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What is the menopause?

 

The menopause is the time when a woman stops having monthly periods. The average age for the menopause is 51 years. At this time, the level of a sex hormone called oestrogen fluctuates and then eventually decreases. This is one of the hormones needed for ovulating (egg producing) and pregnancy.

Once a woman has had her menopause, she can no longer have children. Oestrogen also thickens the womb lining, so once levels drop considerably, menstrual periods no longer occur.

A woman is described as having completed her menopause (or being 'post menopausal') when she has not had a period for at least one year. The whole process of going through the menopause is described as the 'peri menopause' and this phase can last for a few years.

During this time, many women will experience some physical and emotional symptoms due to the decreasing levels of oestrogen. These will vary widely but can commonly include tiredness, hot flushes, changes to skin and hair, joint pains, night sweats and mood swings.

 

What is the link between osteoporosis and the menopause?

Bone is alive and is continually renewing itself. A process where cells inside the bone get rid of old bone and replace it with new bone is happening in all of us all the time. This is often called 'bone turnover' and affects our bone density. Bone density is the quantity of bone that helps to indicate bone strength.

Oestrogen plays an important role in the bone turnover process. When the levels of this hormone decrease at the menopause, the rate of bone turnover increases and a woman's bone density decreases. A premature or early menopause (before the age of 45) is known to be a risk factor for developing osteoporosis later in life, which puts a woman at a higher risk of breaking bones.

 

What is Hormone Replacement therapy (HRT)?

HRT is a medical drug treatment that contains oestrogen. It may also contain another hormone called progestogen. Progestogen is a man made version of a hormone called progesterone which is also produced at lower levels after the menopause. Progestogen is prescribed to protect women from the increased risk of womb cancer associated with 'oestrogen only' HRT. 'Oestrogen only' HRT should only be given to women who have had their womb removed (hysterectomy).

 

How does HRT work?

By taking HRT, a woman's oestrogen hormone levels increase again and for many women this helps to overcome the symptoms that are often associated with the menopause.

It is also evident that by increasing a woman's oestrogen levels, HRT can help to prevent the continued decrease in bone density and therefore reduce the risk of the fractures associated with osteoporosis.

Therefore, women who have had a premature or early menopause may be advised by their doctors to consider using HRT up to the age of 50 to help to protect their bones. There is also clear evidence that combined HRT (oestrogen plus progesterone) reduces the risk of colon cancer.

 

Who can take it?

The way HRT is used has changed a great deal in the last few years. It has always been widely prescribed to women to help with their menopausal symptoms but some women used to also stay on it for many years to help keep skin and hair looking healthy and provide a general sense of well being.

Women were often also prescribed HRT to prevent and treat osteoporosis and again would stay on it for many years.

The publication of two large clinical studies in 2002 and 2003 resulted in major changes in the way HRT is used. These studies were the Women's Health Initiative in the USA and the Million Women study in the UK. Although there is still some discussion among some specialists about the conclusions of these studies, both provided evidence for potential risks associated with HRT. They concluded that the risks associated with HRT may outweigh the potential benefits and that long term use of HRT was not appropriate to prevent chronic diseases. This research then prompted the UK's Medicines and Healthcare products Regulatory Agency (MHRA) to offer some guidance to health professionals and the general public on how HRT is most safely and effectively used.

The MHRA advises that HRT may be used:

+At the lowest suitable dose for the shortest period of time for the relief of menopausal symptoms.

When used in this way, the benefits outweigh the risks.

+At the lowest suitable dose in younger women who have experienced an early menopause, both for treating their menopausal symptoms and for preventing osteoporosis. They should only take it up until the age of 50.

It is believed but not yet proven, that only HRT taken beyond the average age of the menopause (about 51 in the UK) appears to count when assessing risk.

HRT is no longer used by most doctors as a first choice treatment for long term use in osteoporosis.

There is a range of other medications that would be prescribed if a woman had osteoporosis which required treatment. These work quickly to reduce the risk of broken bones in those people who are at high risk of fractures. Some women may be taking HRT as an osteoporosis treatment if they have been unable to tolerate other osteoporosis treatments and have seriously considered the potential risks and discussed these with their doctor. Alternatively, they may also be using HRT, usually over the short term, for relief of severe menopausal symptoms. Some women simply chose to use HRT long term for osteoporosis having weighed up the risks and benefits. As with all medications, women should discuss their options with their GP.

 

How is it taken?

HRT can be taken in several different ways. There are tablets, patches that you stick on your skin, implants, gels you rub on your skin, a vaginal ring and a nasal spray. There are also rings, creams and pessaries that can be inserted into the vagina which are only used for the relief of specific symptoms such as vaginal dryness.

HRT comes in three forms. Sequential combined therapy is where the two hormones, oestrogen and progestogen, are taken separately during the month causing the woman to have a bleed similar to a menstrual period. Continuous combined therapy is where the two hormones are taken together continuously during the month and so no bleed occurs. This treatment is only prescribed to women who are at least a year past the menopause to reduce the risk of irregular bleeding. Oestrogen only HRT contains no progestogen and is given to women who have had their womb removed.

These products come in a wide variety of doses and ingredients. This means that there is a wide variety to choose from so most women wanting to use HRT will find something that suits their needs.

Minimum doses of oestrogen required for bone protection.

Drug Dosage Frequency

Estradiol 1-2 mg Daily

Conjugated Equine Oestrogen 0.625 mg Daily

Transdermal Estradiol Patch 50 µg Daily

Estradiol gel 1.5 mg (two measures) Daily

Estradiol implants 50 mg 6 monthly

 

What are the risks associated with HRT?

HRT is associated with an increase in a woman?s risk of certain health problems:

+Heart disease - Some HRT products that were studied were found to increase a woman's risk of heart disease. Not all products have been studied, so the situation remains unclear as to whether this applies to all.

+Stroke - A woman's risk of a stroke naturally gets higher the older she is and studies show this risk is increased further by being on HRT over five years. For women in their 50's who have not used HRT, the risk of stroke is about three strokes in every 1,000 women. This increases to four in 1,000 for women that do use HRT for five years. For women in their 60's 11 out of 1,000 will naturally have a stroke in a five year period but taking HRT for five years increases this to 15 in 1,000.

+Blood clots (venous thrombo embolism - VTE) - Again, the natural risk of VTE is increased by age but studies also indicate that HRT increases this risk again, particularly in the first year of use. Three out of every 1,000 women in their 50's will naturally develop a blood clot in any five year period. Taking HRT for five years increases this to seven women in 1,000. Eight out of 1,000 women in their 60's will naturally develop a blood clot in a five year period but this increase to 17 in a thousand when HRT is used.

+Breast cancer - Studies on the different types of HRT show an increase in the risk of breast cancer occurring. Again, this risk also seems to naturally increase with age. Thirty two out of every 1,000 women in their 50's will naturally develop breast cancer before they are 65. This increases to 38 out of 1,000 women aged 50 when using combined HRT for five years and this increases again to 51 women over 10 years use of combined HRT. Oestrogen only HRT shows less of a risk at an extra one to two cases over five years and five cases over 10 years. The studies have also shown that the risk of breast cancer then declines again after HRT is stopped and after five years, a woman's risk is similar to that of a woman who has never used HRT.

+Endometrial cancer (cancer of the womb lining) - The natural risk of endometrial cancer is five cases in 1,000 women. Oestrogen only HRT increases this risk to nine cases over five years and 19 cases over 10 years progestogen is added to HRT as helps to protect the lining of the womb against cancer.

+Ovarian cancer - Oestrogen only HRT is thought to very slightly increase this risk when used long term. The natural risk is nine cases in every 1,000 women. Oestrogen only HRT is thought to raise this to 10 cases over five years and 12 cases over 10 years.

The information and figures about these risks comes from the MHRA Safety of HRT document dated March 2004.

What are the side effects of taking HRT?

As with any other medical treatment, side effects may be experienced by some women. Even if side effects are experienced, they may still be mild and go away after a short time.

These can include:

+Breast enlargement and tenderness

+Weight gain

+Breakthrough bleeding

+Headache

+Dizziness

+Raised blood pressure

+Gastric upset, nausea and vomiting

Please note this is not an exhaustive list of side effects. Always read the information sheet that comes with any medication you use for a full list.

Further useful information can be obtained from:

Women's Health Concern, Whitehall House, 41 Whitehall, London SW1A 2BY Website:www.womens-health-concern.org

E-mail:counselling@womens-health-concern.org

Nurse counselling Helpline: 0845 123 2319 (local rate)

British Menopause Society, 4 / 6 Eton Place, Marlow, Buckinghamshire. SL7 2QA Telephone 01628 890199

Website: www.the-bms.org

To obtain other NOS publications and Information Sheets, go to www.nos.org.uk or telephone

0845 130 3076 or 01761 471771

To contact the NOS osteoporosis nurses telephone the NOS Helpline on 0845 450 0230 or e-mail them on nurses@nos.org.uk