Menopause is a time of life which brings a range of symptoms—some of which will be felt severely by some women, while others barely suffer at all—accompanied by a great deal of sensationalised media coverage
For a start, the term “menopause” is often attributed to the years of symptoms experienced by women reaching the end of their reproductive years—but that’s not quite accurate.
The menopause is defined as a woman’s final menstrual period. When many people refer to “menopause,” what they actually mean is the “perimenopause”—that transitional time from when irregular periods begin, to 12 months after the occurrence of the final menstrual period.
“My personal experience as a pharmacist indicates that most people (both women and men) have a vague idea of what menopause is linked to hot flushes, mood swings, decreased libido and vaginal dryness, and sleep disturbances,” says Dr Judith Singleton, from the Faculty of Health at the Queensland University of Technology.
“However, I think most would not be aware of perimenopause and that there is a difference between perimenopause and menopause itself as well as other possibly lesser known symptoms such as memory loss or disturbance, the weight gain, and depression.
“Once women reach that age they tend to do a lot of research on the internet for themselves – pharmacy customers today tend to be better informed than ever before and there are excellent sources of information which many women access themselves or can be directed to by their pharmacist.
“Unfortunately, people tend to read lots of forums as well so there is also a lot of misinformation out there that pharmacists could help clarify.”
Fear of HRT
While hormone replacement therapy – now known as menopausal hormone therapy (MHT) – is still the major treatment for menopause symptoms, many women are worried about taking it due to widely-reported 2002 findings from the Women’s Health Initiative, says Dr Elizabeth Farrell, gynaecologist and Medical Director at Jean Hailes for Women’s Health.
“There is still fear in the community around the Women’s Health Initiative and their breast cancer findings,” she says.
“The data from the study was not presented accurately and was reported in the media creating fear and panic. The data was not presented giving the absolute risk of breast cancer which is very low.”
Dr Treasure McGuire, from the University of Queensland’s School of Pharmacy, explains that mainstream media reporting on the WHI findings around breast cancer, and the early termination of the combination therapy arm of the study, had a significant ripple effect throughout the pharmaceutical sector, the women’s health stakeholder sector and among women with an interest in managing their symptoms.
In 1991, around the world 13% of women aged 50-plus were using HRT. By 2000, this proportion peaked at 27%, she says.
“In the world of 2000, it was becoming the norm,” Dr McGuire says. “But that all changed in 2002.
“We have a scenario where the pendulum swings. We were pro-HRT, then we were anti-HRT – to the point where the learned bodies in this area have changed the name. It’s no longer HRT, instead it’s MHT, and that’s to try and take some of the inappropriate stigma away from these drugs.”
Pre-2002, HRT was taken not only for management of symptoms such as hot flushes and to slow the development of osteoporosis: it was also thought to be cardiovascular-protective. This has now only been shown to be the case in certain cohorts – for example, women with an intact uterus who are younger than 60 years of age or within 10 years of menopause.
Dr McGuire says that the WHI has taught stakeholders about how such mainstream media reports affect help-seeking by affected individuals.
“If you think about the Catalyst program recently on statins, it’s a similar story.”
The eight extra cases of breast cancer are all the public remember about the WHI data as reported, she told the AJP.
“There were also eight less cases of colon cancer. Nobody ever said, ‘HRT protects you from colon cancer’. We overestimate and focus on risk, rather than benefit.”
The fear generated by the 2002 reports, and the fact that many women stopped taking HRT as a result, resulted in more harm than benefit overall, she says.
“The media has a lot of responsibility when it comes to reporting on the latest in clinical trials, because people latch onto these reports as the be-all and end-all.”
The combination therapy arm of the WHI was terminated early, in 2002 after just over five years; meanwhile the oestrogen-only arm was terminated in 2004, also early. But outcomes of this latter study did not gain the same kind of media traction as the breast cancer finding.
“It was terminated because of an increased risk of stroke. When that happened, the media didn’t raise an eyebrow.
“We now know, fairly comfortably, that there’s a window of opportunity for women to use MHT, and unless there are major contraindications in family history et cetera, then in that decade from the beginning of the transition into the climacteric period, for most women the benefits of managing those vasovagal symptoms outweighs the risk,” Dr McGuire says.
She says meta-analyses show that oestrogen MHT is still the most effective means of treating hot flushes and has a role preventing bone loss.
“We can say pretty confidently that if you’re on MHT, you will reduce your fracture risk. You’ll probably increase your thrombosis risk and you may increase your stroke risk on oral MHT, although the absolute risk of stroke with initiation of MHT before age 60 years is rare.
“We need to ask women what they know, what their perceptions are of risk. How willing are they to tolerate risk? Some will say that if there’s any risk, they won’t do something; we can’t make decisions for people, but need to understand where they sit in that risk tolerance spectrum.
“If they’re risk intolerant they’re not going to feel comfortable taking MHT.
“It’s a shared conversation. We probably don’t do that enough of that with women with reproductive issues. The more the pharmacist and their other primary health carer – the GP – do that, the more women will rely on us and the more comfortable they will be in their decision-making.”
What’s the risk?
Just how high is that increased risk of breast cancer? Judith Singleton explains that combination HRT increases the risk of breast cancer by 75% even when only used for a short time.
“There is also an increased risk that a woman diagnosed with breast cancer will die of the disease. The risk of developing breast cancer is highest in the first two to three years of taking the combination HRT.
“After ceasing the combination HRT, it takes approximately two years for breast cancer risk to drop back down to average. Oestrogen-only HRT increases breast cancer risk but only when used for more than 10 years. This type of HRT also increases the risk of ovarian cancer.”
She also highlights the importance of tibolone, the synthetic steroid which has a different pharmacological and clinical profile to the sex steroids.
“Tibolone has a complex mode of action,” says Dr Singleton. “It is an oral medication that is metabolised rapidly in the intestine and liver into active metabolites, two of which have an oestrogenic action in various tissues such as bone and vagina, and a third which binds to both progesterone and androgen receptors.
“There is evidence from the observational Million Women Study that tibolone increases the risk of breast cancer more than oestrogen-only therapy, but less than combined HRT.”
Two patient groups also need to be discussed, she says.
“Women who have tested positive to an abnormal breast cancer gene (BRCA1 or BRCA2) should not take HRT as they already have an abnormally high risk of developing breast cancer. The hormones in HRT can cause hormone-receptor-positive breast cancers to develop and grow.
“Another patient group to consider are women successfully treated by surgery for early stage breast cancer. These women often experience severe hot flushes as a result of adjuvant pharmacological treatment (tamoxifen, aromatose inhibitors, gonadotropin-releasing hormone (GnRH) analogues or chemotherapy).
“Combination HRT, oestrogen-only HRT, and tibolone are contraindicated in this patient group because of the risk of breast cancer recurrence.”
Dr Singleton stresses that it is important to alert patients to the fact that so-called “bioidentical” or
“natural” hormones have the same higher breast cancer risk as synthetic hormones.
“‘Bioidentical’ means that the hormones in the products are identical to the hormones produced by the human body,” she told the AJP.
“They are said to be ‘natural’ because they are derived from plants as opposed to synthetic hormones that are produced in a laboratory but are also chemically identical to the body’s hormones.
“Unfortunately, many of these products are registered with the TGA as AUST L (Listed medicines) rather than AUST R (registered medicines). Listed medicines are assessed by the TGA for quality and safety but not efficacy i.e. the TGA has not evaluated them to determine if they actually work.
“It’s the same in the USA – many of these herbal and ‘natural’ (bioidentical) hormones fall outside the jurisdiction of the FDA and so aren’t subject to the same level of regulations and testing that prescription HRT medications are.
“The issue is women purchasing these ‘natural’ products online and being unaware that they are still exposing themselves to this increased risk of breast cancer.”
Changing the conversation
The menopause is probably talked about more in the 21st century than in the past – but is that discussion actually helpful?
Dr Singleton says that Australia suffers in general from ageism discrimination in the workforce, and that menopause is linked in with this phenomenon as an “old woman’s condition”.
“It shouldn’t be a taboo subject – we need to understand and support female colleagues going through perimenopause or menopause. Also, many younger women also experience menopause due to surgery,” she says.
“But equally, women should not have to be at the receiving end of seemingly lighthearted comments and jokes about menopause.
“You wouldn’t believe how many men find it funny to crack the ‘are you having a hot flush Mary?’ when an older woman comments that it’s hot.
“So, whilst it shouldn’t be taboo, I think we need to remove the inappropriate comments and jokes out of the workplace and certainly not discuss menopause with patients at the front counters of busy community pharmacies where all the world can hear the discussion.”
This is particularly important when discussing symptoms such as those which affect sexual function.
“Reduced sexual activity due to pain on intercourse, vaginal dryness, and reduced libido can cause relationship problems and contribute to depression,” says Dr Singleton.
“It is a symptom that should be treated very seriously if a female customer plucks up the courage to discuss this matter with you. If a couple have tried personal lubricants and it is still not helping uncomfortable intercourse, I would recommend the woman seeks the advice of a gynaecologist and even better, one who specialises in menopause (there are menopausal specialists).
“First, risk factors have to be weighed against the impact of menopausal symptoms such as sexual function. It is always tricky broaching or discussing these tricky areas – but keep your tone professional, sympathetic, and try not to look awkward or uncomfortable as this will make the patient feel uncomfortable as well.
“We need to handle this situation like any other less embarrassing patient interaction – calm, professional and above-all caring. Certainly, we should not push our opinion or ‘judge’ a patient if their choice is counter to our suggestions.
“Also, take the patient to a private counselling room – certainly do not broach the topic at the busy S2/S3 counter. Pharmacists need to keep in mind the Australian Privacy Principles.”
Community, consultant and locum pharmacist and 2010 PSA Pharmacist of the Year Karalyn Huxhagen says pharmacists can help by bridging gaps in knowledge imparted by GPs, and reaching out to their network of local health providers to find help for customers experiencing menopausal symptoms.
“There are deficits in knowledge,” Ms Huxhagen says. “A lot of people don’t realise that the symptoms can go on for a very long time. What I see in clinical practice is that women come into the pharmacy and say, ‘I’m not taking any more of these – it’s been five years, surely I’m over it’.
“They go off the medicine for a couple of months and then they come back and they’re on it again.”
She says that doctors don’t always have the time to explain the range of physiological changes which can take place to their patients, so pharmacists can have a role in helping.
“I think there’s a bit of a gap in explaining those ups and downs of hormone levels, or what’s going to happen if your uterus is still functioning, if you still have one – it doesn’t just shrivel up and die when you turn 55 – or the involvement of the liver.
“There’s a disconnect. People make fun of it, but they don’t really talk about the depth of it. They’ll say things like, ‘I sweated a gallon today,’ or ‘I’m sick of the mood swings and my husband wants to kill me,’ but they don’t get that bigger picture, and they probably don’t have the opportunity to sit down with their husband or family and say, ‘these mood swings are significant and I can’t control them’.
“Often asking for help, and the resultant intervention, is some time after the symptoms start.”
Ms Huxhagen suggests pharmacists could ask patients who come in to ask about symptoms such as mood swings or hot flushes to start keeping a symptom diary.
“We can explain that these are a collection of symptoms, and you really need to just write down everything. Write down that four nights out of one week, you woke in a lather of sweat; or that every morning you woke with a crashing headache; or that you’ve had to buy a bra two sizes bigger because your boobs are so tender.
“Then book a long consult and have that conversation with your GP.”
Pharmacists should also not be afraid to reach out to specialists in their local area, she adds.
“We have a brilliant ob/gyn team here in town, a husband and wife team, and we refer a fair number of women to them. We say, ‘why don’t you consider going and seeing these guys, because it’s their speciality of practice?’”
Treasure McGuire agrees that getting to know local health professionals is an important step in helping women manage their symptoms.
“What better way to introduce yourself to a GP you don’t know, than to say you have a regular patient who’s asked these questions, and they’d like to discuss them with you, their GP.
“GPs will come to you if they have trust and respect for you as a peer, and this is part of that journey. The more we use our medicines expertise and involve the other key players in the global health village, the more likely we are to build those kind of relationships where we keep our customer for longer and are able to help them more.
“This is not about dispensing an antibiotic that somebody takes for five days. Women need to be comfortable with the long-term impact of their decision to use or not use MHT. Pharmacists can be part of that journey.”
Menopause: signs, symptoms and linked conditions
Dr Elizabeth Farrell told the AJP that in western societies, the natural age of menopause occurs between a wide age range of 45 – 60 years, with most occurring between 48-53 years. The average age is 51 years.
“The menopause signs and symptoms can be attributed into three categories. About 20% of women will have no symptoms except their period stopping, about 20% will have severe symptoms impacting on quality of life however the majority of women will have mild to moderate symptoms.
“Periods can stop suddenly whereas other women will have a decrease in frequency and flow as they lead up to their final period. However, some women have chaotic periods which may be heavy, prolonged, painful and cause an increase in pre-menstrual like symptoms. It is this last group who may be counselled to seek assessment by their GP.
“As the perimenopause is a transitional time and hormones are altering from the irregularity in the production of the ovaries there can be extreme ranges of hormone levels with women having high hormone levels one week and low the next. With the chaotic release of hormones women may find their mood alters, they’re more irritable and less able to cope.
“It is in this transition and after the final period that women may experience severe hot flushes and night sweats impacting on quality of life. Women may experience vaginal dryness and have discomfort with intercourse, may develop urinary symptoms including urinary tract infections (UTIs) as well as general joint aches and pains.”
She says that menopause is not linked to causing conditions such as diabetes or depression, but that women who are predisposed to depression or other mood disorders may find their condition is exacerbated during perimenopause.