominantly in older women, over the age of 60 years, who would not normally be started on HRT anyway. In general, the decision to use HRT in women who are experiencing menopausal symptoms which are adversely affecting their quality of life should be based on an individual assessment of the risk:benefit ratio. Overall, HRT is relatively safe to prescribe for women around the age of natural menopause without increasing the risk of cardiovascular disease, but it should be avoided in women with a history of vascular disease (stroke, myocardial infarction) or pulmonary embolism, where the benefits are less likely to outweigh the risks.20 However, if menopausal symptoms are severe, then consideration may be given to prescribing HRT via the transdermal route as this would appear to reduce associated CVD risk.21 All women contemplating HRT should be informed of the possible slight increased risk of breast cancer that may come from using HRT for 3-5 years or more.22
NON-HORMONAL OPTIONS
Clinicians are often asked to recommend complementary therapies for menopausal symptoms as women perceive them to be more ‘natural’. However, it is worth remembering that menopausal symptoms are primarily due to oestrogen deficiency and that HRT aims to replace oestrogen that is lost at the menopause. Many women will be unaware that modern HRT is often made from natural, plant-based sources. In contrast, the therapies which they may view as being more ‘natural’ may in fact be unreliable, untested and not without side effects. That is not to say that HRT should be painted as a panacea for all menopause ills – indeed the menopause consultation should include full and frank discussion of the risks and benefits associated with taking HRT so that the woman can make an informed decision about how she would like to manage her menopausal years.
Black cohosh, agnus castus, red clover and soya are some of the non-hormonal options that women may ask about. There is conflicting evidence from the research looking at these products and women should be made aware of this.23-25 It is important not to be judgmental, and to offer advice based on what is known, respecting the individual’s point of view and preferences.
CONCLUSION
General practice nurses are in an excellent position to offer information and advice on issues related to the menopause and may often be the first port of call for women going through ‘the change’. They should therefore have an understanding of the key symptoms and the evidence based therapies available. As well as giving advice about hormonal and complementary therapies, the practice nurse should encourage women to improve lifestyle behaviours where indicated. Eating healthily, maintaining a BMI between 20–25kg/m2, taking regular exercise, stopping smoking and ‘sensible’ alcohol consumption can all help to reduce cardiovascular risk and improve overall wellbeing.
For those women who are affected by vasomotor symptoms, mood changes and/or genitourinary symptoms, there are many options available to reduce symptomology and improve overall wellbeing and quality of life. Health care professionals should aim to assess the risk:benefit ratio of a range of treatments. In many cases the benefits of HRT are likely to outweigh the risks and this is particularly so when HRT is used in the short term at the lowest possible dose required to relieve symptoms.
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