Menopause screening

As the menopause approaches, the ability of the ovaries to respond to certain hormones decreases. This leads to an increase in the production of these hormones (follicle stimulating hormone, or FSH, and luteinising hormone, or LH). The levels of these hormones can be measured as an indicator of the approaching menopause. Home kits are available that check for raised FSH in the urine. Blood tests are also available, however the sample should be taken between the third and fifth day of a woman’s period as the levels of the hormones will vary significantly throughout her cycle.

It is important to note that a normal level of these hormones does not mean the woman is not entering the menopause and a raised level does not mean that the ovaries are definitely going to stop functioning. This is because the level of FSH can vary as a result of other factors, such as stopping some forms of hormonal contraception. A decision to stop using contraception should therefore not be made based solely on raised FSH levels.

The diagnosis of menopause should be made on a combination on factors, including:

• history of period pattern
• presence of menopausal symptoms
• occasionally, measurement of FSH, LH and oestrogen levels (these are most useful when premature menopause is suspected, if there is no regular period pattern, when unusual symptoms are present and when fertility appears to be reduced).

Web links associated with menopause screening

The British Menopause Society is dedicated to increasing awareness of postmenopausal healthcare issues and promoting optimal management of the menopause through conferences, roadshows and publications.
www.the-bms.org/

Menopausematters.co.uk is an independent, clinician-led website. It provides easily accessible, accurate, up-to-date information aimed at women and healthcare professionals about the menopause, its symptoms, and treatment options.
www.menopausematters.co.uk

Marie Stopes International Global Partnership is an organisation that provides sexual and reproductive health information and services. It has a website covering options and services in the UK on abortion, contraception, emergency contraception, male and female sterilisation and health screening, including menopause screening.
www.mariestopes.org.uk

General web links associated with the menopause

The 2004 PRODIGY guidance on management of the menopause covers the management of the menopause, including the place of both hormone replacement therapy (HRT) and alternatives to HRT. It provides comprehensive information about HRT and prescribing protocols for different patient scenarios.
www.prodigy.nhs.uk

The Natural Menopause Advice Service (NMAS) was established to help women to manage the menopause successfully. It has a number of factsheets written by clinicians available on its website.
www.nmas.org.uk

The NHS Direct on-line health encyclopaedia covers the menopause.
www.nhsdirect.nhs.uk/en

GP notebook is a system designed to provide a concise synopsis of the entire field of clinical medicine with material organised systematically to ensure rapid retrieval of information. There is a section on the menopause.
www.gpnotebook.co.uk

NetDoctor has a section on the menopause, what it is, its symptoms and their treatment.
www.netdoctor.co.uk

Patient UK provides evidence-based information on health, disease and related issues, written by GPs. It contains information on the menopause.
www.patient.co.uk

Early Menopause UK provides advice, support and information on the menopause, particularly aimed at women going through it early, for example as a result of a hysterectomy or cancer treatment
www.earlymenopauseuk.co.uk

Articles published in the British Medical Journal on the menopause and HRT since January 1998 are available at:
www.bmj.com

Cancernet has a section on the menopause and its symptoms.
www.cancernet.co.uk

The International Menopause Society aims to promote knowledge, study and research on all aspects of ageing in men and women.
www.imsociety.org

Women’s Health Concern is a charitable organisation, which aims to help educate and support women with their healthcare by providing unbiased, accurate information. It has a factsheet on the menopause.
www.womens-health-concern.org

The British Menopause Society is dedicated to increasing awareness of postmenopausal healthcare issues and promoting optimal management of the menopause through conferences, roadshows and publications.
www.the-bms.org

Menopausematters.co.uk is an independent, clinician-led website that provides accessible, up-to-date, accurate information about the menopause, its symptoms and how these symptoms can be treated. It covers HRT and alternative therapies.
www.menapausematters.co.uk

Breast screening

Breast screening is used to enable early detection of breast cancer. It involves an X-ray of each breast, while it is being compressed (a mammogram). The NHS has a breast screening programme for women over the age of 50 years, which was set up by the Department of Health in 1988. Early detection means a good chance of successful treatment. Around half of all breast cancers detected by screening are small enough to be removed without removing the whole breast.

Younger women are not offered routine screening because mammograms in pre-menopausal women are not as useful in the detection of early stage breast cancer, because the breast tissue is denser.

Further information and a range of guidelines on breast screening, aimed at different healthcare professionals are available from the NHS cancer screening website.

Websites associated with breast screening

The NHS has produced a number of publications, including Breast screening: the facts, to inform women about what breast screening can and cannot do. It has a number of publications on its website, including guidelines for healthcare professionals.
www.cancerscreening.nhs.uk

CancerHelp UK gives information about cancer for anyone who has concerns about cancer, principally people with cancer, their relatives and friends.
www.cancerhelp.org.uk

Cancer Research UK has information on its website on all types of cancer, including a section on breast cancer screening.
www.cancerresearchuk.org

GP notebook is a system designed to provide a concise synopsis of the entire field of clinical medicine with material organised systematically to ensure rapid retrieval of information. There is a section on breast cancer, including breast cancer screening.
www.gpnotebook.co.uk

Sexual dysfunction

Many women enjoy sex more after the menopause. However, some problems may occur around the menopause. Some postmenopausal women find that they do not feel like having sex or that their orgasms can become less intense. The two most common problems that arise after the menopause are:

• discomfort during sex
• loss of libido (sex drive).

After the menopause, a woman’s body produces less oestrogen, which over time tends to alter the tissues around the vagina, making it feel smaller and tighter with less lubrication. This can cause some discomfort during intercourse. It can be helped by using lubricants beforehand. Available on prescription are oestrogen-containing creams and pessaries that can replace the oestrogen in the vaginal tissue. Hormone replacement therapy, or HRT can also help as it restores the tissues around the vagina to its pre-menopausal state. However HRT is not recommended for long-term use unless symptoms are troublesome.

A number of women ‘go-off’ sex after the menopause. In extreme cases women do not want to have sex at all. This is unavoidable, however it can be exacerbated by depression or other problems that occur after the menopause, such as hot flushes or a dry vagina. Often these are temporary, but if they persist, can usually be treated (for example with HRT).

Websites associated with sexual dysfunction

NetDoctor is an on-line collaboration between doctors, healthcare professionals, information specialists and patients providing, wherever possible, quality-assessed information on the basis of the principles of evidence-based medicine. It contains a section on sex after the menopause.
www.netdoctor.co.uk

The BBC Health web pages contain lots of information on women’s health, including an article on sex after the menopause.
www.bbc.co.uk

NHS Direct has a Best Treatments website, in which there is a section on loss of libido in post-menopausal women.
www.besttreatments.co.uk

The National Library for Health contains an article on the effects of a testosterone patch on the libido in postmenopausal women.
www.library.nhs.uk

HRT

HRT, or hormone replacement therapy, is available in many formulations, and can be taken as pills, implants and patches. It can contain either oestrogen and progestogen, in which case it is called combined HRT, or oestrogen alone. A comprehensive list of the HRT treatments that are available in the UK can be found on NetDoctor. The main aim of HRT is to alleviate the symptoms of the menopause through a daily dose of oestrogen. Formulations that contain progestogen as well are usually used in women who have not had a hysterectomy.

During the menopause (perimenopause), women often experience erratic periods and can therefore be prescribed a preparation that is designed to mimic the menstrual cycle. The preparation consists initially of oestrogen, and then progestogen is added for the last 12 to 14 days of the cycle. Once a woman has not had a natural period for a year, she is described as postmenopausal and is more likely to be prescribed continuous combined HRT, with which she will not menstruate at all. Side-effects are rare, but can include nausea, breast tenderness, weight gain and fluid retention. If a woman experiences side-effects initially, they usually settle after a few months. If they do not, the medication may need to be adjusted to something that suits her better.

HRT is often taken for around six months. However, because of poor compliance, it usually needs to be taken for a longer period. The Department of Health does not recommend it for long-term treatment unless symptoms require it and other treatments have not proved effective. This is because the health benefits that it was thought to offer, for example protection from heart disease and stroke are now being questioned. In addition, it has recently been confirmed that HRT increases the risk of a woman developing breast cancer and endometrial cancer (cancer of the lining of the uterus).

Further information on HRT can be found at the NetDoctor website.

Websites associated with HRT

The Royal College of Obstetricians and Gynaecologists (RCOG) has compiled a good practice report on HRT in the management of the menopause
www.rcog.org.uk and the guidelines Hormone replacement therapy and venous thromboembolism (19).

Patient UK provides evidence-based information on health, disease and related issues, written by GPs. It contains information on HRT and the menopause.
www.patient.co.uk

The NHS Direct on-line health encyclopaedia contains a section that covers the menopause and HRT.
www.nhsdirect.nhs.uk/en

Women’s Health Concern is a charitable organisation, which aims to help educate and support women with their healthcare by providing unbiased, accurate information. It has a factsheet on HRT and the menopause.
www.womens-health-concern.org

Hot flushes and other symptoms

The most common symptoms of the menopause are hot flushes and sweating attacks, which occur in around three quarters of women. A hot flush lasts for three to six minutes and is caused by something that triggers the blood vessels in the skin to dilate (widen) and the sweat glands to become active, in a similar way that they would if a person were too hot.

Another common symptom is sleep problems. This can be in the form of difficulty in falling asleep, restlessness or night sweats.

Other less common symptoms include depression, mood swings, tiredness and headaches.

Physical and physiological changes that occur during the menopause include:

• thinning of the skin
• vaginal dryness, causing discomfort during intercourse
• loss of libido
• more frequent urination
• unfavourable changes in blood cholesterol levels as a result of falling oestrogen levels
• osteoporosis.
  

Websites associated with hot flushes and other symptoms

The Royal College of Obstetricians and Gynaecologists (RCOG) has compiled a good practice report on HRT in the management of the menopause and its symptoms.
www.rcog.org.uk

Complementary medicine

There is a range of complementary therapy for management of menopausal symptoms. Black coshosh is a well-known complementary therapy, which has been used for centuries by North American Indians for a range of gynaecological problems. Black cohosh (or Cimicifuga racemosa) is a member of the buttercup family and is a woodland perennial. It has similar properties to plant oestrogens and it binds to the same receptors in the body that oestrogen does. People taking drugs for high blood pressure or those sensitive to aspirin and aspirin-related products should exercise caution when taking black cohosh. Further information on black coshosh and other alternative therapies can be found on the Menopause Matters website.

Phytoestrogens are becoming increasingly popular as alternatives to HRT. This is because recent evidence shows that diets rich in phytoestrogens cause women to have a much lower incidence of heart disease, osteoporosis and other ‘western diseases’. In addition, women with a diet rich in these compounds do not suffer with hot flushes and sweats to the same extent as women in the western world. Phytoestrogens are compounds found in plants that have similar activity to oestrogen, and as such help regulate the hormonal imbalances seen in menopausal women. Several supplements containing phytoestrogens have been developed. The two classes of phytoestrogen that have the highest activity are:

• isoflavones (of which four have been identified)
• lignans isoflavones.

Red clover is a good source of all four isoflavones, and the brand ‘Novogen Redclover’ is now endorsed by the British Menopause Society. However, women with breast cancer should exercise caution as some experts believe that even small amounts of oestrogen can have an adverse effect.

For further information on phytoestrogens, visit the Menopause Matters website.

Other complementary treatments that may help include:

• acupuncture
• aromatherapy
• ayurdeva (and ancient Indian holistic approach that includes herbal treatment, detoxification and massage)
• homeopathy
• reflexology.

Diet and exercise are also known to help with the symptoms of the menopause. Women who are fit and healthy tend to cope better with the symptoms than women who are not.

Websites associated with complementary medicine

Patient UK provides evidence-based information on health, disease and related issues, and is written by GPs. It contains lots of information on the menopause, including alternatives to HRT.
www.patient.co.uk

Women’s Health Concern is a charitable organisation, which aims to help educate and support women with their healthcare by providing unbiased, accurate information. It has a factsheet on alternative therapies for the menopause.
www.womens-health-concern.org

The British Menopause Society is dedicated to increasing awareness of postmenopausal healthcare issues and promoting optimal management of the menopause through conferences, roadshows and publications. It has a factsheet on alternative therapies.
www.the-bms.org

Nutritional support

Women who exercise and follow a healthy diet are able to cope better with menopausal changes. A healthy diet will also protect them against diseases such as heart disease and osteoporosis. Women suffering from symptoms of the menopause who want to try to control their symptoms through their diet can contact the Women’s Nutritional Advisory Service (Admin tel: 01273 487366) which designs individualised diets to help with hormonal problems. The organisation claims an 85 to 90% success rate in symptom control after four months of following their recommended diet.

Some women find that spicy foods, caffeine (in tea, coffee, cola, etc), smoking, and alcohol may trigger symptoms like hot flushes. These women may find that avoiding these things may help.

A diet rich in phytoestrogens may be helpful in managing the symptoms of the menopause. There are many forms of complementary medicines available that contain phytoestrogens, but these compounds are also present in the following foods:

• cereals, such as oats, barley rye, brown rice and bulgar wheat
• seeds, such as sunflower seeds, sesame seeds, pumpkin seeds, poppy seeds and linseeds
• pulses, such as soya beans and soya-based products (except soya sauce)
• beans, such as chickpeas, kidney beans, haricot beans, broad beans and green split peas
• vegetables, such as red onions, green beans, celery, sweet peppers, sage, garlic, broccoli, tomatoes and bean sprouts.

Some commercially available foods also contain phytoestrogens, such as Bergen bread, Provamel yoghurts and "So Good" milk.

Diets rich in calcium (available in dairy products) and vitamin D (found in oily fish, dairy products and margarine) are important to prevent osteoporosis, which is a common complication of the menopause.

Websites associated with nutritional supports

The National Health Advisory Service (NHAS) is an organisation that provides effective nutritional advice for women on an individual basis. It was formed in 1984 to help women overcome premenstrual syndrome. It has subsequently evolved to provide advice to help women sail smoothly through their menopause, overcome symptoms of irritable bowel syndrome as well as addressing other important health issues.
PO Box 268, Lewis, East Sussex BN7 1QN. Admin tel: 01273 487366

Patient UK provide