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Weybridge Health > Menopause & HRT

 

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Menopause and HRT



The menopause is defined as the last spontaneous menstrual period a woman has, and marks a degree of the decline in function of the ovaries where there is not enough oestrogen being produced to make the lining of the womb grow. The menopause most commonly occurs around age 51 years, but may rarely be as late as 56 or as early as 15. The main hormone produced by the ovary is oestrogen, and it is lack of oestrogen that causes the symptoms of the menopause.
Symptoms
Vasomotor: The commonest symptoms of the menopause are hot flushes, which can occur up to twenty times a day in extreme cases. The flush occurs from the upper chest into the face, lasts a few minutes, and may be accompanied by sweating. Night sweats can be troublesome, waking the woman and sometimes necessitating changes of night attire during the night. This sleep disturbance can contribute to mood changes, which are also seen with the menopause.
Psychological: Anxiety, depression, irritability and mood swings are quite common, and some women may experience palpitations and panic attacks. Women may also find difficulty with short-term memory and concentration.
Genito-urinary: Dryness of the vagina may occur, causing intercourse to become painful. This in term may contribute to loss of sexual interest. Feelings of bladder irritability (cystitis), sometimes with burning of the urine (but not due to infection) may arise, as may urgency to pass urine and sometimes even incontinence (leakage).
Long term effects
Osteoporosis: Loss of oestrogen leads to loss of bone, causing thinning which may result in brittle bones (osteoporosis). Osteoporosis can lead to fractures with only minor trauma, particularly of the spine, the wrist and the hip. Such fractures are painful and may sometimes be life-threatening. Thinning of the skin and poor wound healing may also occur. (See osteoporosis section)
Cardiovascular: Furring up of the arteries accelerates after the menopause and may result in coronary heart disease (angina and heart attacks). Cardiac syndrome X (angina but without blockage of the coronary arteries) is also more common around the menopause. (See coronary heart disease section)
Cognitive: Changes in brain function also occur as a result of loss of oestrogen, with certain functions, including memory, being affected.
Treatment
Hormone replacement therapy (HRT) is the main treatment for preventing or reversing the effects of the menopause.
HRT: The main hormone given is oestrogen, which reduces or abolishes hot flushes, psychological problems and vaginal dryness. It also prevents osteoporosis and fractures, and may help prevent the development of coronary heart disease and possibly dementia later in life. Oestrogen can be given as tablets, skin patches, skin gels, nasal sprays and implants (oestrogen pellets inserted under the skin). Oestrogen stimulates the lining of the womb, making it grow, and if this is allowed to progress unchecked it can lead to cancerous change. A second hormone, progestogen, is therefore added to oestrogen in HRT. This is similar to the second hormone, progesterone, produced by the ovary in premenopausal women, which is responsible for menstrual periods. Progestogens can be given as tablets or skin patches, combined with oestrogen.
With cyclical HRT, usually given to women around the time of the menopause (peri-menopause) or soon after the menopause, the oestrogen is given continuously but the progestogen is added for 12 - 14 each month, resulting in a menstrual-type bleed. This sheds the lining of the womb and thus prevents it from becoming cancerous. Women who have had a hysterectomy do not need a progestogen.
Women beyond the menopause may be given continuous combined HRT, where the oestrogen and progestogen are given together continuously. The progestogen prevents the oestrogen from causing the lining of the womb to grow, and thus prevents any bleeding occurring. Some spotting or bleeding may be seen in the first few months of such treatment, but this usually ceases.
HRT is usually started with the lowest available dose being given. If symptoms have not bee satisfactorily relieved after about 3 months, the dose can be increased. Duration of use for relief of symptoms is usually a year or two,
Side-effects of HRT include breast tenderness, nausea and increased risk of blood clots (including deep vein thrombosis - DVT - and stroke) if the dose is too high. Oestrogen combined with progestogen may lead to a small increase in risk of breast cancer, similar to that arising from drinking alcohol but much less than the increase in risk arising from being obese. It is not known if all oestrogen progestogen combinations increase risk, and oestrogen given alone does not increase the risk of breast cancer.
Tibolone is a drug which acts like both an oestrogen and a progestogen. It is given as a tablet, and is effective in reducing or abolishing menopausal symptoms such as hot flushes. It also prevents menopausal bone loss. It does not produce vaginal bleeding, and is thought not to have the same effect as HRT on the breast. Effects on the heart and brain are unknown.
Raloxifene is a SERM (selective oestrogen receptor modulator), which acts like an oestrogen on the bones but as an anti-oestrogen on the breast and the womb. It helps prevent bone loss and osteoporotic fractures, but not hip fractures. It is associated with a reduction in breast cancer, but may produce or aggravate hot flushes. Any effects on the heart should be known in the near future. It does not cause bleeding, but does not relieve genito-urinary symptoms, Effects on the brain are unknown.
Anti-depressants: SSRIs (selective serotonin re-uptake inhibitors) can help to reduce hot flushes, but they do not help other symptoms and have side-effects of their own.
Alternative therapies: plant extracts, such as phytoestrogens, red clover, black cohosh, have not been shown to be as effective as HRT and often their safety is unknown. They may prove of benefit for relieving symptoms in some women. Some “natural” products, such as progesterone creams, are without any obvious effect.
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Doctor John C Stevenson

Dr Stevenson has particular clinical expertise in the following areas:
Menopause and HRT
Coronary heart disease prevention
Insulin resistance
Cholesterol problems
Calcium problems
Osteoporosis and metabolic bone diseases
Thyroid disorders

as well as general endocrine problems


Practices in Guildford Surrey, Woking Surrey and London

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