Lifestyle & symptoms of menopause

Many women cope with mild menopausal symptoms and don’t need to take any medication or use therapies. Some women manage their symptoms well with lifestyle measures such as eating well and getting regular physical activity.

Other women with symptoms that are affecting their quality of life will need to seek treatment to help them manage their symptoms.

Some treatments are well supported by valid scientific research; others have less evidence to support their use. It is important to have accurate and reliable information before you start any treatment.

Menopause is a unique experience for all women and a range of management options is available for the different symptoms, including:

• healthy living
• menopausal hormone therapy, or MHT (formerly called hormone replacement therapy, or HRT)
• treatments to manage vaginal dryness
• non-hormonal prescription medications
• complementary therapies
• pharmacy-compounded hormone therapy (not recommended).

Healthy living

Lifestyle & symptoms of menopause

Coping with menopausal symptoms can be helped by a balanced and nutritious diet, exercise and relaxation. Women who try to make their lifestyle as healthy as they can appear to have fewer menopausal symptoms, and those symptoms are less severe. Women who are overweight may have more hot flushes than women of a healthy weight.

Some studies have suggested that exercise can reduce hot flushes, but overall there is insufficient evidence to show this.

Tips for dealing with hot flushes

Food and drink	Reduce your intake of: caffeine alcohol spicy foods Eat foods with phytoestrogens, such as: whole bean soy products tofu, tepeh whole grains (e.g. oats, barley, brown rice) legumes (e.g. chickpeas, beans, lentils)	Phytoestrogen may mimic the action of human oestrogen in some women and may help.
Environment	Have fans or air conditioning operating wherever you can Carry a small hand fan Use a water facial spray Have cool drinks available Wear layers of clothing so you can take off what you need to when you are hot	Thinking about your environment and having practical strategies to help you cool down makes coping with hot flushes easier.
Helpful therapies	Supportive therapies but with limited research include: hypnotherapy cognitive behavioural therapy mindfulness. There is no evidence of reduction in hot flushes with relaxation, meditation and paced respiration (deep, controlled breathing).	Relaxation techniques can reduce tension, anxiety and depression.

Healthy weight

A healthy lifestyle during the menopause transition helps with maintaining a healthy weight and, bone and heart health, which are all important for preventing disease later in life. Once women reach menopause, their oestrogen levels drop and their risk for osteoporosis and cardiovascular disease (diseases of the heart and blood vessels, such as stroke) increases, so good nutrition is very important at this life stage.

As women age and move through menopause, the fat that used to sit around the hips moves up towards the waist area. Younger women tend to be shaped more like a pear, and older women like an apple. This shift in weight to the waist area increases the risk of cardiovascular disease, so it is important to try to minimise weight around the waist area.

Trying to minimise weight gain and stay a ‘healthy’ weight can be difficult, but there are techniques to help. For more information go to Healthy living.

Sleeping well

Sleep problems can occur at midlife and during times of hormonal change like menopause. These include problems such as insomnia, where you find it difficult to go to sleep and stay asleep. Twice as many women experience insomnia compared with men.

Menopausal symptoms, particularly hot flushes and night sweats, can disturb sleep and set off insomnia. The night sweats might change your usual pattern of sleep and your body learns this new pattern, so the broken sleep pattern becomes the new norm.

Smoking

Women who smoke might reach menopause one to four years earlier than women who don’t smoke. Women who smoke are also more likely to have menopausal hot flushes.

Giving up smoking is important because after menopause, women have an increased risk of osteoporosis, heart disease and lung cancer. These conditions all occur at higher rates in women who smoke.

Menopausal hormone therapy (MHT)

What is MHT?

The three hormones of particular relevance at menopause are oestrogen, progesterone and testosterone. Menopausal symptoms are created by changes in the levels of the oestrogen hormones. Menopausal hormone therapy (MHT), formerly known as hormone replacement therapy (HRT) and hormone therapy (HT), is the medical replacement of the female hormones oestrogen and progesterone, and sometimes testosterone. MHT is a treatment used to help manage menopausal symptoms, such as hot flushes and night sweats, when they are interfering with your life.

What are the benefits of MHT?

MHT can provide relief for many of the common symptoms of menopause, such as hot flushes, sweats, mood swings, irritability, insomnia, joint aches and vaginal dryness.

Types of MHT

Oestrogen and progesterone therapy

Oestrogen is the main hormone prescribed to relieve menopausal symptoms, and for women who have had a hysterectomy, this may be all they need.

In women who still have their uterus, oestrogen alone can overstimulate the cells lining the uterus, causing an increased risk of endometrial cancer (cancer of the uterus).

To remove the risk of overstimulation, women who have not had a hysterectomy need to take progesterone, or a synthetic form known as ‘progestin’, together with the oestrogen. ‘Progestogens’ is the name used to refer to both the natural form of progesterone and the synthetic form, ‘progestin‘.

Testosterone therapy

Women with a low testosterone level who are experiencing loss of libido, lack of energy and ongoing fatigue, even when taking oestrogen therapy, sometimes benefit from low-dose testosterone replacement. Testosterone treatment in women aims to restore levels to the typical range.

Some studies have shown women who experience a loss of sexual interest at menopause can benefit from testosterone therapy when it is used together with oestrogen.

A study of women in Australia who had no complaint about their sexual function showed that low sexual desire, arousal, responsiveness and other aspects of female sexuality were not significantly related to low testosterone levels. However, there was a relationship between some aspects of sexual function and other hormones that go on to make testosterone in the body (DHEAS and androstenedione). On the other hand, women seeking help from health professionals because they are concerned about their diminished sexual function often have low testosterone levels.

What are the risks of testosterone therapy?

This therapy is an area of ongoing research to better identify a safe and effective dose of testosterone for women.

Currently, no form of testosterone therapy for women is officially approved in Australia by the Therapeutic Goods Administration (TGA). (The TGA is a government body that assesses and monitors activities to ensure therapeutic goods available in Australia are of an acceptable standard.)

Testosterone treatment in women has been associated with an increased risk of developing:

• oily skin
• acne               
• excess facial and body hair growth
• scalp hair loss
• irritability
• aggression.

Serious potential side effects include deepening of the voice and enlargement of the clitoris, both of which are irreversible. Monitoring testosterone blood levels is important to maintain levels within the normal range to reduce the risk of side effects and serious long-term risks.

One study of testosterone-only treatment in postmenopausal women reported an increased risk of breast cancer compared to women who had received a placebo, or dummy treatment. Most studies of testosterone in women have been performed in postmenopausal women who have undergone a surgical menopause (removal of both ovaries) and have used MHT (oestrogen +/– progestogen) as well as testosterone.

If you are considering testosterone therapy, talk to your doctor to gain a clear understanding of what is currently known about this therapy. It is essential for women undergoing testosterone treatment to be supervised by doctors who are experts in this area.

Tibolone (Livial or Xyvion)

Tibolone is a synthetic hormone and its actions are similar to oestrogen, progesterone and testosterone.

Tibolone acts like	What it affects	Symptoms it assists in preventing
Oestrogen	brain bones vaginal tissue	flushes bone loss dryness and soreness
Progesterone	womb/uterus	overgrowth of the endometrium and subsequent bleeding.
Testosterone	brain sexual function	lowered mood or libido, although women’s responses vary

It can help to improve mood and sleep quality, decrease hot flushes and improve general wellbeing. Tibolone may also help sex drive by improving vaginal secretions, increasing free testosterone and elevating mood.

Tibolone is not associated with an increased risk of breast cancer in women without breast cancer; however, the multinational study of women with menopausal symptoms and breast cancer showed that Tibolone increased the risk of recurrence compared to placebo.

It should also be noted that Tibolone may interfere with the effectiveness of breast cancer therapies, so is therefore not recommended for women with breast cancer.

Conjugated oestrogens & Bazedoxifene (Duavive)

This is a combination therapy of an oestrogen with a SERM (selective oestrogen receptive modulator). It blocks the oestrogen effect in the lining of the uterus, so no added progestogen is needed.

How does MHT work?

Because the symptoms of menopause, such as hot flushes and vaginal dryness, are related to low or fluctuating oestrogen, replacing oestrogen for a period of time helps to control these symptoms.

There are many ways to treat hot flushes and vaginal dryness, but no other treatment has been shown to be as effective as oestrogen replacement therapy.

How long do you take MHT?

Current guidelines recommend women who take MHT for menopausal symptoms take the lowest effective dose to alleviate symptoms for as long as is needed. For the treatment of symptoms, women can stay on MHT for as long as is required to relieve their symptoms. Current thinking is that the benefits of MHT far outweigh the risks in healthy women within 10 years of the menopause or between 50 and 60 years of age.

MHT does not need to be discontinued after five years because:

• the mean duration of menopausal symptoms is approximately eight years
• 20–25% of women will have bothersome symptoms in their 60s and 70s
• 10% of women will have bothersome symptoms for 10 years or more.

Every year, it is important to have a discussion with your doctor about management of your menopausal symptoms. Some women can take MHT safely for many years, but this must be assessed on an individual basis and be supported with annual reviews by your doctor.

In women with premature menopause, MHT is prescribed in high doses and recommended to continue until the age of expected menopause, about 50-52 years.

Ways to take MHT

Pills	Oestrogen and progesterone are available separately or as combined tablets, such as the contraceptive pill packs Conjugated oestrogen & Bazedoxifene Tibolone
Patches	The hormones are absorbed through the skin Some patches contain oestrogen, while others are a combination of both oestrogen and progesterone
Gel	Oestrogen is available as a gel Gel comes in single dose sachets and is used by rubbing into the skin daily
Vaginal creams, pessaries and tablets	Used locally by inserting the cream in an applicator, pessary or tablet containing oestrogen into the vagina Used mainly by women who have vaginal or bladder symptoms
Implants (no TGA approved implant is currently available in Australia)	Implants are: small – less than 1 centimetre long inserted under the skin under local anaesthetic by a doctor
Intrauterine device (IUD)	A progestogen may be prescribed as an IUD, usually initiated in the perimenopause

Dosages and methods of administration vary according to each woman’s needs and responses to MHT. Changes may be needed before a satisfactory method and dose is found for each woman, and such changes should be made under the close supervision of your doctor. It can sometimes take up to six months to find the right combination.

As a general rule when using MHT in midlife:

• start low
• go slow
• review often

The risks & benefits of MHT?

Many studies have investigated whether MHT increases the risk of cancers, further illness and disease. There have been many reports in the media about the risks of MHT.

In 2002, researchers from a large study in the United States (the Women’s Health Initiative trial, or WHI) reported that the risks of MHT outweighed the benefits of taking it. This caused an 80% drop in the use of MHT in the United States, and 50% of women in Australia stopped using their MHT. Professor Henry Burger, a founding director of Jean Hailes, says, “At least half of those women saw their symptoms return and that meant their quality of life significantly suffered”, and “I think that was one of the worst consequences – the decreased quality of life and feeling that you couldn’t do anything about it”.

However, a recent comprehensive review of evidence on MHT has found MHT is an effective and safe treatment for the relief of menopausal symptoms for healthy women. The data from this study has shown that in women between 50 and 60 years, the risks of MHT are low.

The following table lists the benefits and risks of MHT along with conditions that still need further understanding in healthy women between 50 and 60 years, or within 10 years of the menopause. The risks of MHT depend on the type, dose, duration and route of administration or regimen.

Benefits of MHT	Risks of MHT	The relationship with MHT is unclear
Symptom relief for: hot flushes vaginal dryness sleep disturbance with night sweats joint pain and stiffness may reduce deposition of abdominal fat	Breast cancer – 1 extra case per 1000 women treated using MHT per year	Dementia and Alzheimer’s disease.
Decreased risk of: osteoporosis heart disease bone fracture endometrial cancer colorectal cancer onset of type 2 diabetes cataracts	Thrombosis – a low increased risk with oral therapy, especially in the first year of use; less risk with transdermal therapies Stroke – a rare risk Gallstones – increased risk with oral oestrogen and combination MHT Endometrial cancer – if oestrogen alone is given when a woman has her uterus (should have a progestogen) Ovarian cancer – association unsure, but a very rare risk in long-term users Lung cancer – no risk increase	Memory
Other benefits include improvement in: skin and hair headaches aches and pains irritability sleeplessness increased sex drive balance dizziness & vertigo	If you are a smoker, have diabetes, high blood pressure and/or high cholesterol, there is a small but increased risk of thrombosis in taking MHT.	Heart attacks in young women.

Contraindications to taking MHT

• Current, past or suspected breast cancer
• Known or suspected oestrogen-dependent cancer, such as breast and uterine cancers
• Undiagnosed vaginal bleeding
• Untreated uterine lining thickening, which could develop into cancer
• Current thrombosis or DVT (deep vein thrombosis), but a past history would require further investigation to establish if MHT is safe
• Thrombophilia (a group of conditions that lead to an increased risk of thrombosis)
• Untreated high blood pressure, but treated high blood pressure is not a contraindication
• Coronary heart disease, stroke, dementia
• Other rare contraindications include: active liver disease, porphyria cutanea tarda and known sensitivity to active substances or excipients.

Possible side effects of MHT

You may or may not have any of these side effects when you take MHT.

Nausea Fluid retention Feeling bloated Breast enlargement and discomfort	These symptoms may be experienced when you first start taking MHT and become less with time – if they interfere with your daily life, discuss the symptom with your doctor.
Breakthrough bleeding	Some women experience vaginal bleeding in the first six months after starting MHT. In most cases this can be helped by changing the dose or type of MHT. Persistent, unexplained, unscheduled vaginal bleeding should be investigated.
Weight gain	Most studies do not show a link between weight gain and use of MHT In several studies, women who used MHT had less weight gain than those who did not use MHT Women are prone to weight gain around the stomach in midlife (40s–50s); MHT may reduce this

Should you take MHT?

• Jean Hailes strongly advocates that women take a balanced, evidence-based and informed approach to their healthcare: all risks and benefits should be considered when deciding whether to use MHT
• Current recommendations by world experts in menopause, including our own doctors, suggest the benefits of MHT outweigh the risks for healthy menopausal women
• If you choose MHT, you should take the lowest effective dose for only as long as required for your symptoms, and regularly review your reasons to continue (or not) with your doctor
• MHT can be stopped at any time. Once you’ve stopped treatment, any increase in breast cancer risk lessens over time and is lost within five years
• Jean Hailes recommends each woman discusses her decision about taking MHT with her doctor regularly and whenever there are any concerns.

Breast cancer & MHT

For otherwise healthy women, taking MHT for 2-5 years to relieve menopausal symptoms causes little if any increase in breast cancer risk.

Chance of developing breast cancer in a given year:

If you are not taking MHT during menopause	If you take MHT for five years during postmenopause
3 in 1000 chance	4 in 1000

The following factors put you at a higher risk of developing breast cancer than taking MHT:

• having more than two standard alcoholic drinks per day
• being overweight or obese
• having your first child over the age of 35
• having your menopause in your late 50s

This risk should also be seen within the context of the benefits of MHT; taking MHT can significantly improve a woman’s quality of life and reduce the risk of developing osteoporosis, diabetes, colon cancer and possibly heart disease.

Research and best-practice guidelines suggest that menopausal women review their reasons to continue MHT (or not) with their doctor once per year, or more regularly if they have any concerns.

Lung cancer & MHT

For otherwise healthy women younger than 60, taking MHT for the symptoms of menopause, there is no evidence of increased lung cancer risk, or of increased death from lung cancer. For women older than 60, the increased risk of lung cancer is very small.

Chance of developing lung cancer	Chance of dying from lung cancer
3 in 10,000 increased risk	5 in 10,000 increased risk

The following factors put you at a higher risk of developing lung cancer than taking MHT:

• past smoking
• current smoking
• passive smoking (inhaling smoke from others smoking around you).

Older women who are heavy smokers should not use MHT.

Cardiovascular disease & MHT

Cardiovascular disease (disease of the heart and blood vessels) is the leading cause of death in postmenopausal women. Women aged 50-59 years are generally either perimenopausal or postmenopausal. Cardiovascular disease is uncommon in this age group, but the incidence increases rapidly after 60 years of age.

MHT and cardiovascular health	MHT and cardiovascular risk
MHT in tablet form: reduces cholesterol has positive effects on the blood vessel wall	MHT can increase the risk of blood clots forming when blood-vessel plaques (clogged arteries) rupture.
The standard dose of MHT, usually started around the time of menopause, causes no significant increase in cardiovascular disease and may be cardio-protective.	MHT should be avoided in women who have established cardiovascular disease. Increased risk if women commence MHT after 60 years of age.

Managing vaginal problems

The loss of oestrogen at menopause causes changes in the tissues of the vulva, vagina and bladder. Refer to ‘Bladder health’ and/or ‘Vaginal & vulval problems’.

Some of the ways you can manage these symptoms are outlined below, but it is important to discuss with your doctor what is the most suitable option for you.

Dry vagina treatments

Lubricants or oil	Olive oil, sweet almond oil, Pjur, Astroglide and YES
Vaginal moisturisers	Replens and YES
Black cohosh	Topically (as a cream or pessary/pellet), black cohosh has been shown to be effective for vaginal dryness, but more research is still needed on its effectiveness.
Linseed (flaxseed)	About 2 tablespoons included in your daily diet has been shown to reduce vaginal dryness.
Vaginal oestrogen	Oestrogen can be applied directly to the vagina in the form of a cream, tablet or pessary This may be the only treatment required if a woman has only vaginal/vulval or bladder symptoms May be needed as well as MHT (or other medication) prescribed for menopausal symptoms May be suitable for women who cannot take MHT (eg. women with cardiovascular disease). Should be discussed with a doctor Post-breast cancer: use lubricants and moisturisers first low-dose vaginal oestrogen may be considered (after consultation with the woman and her breast cancer doctors) minimal absorption of oestrogens into the blood circulation not recommended if a woman is on aromatase inhibitors (after consultation with the woman and her breast cancer doctors) Requires a prescription
Menopausal hormone therapy (MHT)	Is very effective in managing vagina and bladder symptoms Can be taken in tablet, gel, or patch form
Vaginal laser therapy	Has been used to improve vaginal dryness where oestrogen therapy is contraindicated These studies are short term, and the long-term risks and benefits are yet to be determined

Non-hormonal prescription medications

Some women are not able to use hormone-based treatments for menopausal symptoms such as hot flushes and sweats. (See ‘Contraindications to taking MHT’ above.)

Other women just prefer not to take MHT and want to look for other treatment options. Some of these non-hormonal prescription medications are outlined below and are used ‘off label’ (which means they are being used not for the approved indication).

Studies have shown a reduction in flushing and sweating within four weeks of taking the recommended dose.

Antidepressants

A group of antidepressants called SSRIs/SNRIs (selective serotonin or serotonin-norepinephrine reuptake inhibitors – for example, venlafaxine, paroxetine, escitalopram and fluoxetine) have been studied and found to relieve hot flushes. If these medications are going to be effective in reducing hot flushes, they will do so quite quickly. Like all medications, these can have side effects, some examples being nausea, dry mouth and/or insomnia. Paradoxically, sometimes these medications can cause sweats. In breast cancer survivors on tamoxifen, paroxetine and fluoxetine should not be taken as they can reduce the effectiveness of the tamoxifen.

Gabapentin

Gabapentin is an anticonvulsant and chronic pain medication and has been shown to diminish hot flushes. Side effects may include a rash, dizziness and sleepiness, so it should be taken mainly at night.

Clonidine

Clonidine is a medication for high blood pressure and migraine that has been shown to reduce hot flushes. Side effects may include dry mouth, dizziness and drowsiness.

Complementary therapies

Many women are keen to explore non-medical options to manage their menopausal symptoms. There is increasing evidence looking at the effectiveness of many of these treatments, but very few studies meet the gold standard of research. Some of these treatments are traditional remedies that have been used for many years, but may not have scientific research to support their use. More research on the effectiveness and safety of herbal therapies for menopause is needed.

To make an informed choice about a treatment for menopausal symptoms, it is important to do some reading, from reputable sources of information, about treatments you are considering. Some promoted remedies can be expensive and unproven. Jean Hailes aims to provide the best available information based on current evidence.

It is also important to see a qualified practitioner for advice, and to give all the health professionals you are seeing information about any medications or treatments you are taking or receiving, as there can be interactions.

Herbal therapies and remedies for menopause

Herbal remedies, such as black cohosh and red clover, may be considered as an option for some women in the management of menopausal symptoms, such as hot flushes, night sweats and vaginal changes. Some herbs, such as St John’s wort, may help to manage mood changes, such as anxious thoughts and depressed feelings. Other herbs may help with fatigue, low energy or sleep disturbance.

For more information go to Herbs used in the management of menopause.

Phytoestrogens & menopausal symptoms

Phytoestrogens (plant oestrogens) are compounds that occur naturally in plants and that, under certain circumstances, show some of the same activities as the female hormone oestrogen.

Phytoestrogens are much weaker than human oestrogen, and their effects are different from the hormones found in menopausal hormone therapy (MHT).

About one in three women may benefit from a phytoestrogen-rich diet to reduce menopausal symptoms, as these women have the particular bacteria in the gut that helps to convert the phytoestrogens in soy to a more potent form. Read more about phytoestrogens and why they can be beneficial for some women going through menopause.

Other complementary therapies

Research has considered management of menopausal symptoms with other therapies such as:

• hypnotherapy
• cognitive behaviour therapy
• mindfulness therapy
• acupuncture
• traditional Chinese medicine
• nutrition.

Over-the-counter products

There are many complementary and alternative medicine (CAM) products that contain various formulations of herbs and/or nutrients that are available over the counter for management of menopausal symptoms. The quality of herbs used in these products, including those bought over the internet, can vary. The best way to use herbal remedies for the treatment of menopausal symptoms is under the guidance of a health practitioner trained in their use.

Pharmacy-compounded hormones

Pharmacy-compounded hormones (sometimes referred to as bioidentical hormones) are mixtures of hormones made in compounding pharmacies that are promoted as hormones ‘exactly like our own’ hormones. They can contain oestrogens, progesterone and sometimes other hormones such as testosterone.

The hormones are made into capsules, creams, gels, drops applied to the tongue, lozenges or troches (soft square-shaped tablets) sucked in the cheek.

These hormone products are often marketed using the term ‘natural’, but all hormone therapies are manufactured synthetically in a process similar to the manufacture of the oral contraceptive pill. It is misleading to suggest these preparations have advantages over pharmaceutical oestrogen therapies approved by the TGA (the Therapeutic Goods Administration).

While some women report their menopausal symptoms improve using compounded hormones, this can come at a cost. Not only is this an expensive way to get hormone therapy, but there are real concerns over the safety and effectiveness of compounded hormones. Currently, there are no controls and regulations on their production, prescribing or dosing.

There are questions about the safety and effectiveness of pharmacy-compounded hormones:

• We have no research evidence that the recommended doses of the hormone preparations made by compounding pharmacists are safe or effective
• It has been claimed this form of hormone therapy does not cause side effects, but this therapy is similar to all prescription hormone therapies, and therefore should have the same risks and benefits. This is unproven and unlikely, with many women presenting with known complications of oestrogen and testosterone therapy while on compounded hormonal preparations
• Blood levels of hormones can be very high on troches therapy, and until further research is done, women need to be cautious
• There is no adequate data to show:
  • what dose of the progestogen (progesterone) is appropriate
  • whether the progestogen is absorbed well through the cheek
  • whether it protects the lining of the uterus from conditions such as endometrial (uterine) cancer
• The pharmacists making the compounded preparations are not required to adhere to the codes of conduct of the professional pharmaceutical body, Medicines Australia, as these codes apply only to pharmaceutical companies
• There is limited formal quality control or quality assurance on individual formulations
• Hormone formulations made in a pharmacy are expensive as they are individually prepared.

Further research and regulation of pharmacy-compounded hormones is needed before they can be recommended for use with menopausal symptoms. It is important when seeking any medical treatment that you consult a health practitioner face-to-face, rather than over the phone. Receiving advice or a prescription for medication without the proper advice is not advised.

Women seeking compounded hormone therapy should know that the majority of pharmaceutically produced MHT products in Australia contain oestradiol, identical to the main oestrogen the body makes before menopause, hence, by definition, it is ‘bioidentical’. There is also a progestogen now available in Australia called ‘micronised progesterone’. This hormone is identical to the progesterone made by the body before menopause, so there is an option to use ‘bioidentical’ hormone therapy containing oestradiol and progesterone that has been thoroughly tested for safety and effectiveness in women around menopause.