Recognising menopausal symptoms and their implications

What you should already know:

The average age of menopause in the UK is 51¹. The menopause is a normal life event for women, not an illness or medical condition. As the life expectancy of women has increased over the past century many women, on average, spend one-third of their lives being postmenopausal.

The most common menopausal problems are vasomotor symptoms (i.e. hot flushes and night sweats). Other symptoms include mood changes, memory loss, vaginal dryness and soreness, reduced libido, sleep disturbances, joint pains and muscle stiffness. These symptoms can be non-existent, last for a few years, or even decades. Around 75% of menopausal women experience symptoms, with one third of these describing them as severe.

The perimenopausal fluctuations in oestrogen and ultimately its decline, cause acute menopausal symptoms. Usually these begin with a change to the menstrual pattern, but the distribution of oestrogen receptors throughout the whole body explains why numerous widespread menopausal symptoms can occur.

The diagnosis of menopause can usually be made on symptoms alone in women over the age of 45. Only in those under 45 should a serum FSH be performed with two raised FSH levels taken 4-6 weeks apart being diagnostic. However, due to daily fluctuations in FSH in the perimenopause, a normal FSH in the transitional period should not be a reason not to treat menopausal symptoms.¹

Premature ovarian insufficiency (POI) is menopause occurring below the age of 40 and affects 1% of women.³ Often there is a delay in the diagnosis being made with women presenting several times before the diagnosis is considered. These women with POI require HRT (unless there is a contraindication) until at least the average age of menopause in order to prevent the increase risks of cardiovascular disease, dementia and osteoporosis which are otherwise associated with POI.³ They often need psychological help to come to terms with the diagnosis.

What isn’t as widely known, but you should think about:

The menopause consultation should be an opportunity for a mid-life check-up as medical intervention at this point of life can offer women years of benefits from preventive healthcare.

After the menopause there is an increased risk of:

• Cardiovascular disease.
• Type 2 diabetes.
• Osteoporosis.
• Osteoarthritis.
• Hypertension.
• Raised cholesterol.
• Dementia

In addition, women with POI have a greatly increased risk of CVD and these women need appropriate hormonal therapy.

Although hormone blood tests are not usually required in order to make a diagnosis of menopause, the following investigations may be considered:

• Lipids to aid calculation of cardiovascular risk score.
• HbA1c to check for diabetes if women have other risk factors.
• Thyroid function tests as many of the symptoms of menopause are similar to those of thyroid disease.⁴
• DEXA scan for women with POI and those with increased fracture risk.

Lifestyle intervention at this juncture with regards to normalising body mass index, blood pressure, stopping smoking and increasing exercise will have beneficial effects in the longer term.

In addition to treatment of menopausal symptoms for compassionate reasons to relieve the suffering the symptoms cause, there are also long-term health benefits for hormone replacement therapy. If given in the ‘window of opportunity’, below the age of 60 and within 10 years of the menopause, it has been shown to be beneficial in improving cardiovascular health⁵ and cognitive function⁶. It is bone protective if started at any age.⁷

There is also a strong economic argument for giving women a symptom free menopause. Women make up almost half of the UK workforce. As retirement age increases, women are working longer and so a huge proportion of the UK labour force will experience menopause transition during their working lives. The March 2019 Office of National Statistics estimate is that there are around 4.38 million women aged 50-64 years old in employment in the UK.⁸ Significant numbers of women find individual symptoms associated with the menopause transition problematic at work.⁹ About half of menopausal women find it difficult to cope with work during the menopausal transition.¹⁰

The British Occupational Research Foundation report found that poor concentration, tiredness and poor memory are the most troublesome symptoms at work and 42% thought their perceived job performance had been negatively impacted on by menopause.¹¹ Menopausal symptoms should therefore be viewed as an occupational health issue.¹²

Dr Alice Scott is a GP in Shenfield, Essex. She has a special interest in the menopause.

Dr Louise Newson is a GP and menopause specialist in Stratford-upon-Avon. She is also a director of the Primary Care Women’s Health Forum.

References

1. NICE. Menopause: diagnosis and management. NICE Guideline [NG23]. 2015. Available at: www.nice.org.uk/guidance/NG23
2. Baber RJ, Panay N, Fenton A. IMS Writing Group. 2016 IMS Recommendations on women’s midlife health and menopause hormone therapy. Climacteric 2016; 19 (2):109-50.
3. Maclaran K, Panay N. Current Concepts in Premature Ovarian Insufficiency. Women’s Health 2015; 11 (2): 169-182.
4. M. M. Uygur, T. Yoldemir & D. G. Yavuz (2018) Thyroid disease in the perimenopause and postmenopause period, Climacteric, 21:6, 542-548, DOI: 10.1080/13697137.2018.1514004
5. Lobo RA, Pickar JH, Stevenson JC, Mack WJ, Hodis HN. Back to the future: Hormone replacement therapy as part of a prevention strategy for women at the onset of menopause. Atherosclerosis 2016; 254: 282-290.
6. Maki P. Is timing everything? New insights into why the effect of estrogen therapy on memory might be age dependent. Endocrinology. 2013;154(8):2570–2572.
7. Villiers TJ, The role of menopausal hormone therapy in the management of osteoporosis. Climacteric. 2015;18 Suppl 2:19-21.
8. Office of National Statistics March 2019: https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/employmentandemployeetypes/datasets/employmentunemploymentandeconomicinactivitybyagegroupnotseasonallyadjusteda05nsa
9. The effects of menopause transition on women’s economic participation in the UK. Government Publication July 2017: https://www.gov.uk/government/publications/menopause-transition-effects-on-womens-economic-participation
10. T. Kopenhager & F. Guidozzi (2015) Working women and the menopause, Climacteric, 18:3, 372-375,
11. Women’s Experience of Working through the Menopause Amanda Griffiths, Sara MacLennan & Yin Yee Vida Wong A Report for The British Occupational Health Research Foundation 2010 https://www.bohrf.org.uk/downloads/Womens_Experience_of_Working_through_the_Menopause-Dec_2010.pdf
12. https://www.som.org.uk/sites/som.org.uk/files/Guidance-on-menopause-and-the-workplace.pdf