Issues with body temperature regulation that can disrupt sleep; joint and muscle pain; changeable mood (from low mood, to anxiety and anger); dry, itching skin all over the body (yes, I mean everywhere!); brain fog. These are just some of the symptoms that can disrupt your life and your relationships with family and friends. There is also the accompanying increased risk of cardiovascular disease and osteoporosis.
Understanding the menopause
The underlying cause for all of these problems is not a disease process. The menopause is a normal physiological event that occurs in every woman during her life. On average the age of menopause is 51 years, however, it can occur a couple of years either side of this. In the years leading up to the menopause, the perimenopause, the ovaries start to lose responsiveness, resulting in a decline in the female ovarian hormones (oestradiol and progesterone). These reducing hormone levels can cause women to experience some of the issues above, as well as changes in the menstrual cycle. Cycles can become erratic in timing and nature, reflecting the variable rate of change in female hormone production during this stage in the female hormone journey. This perimenopause phase can vary in length, although ultimately when the ovaries shut up shop, periods cease and the ovarian hormones remain consistently low, signifying that menopause is reached.
Whilst the menopause is a natural, expected physiological event, that does not mean that this part of a woman’s life is without challenges. Nor does this mean that women should resign themselves, or indeed accept a reduced quality of life. With increasing life expectancy, women may spend at least a third of their lives in the menopausal state. A couple of hundred years ago, even if they survived childbirth, not many women reached the age of menopause. Today, far more women than ever before will experience the consequences of low female hormones that comes with menopause, potentially for 30 years or more of their lives.
Menopause is a significant point a woman’s life from a physical and psychological point of view. Even if she has made an active decision not to have children, menopause closes the chapter on this possibility. It can also be a time of life where things are changing: “children” have grown up and are leaving home, parents are getting older and new work colleagues seem to look very young. It can seem overwhelming, when these events coincide with the seismic changes in female hormones, that are impacting physical and mental wellbeing.
Talking about the menopause
As a woman and a female doctor, having experienced all the calling points of the female hormone journey, I am passionate about explaining the complexities of hormones: how to recognise key changes in hormones and what to do from a practical point of view. Including the menopause as part of the discussion of puberty and menstrual cycles at school (for boys and girls) would mean everyone has at least heard the word “menopause” from a young age. This would help make future conversations less challenging, where “the change” is only whispered amongst our grandmothers. Certainly, when I have been invited to make presentations and speak with teenagers, they have been interested to hear to full story of hormones.
Medical doctors have an important part to play in disseminating accurate information and supporting women through this hormone journey. There are some excellent resources for both non-medically qualified and medical professionals such as the British Menopause Society and Women’s Health Concern, Royal College of Obstetrics and Gynaecology and the NICE guidelines. These include advice and current best clinical practice for everyone to peruse. Framing questions empathetically is crucial. Some may be reticent to talk about vaginal dryness. Menopause should not be a source of embarrassment; it is the expected, normal physiology of hormones. Each of us will experience this differently.
As a female doctor, with the time of my menopause approaching, I had done my due diligence on this topic. I had read in detail the excellent resources I mentioned above. Nevertheless, experiencing those symptoms listed at the start of this blog, I appreciated that this would be an even more disconcerting and indeed a very frightening experience, if I did not know that my hormones were changing in a normal and expected way. Fortunately, having done my research based on these open access resources above, I knew that hormone replacement therapy (HRT) would help as HRT improves quality of life and all-cause mortality (death from all causes).
Researching the dose and form of HRT from these resources, it made logical sense that my body would appreciate exactly the same molecular structure of hormones that I had been producing myself to date. Taking oestradiol transdermally, through the skin, avoids any entanglement with the liver. Gel was a more attractive, discrete proposition that a patch. For the progesterone component of HRT (which is a must unless you have had a hysterectomy) micronised progesterone fitted the description of being the same molecular structure as body produced. The extra bonus is that this exact, optimal form of HRT is available on the NHS in a licensed and regulated format. Having no contraindications for HRT, I was left in no doubt that this form of HRT would be what to ask my GP about.
In an editorial published in the British Medical Journal, Professor Janice Rymer, Vice President of the Royal College of Obstetrics and Gynaecology, presented unequivocal evidence about the misinformation surrounding HRT, which risks further damaging setbacks for women’s health.
It is tragic and bewildering that a replacement therapy that restores hormones to physiological levels and improves quality of life for women has been misrepresented. Sadly, the focus has been almost entirely on potential side effects, to the exclusion of the benefits of improving health and quality of life. After all, there seems to less reluctance giving testosterone replacement to men.
For younger women there are no qualms about giving supraphysiological doses of hormones, in non-molecular identical forms, found in many combined oral contraceptive pills to supress internal hormone production (ironically supressing oestradiol and progesterone to the low levels seen in menopause). The combined oral contraceptive pill continues to be given, in some cases, to those women with functional hypothalamic amenorrhoea (FHA), where this practice is advised against by the Endocrine Society.
In conclusion I think the underlying issue is that, despite inspiring advances across many fields, there continues to be the pervasive perception that female hormones are solely about fertility. Whilst there is no denying that this is the evolutionary purpose of ovulation, female hormones are crucial to all aspects of health. This applies whatever the age of a woman.
 British Menopause Society & Women’s Health Concern 2020 recommendations on hormone replacement therapy in menopausal women. https://thebms.org.uk/publications/consensus-statements/bms-whcs-2020-recommendations-on-hormone-replacement-therapy-in-menopausal-women/
 Royal College Obstetrics and Gynaecology website “Menopause and women’s health in later life” for patients
 National Institute of Clinical Excellence. Menopause: Diagnosis and Management Update 2019.
 Janice Rymer, Kate Brian, Lesley Regan. HRT and breast cancer risk. Editorial BMJ 2019;367:l5928 doi: 10.1136/bmj.l5928 (Published 11 October 2019)
 Gordon C, Ackerman K, Berga S et al Functional hypothalamic amenorrhea: An endocrine society clinical practice guidelineJournal of Clinical Endocrinology and Metabolism (2017) 102(5) 1413-1439