Menopause Treatment – How to make it work for you
About 20% of women going through the menopause suffer with bothersome and disruptive symptoms. For these women menopause treatment can provide welcome relief from symptoms like hot flashes, anxiety, depression, vaginal dryness and discomfort.
Before considering menopause treatment it is important to understand the causes, concerns, diagnosis, investigations and risks associated with menopause. There are a variety of treatment modalities and they mostly deal with managing the symptoms of the menopause.
Some conditions which affect a woman adversely as she goes through the menopause are silent and are only detected when we look for them deliberately with questionnaires and investigations. These are Diabetes mellitus, hypertension, heart disease, osteoporosis, cancers and dementia.
Therefore, the treatment of menopause focusses on managing symptoms and these serious conditions through lifestyle modification and medication if required. The most effective medication for menopause symptoms remains hormone therapy with estrogen. However, many women either cannot or do not wish to take hormones for their menopause symptoms.
Menopause is not an illness and it cannot be cured, but it can be managed well. If you are concerned about how to deal with the menopause when it happens, you need the right information and guidance on how to make it work for you without significant side effects and complications.
When the treatment fits your needs, the symptoms associated with menopause are less likely to cause a disruption in your life or affect your quality of life. You are also more likely to choose those treatments that have the least side effects or complications associated with them whilst managing your symptoms. It is a fine balance because menopause is fraught with changing hormone levels for several years.
In order to get the treatment that works for you, you need to learn how to track symptoms and identify your risk factors for serious illnesses like Diabetes Mellitus, Hypertension, Obesity, Heart disease, cancers and dementia.
A tracker gives you a better idea of the areas of your health you need to focus on as you go through the menopause. Your health in your 20’s and 30’s determines the kind of menopause you are likely to go through. How you manage your menopause determines the quality of your life and even your survival as you go into your 70’s and 80’s.
In this article we will define menopause and early or premature menopause.
This will be followed by a discussion about the risks associated with menopause, how to diagnose menopause and essential investigations to do before starting treatment.
In treatment modalities we will discuss how natural methods as well as hormonal methods can be useful in managing symptoms of menopause.
Towards the end, we will discuss lifestyle modifications and other important aspects that will affect how your menopause treatment will work for you.
What is menopause?
The word ‘menopause’ comes from the Greek words ‘menos’ meaning month, and ‘pause’ meaning to stop. Therefore, the word ‘menopause’ means ‘when the period stops’.
The North American Menopause Society defines menopause as a natural event that is confirmed when a woman has missed her periods for 12 consecutive months.
This is usually known in retrospect. If you experience symptoms of the menopause whilst still having periods you will be said to be in perimenopause which can start upto 10 years before the last period and up to 10 years after the last period.
Menopause symptoms are the result of declining estrogen levels as the eggs in the ovary die out and no longer secrete estrogen. There is a decrease in the production of estrogen, progesterone and testosterone.
Additionally, there may be an imbalance between what estrogen there is and circulating testosterone and cortisol which results in a variety of other symptoms such as excess hair on the face, receding hairline, apple shaped obesity and abnormal lipid profile.
The average age of menopause is between the age of 50 – 52 years plus or minus 5 years across the globe. In countries like India the average age of menopause is earlier at 47 years of age.
You should consult your doctor for distressing menopausal symptoms if:
- Your periods are heavy or irregular or if you bleed in between periods or after sex.
- Your heavy periods leave you feeling tired or drained or without any stamina to get through a normal day that you used to be able to manage well.
- If your anxiety, depression or tearfulness is much worse and affects your day-to-day functioning.
- If symptoms like hot flushes / hot flashes (also called vasomotor symptoms) are affecting your sleep or daily quality of life.get menopause symptoms if you have had a
When you visit your doctor, take a note book or diary with you and also have a friend or relative accompany you so that you can ask any questions and take notes as well. You can discuss a variety of medical and over the counter treatments with your doctor and how they would affect your symptoms and any existing illnesses or their medication.
What are the major symptoms during the menopause that might need treatment?
Common symptoms of the menopause can be physical (hot flashes, night sweats, body ache, joint pains, palpitations, sleep disturbance), psychological (depression, anxiety, fearfulness, tearfulness, loss of confidence, mood swings) and urogenital (overactive bladder, stress incontinence, bowel disturbance, vaginal dryness and painful intercourse).
Hot flushes/ hot flashes / vasomotor symptoms are the most common and distressing complaint for which women need help during the menopause. About 20% of women find them incredibly distressing and unpredictable. 5% of women continue to experience hot flashes well into their 70s and 80s although the intensity does decrease with time.
Hot flushes present with recurrent periods of sudden, explosive, overwhelming uncomfortable sensation of intense heat or flushing that begins on the face or upper part of the neck and then radiates to the upper chest. Hot flushes can be associated with palpitations (a feeling of rapidly beating heart), a feeling of anxiety and red blotching of the skin. Hot flushes can last for 2-5 minutes, varying in frequency with some women experiencing episodes multiple times in a day and even at night.
Sleep disturbances occur in up to 50% of women. Insomnia is a serious problem for many women such that it is called a hallmark symptom of the menopause. Sleep disturbances are a serious health concern and can be associated with worsening depression, loss of energy, sexual dysfunction and even heart disease.
Sleep apnoea can present for the first time at menopause and needs attention from a sleep specialist for diagnosis and treatment. If you have insomnia or snore a lot you should get assessed by a sleep specialist too.
Vaginal dryness and discomfort can worsen sexual dysfunction at menopause. Recurrent urinary infections, frequency and urgency can also cause a deterioration in quality of life at menopause. Many women also complain of bowel problems and fecal incontinence at this time. This symptom complex is known as the genitourinary syndrome of the menopause.
What is premature menopause or early menopause?
Premature menopause is when the ovaries stop producing eggs before the age of 40 years and periods also stop. This affects 1% of women under the age of 40 years.
What are the causes of premature or early menopause?
The causes for premature ovarian failure are unknown. It may be due to autoimmune disorders, genetic causes, infections, enzyme deficiencies or metabolic syndromes. The commonest cause is often surgery to remove the uterus and ovaries for treating malignancy or other serious condition. Drugs used to treat cancer can also cause premature menopause.
What are the risks of a premature menopause or early menopause?
Women with premature menopause are at risk of premature death, neurological diseases, psychosexual dysfunction, mood disorders, osteoporosis, ischemic heart disease and infertility. It is important to approach your doctor if you think you might be going through the menopause before the age of 40 years so that you can be investigated appropriately and treated correctly.
What are the symptoms in a woman with early menopause?
Symptoms of premature menopause are similar to those of other menopausal women. However, symptoms tend to be much worse especially if they follow surgery or drug therapy for cancer. The symptoms can be complicated by depression and anxiety that may already exist due to the illness that caused premature menopause.
What is the treatment for early or premature menopause?
The treatment for premature menopause depends on the results of investigations that helped to determine the cause.
Hormone replacement therapy is the corner stone in the prophylaxis and treatment of premature menopause. This is important because of the need to prevent osteoporosis, heart disease and dementia associated with decreased estrogen levels. A woman with premature menopause will have many years without adequate estrogen and well suffer serious consequences if it is not replaced at least till the normal age of menopause.
When premature menopause is caused by surgery for breast cancer or other hormone dependent cancer, treatment can be complex. It needs to be discussed with the surgeon so that the woman receives the best care for her symptoms without complicating the care for the cancer.
How is menopause diagnosed?
For most women in their late forties or early fifties, no special test is required to diagnose menopause. An assessment of symptoms and their severity is sufficient.
However, for those suspected of going through a premature menopause a blood test measuring FSH (follicle stimulating hormone) is the investigation of choice. A level above 40 mIU/ml suggests that there may not be any eggs left in the ovary. In these women it may be appropriate to test estrogen levels so that treatment can be titrated to obtain optimal levels.
Women with premature menopause will also have genetic tests, tests for autoimmune conditions, bone density assessment and investigations to determine their risk for diabetes mellitus and heart disease.
What are the baseline investigations before starting menopause treatment?
It is best to discuss your symptoms with your doctor and take an assessment to determine their severity. Your doctor will request some baseline tests and some additional ones depending on your existing illnesses or medication if any.
Commonly requested tests before starting treatment can include:
A full blood count, thyroid function tests, lipid profile, kidney and liver function tests, blood sugar and HbA1C.
Depending on the results of these tests and your symptoms the doctor may also request the following:
- Additional tests to determine thyroid function including tests to rule out autoimmune conditions affecting the thyroid gland
- Tests to rule out Diabetes mellitus
- Tests to rule out heart disease – these can include an ECG, a treadmill test (TMT) and a 2D Echo
- Tests to determine bone health – Bone density scan also called a DEXA scan
- Bladder and bowel tests – including a urine and stool examination, a bladder diary, ultrasound examination and urodynamics
- Gynaecological assessment and examination, Pap smear test, a pelvic ultrasound examination and blood tests
- Breast examination and assessment with mammogram or sono-mammogram
What are the different menopause treatments available and how to choose between them?
Menopause treatment – Natural or complementary therapies
Many women think about using “natural or home remedies for menopause” because they do not want to use hormone therapy. They also search for the “best over the counter menopause treatment” or “herbal remedies for menopause” and this can be very misleading because the evidence that they actually work is very limited.
Even more worrying is the question “How can I increase my estrogen levels?” This implies some understanding of the fact that menopause symptoms are because of decreasing estrogen levels. Yet, they do not want to take hormone therapy because it is seen to be artificial and has a long list of risks and side effects in the pamphlet that accompanies it. Never mind that it has actually been studied in various research projects and there is stringent documentation and control over the whole process of manufacturing and distributing the product as a medicine and not just a supplement.
When considering balancing hormones in the perimenopause and menopause you need to consider the lifestyle interventions that help you to lower stress, boost oxytocin levels and reduce the risks associated with poor health choices. It isn’t just about medicines – natural or otherwise.
Non-hormonal menopause treatment, also called natural menopause treatment or complementary therapy includes various food and herb choices, nutritional supplements, herbal menopause treatment, home remedies for menopause, exercise, yoga for menopause, acupuncture, acupressure, homeopathy, ayurvedic treatment for menopause and a whole lot of techniques and strategies to deal with the psychological problems associated with menopause also known as mind-body therapies.
Unfortunately, women take these without being assessed for serious complications that can occur during menopause including heart disease, diabetes, hypertension and various estrogen dependent cancers like breast cancer.
It is better to discuss your concerns with your doctor and talk about what you have been researching, especially online. Many products sold over the counter or online do not have the recommended standards required for medicinal products and are marketed as nutritional supplements. Their hormonal effects can be inconsistent and dangerous if you already have problems like heavy periods or a thickened endometrial lining or breast disease.
Menopause treatment – herbal remedies
Several herbal remedies for menopause haven’t been studied in the rigorous manner required to grade them as medicinal products. This means that all their benefits and harms may not be documented. Several herbs can interfere with existing medication as well.
Herbal remedies are often available over the counter or online or as part of nutritional supplements. These include Black cohosh, Red Clover, Soya Isoflavones and other Phytoestrogens, Wild Yam and its cream, Evening Primrose oil, St John’s Wort and many more.
Vitamin E, soy isoflavones, and St John’s Wort may help some symptoms like hot flashes and dry skin. For many women, buying the same product their friend uses or what the latest magazine article recommends can fulfil a need to feel they are addressing some of their problems some of the time.
Unfortunately, there is conflicting evidence for the benefit of several herbal remedies. Some can even cause harm because they have hormonal effects that cannot be measured or they don’t actually help you. This can cause a delay in getting the help you need especially for conditions that affect your survival and quality of life.
Particularly important are herbs that affect liver and kidney function because several drugs are metabolised in the liver and excreted via the urine by the kidneys. If you are considering buying herbal / natural / Chinese herbal/ ayurvedic herbal products online or over the counter please consider discussing this choice with your doctor first.
Menopause treatment – alternative therapies
Some therapies like acupuncture and acupressure do show some benefit but it is variable. You might need to see several specialists before you find one that offers a treatment regime that works for you.
At present there is insufficient evidence for Homeopathy, Bach flower remedies, ayurvedic medication to recommend it for all women suffering with menopausal symptoms. If you decide to use these medicines, please discuss it with your doctor first and be aware of potential side effects and interactions with existing medication.
Menopause treatment – Mind-body techniques
These include CBT (cognitive behavioural therapy), Hypnotherapy, Yoga, Magnet therapy, Meditation and Mindfulness, Energy medicine, Reiki healing, Crystal therapy, Hopi Ear Candles, Aromatherapy, massage and several more.
Of these, CBT and mindfulness-based stress reduction have some evidence suggesting that they help women cope with hot flushes, insomnia and mood swings.
Many of these techniques help with insomnia and the quality of sleep. These therapies need to be used in addition to the lifestyle changes that help improve the quality and depth of sleep.
Yoga and pranayama for menopause has shown some benefit for vasomotor symptoms, but women need to be consistent with their efforts and receive training from authentic sources. The main effect is on coping with vasomotor symptoms.
New research suggests that persistent severe vasomotor symptoms may be a predictor of heart disease in menopausal women. Therefore, there may seem to be some benefit in using complementary therapies that help with vasomotor symptoms – this research is still awaited but would be an interesting topic to investigate.
You can read this summary about the evidence for various complementary therapies.
Complementary therapies fact sheet from the Australian Menopause society – https://www.menopause.org.au/images/factsheets/AMS_Complementary_Therapies_Sheet.pdf.pdf
Menopause treatment – menopause hormone therapy or MHT
Hormone therapy for menopausal symptoms usually means a prescription for a tailored dose of estrogen delivered either through tablets, patches, gels, implants, vaginal creams or rings.
Women who have an intact uterus need progesterone along with estrogen to protect the lining of the womb from unopposed estrogen. Some women may benefit from a small dose of testosterone delivered through patches, gels or implants.
According to the consensus statement of a number of specialists of the IMS (International Menopause Society) estrogen should be used in women who suffer with severe menopausal symptoms that adversely affect their quality of life. It needs to be used in the smallest dose required to reduce the severity of the symptoms and for the shortest duration necessary. At present hot flushes and vaginal dryness and discomfort are the symptoms under focus.
There is no current recommendation about prescribing estrogen to ALL women going through the menopause for the purpose of preventing osteoporosis or ischaemic heart disease. These diseases kill many women across the world every year and preventing them would certainly make a difference to their survival. The risks need to be weighed against the potential benefits of such therapy.
Progesterone is prescribed along with estrogen to women with an intact uterus in order to protect the lining of the womb from unopposed estrogen. If estrogen is given continuously all by itself it can cause the lining of the womb to thicken and develop cancerous cells. Progesterone helps to keep the lining under control and in women who are premenopausal, can promote regular endometrial shedding. Progesterone is often prescribed as tablets to be taken for 10- 14 days of each month of estrogen treatment. Newer methods include the Levonorgestrel Intrauterine system (Mirena IUS), patches and creams.
Testosterone is prescribed to women with low libido or loss of desire for sex that causes distress, provided there are no other contraindications. Testosterone is not given to women with breast or uterine cancer or those with existing liver disease or heart disease. Testosterone for women is usually given as a transdermal gel or patch or implant. Tablets or injections that are meant for men are avoided for women because of the risk of over dosing. Other indications for testosterone can be loss of skeletal muscle mass (sarcopenia) and bone loss.
Having said that, it makes sense to first put in to place the lifestyle interventions that are evidence based and known to prevent osteoporosis, heart disease, cancers and dementia before resorting to medication, whether hormonal or non-hormonal.
Lifestyle recommendations for menopause treatment
A number of lifestyle recommendations have been made by several menopause societies worldwide. These include diet, exercise, smoking cessation and safe levels of alcohol consumption for maintaining the health and quality of life of peri- and postmenopausal women.
Weight management in the menopausal years is crucial to preventing heart disease, diabetes mellitus, hypertension, cancers and dementia. Nutrition and exercise along with optimal mindset training can help to bring weight under control and the waist circumference under 35 inches. You can read more about weight gain in menopause and what to do about it in my article.
Exercise in menopause
Exercise in menopause helps not just to keep weight under control but specifically helps manage many of the symptoms of menopause such as hot flashes, anxiety, depression, loss of energy and drive, poor stamina, muscle strength and bone health. Exercise also has a positive effect on social, marital and sexual relationships and functioning.
Exercise plays an important role in the prevention and management of Diabetes mellitus, hypertension, heart disease, cancer and dementia.
An ideal exercise regime is one which you can commit to, which gives you the results you seek and to some extent is also enjoyable. It also needs to be a part of a habit stacking system that encourages you to incorporate it into your life without the use of too much will power.
Your exercise routine needs to include some combination of the following. Some exercises can overlap combinations and you get a greater effect for the same effort!
- Aerobic exercise for cardiovascular health and brain health
- Strength and muscle building to prevent sarcopenia
- Balance and coordination training to prevent falls and fractures
- Weight bearing exercises like running and walking to build bone strength
- Exercises like yoga, tai chi, martial arts, dance to improve balance, coordination and spatial awareness.
You can see how some exercises give you benefits under several categories and can also be fun e.g., dancing, martial arts training, team sports
Smoking and alcohol consumption and menopause
If you are a smoker you can expect a rougher ride through menopause than someone who doesn’t smoke. Initially you may feel smoking helps you to cope with the disruption caused by hot flashes, anxiety, insomnia, worry and tension.
As menopause progresses all these symptoms get worse and you will find yourself less able to cope with them. It is safer to find a way to stop smoking way before you enter your 40s than to wait till you reach the menopause.
Smoking increases the risk of dying due to any cause (all cause mortality) by up to 4 times and this is worse in menopausal women.
Alcohol has complex effects on the health risks and symptoms of menopause. Alcohol is metabolised in the liver and can be responsible for increasing circulating estrogen levels, thereby increasing the risk of all those illnesses associated with higher estrogen levels – e.g., breast cancer, fatty liver changes, endometrial cancer, gall bladder disease, thrombosis etc
Alcohol can worsen certain menopausal symptoms like hot flashes, anxiety and depression. An occasional drink will not really harm you but prolonged drinking bouts on a daily basis will cause a lot of harm and is best avoided. Binge drinking is particularly harmful because of its added risk of becoming drunk and then suffering falls and fractures.
Suffice to say that alcohol and menopause can be a dangerous cocktail!
Menopause and sleep disorders
Sleep disorders in menopause are so common that insomnia is called a hallmark of menopause. Over 50% of women suffer with some form of insomnia during the menopausal years. Difficulty falling asleep, difficulty staying asleep, snoring, sleep apnoea, waking up tired and unrefreshed, day time sleepiness, loss of concentration and focus are just some of the symptoms of sleep disturbance in menopause.
Sleep disruption at menopause is why some women perceive a worsening of their vasomotor symptoms, tiredness and poor stamina. Sleep disorders at menopause have also been shown to be associated with a worsening of heart disease, hypertension, diabetes mellitus and dementia.
In order to get the best results from your menopause treatment you need to ensure you get good quality, depth and quantity of sleep.
The following sleep hygiene tips will be of help:
- Set fixed sleep and wake times
- Build up sleep routine and a morning wake up routine
- Ensure dark lights at least two hours before bedtime and sunlight within 30 minutes of wake-up time
- Eat your last meal at least 3 hours before bedtime
- Avoid blue light devices in the 3 hours before sleep time
- Keep room temperatures cool – 18 degrees centigrade preferable
- Avoid using the bedroom for anything other than sleep or sex
- If you snore – get assessed by a sleep specialist and an ENT specialist to rule out sleep apnoea
- Keep your bedclothes and nightclothes in layers so that you can take off layers and put them back on if you get cold after a night sweat.
- Keep track of bladder problems and get help if you wake up more than twice at night to go to the bathroom
- Menopause hormone therapy is very effective at improving sleep quality and quantity and should be considered before poor sleep habits become ingrained
Relationships and menopause treatment
Menopause is a time of transition where existing and new relationships can pose a challenge. The anxiety and depression associated with menopause is worsened if relationships with partners, children or parents are strained.
The empty nest syndrome is a reality for many women in their 40s and 50s. Children often go through puberty the same time as mothers go through menopause and this can be problematic for many women. Menopause and puberty are both times of great hormonal upheaval.
Poor communication skills and verbal arguments can damage long term relationships and cause a great divide in families. Sometimes couples find that they don’t really know each other that well and will separate because there is nothing to hold them together any more.
Sexual problems such as loss of desire and arousal, vaginal dryness and pain can put a pause to sexual relations. Male partners of the same age may also be suffering with sexual problems of their own like difficulty getting an erection or loss of desire. Side effects of medication for illnesses can cause sexual problems too.
Relationship stress is an important cause of worsening menopause symptoms and risks for heart disease and hypertension especially if there is a lot of anger and aggression involved.
If you are in a toxic relationship and need help speak to your doctor or get help from a social worker who deals with domestic abuse situations.
The menopause transition can be a prolonged one for some women, spanning over a decade. Having good social and relationship support is crucial when going through the health challenges menopause can bring. Lack of social support and poor relationships can aggravate symptoms and worsen depression and anxiety. Both these are associated with worse health outcomes and survival.
You can ensure that you get the best out of your menopause treatment if you follow a few guidelines.
Talk to your doctor about your symptoms and learn how to track them so you know if they are worsening and if they are impacting your quality of life adversely.
Discuss your preferences for menopause treatment with your doctor so that the benefits, risks and harms can be openly talked about and you know where you stand and what to expect from your treatment choices.
Follow the lifestyle modification guidelines alongside your plan and you may find that you do not really need treatment or it can be for a limited duration. You can then avoid the risks and side effects associated with that particular treatment option.
Follow a systematic approach to annual health screening and book in with your doctor regularly. Menopause symptoms can change even on a daily basis and it is important to have a doctor you can check in with if you notice significant or bothersome changes to your symptoms. Maintain a symptom tracker, journal or diary to chart your progress through the years.
Your treatment plan needs to include a review of symptoms that bother you as well as the silent illnesses – Diabetes mellitus, hypertension, heart disease, osteoporosis, cancers and dementia. Any medication you take whether hormonal or non-hormonal needs to be judged on the basis of the benefit it offers in these areas.
I hope this has helped you to design a menopause treatment plan that works for you.
Here is wishing you all the very best in your menopause journey! Do write to me at firstname.lastname@example.org about what you found useful in this article.