The menopause: What does latest advice say about HRT?
The menopause can have a big impact on a woman's health and quality of life, but its seriousness is often underestimated and misjudged. Lisa Salmon reports on the new guidelines hoping to change this.
When a woman's reproductive life comes to an end, she hits the menopause - or, to be more accurate, it hits her.
On average, UK women start the menopause at 51, though it can begin much earlier (before the age of 40, it's known as "premature menopause"), and it can bring with it a range of symptoms, from irregular periods, hot flushes and mood swings, to the brittle bone disease osteoporosis. In the years following the menopause, a woman's heart disease risk rises, too.
Some women are lucky, only knowing they've been through "the change" because their periods have stopped. But around 80% experience symptoms to some degree, which typically continue for around four years after their last period, while for around 10%, symptoms can go on for up to 12 years.
However, although the menopause can have a huge effect on a woman - and her family - its effects are often underestimated by both medical professionals, and women themselves. In a bid to address this, the National Institute for Health and Care Excellence (NICE) has issued the first draft guidelines for health professionals who treat menopausal women.
The guidelines, currently under public consultation with final drafts set to be published in October, include offering care that considers the woman's symptoms and preferences, explaining menopause symptoms and stages, suggesting helpful lifestyle changes, discussing the benefits and risks of treatments, such as hormone replacement therapy (HRT), and possibly offering cognitive behavioural therapy to help relieve anxiety.
Professor Mark Baker, Centre for Clinical Practice director at NICE, says: "Menopause affects millions of women, and its symptoms can severely upset day-to-day life. The effects of menopause are often misunderstood and underestimated.
"When women seek medical help for their symptoms, there is considerable variation in what is offered to them."
SIGNS & SYMPTOMS
Symptoms can vary greatly, but include irregular periods, hot flushes and night sweats, mood swings, fatigue, anxiety and depression and sleeping problems. Headaches and palpitations may also occur, along with a loss of libido, vaginal dryness and pain and urinary problems, brought on by a reduction in the amount of the female sex hormone oestrogen being produced (this stage is called the perimenopause).
This reduction eventually leads to eggs not being released by the ovaries every month, so a woman's periods stop - this needs to happen for 12 consecutive months before menopause has officially been reached.
In addition to the better-known hot flushes and mood swings, the loss of oestrogen can lead to other health problems, including osteoporosis, as oestrogen, important for bone health, usually aids in protecting them against thinning.
"One woman may sail through the menopause with no problems," says Mr Edward Morris, a consultant in obstetrics and gynaecology and chairman of the British Menopause Society (BMS). "Whereas another woman even from the same family may have severe problems. The severity isn't predictable."
If a woman has a surgical menopause, where her ovaries are removed for medical reasons, she will often have a sudden menopause with severe symptoms. Angelina Jolie, who carries the faulty BRCA1 cancer gene, made the decision to have her ovaries and fallopian tubes removed this year, at the age of 39, to reduce her risk of cancer (she'd previously had a double mastectomy).
"I am now in menopause. I will not be able to have any more children and I expect some physical changes," the Hollywood star said afterwards. "But I feel at ease with whatever will come, not because I am strong but because this is a part of life. It is nothing to be feared."
TO HRT OR NOT TO HRT?
Over the last decade, there has been much debate about the possible risks and benefits of HRT, which helps relieve menopausal symptoms by replacing oestrogen. While it's been suggested that HRT may be linked to an increased risk of breast cancer and cardiovascular disease, the NICE draft guidelines stress that menopausal women and healthcare professionals should understand that HRT doesn't increase cardiovascular disease risk when started in women aged under 60, and doesn't affect the risk of dying from cardiovascular disease either.
In addition, the guidance states that HRT doesn't affect the risk of dying from breast cancer, and that HRT with oestrogen alone is associated with little or no increase in the risk of breast cancer. HRT with oestrogen and progestogen can be associated with an increased risk.
NICE also stresses that any increase in breast cancer risk is related to treatment duration, and reduces after stopping HRT.
Morris says only around 10-15% of the women who could benefit from HRT are actually take it, observing: "That's a personal choice, and I can understand why a lot of women think that after the age of 50, they're not designed to live with hormones, but we're not necessarily designed to live as long as we do, either.
"HRT's a choice that not many women make, and a lot of it's due to news stories about HRT over the last 10 years or so.
"It's like any medicine - you've got to have a cautious approach, and make sure it's the right drug for the right person at the right time.
"Nothing's a cure-all, and you've really got to think hard about it."
Surveys have suggested that around 70% of menopausal women try alternative remedies to help relieve their symptoms. Such remedies include phytoestrogens - plant substances that have effects similar to those of oestrogens - black cohosh, evening primrose oil and ginkgo biloba, as well as therapies like homeopathy, acupuncture and reflexology.
Reports surrounding the effectiveness of such approaches are largely anecdotal; however, many women swear by them for minimising symptoms and improving quality of life.
The BMS points out that there's little scientific evidence that complementary and alternative therapies can help menopausal symptoms or provide the same benefits as conventional therapies.
LIFESTYLE PLAYS A PART
Losing weight can reduce the severity of hot flushes, notes Morris. "Women who are overweight have more severe hot flushes, so if you can lose weight, that makes a big difference," he stresses.
- More information about the menopause can be found via Women's Health Concern, the patient arm of the British Menopause Society: www.womens-health-concern.org