Menopause is a natural process that all women will experience, but like many other matters affecting womens health, is often discussed in hushed voices and brushed under the carpet! The symptoms can be debilitating so it can be helpful to understand practical ways to manage menopausal symptoms.
As a society we need to talk about menopause and be more open about it. The symptoms that accompany it can be extremely disruptive, and affect your daily life.
This blog post was written in collaboration with Dr Paula Greally to try explain some practical ideas to help improve the symptoms.
What is menopause?
Menopause happens when periods cease. Perimenopause is the time from when a woman starts to experience symptoms up until her periods stop.
Post menopause is defined as experiencing no menstrual period for 12 months. The average age of the menopause in the UK is approximately 51 years of age (1).
If a woman has menopause before the age of 40 years of age it is called premature menopause.
Menopausal symptoms are caused by declining hormone levels, particularly oestrogen levels. But other things can also influence the symptoms, for example changes in diet and exercise, lifestyle or medications.
70% of women will experience vasomotor symptoms such as hot flushes and night sweats according to the British Menopause Society (1). These symptoms can come on while women are still having periods due to the gradual reduction in hormone levels.
The symptoms can last variable amounts of time, from months to years.
What happens to the vagina?
The cells lining the vagina are dependent on oestrogen, so after the menopause, this lining thins. This causes symptoms of vaginal dryness, itching, and often pain during intercourse.
On examination, the vagina typically appears pale and flattened with scanty pubic hair.
What are the symptoms?
The symptoms can be wide ranging and varied.
Early symptoms include:
1. Physical:
- Change in period frequency and amount/duration of bleeding
- Night sweats
- Hot flushes
- Palpitations
- Headaches
- Joint pains
- Insomnia
2. Psychological:
- Mood swings
- Anxiousness
- Irritability
- Forgetfulness
- Poor concentration levels
- A feeling of inability to cope
3. Sexual:
- Vaginal dryness
- Uncomfortable intercourse
Later during menopause/post menopause:
Women can start passing urine frequently, have discomfort passing urine, leaking and urinary tract infections, further vaginal dryness, itching and burning. These symptoms can be particularly debilitating and distressing.
Other symptoms that women can experience are skin itching and hair thinning.
What can women do to help these symptoms?
There are several different approaches women can try to practically help with these symptoms.
General lifestyle changes:
- Keep a healthy weight with a BMI of 18.5-25kg/m2 and stop smoking: being overweight has been shown to increase hot flushes & increase risk of cardiovascular disease, type 2 diabetes & osteoporosis (thining of the bones).
- It is never too late to stop smoking!
- Minimise alcohol intake: decrease to 2 units/day or less. Excess alcohol can make hot flushes worse & can contribute to osteoporosis and cardiovascular disease.
- Adopt a Mediterranean style diet:
- At least 5 portions of fruit & vegetables/day with one or two servings of oily fish per week. If eating meat, chose lean meat.
- Protein is very important for menopausal women as they are less able to build muscle mass compared to men of the same age.
- The recommended intake of fibre for women is 25-35g of fibre/day (@orlawalshnutrition has some great posts about fibre).
- Keep your diet low in saturated fat and sugar & high in calcium and vitamin D (see below).
- Ensure adequate calcium and vitamin D intake for good bone health: The National Institutes of Health recommends 1200mg of dietary calcium daily for women & the National Osteoporosis Society recommends 700mg/day.
- This should come from your diet, but some women may benefit from calcium supplements.
- Vit D is also important for bone health & 10micrograms/day is recommended as a supplement for most women. Some may need higher supplement levels depending on their vit D blood levels.
- 150 minutes of physical activity per week: this helps protect bones, maintain muscle mass & can help with hot flushes.
- A mix of cardiovascular & weight bearing exercise is best for bone & heart health.
- Pelvic floor exercises can really help with some of the urinary symptoms of menopause & a check in with a women’s health physio can be beneficial for this.
Sweats and flushes:
Hot flushes and night sweats are the most common symptoms of the menopause. They can start before periods stop and can be particularly bad for the first year after the final menstrual period.
They may start as an intense heat in the upper body, arms and face and this can progress to the skin flushing and extreme sweating.
These sweats and flushes are often associated with a feeling of anxiety and a sense of the heart racing. Often, they can happen at night and women may be known to leave their bed to go to an open window to cool off, some needing to change their nightwear due to sweating.
Depending on the severity of the flushes, there are several things that women can try:
- Avoid triggers! Women may notice that certain things can trigger flushes like alcohol, caffeine, spicy food, warm temperatures, stressful situations. Some of these triggers may be avoidable and thus stave off the flush.
- Thermal water sprays – these are available in most pharmacies and there are many different brands of thermal water sprays which women can try. The water is sprayed as a fine mist onto the face, chest, arms etc. and can help the skin feel cooler instantly.
- Wears layers during the day that are easy to remove on and off.
- Sleep in a cool room. Try a gel cooling pad tucked into the pillowcase or alternatively a frozen icepack under the pillow (put in a Ziplock bag so it doesn’t wet the pillow) and turn the pillow over when the underside is cool. Lie on the cool side of the pillow and do not put the icepack directly to the face!
- Some people find breathing exercises can help with hot flushes/sweats. The North American Menopause Society has fantastic information here.
Psychological symptoms
Cognitive Behavioural Therapy (CBT) is recommended by NICE in the UK for helping with depression and anxiety associated with the menopause (2).
CBT can also be hugely helpful for hot flushes and sweats. The Women’s Health Concern has a wonderful factsheet about CBT for the menopause available here.
Urinary and Sexual issues
Reduced oestrogen levels can result in vaginal dryness. Vaginal secretions can also decrease which results in reduced lubrication.
This can lead to discomfort with intercourse, burning and dryness down below, itching, increased urination, increased urinary tract infections and sometimes incontinence of urine.
First-line therapy, available over the counter, for vaginal discomfort is using non-hormonal vaginal moisturizers and lubricants. They are useful mostly for women with mild symptoms. Vaginal moisturizers are intended for use routinely, typically two or three days per week, not just during sexual activity. These products are typically bioadhesives.
These non-prescription products can be bought in most large pharmacies in the UK and Ireland.
1. Lubricants eg YES and Sylk
Lubricants should be applied before intercourse.
Women should be aware that oil-based lubricants cannot be used with latex condoms or diaphragms. However, water-based lubricants are available which can be used with latex products.
2. Vaginal Moisturisers: Replens, Regelle and Hyalofemme
Vaginal moisturisers provide longer term relief and should be applied regularly independent of when you are having intercourse. These are water based products and therefore they are compatible with latex condoms and diaphragms (3).
3. Skincare
Skin becomes drier during and after the menopause and woman may find that their skin care needs may change.
The American Association of Dermatologists recommend using SPF and moisturiser daily to protect ageing skin. They also recommend using a mild cleanser instead of soap to prevent stripping the skin of moisture. More information available here.
Medications for management of menopausal symptoms
The next stage in the management of menopausal symptoms is to have a chat with your GP or OBGYN about medications which can be used to help.
An initial option for managing painful intercourse would be Vaginal estrogen. This can can improve dryness or discomfort (burning, itching, irritation), tissue fragility (this may result in postcoital bleeding or fissures), or painful intercourse.
Adequate estrogen therapy leads to restoration of the normal vaginal acidic pH, thickening of the outer skin layers, increased vaginal secretions, and decreased vaginal dryness. It can also reduce the incidence of urinary tract infections and overactive bladder symptoms.
If symptoms do not improve with these topical treatments the next step would be to discuss starting systemic treatment, meaning oral HRT.
Hormonal Replacement Therapy (HRT) is the gold-standard treatment which has shown to help with a range of symptoms of the menopause but also offers women protection against cardiovascular disease, osteoporosis and maintenance of muscle mass.
However there needs to be a discussion with your healthcare provider regarding the risks versus benefits of HRT according to the woman’s individual situation.
It is important to personalise all treatment discussions. All women will experience different severities when it comes to menopausal symptoms – some barely notice any change while others have the full range. Therefore there is no treatment that is right for everyone.
There are also non-hormonal medication options available for which healthcare providers can provide information and advice.
There are several completementary therapies for which there is mixed evidence:
- Phytoestrogens: the most important being isoflavones (found in soybeans, chickpeas, red clover) & lignans (found in flaxseeds, cereal bran, whole cereals, veg, legumes & fruit)
- A Cochrane review 2013 reported slight reduction in some studies in flushes/sweats but overall no better than placebo. More research needed.
- Phytoestrogen supplements are NOT recommended for women with breast cancer.
- Black Cohosh: this is an herbal remedy which can help with hot flushes but not as well as HRT.
- A Cochrane Review 2012 found there is not enough evidence to support its use for menopausal symptoms, but more research is needed.
- Long-term safety is unknown and cannot be used if a woman has liver disease & can interact with some medications (mostly cancer therapies).
- Ginseng: A Cochrane-style review 2013 = no effect on menopausal symptoms.
- Evening Primrose Oil: Evidence = effects on menopausal symptoms is no better than placebo (as per BMS).
- Sage: a very popular therapy. No good scientific studies on its effectiveness have been published.
- St John’s wort: limited evidence that it can help with flushes/sweats but there are concerns about interactions with multiple medications. Women with breast cancer who are taking Tamoxifen absolutely CANNOT take St John’s wort as it stops Tamoxifen from working.
- Some clinical trials have shown good results with acupuncture when compared with no treatment.
Hopefully some of these tips are helpful!
References:
1. Hillary T, Abernethy K, Hamoda H et al. (2017). Management of the Menopause. 6th Edition. Plymouth UK. The British Menopause Society
2. National Institute for Health and Care Excellence. Menopause: diagnosis and management Guideline [NG23]. London: NICE; 2015 Available at https://www.nice.org.uk/guidance/ng23/chapter/Recommendations
3. Edwards D, Panay N. Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubrication and moisturizer composition? Climacteric, 2016; 19(2): 151-61