Treatment for symptoms of the menopause

Menopause is when you have not had a period for twelve months. It happens when your ovaries stop releasing eggs or your ovaries have been removed and the amount of estrogen hormone in your body falls.

Most women in the UK have their menopause between the ages of 45 and 55 years, with the average age being 51 years. The average age of menopause tends to be lower than this in women from African and Asian countries:

• India and Pakistan: 46-47 years
• Africa and the Caribbean 49 years.

Some women undergo menopause due to surgical or medical treatment, for example surgery to remove both ovaries. If you are thinking about treatment that will bring on menopause, your healthcare professional should give you information about how the treatment may affect you.

Menopause can happen earlier in some women. If it starts before the age of 40 years, it is known as premature menopause or premature ovarian insufficiency.

The time around your menopause, when your estrogen levels are falling, is called the perimenopause. This can last from a few months to several years. Around half of all women notice physical and/or emotional symptoms during this time.

The most common symptoms are:

• hot flushes
• night sweats
• vaginal dryness
• low mood and/or feeling anxious
• problems with memory and concentration (brain fog)
• joint and muscle pain
• loss of interest in having sex.

Every woman experiences menopause differently. Some experience one or two symptoms, which may be mild, while others have more severe and distressing symptoms. Some women go through menopause without needing treatment, or they may make changes to their lifestyle. Others may prefer some form of treatment to manage their symptoms, such as hormone replacement therapy (HRT) or an alternative treatment.

If you have symptoms of menopause and are over 45 years of age, you will not usually need any hormone tests to diagnose menopause. Your healthcare professional will offer you treatment based on your symptoms alone.

Lifestyle changes

Regular aerobic exercise, such as running and swimming, may help. Low-intensity exercise, such as yoga may help symptoms but weight-bearing exercise can be protective to bone strength:

• Low-impact weight-bearing exercises: walking and stair-climbing.
• Moderate-impact weight-bearing exercises: running, dancing, and tennis.
• High-impact weight-bearing exercises: basketball, volleyball and netball.

Reducing your intake of caffeine and alcohol and stopping smoking may also help to reduce hot flushes and night sweats.

HRT is the most common form of prescribed treatment for menopausal symptoms. It helps to replace the hormone estrogen in your body, which decreases around your menopause. You may sometimes also need other hormones (such as progestogen and testosterone) that your body is no longer producing.

If you are thinking about taking HRT, your healthcare professional should discuss the benefits and risks with you before you start the treatment. This discussion should cover both the short-term (over the next 5 years) and the longer term (beyond the next 5 years) benefits and risks for you.

Your healthcare professional should also tell you about available alternatives to HRT along with their benefits and risks.

The type of HRT that you are prescribed depends on your individual situation. If you have a uterus (womb), your healthcare professional would recommend a combination of estrogen and progestogen HRT (combined HRT).

Estrogen comes in the form of tablets, skin patches, implants, body gel or spray, or vaginal ring, cream or pessary. However, estrogen alone can cause abnormal thickening of the lining of your uterus, known as endometrial hyperplasia. For further information, see RCOG Patient Information Endometrial hyperplasia. Adding enough progestogen will prevent this. Progestogen comes in the form of tablets, patches or a hormone-containing coil.

If you start combined HRT before your menopause or within 12 months of your last period then your healthcare professional may recommend ‘cyclical’ combined HRT, which should give you regular monthly periods.

If you start combined HRT more than 12 months after your last period, your healthcare professional may recommend ‘continuous’ combined HRT (bleed-free HRT). You may have some vaginal bleeding in the first 3 months, but after this, it should stop.

If you have had a hysterectomy then your healthcare professional may offer you estrogen-only HRT. If you have a history of endometriosis, you may still be offered combined HRT following a hysterectomy.

If you have a low sex drive after the menopause, your healthcare professional may offer you another hormone called testosterone. This comes in the form of a gel. Testosterone is not licensed for this use, but is safe to take.

The effects of HRT have been studied worldwide and research shows that, for most women, HRT works and is safe.

• It is an effective treatment for hot flushes and low mood associated with menopause.
• It can improve sexual desire and reduce vaginal dryness.
• It helps keep your bones strong by preventing osteoporosis.
• HRT can reduce the risk of heart disease if started under the age of 60 years.

• HRT with estrogen alone (used for women who have no uterus) is linked with little or no increased risk of breast cancer.
• HRT with estrogen and progestogen can increase your risk of breast cancer. This risk is higher the longer you stay on it and reduces when you stop HRT.
• Your individual risk of developing breast cancer depends on underlying risk factors, such as:
• your body weight
• your drinking and smoking habits
• family history of cancer.
• HRT taken as a tablet increases your risk of developing a blood clot (DVT). If you take HRT as a patch or gel, this does not apply to you.
• If you have other risk factors for developing a blood clot, for example, if your BMI is 30 or more, your healthcare professional should recommend estrogen as a patch or gel.
• HRT in tablet form slightly increases your risk of stroke, although the overall risk of stroke is very low if you are under the age of 60 years.

Your healthcare professional should discuss your individual risks based on the research evidence at your consultation.

HRT may still be an option for you and you should discuss this with your healthcare professional, who may seek advice or refer you to a menopause specialist.

HRT should not affect your blood sugar control. If you have diabetes or high blood pressure, your healthcare professional may consult with a specialist before prescribing HRT.

It is not known whether HRT affects the development of dementia.

HRT does not provide contraception. If your last period happens over the age of 50, you will need to keep using contraception for 1 year. If your last period happens before the age of 50, you will need to keep using contraception for 2 years.

You should have a review appointment with your healthcare professional after 3 months of starting HRT. If you are not having any issues, you should have a yearly appointment thereafter.

You may notice some vaginal bleeding in the first 6 months of starting HRT. If you experience any unexpected bleeding after 6 months then you should see your healthcare professional straight away.

There are no set time limits for how long you can be on HRT. The benefits and risks of taking HRT will depend on your individual situation, and your healthcare professional should discuss these with you.

You can stop your HRT suddenly or reduce gradually before stopping it. The chances of your symptoms coming back is the same either way.

If your menopausal symptoms are not responding to HRT or if it is not safe for you to take HRT, your healthcare professional may seek advice from, or refer you to, a menopause specialist.

Not every woman needs or chooses HRT for menopausal symptoms. This may be because of your own or family history, or because you have concerns about the safety or side effects of HRT. Treatment options available without prescription are discussed in this section.

Herbal medicines

Plants or plant extracts, such as St John’s wort, black cohosh and isoflavones (soya products), can help reduce hot flushes and night sweats for some women. However, their safety is unknown and they can react with other medicines that you may be taking for conditions such as breast cancer, depression, epilepsy, heart disease or asthma. You should check with your healthcare professional before taking any herbal medicine.

Unlike conventional medicine, there is no legal obligation for herbal medicines to be licensed. Unlicensed products may vary greatly in their actual contents.

If you buy herbal products, look for a product licence or Traditional Herbal Registration (THR) number on the label (see image) to ensure that what you are buying has been checked for purity. It is advisable to buy herbal medicine from a reputable source.

Alternative therapy

Alternative therapies such as acupressure, acupuncture or homeopathy may help some women. More research is, however, required on the benefits from these therapies and, if they are used, they should be carried out by qualified professionals.

Complementary therapy

You may wish to try a complementary therapy, such as aromatherapy, although the effects of these therapies specifically on your menopausal symptoms have not been well studied.

Bioidentical hormones

‘Bioidentical’ hormones are not regulated or licensed in the UK, as there is a lack of evidence that they are effective or safe to use.

Cognitive behavioural therapy (CBT) may be helpful in treating low mood and anxiety related to menopause. If your low mood is caused by depression, antidepressants may be a helpful treatment for this symptom.

Low mood may be a symptom of your menopause/perimenopause and so HRT may be a treatment worth considering.

Libido is complex and your healthcare professional should consider a holistic assessment. HRT containing estrogen and/or progestogen may be helpful as treatment for low sexual desire during menopause.

If this does not work, and no other cause is found by your healthcare professional, then you can talk to them about whether to consider adding another hormone called testosterone.

Testosterone may be used “off-licence” to help your symptoms. This means that it is not licensed for this condition, but may be useful in treating your symptoms. Your healthcare professional should discuss the benefits and risks of treatment and the role of blood tests.

If you are having hot flushes and night sweats, your healthcare professional may offer you HRT after discussing its benefits and risks. You may wish to discuss the alternative options described above with your healthcare professional.

Your healthcare professional can prescribe non-hormonal medical treatments, such as clonidine or gabapentin for hot flushes. Some antidepressant medications such as venlafaxine have been shown to improve hot flushes.

If you are taking tamoxifen, you should not be prescribed the antidepressants paroxetine and fluoxetine.

Vaginal moisturisers and lubricants

Many women find using vaginal moisturisers and lubricants helpful for vaginal dryness. These can be bought at your local pharmacy or prescribed by your healthcare professional.

Vaginal estrogen

Vaginal estrogen comes in the form of a tablet, cream, gel, pessary or ring. It can help with vaginal dryness and can be used with non-hormonal moisturisers and lubricants.

Vaginal estrogen is absorbed locally. Because only a small amount gets into the rest of your body, you do not have to take progestogen when taking vaginal estrogen. If you have a history of breast cancer, please ask your healthcare professional about using vaginal estrogen.

You can use low-dose vaginal estrogen for as long as you need to and you can safely use it alongside HRT. Vaginal estrogen can also reduce bladder infections and help urinary symptoms. If you have any unexpected vaginal bleeding, you should tell your healthcare professional.

Other treatments include:

• Prasterone: a vaginal pessary that releases estrogen
• Ospemifene: a tablet that increases the effect of estrogen in your vagina.

In England, you may be able to reduce your prescription charge by getting an HRT Prepayment Certificate (HRT PPC). See further information below.

This is when you go through the menopause before the age of 40 years. Usually, there is no cause for this. Some causes include surgery on the ovaries, chemotherapy, or radiotherapy to the pelvis.

Other less common causes include genetic conditions, such as Turner syndrome, and some autoimmune diseases.

If your periods come less often or stop before the age of 40 years and/or you experience menopausal symptoms, you should see your healthcare professional. You will be offered blood tests to measure your hormone levels to help diagnose premature menopause. The diagnosis is made after two blood tests performed 4–6 weeks apart.

You are likely to notice the symptoms of menopause, such as hot flushes and mood changes. There is also an increased risk of developing osteoporosis and cardiac disease in later life. Osteoporosis can lead to broken bones if not treated. Premature menopause will affect your fertility, and lower your chance of getting pregnant.

Treatment for premature menopause involves the replacement of hormones in the form of either HRT or the combined oral contraceptive pill. Both are effective in treating hot flushes and keeping your bones strong.

The combined oral contraceptive pill has the advantage of also providing contraception. HRT may be a safer option if you have other conditions, such as high blood pressure or diabetes.

It is important for you to continue the treatment at least until the average age of natural menopause. By taking HRT, you are replacing the hormones your body is lacking, and so there are no added risks.

If you are thinking about getting pregnant, you will need a referral to a fertility specialist. Your healthcare professional may also suggest referral to a menopause specialist.