I will be presenting this evening on menopause HRT and other treatment options. So a quick overview of what I will be discussing this evening, we will go through some definitions, we will go through the symptoms of menopause and perimenopause and ill be looking at HRT and HRT alternatives.

Just to start with some definitions so we are all on the same page, I thought I would start with hormone because it’s a word that gets thrown a lot, women tend to feel like we are ruled by our hormones and its important to know what it is.

A hormone is essentially a chemical messenger that’s released from one part of the body and sends a message to another part of the body and an effect is created, for example FSH which is follicle stimulating hormone is released by the brain and sends a signal to the ovary to release an egg and ovulation happens. Now perimenopause/menopause/post menopause are words we hear a lot and especially at the moment we are hearing a lot of, its helpful to know exactly what all these different terms mean, so I will start with menopause. Menopause is essentially the end of a women’s reproductive life cycle, when she stops her periods, she stops ovulating and because she is no longer ovulating, her oestrogen levels drop quite significantly and its really the drop in oestrogen which causes symptoms of menopause.

For most women menopause happens at around 51 and the average duration of symptoms depending on various factors is around 7 years. Now perimenopause is the leadup to menopause, women tend to still be having periods at this time but they start to become erratic. We see a lot of hormonal fluctuations and the changes in these hormones account for symptoms. For most women perimenopause starts at around 45.

Then post menopause is the period of time where you have then gone through your perimenopause, you have gone through your menopause and you go through a phase where you are no longer symptomatic, so you are still not having periods, you are still not having oestrogen but you are no longer symptomatic because of the low oestrogen.

Then HRT or MHT the terms are used interchangeably, so HRT is hormone replacement therapy, MHT is menopause hormone therapy and really the mainstay of hormone replacement therapy is oestrogen as I said earlier it is the loss of oestrogen in menopause which causes symptoms. So by replacing the oestrogen that helps to improve the symptoms and then depending on whether or not a woman’s has a uterus a progestogen is added alongside that.

What are some of the symptoms of perimenopause and menopause, I think many of us know or associate menopause with hot flushes and night sweats, and while those are definitely the kind of classic symptoms there are over 40 different symptoms of perimenopause and menopause.

I tend to break them up into physical, mental/emotional and genitourinary symptoms I just helps to make it a bit easier to go through everything. Physical symptoms as I mentioned earlier those include your hot flushes and night sweats then around the perimenopause we see irregular period so your cycle could become shorter or longer.

Its often a time when a women experience heavier periods as well it has to do with the fact that if you are not having a cycle where you have ovulated it means that the lining of the uterus builds up over one or more cycles and so we start to see these really heavy periods and that can be very bothersome for women.

Around this time we start to see a change in sleep as well, sleep can be disturbed by night sweats or in women who are not having night sweats they could still have poor sleep. The kind of typical pattern that patients would describe to me is that they are exhausted, they get into bed and fall asleep straight away but come 2 or 3 in the morning they are wide awake, mind is racing, tossing and turning, cant go back to sleep until half an hour before the alarm goes off and they wake up feeling exhausted, so again fatigue a really common symptom, it could be due to lack of sleep, it could simply be due to the changes or loss of oestrogen as well.

Joint aches and stiffness is a really common symptom as well and various muscular skeletal complaints, dry eyes and changes in hair skin and nails we have lots of oestrogen receptors all over the body including in places where we produce fluids, our mucosa of our eyes, our mouth, vagina, bladder so we often see things like dry eyes and dry mouth around this time, along with as I said dry skin, hair and nails. Bloating and wait gain really common as well, the weight gain is very multifactorial, it could be due to the fact that you are tired and not sleeping as you well, you are achy, your sore and not exercising as much you might be reaching for different kind of comforting foods but there are hormonal aspects as well which would make women more prone to gaining weight and kind of changing body shape at this time, we see women tend to gain weight around the middle and lose the waist, that’s quite typical of changes in oestrogen.

Breast tenderness is more of a perimenopausal symptom and that’s to do with the fluctuating hormones. Now not to be overlooked by the mental and emotional symptoms these can be quite significant for a lot of women, women who have pre-existing history of anxiety or depression are prone to this getting worse around perimenopause and menopause but we also know that women can experience new onset changes around this time as well and that can range from feeling anything from low/flat or depressed to having mood swings especially before period, a lot of irritability, rage, anxiety, feeling overwhelmed, loss of confidence and brain fog this is a really common symptom and one which is very concerning for a lot of women.

As the brain has so many oestrogen receptors when we are having all these fluctuating hormone levels or the oestrogen drops off the brain needs to work a bit harder and one of the things we typically see around this time around the kind of brain fog is issues with verbal memories, so women will struggle to remember the names of people even though they know exactly what it is they can’t get the word out or they might forget what people have told them and as I said this can be very concerning a lot of women will come to me and say could I have early Alzheimer’s or dementia and brain fog is not a precursor for that it is concerning and like I said not a risk factor for Alzheimer’s or dementia.

Then lastly the genitourinary symptoms as I mentioned earlier because we have so many oestrogen receptors along mucosa including the vagina, vaginal dryness is a very common symptom and this can lead to pain during intercourse as well we see a lot of bladder issues so urgency, frequency, incontinence and leaking and recurrent UTI’s as well and low libido.

The genitourinary symptoms are often symptoms women don’t want to talk about but it is important as they can be very bothersome and uncomfortable and so you know if you are having those issues they need to be addressed alongside the physical and emotional issues.

This lead onto if you are having symptoms how do we treat them and this is where HRT starts to come in and we start to have a conversation about it, as I mentioned earlier is the end of a women’s reproductive life cycle, it’s a very natural phase of a women’s life, its not a disease to be treated but because these symptoms for many women are really distressing and significantly impact all areas of her life she is looking for some sort of treatment and we know that HRT is the most effective way to treat these symptoms.

HRT has come quite a long way, it has been very good, very bad, and now somewhere in between, looking at the heyday of HRT, HRT was actually first released to market in the 1940s and that was Premarin which is the conjugated equine oestrogen, it was oestrogen which came from pregnant maze urine, that’s where the name Premarin comes from.

It was really in the 1960s where it really picked up steam, there was a book published by a man and supported by big pharma and there was a lot of messages around the benefits of HRT in keeping women kind of young, sexy and healthy it make women more pleasant and husbands were very grateful for this and there was very much the narrative that menopause was a hormone deficiency disease and should be treated with HRT and so between the 1960s and 2000s there was a massive uptake in prescriptions of HRT many women were on it and it was only around the early 2000s when a study which had been going on for a few years, the results of which were published called The Women’s Health Initiative.

The results of that study were quite alarming in that they noticed a significant increase in breast cancer, clot, heart disease, stroke things like that. There are a lot of issues with that study we know now that the patient population that the study was done on was probably not reflective of women who are actually in menopause, the type of menopause they used, and the doses were quite different, and the way that the data was interpreted and released to the public were incorrect, so there was a lot of issues with that study but with that messaging we started saying don’t take HRT, a lot of doctors stopped prescribing it, a lot of women stopped taking it and so having seen this big rise of the use of HRT in 1960s up until the early 2000s we then saw a big drop off.

If women were prescribed that they were told you can only take it for a short time, you have to stop it at 60, there was a lot of fear around HRT. Now going into 2020 and above there is a lot more conversation around menopause and HRT a lot more women are understanding if they have symptoms they should be offered something to treat those symptoms.

We have you know more data and information about HRT and know that it’s a lot safer than it was published in the early 2000s, we have different types of HRT and we have different doses, a lot more patient prescribing guidelines, so we feel very comfortable prescribing HRT now but myths still exist, women still worry that you can only take HRT if you have severe symptoms, if you have a family history of breast cancer you cant take it, HRT might cause dementia might prevent dementia, there is still a lot of conversation and a lot of uncertainties for women around HRT, and I think the role of your healthcare provider should be to reassure you around HRT and to prescribe it if you are having symptoms so that you can feel better.

As I mentioned earlier we have a lot more safety data, more treatment options, better guidelines, better access to information, I think this is really important, women now feel a lot more empowered to you know go to their doctor armed with information and symptoms and discuss HRT and menopause and so we have more patient advocacy and autonomy as well.

If you google what is HRT? It can be a bit of a mind field because there are all different types and subcategories of HRT. As I mentioned earlier HRT is hormone replacement therapy, giving you exogenous hormones, so external hormones to replace internal hormones and treat symptoms. HRT can be broken down into various different categories as I have outlined here, so the first category which ill go through is synthetic versus bioidentical.

So bioidentical is a term you might have heard of, its kind of a big term in HRT at the moment a bioidentical hormone essentially means a hormone which looks almost identical to our own natural hormones and in theory its then better tolerated from a scientific perspective and possibly lower risk.

A synthetic hormone is one which is made in a laboratory it has a similar structure but not an identical structure. Synthetic doesn’t mean bad you know the oral contraceptive many of them are synthetic hormones and women have relied on oral contraceptive for many years and its you know been a great medication for a lot of women, but we do see with synthetic versus bioidenticals, bioidenticals are often better tolerated but it certainly doesn’t mean they are better, it very much depends on the woman and what her aims of treatment are. In terms of bioidentical there is a bit of a overlap in that there are also something called compounded bioidentical HRT so this means HRT which is made in private pharmaceutical kind of laboratories the doses are made up according to the patients blood results, it is not something which is endorsed by the menopause society’s they would very much recommend going with pharmaceutical grade bioidentical hormones rather than the compounded hormones.

Now oral versus transdermal, again something that has come to market fairly recently are these transdermal hormones, that means hormones oestrogen specifically which it gets absorbed through the skin as opposed to oral which is taken by the mouth. The big difference between that is oral oestrogen is metabolized through the liver whereas transdermal is not and when oestrogen is metabolized through the liver it kicks off some clotting factors in the liver as well and that can potentially increase the risk of a clot, again it doesn’t mean that oral HRT is bad, it doesn’t mean if you take it you will get a clot, it just means for patients who are at a higher risk of a clot for example if they were a smoker or if they had a family history of clots we might choose transdermal as a safer alternative.

Then oestrogen versus oestrogen plus progesterone or progestogen this depends on whether or not a woman has a uterus, so oestrogen is the hormone we need to use to treat the symptoms but oestrogen given by itself cause the lining of the uterus to grow and if this happens continuously of a period of time it increases the risk of endometrial cancer.

If we combine oestrogen plus progesterone in a woman with a uterus stops that from happening. Then lastly systemic vs local HRT, so systemic HRT is HRT given through the skin or orally, it has an effect over the whole body, local oestrogen is given for vaginal and bladder symptoms only so that would be a cream which is inserted vaginally, its very effective at treating the genitor urinary symptoms nut it will have no impact on the other physical or emotional symptoms. Local oestrogen is extremely low dose, its extremely safe and almost all women who are in menopause and have gentry urinary symptoms can take it.

Its all well and good knowing what HRT is but also important to know who could take it. HRT is indicated for the treatment of symptomatic women in perimenopause and menopause, so if you are having symptoms that are bothering you, a lot of people say to me well how many symptoms should I be having? How bad should the symptoms be? Really it depends on you, every woman is different, every woman will experience menopause differently, you might have one or two issues and that’s a big issue for you, you might have ten and they are not a big issue for you, but if you are having symptoms which are impacting you in any way those symptoms could be treated with HRT.

We also know HRT should be prescribed for women who go into early menopause or who have premature ovarian insufficiency, early menopause is defined as going into menopause before the age of 45 and premature ovarian insufficiency is before the age of 40. These patients are at a higher risk of developing osteoporosis and cardiovascular disease as of a result of the oestrogen deficiency and so in these women we offer HRT to replace the hormones they would have naturally had up until the age of natural menopause which is around 51. Surgical menopause is when a woman’s ovaries are removed this might be part of a hysterectomy or it might be done as a separate procedure for things like in women who are a high risk of getting ovarian cancer.

Again, if this happens in women who are below the age of menopause we want to replace the oestrogen that those ovaries would have been producing to prevent the risk of osteoporosis and then it actually can be considered as treatment for osteoporosis in symptomatic women, so women symptomatic of menopause under the age of 60.

The big kind of NO’s for HRT, so who cant get HRT, this is women who have had a personal history of breast cancer and some types of ovarian cancer, look this is a bit nuanced, we do have patients who have had breast cancer before and that you know, and they are having a lot of symptoms they come and see us and we have a discussion around it but its very much weighing up risks versus benefit and you know when we are looking at this category, the yes category we know that the benefits significantly outweigh the risks so we know that it is very safe for women to take. In this category the benefits are likely outweighed by significant risk for a woman with history of breast cancer there is a much higher risk of recurrence of breast cancer if she goes on HRT.

The maybe category is where we need to decide what is the benefit, what is the risk and does that benefit outweigh the risk and can we use HRT. So, these categories include women who are over 60 or more than 10 years after there last menstrual period, if they have had a previous clot if they have had a previous stroke or heart attack and if there is a significant family history of breast cancer again its not to say these women can’t get HRT, its very much a decision to be made between the patient and her doctor and looking at all the various factors.

The main benefits of HRT is symptom relief, that’s the primary reason to use it and it’s the best thing you will do to improve you symptoms, and the symptoms are really what we went through earlier so in terms of your mood symptoms, vasomotor symptoms, the genitourinary symptoms, those will improve with HRT, musculosketal and sexual functions, we know we have good evidence, if you take HRT and you are in menopause those symptoms will be improved.

As I mentioned earlier it should also be considered first line for prevention and treatment of osteoporosis that would be in our kind of younger patients who go into early menopause or have been diagnosed with osteoporosis. They talk about a critical window for HRT and this is really about when should we be using HRT to ensure that there’s benefit from a kind of cardiovascular perspective because we do have good evidence HRT reduces the risk of cardiovascular disease but it must be started within that critical window which seems to be within 10 years of the last menstrual period or before the age of 60.

On my slide earlier about the kind of changes in HRT and the views to it, there was something about dementia, there appears to be a reduction in dementia risk when we use HRT but we need more evidence and it is certainly no reason to be prescribing HRT we shouldn’t be using it you know giving it to asymptomatic women to reduce the risk of dementia because we don’t have good enough evidence to say that and then as I mentioned earlier benefits for early menopause and premature ovarian sufficiency.

Now what are the potential side effects and risks? Its these risks which have been overstated over the years and that’s what many women are afraid of. The side effects are you know the most common ones would be breast tenderness, irregular bleeding, some fluid retention, certainly not weight gain but fluid retention, headaches and GIT symptoms, these are often temporary and can often be alleviated by changing the type of HRT that we use.

Now the big kind of risks around HRT be the increased risk of breast cancer and then potentially endometrial cancer, clot and stroke, the endometrial risks comes into play if we are not using progesterone alongside oestrogen or enough progesterone alongside oestrogen but if you are on a regimen and if you have a uterus and you are on oestrogen plus progesterone that risk is very insignificant and the clot and stroke risk again depends on the type of HRT that we use, if we are using transdermal its very low.

The breast cancer risk overall is very low as well this is a graphic from the British menopause society and it shows that 23 per 1000 cases of breast cancer diagnosed in the UK an additional 4 cases occurred in women who were on HRT, so yes there is a risk but its significant and certainly not as dramatic as what was stated in the past. However, for some women this risk might be unacceptable and she may decide so doesn’t want to take HRT.

In that case for women either can’t take HRT, that are in that no category of the slide I showed earlier or they don’t want to take HRT, they might still have symptoms though that they want to treat and that are bothersome and that’s when we need to look at non-hormonal therapy.

Sometimes I say this to patients and they so oh but you know I don’t want to go on supplements, I want medication, and I want to make it clear that there are medical treatments available that are not hormonal but can still very effectively treat your symptoms. So, the first class of medication would be anti-depressant medications these are your SSRI/SNRI we are certainly not using these medications for women who are depressed in their menopause we are using it because it treats the symptoms of menopause like hot flushes and night sweats. Its very effective at treating symptoms, it can obviously help with positive mood benefit, it may help with sleep and we typically use much lower doses in menopause or menopausal symptoms compared to the doses which are used in clinical depression. Clonidine and oxybutynin are medications which help with hot flushes and night sweats, they don’t have any other benefits and they tend to have side effects that are quite unpleasant including dry mouth and headaches so a lot of patients will stop taking them as they find it quite difficult medication to take.

Gabapentin is an interesting medication, its an anti-epileptic its also used for chronic pain, it can also be used as a mood stabilizer and again has good benefit for alleviating hot flushes and night sweats, it can have a sedative effect so good for sleep and may help with mood as well. Then veoza is a brand new medication which has just been released, it’s a really exciting development because it is the first medication which has been designed specifically to treat hot flushes and night sweats, so these other medications have other indications and they also have the benefit of treating hot flushes and night sweats, whereas veoza is designed to work in the brain to stop hot flushes and night sweats from originating and it’s a great option for women who are not able to take HRT.

Under medical therapies I have put psychotherapy and CBT as well, CBT is cognitive behavioural therapy we have really good evidence for this in terms of helping with hot flushes and night sweats and help with mood and sleep as well. CBT is a specific form of psychotherapy, kind of helping with reframing thoughts about events and a lot of women find it very useful either by itself or in addition to these other medications.

Looking at the non-medical alternatives these are things that probably all women should be doing anyway to support their health during this time but for women who didn’t want to take HRT or they felt that their symptoms were mild and they wanted to manage it from a lifestyle perspective these are things that we should be looking at.

I must say a lot of women struggle to implement these changes when they are not feeling great, sleep hygiene is very important but when your sleep is being constantly disrupted because of night sweats its quite difficult to make those changes but sleep hygiene is really around things that we all know should be doing, don’t be on your phone late at night, going to be at the same time, don’t drink coffee too late in the day, just optimizing things to make sure you have a better sleep quality.

Weight management and diet, it is important to maintain a healthy BMI, during this time a women’s risk of cardiovascular disease increases when she goes into menopause and so we want to try and reduce that by managing lifestyle factors. The best kind of diet is probably a Mediterranean type diet that’s a lot of brightly coloured fruits and vegetables, lean protein, healthy wholegrain carbohydrates, good fats and a reduction in really processed and refined carbohydrates and sugars.

Then stress management is something much easier said than done, they talk about doing things like yoga, meditation, breathing exercises, all things to help reduce stress in the moment, like I said easier said than done. Supplements are a big one if you are going into any health food store and you ask for something to help with menopause there are almost hundreds of options available, a lot of them at best wont work or at worst could have some harmful side effects, so I would be cautious of the wide range of supplements that are available. I always recommend my patients to take vitamin D especially during the winter, we just don’t get enough sunshine unfortunately and omega 3’s are quite helpful as well if you are not getting kind of two portions of fatty fish a week, otherwise you don’t need to be buying hundreds of expensive supplements. Acupuncture, a lot of women will anecdotally report that it helps their symptoms, it is unlikely to do harm, so you know if this is something that makes you feel better there is no issue with using it although the actual data in terms of efficacy is quite sparse.

Cold exposure, this is you know when I moved to Ireland, I’m from South Africa, I was quite amazed at how many people were swimming in the freezing cold see and I have noticed a lot of women as well, interesting they have recently released a study in the UK which showed that women who regularly sea swam had a reduction in menopausal symptoms or perceived reduction so there is definitely something to it, I think it’s a big social thing as well which is really important as well from a lifestyle perspective but again as long as you are dressing warmly afterwards, you have got your tea and your dry robe its probably unlikely to do harm and could be a nice thing to add.

In summary menopause is not a disease it is a natural phase of life but if this phase is accompanied by bothersome symptoms they should be treated. HRT is the most effective treatment and while HRT has been thought of as very good and then very bad it is kind of somewhere in the middle now and we know that it’s a safe effective option to be used although it’s certainly shouldn’t be used solely for the prevention of disease. There are good alternatives for women who can’t or choose not to take HRT.

Cholesterol levels can definitely increase postmenopausal but statins are still the preferred way to treat them, HRT is not indicated to treat high cholesterol.

In theory you can be on HRT for the rest of your life, previously there was this cut off you could be on it for five years or up to the age of 60, and that’s changed, women can be on it for as long as they are getting benefit from the HRT and there are no side effects or major health issues that arise. If you come off HRT your not going to go into menopause again, really the principle of HRT is to treat the symptoms during menopause but once you go into post menopause and those symptoms significantly reduce at that point we could take you off HRT and those symptoms shouldn’t come back because you are now in post menopause.

Patient dependant really around symptoms, so if you are getting symptoms in your mid 40s and they are bothersome consider it, if you are only starting to get symptoms in your early 50s consider it, but its really around rather than age go by symptoms and how bothersome they are.

Your fertility declines as you through perimenopause because your egg numbers reduce, ovulation becomes sporadic, pregnancy is not impossible in perimenopause, its about a 1% chance of falling pregnant and then menopause can’t fall pregnant for they say that you should consider using contraception up until one year post your last period. So, contraception is still advised and the best options would be condoms, the progesterone only pill which can be used up until the age 55, the marina coil or vasectomy if your partner is open to that.

So that’s really important as I mentioned with in the symptoms there are a lot of genitor urinary symptoms that occur during perimenopause and menopause, and a lot of changes in the vagina, the vulva, the bladder, the pelvic floor and women might start to experience bladder issues but also bowl issues as well including things like faecal incontinence so any bladder issues that are bothersome around that time a pelvic floor therapist can be incredibly helpful and help you to know which muscles to engage and which muscles to relax and how to manage those symptoms, rather than just relying on medication.