FAQ

Menopause is the time in a woman’s life when menstrual periods permanently stop, as she reaches the end of her natural reproductive life. Natural menopause occurs when the ovaries inherently begin decreasing their production of the sex hormones estrogen and progesterone. Menopause can also be induced by the surgical removal of both ovaries. The definitive cessation of menstruation is preceded by several months to several years of irregular menstrual cycles which is called peri-menopause. Menopause is a retrospective clinical diagnosis, as the final menstrual period can only be defined if followed by 12 months of amenorrhoea.¹

The menopause is a natural part of ageing that usually occurs between 45 and 55 years of age, as a woman's estrogen levels decline. In the UK, the average age for a woman to reach the menopause is 51.²

In the short term, the decrease in production of sex hormones estrogen and progesterone is responsible for many physiological changes which can manifest by troublesome physical symptoms such as hot flushes and night sweats, vaginal dryness, muscle pain, joint stiffness, etc. In the longer term, menopause can be associated with an increased risk of cardiovascular disease and osteoporosis as the lack of hormones induces a loss of bone density.¹

Because of its rather troublesome and distressing symptoms, menopause can potentially have a strong impact the quality of life including physical health, relationships, hobbies and even work life. For example, hot flushes can disrupt sleep and make women feel tired, vaginal symptoms can affect libido and sex life, forgetfulness and loss of concentration can make work life difficult.^11,14

There are both physical and psychological manifestations of the menopause. Symptoms include hot flushes, night sweats, insomnia, reduced libido, vaginal dryness, headaches, mood changes, irritability, anxiety, palpitations, joint stiffness, aches and pains, reduced muscle mass, recurrent urinary tract infections, low mood, skin changes (dryness, elasticity), difficulty with memory and concentration.^1,11,14

Every woman experiences menopause in their own way. 80% of menopausal women will experience some symptoms, either physical or psychological.¹⁴ In a survey by the BMS (British Menopause Society), 79% of women surveyed experienced hot flushes and 70% experienced night sweats.¹¹

The duration of menopausal symptoms varies from one woman to another. Symptoms are thought to last for a median duration of 4 years, however, 10% of women may continue to experience symptoms for as long as 12 years following the last menstrual period.¹⁵

HRT (hormonal replacement therapy) aims to relieve symptoms caused by lower levels of female hormones during the menopause. Hormonal treatment of menopause usually involves the use of a daily estrogen alone or in combination with a progestogen taken daily or sequentially. It works by restoring the levels of sex hormones in your body.

Not all women have indications for HRT (hormonal replacement therapy). HRT is indicated for the treatment of estrogen deficiency symptoms in menopausal women, such as vasomotor symptoms, and others which may significantly impact their quality of life. HRT should not be recommended without a clear indication and should be individualised, and also adapted over time. HRT should not be initiated in women over the age of 70 years old, or women with history of breast, ovarian or uterine cancer, history of blood clots, liver disease or untreated high blood pressure.¹

The prescriber should consult the individual HRT product SmPC for full information.

HRT (hormonal replacement therapy) comes in multiple forms such as pills, gels, patches or sprays to fit every woman’s needs.

In women who have an indication for HRT (hormonal replacement therapy), it is recommended to start as early as possible. A higher benefit risk balance is achievable if treatment is initiated in proximity to the start of menopause.⁴ Timely initiation of treatment is important. In the age group 50-60 years or within 10 years after menopause, the benefit of HRT is more likely to outweigh the risk.¹

Risks and benefits of HRT (hormonal replacement therapy) differ depending on age of women and menopausal state. The short- and long-term benefits of HRT are:⁵

• Relief of hot flushes and night sweats⁵
• Alleviate urinary and vaginal symptoms⁵
• Prevention of osteoporosis in postmenopausal women at high risk of future fractures who are intolerant of, or contraindicated for, other medicinal products approved for the prevention of osteoporosis^12,13
• HRT may improve joint and muscle pain, mood swings, sleep disturbances and sexual function¹
• Women aged younger than 60 years or who are within 10 years of menopause onset, might experience a more favourable benefit/risk profile associated with HRT.¹

Risks and benefits of HRT (hormonal replacement therapy) differ depending on the age of women, but also on the type of treatment and regimen.⁶ It is important to have at least one consultation annually to assess the efficacy and tolerability of treatment, and to evaluate the individual's benefit and risk balance. Risks of HRT can include an increased risk of:¹⁰

• Breast Cancer
• Venous thromboembolic disease
• Stroke

In order to minimise the individual risks and optimise the benefits, the treatment type, dosage, route of administration and duration of use should be adapted according to the symptoms and history.

A study investigated the long-term effects of using either oestrogen alone (CEE) or combined HRT (CEE+MPA) for a median duration of 7.2 and 5.6 years respectively. The study found no increased risk of all-cause, cardiovascular, or cancer mortality after 18 years of cumulative follow up.⁷ The NICE guideline (NG23) states that HRT does not increase cardiovascular disease risk when started in women aged under 60 years.¹⁰

Please consult the individual HRT product SmPC for a list of full product contraindications. In general, some of the contraindications include: Current or past history of breast cancer; current or suspected oestrogen-dependent tumours (e.g. endometrial cancer); undiagnosed vaginal bleeding; current or history of idiopathic venous thromboembolism; active or recent arterial thromboembolic disease (e.g. angina, myocardial infarction). Please note this is not an exhaustive list.^12,13

Side effects of HRT (hormonal replacement therapy) may include e.g. breast tenderness, bloating, fluid retention, headaches, mood swings and nausea. In case of bothersome side effects, reducing the dose of estrogen, changing the type of progestogen or altering the route of administration can be trialed.¹⁶

According to the IMS 2016 recommendations, there are no reasons to place a mandatory limitation on the duration of HRT (hormonal replacement therapy), provided that it is consistent with treatment goals. The dosage should be titrated to the lowest effective dose. Whether or not to continue therapy should be decided at the discretion of the well-informed woman and her health professional, dependent upon the specific goals and an objective estimation of ongoing individual benefits and risks.¹