Menopause

1. Menopause Sal Roberts RN RM MSc DFSRH PGA Med Ed (SRH) FRT

2. What is Menopause ? Menopause Perimenopause (Climacteric) • after a year of no periods (amenorrhoea) • usually diagnosed on symptoms, not blood tests unless <45 (NICE 2015) • doesn’t apply • after hysterectomy (unless ovaries removed) • endometrial ablation • Mirena • continuous hormones • from the beginning of menopausal symptoms to the postmenopause

3. Types of Menopause • Premature Ovarian Insufficiency (before age 40) • Early menopause (before 45) • Surgical menopause • Medical menopause • chemotherapy • radiotherapy • Average age at natural menopause 51-52

4. Why is Menopause so important? • 18% rise in people >65yr in last decade • 31% rise in people >85yr • State Pension age rising 66/67 2019 • ONSS 47% of the current workforce is female • 1.7 million (5%) working women affected by menopause and increasing!!

5. Demographics 1850 • Age of menopause - 45 yrs • Life expectancy - 45 yrs 2009 • Age of menopause - 51 yrs • Life expectancy - 82 yrs • Today > 30% life = post menopausal

6. Why is Menopause so important? • 45% menopausal women felt menopause had impact on work • 47% who had taken a day off work couldn't say why • 51% menopause affected sex life • 42% don’t feel as sexy • 36% impacted social lives • 23% more isolated • 50% impacted home life • 38% partners felt helpless to support menopausal woman • 28% partners said menopause caused conflict in relationship • 50% women aged 45-65 with menopausal symptoms have not consulted a Health Professional for help!

7. Menopause Symptoms Vasomotor (Average 2 to 5 years ...) • Hot flushes 79% • Night sweats 70% • Anxiety • Palpitations Psychological symptoms • Poor memory and concentration 20% • Lack of confidence • Low mood/mood swings/Irritability • Panic attacks Sexual, vaginal and urinary symptoms • Reduced sex drive • Painful sex • Vaginal dryness/irritation • Pelvic floor problems 10-40% • UTIs and stress incontinence • Dysuria, frequency, urgency, urge incontinence, nocturia • Prolapse of vaginal wall • ? Body image change

8. Reporting and treatment of Vaginal and Bladder Issues Cumming et al. Menopause International 2007;13:79-83

9. Menopause Symptoms • Periods changing • Insomnia 22% • Weight gain • Headaches • Joint pain and stiffness 18% • Hair loss • Dry, thin, itchy skin • Formication • Osteoporosis 2016 Survey conducted by Ipsos MORI on behalf of the British Menopause Society (BMS)

11. Management of symptoms Discussion / counselling: • Diet and lifestyle • Over the counter options • Hormone replacement therapy • Cognitive Behavioural Therapy (CBT) • Non-hormonal medicines (SSRIs /Venlafaxine/Clonidine/Gabapentin)

12. Lifestyle advice - symptom control and prevention • Loose cotton layers • Fans • Stop smoking • Avoid spicy foods • Avoid hot drinks • Especially caffeine • Exercise • Weight loss and improving bone health • Diet • Weight loss • Phytoestrogens • Improve sugars/carbs • Calcium/vitamin D • ?? Herbal treatments • Reduce alcohol

13. Phytoestrogens Japanese women • Fewer hot flushes • High soya diet containing phytoestrogens • Lower risks of heart disease and hormonal cancers What are phytoestrogens? • Naturally occurring in plant sources • Structurally related to estradiol • Concentrated iso-flavones (phytoestrogens) are found in red clover • Can be taken in tablet form • CEREALS: oats, barley rye, brown rice, couscous and bulgar wheat • SEEDS: sunflower, sesame, pumpkin, poppy, linseeds • PULSES: soya beans and all soya based products (except soya sauce which does not contain any!) • BEANS: chickpeas, kidney beans, haricot beans, broad beans, green split peas • VEGETABLES: red onions, green beans, celery, sweet peppers, sage, garlic, broccoli, tomatoes and bean sprouts • SOYA, LINSEEDS and RED CLOVER are the richest sources • COMMERCIAL PRODUCTS are also available such as Bergen bread, Provamel yoghurts and "So Good" milk

14. Herbal and OTC remedies • Ginseng (mood) Cochrane 2014 • Dong quai (-) Hirata 1997 • Oil of evening primrose (-) Chenoy 1994 • Vitamin E (marginal benefit) (+) Barton 1998 • Multivitamin and minerals no studies • Sage (-/+) Bommer 2011 • Natural progesterone gel (-) Benster 2009 • Magnets nil • Black Cohosh (-) Cochrane 2012

15. HRT WHY? • Control of menopause symptoms in peri or post menopausal women • Treatment of Premature Ovarian Insufficiency (POI) • Osteoporosis prevention

16. HRT Safety • The safety of HRT largely depends on age • Healthy women younger than 60 years should not be concerned about the safety profile of HRT • For most women, the potential benefits of HRT given for a clear indication are many and the risks are few when initiated within a few years of menopause • There are actually very few women who should be advised that they should NEVER use HRT

17. HRT Benefits • Control of menopausal symptoms • Maintenance of BMD (bone mineral density) and reduced risk osteoporotic fractures • Reduced risk coronary heart disease and reduced risk of Alzheimers disease when estrogen started early • Reduced risk colorectal cancer • Reduced risk Type 2 diabetes • Improves muscle mass and strength

18. HRT Benefits For women with Premature Ovarian Insufficiency (Aged under 40): • the risks associated with not using HRT are • low bone density, earlier onset osteoporosis and fractures, • earlier onset of coronary heart disease and increased cardiovascular mortality and total mortality • diminished sexual well-being

19. HRT Risks • Endometrial cancer (if oestrogen only given when uterus present) reduced by addition of progestogen • DVT/PE risk with Oral HRT but not transdermal (patch or gel) • CHD increased when combined HRT started in older women(>60), or with pre-existing CHD – ideal is within 10 years of menopause • Stroke increased when HRT started in older women (> 60 years) • Breast cancer • Increased slightly after a minimum of 5 years’ use of combined HRT • Over the age of 50— additional 3-4 cases per 1,000 women • Risk associated with estrogen alone is very much less • Mortality is not increased.

20. Difference in Breast Cancer Incidence per 1000 women aged 50-59 Womens Health Concern: Understanding The Risks of Breast Cancer

21. Which HRT? Which regimen? Which route? Lots of options: • Systemic or local therapy • Estrogen only or combined therapy • Cyclical or continuous combined therapy • Oral, transdermal, subcutaneous or intrauterine • Tablets, patches, gels, implants, vaginal preparations

22. Cognitive Behavioural Therapy “CBT is a short-term, skills focused form of psychotherapy” • Helps to develop practical ways of managing problems and provides new coping skills and useful strategies • NICE 2015: should be considered for low mood/anxiety as a result of menopause

23. Non-hormonal vaginal options Moisturisers • hold moisture on the vaginal walls and only needs to be used 2 or 3 times per week • Yes • Replens • Regelle • Hyalofemme Lubricants • Sylk • Yes • Durex Play Petroleum-based lubricants can increase the likelihood of infection and damage latex condoms Check the label!

24. Non-medical options • Homeopathy • Acupuncture • Aromatherapy • Reflexology • Relaxation therapy • it’s all about getting through the menopause as comfortably as we can • for some it may involve hormones, for many it won’t

25. More Help Women's Health Concern - www.womens-health-concern.org Menopause Matters - www.menopausematters.co.uk Manage my menopause - www.managemymenopause.co.uk British Menopause Society - www.thebms.org.uk NICE - https://www.nice.org.uk/Guidance/NG23 Thank you!