Perimenopause
and Menopause
Discover the stages of menopause, including symptoms and management strategies, as your menstrual cycles change and eventually cease.
The perimenopause is the transitional period where you have menopausal symptoms but your periods have not stopped. Your periods may remain regular or become irregular. The length of this transitional period varies for each woman, but can last up to a decade.
Menopause is the day your periods have stopped for 12 months. On this day you stop being perimenopausal.
For the rest of your life after menopause, you are termed “post-menopausal.” Whilst your periods have stopped, many other symptoms may remain.
For more information about the symptoms, please read my free resource here.
On the whole, blood tests are not helpful in perimenopause. A normal set of bloods does not exclude perimenopause. In some instances, including in women under the age of 40, bloods may be helpful to identify Premature Ovarian Insufficiency.
Oestrogen is an important hormone for the whole body. Women that are menopausal have an increased risk of certain health conditions such as cardiovascular disease andosteoporosis. Taking steps to mitigate and address these risks is an important part of menopause care.
I welcome all women to book an appointment if they feel they are perimenopausal ormenopausal. A recent report from the All-Party Parliamentary Group for Menopauserecommended that all women be invited for a health check at 45 where menopause should be discussed. Even if you don’t have many symptoms, it’s a really important time to discuss your general health as the risk of certain conditions, such as osteoporosis and cardiovascular disease, can increase after menopause.
A good menopause consultation should offer a holistic approach to assessing yoursymptoms, their impact on you, and the treatment options available. It’s often helpful to come armed with a symptom diary as this can help use the time effectively.I will take a comprehensive medical and hormone history so I can better advise on yourlifestyle and all treatment options available to you, before coming up with a bespoketreatment plan.
Diet and lifestyle
As part of your menopause care, it’s important to ensure time is taken to address all the foundations of health, including looking at your diet, exercise, sleep and stress levels.Spending time optimising each of these areas can help prevent disease, improvemenopausal symptoms and improve overall wellbeing. We normally recommend that all women take a Vitamin D supplement (10mcg) to helpsupport bone health, as most of us in the UK do not get enough from diet and sunlight. If your diet is low in calcium, a calcium supplement may also be recommended.
The most commonly prescribed and effective treatment to manage the perimenopause and menopause is Hormonal Replacement Therapy (HRT). There are however other options available for treatment if you chose to not to have HRT or where HRT may be contraindicated.
Alternative therapies
There a several available alternative and complementary therapies available for menopause care. Acupuncture, yoga, herbal treatments (black cohosh or red clover), aromatherapy and reflexology may be helpful to some women looking for a holistic approach to their health and wellbeing but research is limited into their effectiveness. Whilst some treatments may provide partial relief from some menopausal symptoms, their effects are often transient. For this reason, they are not normally recommended for the sole treatment of the menopause. Cognitive Behavioural Therapy (CBT), a type of taking therapy, is recommended by NICE as a treatment option for anxiety during the perimenopause and menopause. CBT can also help women manage hot flushes and night seats.
Non-hormonal options
Most prescribed alternatives have been evaluated for the effectiveness to support with hot flushes, but some will also help with mental wellbeing. Some can have some side effects that need to be considered in choosing an appropriate choice. Examples include some antidepressants, Clonidine, Gabapentin, Pregabalin, Oxybutynin and Fezolinetant.
Hormonal replacement therapy
Learn about HRT, its benefits and risks, and how it can help manage menopausal symptoms by replacing lost hormones.
Systemic HRT is an effective treatment to manage the symptoms of perimenopause and menopause. We have oestrogen receptors all throughout our body and replacing it with hormone therapy helps to improve menopausal symptoms and health consequences.
HRT normally consists of two main female hormones – oestrogen and progestogen. Whether you need one or both depends on your personal health history. Women without a uterus will normally be offered Oestrogen-only HRT (there are some exceptions to this such as a history of severe endometriosis) where as a combined Oestrogen and Progestogen preparation will be offered to those with a uterus. A third hormone, Testosterone, may also be prescribed by some specialist clinics for symptoms of low libido. Systemic HRT can be safely used with additional vaginal oestrogens.
HRT comes in many forms, including patches, gels, sprays and tablets and your GP or health care professional will help you choose the most appropriate preparation for you. Most doctors will recommend Body-identical HRT, which consists of a transdermal Oestrogen (gel, spray or patch) and an oral micronised Progesterone called Utrogestan. This is the safest and most regulated way to prescribe HRT and are precise duplicates to the natural hormones produced by your ovaries. This is different from Compounded Bio-identical HRT which are unlicensed and unregulated hormonal preparations made up by specialist pharmacies. They are not recommended by the British Menopause Society due to concerns regarding their safety and efficacy.
Vaginal oestrogens, also known as topical oestrogens, can be used to help support vaginal and bladder symptoms relating to perimenopause and menopause. As they work locally to just the vaginal and vulvar tissues, they are low risk and can be safely used by the majority of women. Vaginal oestrogens come in the form of pessaries (tablets inserted into the vagina), creams and rings. They can be effective at reducing vaginal dryness and irritation, and urinary symptoms such as urgency, frequency, urinary incontinence and recurrent UTIs, and can be used long term. Systemic HRT, applied to the skin or taken orally as mentioned above, can be safely used with additional vaginal oestrogens so please do speak to your GP for assessment. Vaginal moisturisers and lubricants such as Sylk, Replens or YES may also provide symptom relief.
Other treatments are also available through specialist clinics and include Ospemifeme, an oral selective oestrogen receptor modulator (SERM), and a vaginal gel of dehydroepiandrosterone (DHEA).
In addition to helping with the symptoms for the menopause, there are also health benefits of taking HRT. Osteoporosis risk is reduced and for women starting HRT within the first ten years of the menopause, HRT use has also been shown to be associated with a reduction in cardiovascular disease. There may also be a reduction in the risk of colorectal cancer, Type 2 Diabetes and dementia but further research is needed.
For the majority of low-risk women, starting HRT within the first ten years of the menopause, HRT is a safe and effective treatment, particularly when using a body-identical preparation (transdermal oestrogen and an oral micronized progesterone). Potential risks will depend on the type of HRT used and the duration of use.
Risks such as blood clots, breast cancer and endometrial cancer will be different depending on the type and/or duration of HRT used. Body-identical HRT is the safest of all HRT and therefore often the prescription of choice. Transdermal oestrogens do not increase clot risk and Utrogestan containing HRT has been shown to not increase breast cancer risk for the first 5 years of use (Fournier et al) but longer-term data is needed.
As with all medications, I will take a detailed history of your symptoms and past medical history and fully discuss any risks, potential side effects and benefits so you can make an informed choice.
PMS & PMDD
Premenstrual Syndrome (PMS) & Premenstrual Dysphoric Disorder (PMDD). Find information on the causes and treatments, including lifestyle changes and medical options to ease physical and emotional symptoms.
Many women experience mild physical or emotional PMS without it being too troublesome. Someone however (reported as between 3-30% and likely under reported) experience severe physical and psychological symptoms in the luteal phase (after ovulation) of their menstrual cycle which disappear or reduce with the onset of menstruation. Such symptoms affect interpersonal relationships and a woman’s ability to perform day to day activities.
Symptoms of PMS include:
- Mood swings
- Feeling upset, anxious or irritable
- Tiredness of trouble sleeping
- Bloating or abdominal pain
- Breast tenderness
- Headaches
- Spotty skin
- Greasy hair
- Changes in appetite and sex drive
Pre-menstrual dysphoric disorder is considered the most severe form of PMS with the greatest impairment on a woman’s quality of life and ability to function.
Physical and emotional symptoms are intense and in some cases woman can feel suicidal. For the full diagnostic criteria, see here
The exact cause of PMS remains unknown. Research has shown that hormone release levels are normal, but that there may be an increased sensitivity to cyclical changes of hormones in the menstrual cycle.
In order to diagnose PMS, you must use a symptom log or diary across two prospective cycles. The Blue Moons Diary can be purchased online or alternative you can visit the National Association of PMS
Lifestyle
Good, holistic care starts with looking at a patient’s lifestyle to identify any contributing factors. Addressing stress and dietary measures such as reducing caffeine, alcohol and carbohydrate binges may help to reduce symptoms. Exercise has also been shown to play a role in improving physical and mental symptoms.
Complementary therapies
Data looking at the efficacy of complementary therapies and dietary supplements in the management of PMS is limited.
Many preparations available online are unregulated and may interact with conventional medications and should be used with caution. Acupuncture and reflexology may offer benefits to some woman but it is not backed by sufficient evidence to be widely recommended.
There is some evidence that Vitamin B6, Magnesium. Vitamin D and Calcium could offer some benefits but more research is needed.
Evening Primrose Oil may offer improvement of hormonally related breast tenderness only. Agnus Castus and St John’s Wort are offering some promising results but more research is needed.
Cognitive Behavioural Therapy
Cogntive behavioural therapy has been shown to improve PMS and should be offered routinely to all women.
Medical therapy
Premenstrual syndrome is thought to be related to cyclical ovarian function. It therefore follows that many of the available treatments aim to work by supressing ovulation and therefore the distressing cyclical symptoms that accompany it.
Treatments include a Combined Oral contraceptive Pill, Hormonal replacement therapy (HRT) or a medication called a Gonadatrophin Releasing hormone analogue (with add back HRT). Side effects and risks vs benefits need to be carefully considered with all treatment options. Body identical Progesterones used as monotherapy may also offer some benefit but data is limited.
The antidepressant Serotonin Reuptake Inhibitors have been shown to be an effective treatment for PMS in randomised controlled trials. This can be given throughout the cycle, or just in the second half or luteal phase.
Surgery
In severe cases, where medical therapy has failed to improve symptoms, a woman may be referred for consideration of a Hysterectomy and Bilateral-salpingectomy, this permanently removing her ovarian cycle.
Testosterone
Learn about how Testosterone is an abundant female hormone, and the role it plays in several bodily processes.
Yes, Testosterone is an abundant female hormone, produced by the ovaries and the adrenal glands. It is an important hormone plays a role in several bodily processes.
Hyposexual desire disorder is a term used to describe distressing low libido in women. It is a common condition in women experiencing the menopause. Testosterone levels decline as we age and low libido may be a concern for women experience perimenopause and menopause.
It is important to acknowledge that low libido often has several contributing factors and needs to be addressed via a bio-psycho-social approach. For menopausal women who have persistent low libido despite treatment with HRT, the addition of Testosterone replacement can be helpful. There is no licenced product in the UK for women, so prescribed products tend to me male products prescribed off-label, or Androfeme, a female product imported from Australia.
