frequently asked questions
You asked..here are the answers
How do I know I've started the menopause?
Menopause is defined as the point at which you have not had a natural period for 12 months. The transition up to this point is often referred to as perimenopause or premenopause. Many women who do not have a regular period will not know when this is. For example: those on progesterone-only contraception such as POP or IUS; patients who have had their heavy periods treated with endometrial ablation/myomectomy; or those without a womb but whose ovaries remain.
Often perimenopausal symptoms will develop gradually and can start at any age! My advice would always be do not to wait until you have missed periods for 12 months to seek advice. Seek advice as soon as you start to feel you might be developing any of the symptoms of hormone imbalance as early treatment can be beneficial.
What's the difference between perimenopause and menopause?
Peri- means "around" or "about" and we use the term perimenopause to describe symptoms of reproductive hormone imbalance and fluctuation during the period of time "around" or prior to the menopause. Thus, perimenopause is often a long and poorly defined period of time that can start from any age and can often creep up insidiously.
What are the symptoms to look out for?
Menopause symptoms and perimenopause symptoms can be very similar as they are often due to low or fluctuating levels of important women’s hormones oestrogen, progesterone and testosterone. Due to the widespread presence of sex hormone receptors throughout the body the symptoms and signs can literally impact us from head to toe.
Headline menopause symptoms include, changes to menstrual cycles and periods, hot flushes/flashes, night sweats, weight gain and vaginal dryness.
Often the first signs of menopause and perimenopause are subtle. Early premenopausal or peri-menopause symptoms include new or increasing anxiety, feeling tense or overwhelmed, panic attacks, irritability, mood swings, loss of interest in things, difficulty sleeping, low mood, loss of confidence and self-esteem, memory problems, difficulty concentrating, and brain fog. Early physical symptoms include changes to cycle length, duration and flow during periods, difficulty maintaining weight, night sweats or feeling hot at night, daytime hot flashes/flushes, tiredness, fatigue, low energy, skin, hair and nail changes, palpitations or thumping sensations in the chest, difficulty breathing, increased headache frequency, joint and muscle aches and pains, numbness and pins and needles, recurrent thrush, cystitis and urinary tract infections, painful sex, libido loss and changes to sexual arousal.
Click here to download my symptom-checker based on the The Green Climacteric Scale.
Hormone replacement therapy (HRT) can dramatically improve all of these.
Is weight gain a symptom of menopause and is there anything to stop that?
Weight gain in perimenopause and post-menopause is a very common experience. It occurs as a “normal” response from the body to fluctuations in oestrogen. When the body detects that ovarian oestrogen production is dwindling it compensates by increasing fat cells which are later able to convert other hormones back into oestrogen when ovarian reserve is depleted at menopause. Low oestrogen and testosterone levels also slow down metabolism. Eat well (low GI whole foods will reduce sugar cravings but also crucially avoid dieting/starving as this switches on stress-hormones that encourage weight gain), exercise regularly (weight bearing exercise as well as aerobic is hugely important at this stage), cut down/out alcohol (sorry!) and avoid processed/salty foods that can cause water retention and interrupt gut microbiome (which is a whole other conversation!).
What is HRT actually replacing and why do I need to do this?
Hormone replacement therapy is replacing the reproductive sex- hormones that fluctuate during perimenopause and replaces the hormones that are persistently low postmenopause: most commonly 17beta-estradiol, estriol, progesterone and testosterone. Broadly, we need these to maintain normal function in all the cells of the body! Hence the wide range of symptoms that affect all systems of the body when in insufficient/deficient state.
When is the best time to start HRT? What are the options? Do you ever stop HRT?
If safe, the best time to start is early in perimenopause particularly if symptoms are having significant impact on quality of life. This can help to prevent deficiency symptoms even developing. Every person will be different.
There are many options and depend on lots of factors. The most common and safe regime I prescribe is a combination of transdermal (through the skin) Oestrogen such as Oestrogel, Evorel, Estradot, Lenzetto, Sandrena (all contain 17B-estradiol); plus Utrogestan capsules which contain "body identical" progesterone when progesterone is required; with vaginal Estriol (Vagifem, Blissel, Ovestin, Imvaggis) for any localised vulval or urogenital symptoms; and transdermal testosterone for symptoms of Female Androgen Deficiency Syndrome (FADS), Female Sexual Interest and Arousal Disorder (FSIAD) and Hyposexual Sexual Desire Disorder (HSDD).
Stopping HRT at intervals to assess if symptoms have become manageable is good practice. We aim to use the lowest HRT dose possible to adequately control symptoms. There is no longer any fixed cut off for HRT.
If you take HRT how long do you have to be on it?
There is no defined time frame and the accepted advice is that a person can stay on HRT for as long as they require provided regular review to ensure ongoing prescriptions remain in the patients best interests. I have women in their 80s who refuse to come off it as it has been a lifeline for them! An annual review for individualised management taking into account the risks vs benefits is best practice. It can be helpful to have a regular "break" to determine if symptoms have settled to a tolerable level. The aim is always to ensure the lowest necessary dose of HRT to manage symptoms effectively.
Are there other benefits to HRT besides relieving perimenopausal and menopausal symptoms?
Studies show that HRT started within the optimal "window" of within 5-10yrs of menopause can improve cardiovascular risk and outcomes (i.e. reduce risk of strokes and heart attacks)
HRT will also prevent loss of bone mineral density, protecting against osteoporosis and fragility fractures.
Use of HRT in the perimenopause or premenopause can prevent severe symptoms of oestrogen deficiency developing that can then become difficult to fully "reverse".
How long do you need to be perimenopausal for before the NHS will prescribe HRT?
This upsets me so much. You should not need to suffer unnecessarily for any duration of time if you have symptoms that are causing you difficulties. Unfortunately, there are many health care professionals who (like me) were taught through our training that HRT was not safe and as such many patients cannot access appropriate treatment due to fear of harm being caused. And we all take an oath to first "do no harm". If you are being asked to wait for a defined period of time before you will be allowed the treatment you require, I would consider seeing an alternative NHS GP or seeking a private perimenopause assessment. We can often tailor a treatment plan and request your NHS GP to take on prescribing of this once your symptoms have been stabilised.
Do you have to pay for HRT?
Yes unless you are exempt from NHS prescription charges. As they are priced per item, if you are using a combination of oestrogen, progesterone, testosterone and vaginal treatment you will be charged 4 separate prescription charges. You may wish to apply for an NHS prepayment certificate which can help with costs.
If you seek HRT prescriptions privately there are private prescriptions charges which vary according to products prescribed.
Does HRT increase your risk of breast cancer?
I am going to choose my words carefully here. Use of combined HRT is associated with a small increased risk of breast cancer. In most recent published guidelines there is no significantly increased risk seen in patients using oestrogen-only HRT. We do not yet fully understand if this association is a causative one or a coincident one. Women are most likely to develop breast cancer in their late 40s-50s and this is also when women are most likely to be using HRT. There is a hypothesis that in some women with very early breast cancer cells present, initiating HRT can switch the cancer cells "on" and thus seem to cause breast cancer. This has not been proven despite many meta-analyses of many clinical trials.
What are your thoughts on Compounded bio-identical HRT?
I do not prescribe these. We now have "body-identical" HRT preparations available that are rigorously tested and fully regulated by the MRHA. Compounded bio-identical HRT has not been through the same rigorous safety testing and there are no high-powered clinical studies supporting its benefits over standardised "body identical" preparations. It is also REALLY expensive, and patients require much more close monitoring with annual pelvic scans and more frequent mammograms to ensure no harm is caused - which in turn is very expensive and increases radiation dose exposure.
What type of conditions would not be recommended for HRT?
Active breast, ovarian or endometrial cancer, personal history of hormone sensitive breast cancer, strong family history of breast cancer, and some inflammatory conditions such as Lupus.
What are the alternatives to HRT?
This is a big topic and a question that comes up a lot. HRT remains the most effective way of managing the root cause of perimenopause and menopause symptoms. However, there are additional and alternative things to consider alongside or in place of HRT. These are particularly important for women who are unable to use HRT for safety reasons.
Anti-anxiety and anti-depressant medications such as “SSRI” fluoxetine, paroxetine, escitalopram or “SNRI” venlafaxine can be a real ray of hope for women struggling with mental health issues and hot flushes and can be taken alongside or instead of HRT. There are new drugs in development on the horizon too. Calcium, Vitamin D and bisphosphonate medications are important for bone health particularly for women who cannot safely use HRT.
Specialist Women’s Health and Pelvic Physiotherapists are a valuable resource to consider for Musculo-skeletal and pelvic health problems.
I like to consider “4 pillars” that are relevant to non-hormonal health too:
Nutrition: broadly, aim for stable blood sugar levels and a diverse gut microbiome by eating a high-fibre, whole-food and plant-rich diet with plenty of omega-3’s and calcium. We get very little vitamin D in the diet so I would suggest a supplement at 1000iu daily unless you are deficient. Cut down or cut out alcohol – it really doesn’t help with symptoms or health and well-being in the long term. The supplement industry is BIG and aimed at selling things. If you have a healthy varied diet you are likely to get enough of the micronutrients that you need but if you are looking for supplements consider one that as well as Vitamin D contains B6 and b12, magnesium and maybe collagen. There is no strong research evidence supporting the use of specific herbal supplements.
NICE (National Institute of Clinical and Health Excellence) are clear in their 2015 guidance that to ensure safety approval look for herbal remedies that carry the THR logo. St Johns Wort and Black Cohosh interact with other drugs so do not start these without medical advice. St Johns Wort also makes Tamoxifen ineffective. Isoflavones, red clover and black cohosh are not safe for survivors or women with breast cancer.
Movement & Exercise: move as much and often as possible and try to introduce a variety of activities to challenge the body in broader ways. Pilates, yoga, Strength and weight-training, conditioning, steady-state cardiovascular exercise and low-intensity movement such as walking are all important to consider.
Sleep: prioritise it. Avoid late night blue-light. Increase early morning and daytime daylight to naturally improve melatonin levels. Avoid caffeine after lunch and avoid alcohol which disrupts sleep. Get regular exercise and arm yourself with some relaxation and mindfulness techniques. Consider guided online CBT for insomnia such as Sleepful or Sleepio or invest in 1:1 CBT for insomnia.
Stress- management: Notice thoughts and feelings and how they affect your body and breath. Learn some breathing, relaxation and mindfulness exercises to help down-regulate your stress response. Recognise your warning signs and take pre-emptive action. Snatch moments of mindfulness, sprinkle in and micro-dose with acts of self-care. Share and cultivate nourishing relationships in which you can be honest. Be kind to yourself and approach challenges with Curiosity. Learn to say no, set boundaries, and stick to them. CBT, ACT or coaching can be a worthwhile investment as can complementary therapies to help sooth, calm and nourish such as reflexology and acupuncture.
What would you recommend as a first port of call for researching HRT?
Women's Health Concern is the website of the patient arm of the British Menopause Society and contains information based on their evidence based national guidance.
I think the NHS and Patient UK website are also a good place to start researching.
https://menopausesupport.co.uk/ is home to the #MakeMenopauseMatter campaign founded by the indomitable Diane Danzebrink.
https://www.balance-menopause.com/ is the new website from Dr Louise Newson @menopause_doctor and her team providing excellent evidence-based information advice and guidance. They have also launched the free Balance Menopause App which amazing, alongside https://www.nhmenopausesociety.org/ and https://www.themenopausecharity.org/
Dr Newson was featured alongside Davina McCall documentary Sex, Myths and Menopause on Channel 4 which is also a great place to start learning about perimenopause, menopause and post-menopause problems and solutions