Treatment for symptoms of the menopause

The menopause is when you stop having your periods. 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.

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

The time before your last period, 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
• joint and muscle pain
• loss of interest in having sex.

Every woman experiences the menopause differently. Some experience one or two symptoms, which may be mild, while others have more severe and distressing symptoms. Some women choose to go through the menopause without treatment, while others prefer some form of treatment to manage their symptoms, by using either hormone replacement therapy (HRT) or an alternative treatment.

If you have symptoms of the menopause and are over 45 years of age, you will not usually need any hormone tests to diagnose menopause. Treatment options are offered based on your symptoms alone.

Treatment options for menopausal symptoms include lifestyle changes, non-prescribed treatments and prescribed treatments.
 

Lifestyle changes

Regular aerobic exercise, such as running and swimming, may help, as may low-intensity exercise, such as yoga. Reducing your intake of caffeine and alcohol may also help to reduce hot flushes and night sweats.
 

Non-prescribed treatments

Not every woman 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, 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 remedies 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, this should be done with advice from 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 are not well known.
 

Bioidentical hormones

Commercially available ‘bioidentical’ hormones are not regulated or licensed in the UK owing to lack of evidence that they are effective or safe to use.
 

Prescribed treatments

Hormone replacement therapy (HRT)

See the information on HRT below.
 

Non-hormonal medical treatment

Non-hormonal medical treatments, which would need to be prescribed by your doctor, include clonidine or gabapentin for hot flushes.
 

Psychological treatments

Cognitive behavioural therapy (CBT) is a type of psychological treatment. You may be offered CBT for low mood or anxiety related to menopause.

The type of HRT that you are prescribed depends on your individual situation. If you have a uterus (womb) then a combination of estrogen and progestogen HRT (combined HRT) would be recommended.

Estrogen alone can cause abnormal thickening of the lining of your uterus, which can lead to bleeding. Adding progestogen will prevent this. Progestogen may be given in the form of tablets, patches or a hormone-containing coil.

If combined HRT is started before you have the menopause or within 12 months of your last period then you will be offered a ‘cyclical’ combined HRT, which should give you regular monthly withdrawal bleeds.

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

If you have had a hysterectomy then you will be offered estrogen-only HRT.

Women who notice a low sex drive after the menopause may be offered another hormone called testosterone. This is a hormone linked to sex drive in both men and women.

HRT is available as oral tablets, skin patches, injections, body gel or spray, or vaginal ring, cream or pessary.

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 the menopause.
• It can improve sexual desire and reduce vaginal dryness.
• It helps keep your bones strong by preventing osteoporosis.

• HRT with estrogen alone (used for women who have no uterus) is associated 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 and your drinking and smoking habits.
• HRT taken as a tablet increases your risk of developing a blood clot, which is not the case if HRT is taken 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 are diabetic or have very 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. You need to continue using contraception for 1 year after your last period if this happens after the age of 50 years. If your last period happens before you are 50 years of age then you need to continue using contraception for 2 years.

You should have a review appointment with your healthcare professional after 3 months of starting or changing HRT, and then yearly thereafter if all remains well.

You may notice some vaginal bleeding in the first 3 months of starting or changing HRT, but if you experience any bleeding after 3 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 there are reasons why HRT may not be considered safe for you, your healthcare professional may seek advice from, or refer you to, a menopause specialist.

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

HRT is an effective treatment for low mood. CBT is also helpful in treating low mood and anxiety related to the menopause.

Low mood as a result of the menopause is different from depression. Antidepressants are not helpful unless you have been diagnosed with depression. If you are on antidepressants, it is safe to take HRT as well as use CBT.

HRT containing estrogen and/or progestogen may be helpful as treatment for low sexual desire during menopause. If this doesn’t work then you should talk to your healthcare professional about whether to consider another hormone called testosterone, which is linked to sex drive in both men and women.

Many women find using vaginal moisturisers and lubricants helpful for vaginal dryness. Ask your healthcare professional about the best one for you.

Estrogen given vaginally in the form of a tablet, cream or ring is effective in treating vaginal dryness. Low-dose vaginal estrogens can be used for as long as you need to and can also be safely used in combination with HRT. These can also reduce bladder infections and help urinary symptoms. If you experience any unexpected vaginal bleeding, you should tell your healthcare professional. Other forms of HRT can also help with vaginal dryness.

This is when you go through the menopause before the age of 40 years. Usually, no cause is found for this. It can be caused by surgery on the ovaries, chemotherapy, or radiotherapy to the pelvis. It can also run in families. Other less common causes include chromosomal problems, such as Turner syndrome, and autoimmune disease when the body’s immune system attacks the developing eggs.

If your periods become infrequent 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 are 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 your chance of getting pregnant will be greatly reduced.

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.

While the combined oral contraceptive pill has the advantage of also providing contraception, HRT is a safer option if you have high blood pressure.

It is important for you to continue the treatment at least until the average age of natural menopause. By taking HRT, you are simply 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.