Introduction

Hormonal regulation in the premenopausal female

As a woman exceeds optimum childbearing age, her ovaries stop producing oestrogen and progesterone which regulate the menstrual cycle. As a result, the monthly release of an ova ceases. 

 

Menstruation becomes irregular and less frequent, until eventually stopping altogether. This time of irregular bleeding is known as perimenopause. A reduction in the levels of circulating hormones occurs usually over several years, and during this time women can experience significant symptoms from the decreasing oestrogen levels. These are discussed in more detail below.

 

A woman has reached the menopause once she has not menstruated for one year. The average age for a woman in the UK to reach the menopause is 52. Following this point, she is described as post-menopausal.

 

The menopause can also occur at any age earlier than it would have naturally if a woman has both her ovaries removed, for example in a hysterectomy with oophrectomy.

Side effects

Hot flushes

These are the most common complaint and are thought to be a result of increasing gonadotrophin levels in response to newly unresponsive ovaries. They can begin several years before the start of the menopause and persist for years after. During a hot flush a sensation of intense heat is experienced, often accompanied by flushing of the face and body, occurring with varying frequency and lasting a few minutes on average. This can cause great embarrassment to the woman and, if so severe they cause night sweats and affect sleep quality, they can also affect mood and concentration.

 

Vaginal symptoms

Oestrogen is responsible for the elasticity of tissues around the vagina and for the production of vaginal fluid. This secretion lubricates and moistens the vaginal walls, and is also acidic so protects the vagina from infections. As oestrogen levels decline, tissue in the vagina becomes thinner and less elastic, and the number of small mucus producing glands decreases. This can lead to a dry vagina, soreness, dyspareunia and a predisposition to infection. If these changes to the vagina cause significant symptoms, it is known as atrophic vaginitis.

 

Urinary symptoms

During the menopause, lower UTIs such as cystitis are more common. Urgency and frequency of micturition can also be experienced.

Common SEs of the menopause

Treatment options

Lifestyle changes

Before treatment is commenced, steps can be taken to improve symptoms naturally. Hot flushes can be reduced in severity by wearing light clothing, keeping cool, enjoying regular exercise and also taking steps to reduce stress in everyday life. Possible triggers should also be avoided, such as caffeine, spicy food, alcohol and cigarettes.

 

Lubricating gel

If vaginal dryness is the only complaint of the patient, or hormonal treatment would be contraindicated, a lubricated gel may be highly effective. There are certain lubricants designed specifically to help replace the lost moisture and these are available over the counter.

 

Local oestrogen therapy

The use of topical oestrogen has far less side effects than systemic therapy and can be very effective in those with predominantly vaginal symptoms.

 

Oestrogen creams or pessary - Inserted in the vagina using an applicator.

 

Oestrogen-releasing vaginal ring - A synthetic soft rubber ring, which releases oestradiol gradually and is changed every three months.

 

Systemic Hormone Replacement Therapy (HRT)       

This replaces the hormones that the ovaries are no longer producing. There are 3 main types:

  • Oestrogen only – for women who have had their uterus and ovaries removed so have no need for progestogen (as only used to decrease the chance of endometrial cancer). Oestrogen is taken daily.
  • Cyclical – for women who are still having periods but are experiencing menopausal symptoms. On this form of HRT, women will continue to have periods. Oestrogen is taken daily, then progestogen is added for 14 days either monthly or three monthly, causing a withdrawal bleed.
  • Continuous combined – for women who are post-menopausal (i.e. no periods for a year). Both oestrogen and progestogen are taken daily with no break.

 

    It is generally agreed that the benefits of short term HRT (i.e. < 5 years) outweigh the risks. If taken for longer, yearly review with a doctor is advised. Long term use of HRT to prevent osteoporosis is not normally recommended, as alternative medications are available with far lower health risks.

     

    HRT is contraindicated in those who

    • Are pregnant
    • Have untreated hypertension
    • Have liver disease
    • History of Blood clots
    • Previous Heart disease or stroke
    • Have ever had breast, ovarian or endometrial cancer

     

      HRT can be taken in a variety of ways:

      • Oral tablets
      • Pessary
      • Gel applied to skin
      • Cream applied to vagina
      • Skin patch
      • Implant

       

        Some of the common suggested advantages and disadvantages are listed below, although some of these are controversial.

        Advantages and Disadvantages of HRT

        Alternative treatment options

        Antidepressants

        These can be effective in reducing hot flushes, especially SSRIs (selective serotonin reuptake inhibitors). However, they can cause considerable side effects such as nausea and insomnia.

         

        Tibolone

        This synthetic hormone contains a combination of oestrogen and progestogen, so only one tablet must be taken daily. However, it carries the same health risks as HRT.

         

        Clonidine

        Although originally used to treat hypertension, it may also have a beneficial effect on hot flushes. Hypotension can be a common side effect.

         

        Alternative therapies

        Many believe herbal supplements can have an important role to play in treating menopausal symptoms. These include ginseng and soya beans.

        Did you know..

        • A girl is born with all the eggs she will ever have
        • At 16-20 weeks gestation, a female fetus has 6-7 million oocytes. At birth, this has decreased to 1-2 million, and by puberty she has only 350,000!
        • Around 400 mature eggs will be released during a woman's life.
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