What is menopause?

Menopause is a natural event in a woman's life. Menopause occurs when there has been a change in a woman's reproductive hormones and the ovaries no longer release any eggs. Menopause is marked by the end of a woman’s monthly periods. Technically, you have reached menopause when it has been 12 months since your last period. It usually happens between the ages of 45 and 55.

Before a woman’s final period, there is usually a few years of fluctuating hormones, known as the perimenopause. The hormones that are affected are oestrogen and progesterone.

Menopause and perimenopause can cause symptoms that interfere with your daily life. This information explains how treatment can help ease the symptoms if they are troubling you.

Menopause symptoms vary but include hot flushes, night sweats, sleep changes, muscle and joint pains, changes to your vagina, and mood changes.

Treatments for menopause depend on your symptoms and can include:

• lifestyle changes, such as regular exercise, a healthy diet and stopping smoking
• treatments for vaginal dryness
• prescription medicines, including MHT

Menopausal hormone therapy (MHT)

MHT used to be called HRT (hormone replacement therapy). This is the most common medical treatment for the symptoms of menopause. It works by replacing the hormone oestrogen. As you go through menopause, your ovaries slow the production of oestrogen. This decrease in oestrogen leads to menopausal symptoms. After menopause the ovaries stop producing oestrogen.

You can take MHT as a pill, patch, gel or vaginal cream or pessary. MHT is available only on prescription.

MHT is not suitable for every woman. Your GP will be able to advise you if it’s suitable for you. If you have had breast cancer, endometrial cancer or undiagnosed vaginal bleeding, then MHT is not suitable for you.

What are the benefits of MHT?

MHT is the most effective way of relieving some of the symptoms of menopause, particularly hot flushes, night sweats and sleep disturbance. It also can improve your bone density and reduce the risk of fractures. In addition, it can help prevent heart and blood vessel disease in some women, including those who have had an early menopause (between 40 and 45 years).

What types of MHT are there?

There are a few types of MHT:

• oestrogen plus progestogen — for women who still have their uterus
• oestrogen only — for women who have had a hysterectomy
• tibolone
• oestrogen plus SERM (selective oestrogen receptor modulator)

Combined oestrogen and progestogen MHT is suitable for women who still have their uterus. Taking oestrogen on its own would increase the risk of cancer of the lining of the uterus (endometrial cancer), but the progestogen (a synthetic form of the female hormone progesterone) helps protect against this. With this type of MHT, the oestrogen is taken continuously, but the progestogen may be either continuous or cyclical (taken 10-14 days of each cycle).

Oestrogen-only MHT is suitable for women who have had their uterus removed (hysterectomy).

Tibolone acts as a combined hormone therapy, with some effects of oestrogen, progesterone and testosterone. It is a synthetic steroid which is taken as a tablet. Tibolone can help with hot flushes and prevent bone loss after menopause. It can also help improve sexual function. It is not suitable for women who have had breast cancer.

Oestrogen plus SERM is a newer treatment for menopause. It is a combination therapy containing an oestrogen with a SERM (selective oestrogen receptor modulator) called bazedoxefine. It is taken as a tablet and can improve menopausal symptoms of hot flushes and night sweats, and prevent osteoporosis. It is less effective than combined oestrogen plus progestogen MHT, but has fewer side effects of breast tenderness and vaginal bleeding. It is only suitable for women with a uterus.

What are the risks of MHT?

Different types of MHT have different risks. Your GP is best placed to advise what type of MHT might be best for you, based on your symptoms, medical history and what stage of menopause you are at.

For most healthy women who are under 60 and perimenopausal or menopausal and who are experiencing menopause symptoms, the benefits of MHT outweigh the risks.

Combined MHT (oestrogen plus progestogen) and oestrogen-only MHT

Women taking these types of MHT may have a slightly increased risk of breast cancer, stroke, blood clots and possibly coronary heart disease.

Breast cancer risk is slightly increased with combined MHT to roughly one extra case per every 1000 women treated for 1 year. The risk is lower or may be non-existent with oestrogen-only MHT.

Risk of blood clots is increased very slightly with these types of MHT — one extra case per 1000 women on tablets, but patches and gels have minimal or no risk.

Stroke risk may be increased with both combined and oestrogen-only MHT in women 60 and over or who are more than 10 years beyond the onset of menopause. Women with risk factors for stroke may be recommended to use a patch or gel form of MHT.

Coronary heart disease risk is increased by nearly 1 extra case per 1000 women treated for a year with combined MHT, but there is no increased risk with oestrogen-only MHT.

Tibolone

There is no increase in risk of blood clots with tibolone. Stroke risk may be increased if tibolone is started after 60 years of age. The risk of breast cancer is not increased up to 3 years of use, but there is a slightly increased risk of breast cancer in women taking it for several years. Women who have had breast cancer should not take tibolone because there is an increased risk of recurrence.

Oestrogen plus SERM

This combination therapy has been in use for a relatively short time, so any long-term risks, are unknown.

What are the possible side effects of MHT?

MHT may cause some side effects, especially for the first few months after a woman starts taking it. These include nausea, fluid retention and bloating, and breast tenderness or swelling.

Breakthrough vaginal bleeding is another possible side effect of MHT. Breakthrough vaginal bleeding is bleeding outside of when you are expected to be bleeding (if at all). It’s often experienced as spotting.

See your doctor about any side effects, especially unpredictable, heavy or unexpected vaginal bleeding. You may be able to take a different dose or type of MHT.

MHT does not cause weight gain.

Vaginal oestrogen

Vaginal dryness is a common symptom of menopause. Your doctor can prescribe topical vaginal oestrogen (as pessaries or cream) to help relieve the dryness and discomfort. It may also help relieve painful sex due to the menopause. Vaginal oestrogen may not be suitable long term for women who have had breast cancer.

MHT may also relieve the symptoms of vaginal dryness, but some women find they need vaginal oestrogen as well as MHT to relieve their symptoms. Vaginal lubricants and moisturisers may also help.

How long do you take MHT for?

Guidelines recommend that women take the lowest dose of MHT that helps their symptoms for as long as they need to. If you stop taking MHT your menopausal symptoms may return. Symptoms of menopause typically last for 8 years.

Discuss your symptoms with your doctor at least once a year, so that you can review your need for treatment.

Are there non-hormonal options for menopause symptom relief?

There may be non-hormonal options available to you. Talk to your doctor about your options.

Bioidentical hormone therapy

Bioidentical hormones are synthetic hormones made by compounding pharmacists (also known as compounding chemists). They are usually formulated as a combination of hormones, such as oestrogen, progestogen and testosterone. They are given as creams, troches (a hard tablet that dissolves under the tongue) and pessaries.

Even though they are promoted as being ‘natural’ — bioidentical hormones are made in a laboratory just like prescription MHT. Women who can’t take prescribed MHT for safety reasons should not take bioidentical hormone therapy.

Bioidentical hormones are not regulated for safety and quality, like prescription MHT. They are not recommended by peak Australian women’s health organisations.

Complementary medicines for menopausal symptoms

There are many complementary products that are claimed to help relieve menopause symptoms. They are often promoted as ‘natural’ or herbal. It can be difficult to know whether they are safe and free of contamination. Some of the therapies that have been studied are:

• wild yam cream, omega-3 supplements or evening primrose oil — there is no evidence that these are effective in treating menopause symptoms
• black cohosh — the evidence for black cohosh is inconsistent — some studies show it’s effective, other studies don’t. In addition, it may cause liver damage in some women
• red clover — this has not been consistently shown to reduce menopausal symptoms, so it’s not recommended

If you are considering taking a complementary medicine talk to your doctor or pharmacist about the risks and benefits.

Important information about menopause medication

All medicines can have side effects. For women experiencing troublesome menopause symptoms, the risks need to be weighed up against the benefits.

If you decide to use MHT, then take the lowest dose to reduce your symptoms and regularly see your doctor to review it.

Before taking menopause medicines, you may wish to ask your doctor about:

• their side effects
• their benefits
• what to do if you miss a dose
• what to do if you experience side effects

Talk to your doctor if you feel unwell when taking your medicines.

Do not change your medicines or stop taking them without talking to your doctor.