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Learning objectives
After reading this feature, you should be able to:
- Recognise the signs and symptoms of the menopause and the impact they have on women’s lives
- Discuss the different types of HRT and current clinical thinking on the balance
of benefit versus risk - Provide information to female customers to help them make informed choices on menopause symptom relief.
Key facts
- There are an estimated 13 million peri- and post-menopausal women currently living in the UK
- Management options for the menopause include hormone treatments and lifestyle interventions
- Pharmacy has an important role to play in menopause management – from timely diagnosis to evidence-based advice on sympton management.
Information about the menopause is very easy to come by nowadays thanks to widespread coverage in the media and on the internet — but not all the advice on offer is reliable. This is where community pharmacy teams can help.
Menopause marks the cessation of a woman’s menstrual cycles and the end of the reproductive period of life that began at puberty. There are an estimated 13 million peri- and post-menopausal women in the UK – around one in four of whom will experience severe and debilitating symptoms.1 Menopause occurs as a natural part of the ageing process, most commonly between 45 and 55 years of age, but can also be triggered by hormonal treatments or surgical removal of the reproductive organs.
Menopause occurs when ovulation stops – leading to a fall in levels of key reproductive hormones, most notably oestrogen but also progesterone and testosterone. Menopause that occurs before the age of 45 years is known as premature ovarian insufficiency (POI). This affects around one in every 100 women in the UK and can occur spontaneously or as a result of oophorectomy, cytotoxic cancer treatment, underlying health conditions such as Addison’s disease and Down’s syndrome, or an autoimmune disorder like type 1 diabetes.2,3
The journey towards menopause – officially confirmed when a woman has not had a period for at least one year – can be a long one, punctuated by irregular menstruation and a host of problematic symptoms. This perimenopausal period lasts around four years on average and is characterised by lighter or more irregular periods. In addition to changes to their menstrual cycle, most women will experience other peri and/or postmenopausal signs and symptoms, which can exert a significant impact on quality of life.
Common symptoms include hot flushes, night sweats, vaginal atrophy and dryness, sleep disturbances, mood changes, anxiety/depression, reduced libido, and issues with cognition and memory – known as 'brain fog'. The majority of women who experience these symptoms report behaviour changes as a result, and almost half of menopausal women say they feel depressed.1
Hormone treatments
Different types of hormone replacement therapy (HRT) are available to treat the symptoms of menopause and come in a range of formulations including tablets, skin patches, gels and implants.
HRT products are centred around the two key female reproductive hormones – oestrogen and progesterone – which may be taken together (combined HRT) or as oestrogen-only HRT. The latter is generally only recommended for women who have undergone hysterectomy.
The recommended treatment schedule for HRT hinges on whether a women is in the initial stages of menopause or has already been experiencing symptoms for some time. The two key types are cyclical (also known as sequential) HRT or continuous combined HRT.
Cyclical HRT is suitable for women with menopausal symptoms who are still menstruating. If periods are regular, then monthly HRT is recommended; if periods are irregular, then women may have three-monthly HRT. Both involve taking daily oestrogen with additional progestogen for the last 14 days of the one-month or three-month period respectively to mimic the natural reproductive hormone cycle.
Women who are definitively post-menopausal (i.e. have not had a period for at least one year) typically receive continuous combined HRT where oestrogen and progestogen are taken daily with no breaks.
It is generally recommended that HRT is continued for a few years, until the point where menopausal symptoms have passed, before gradually tapering the dose. Sudden cessation may lead to a resurgence of symptoms.
Hot topic
In 2002, the Women’s Health Initiative Study published research purporting to show an increased risk of both breast cancer and cardiovascular disease in women taking combined oestrogen and progesterone HRT.4 These findings led to thousands of women abandoning their HRT prescriptions and succumbing to difficult menopausal symptoms.
Since then, HRT has continued to be a hot topic – with the publication of a steady stream of often conflicting research and evidence on the benefits and risks. It should then come as no surprise that, as the Menopause Charity points out, “many GPs, nurses and pharmacists feel deskilled in this area as we have moved through nearly two decades of the media demonising HRT. The result of this is that many women now struggle to access up-to-date information about the menopause in general, as well as HRT”.2
Clinical thinking on HRT has now evolved to recognise that, as stated explicitly by the NHS, “the risks of HRT are small and usually outweighed by the benefits”.3 Current perspectives on the benefits/risks of HRT have been further refined by increasing awareness of the negative toll of the menopause on physical health, as well as mental wellbeing.
The key advantage of HRT lies in its ability to effectively ameliorate both physiological and psychological menopause effects. By replacing the female hormones that decline naturally with age, HRT can combat the hormonally-driven symptoms of menopause, with the added advantage of helping to prevent the development of osteoporosis.
On the risk of breast cancer, the NHS says that women who take HRT for more than one year have a higher risk of breast cancer than women who never use HRT. “The risk is linked to all types of HRT except vaginal oestrogen. The increased risk of breast cancer falls after you stop taking HRT, but some increased risk remains for more than 10 years compared to women who have never used HRT.”
To put this into perspective, a recently published analysis by the British Medical Journal estimated that for every 10,000 women who take combined HRT, between nine and 36 extra cases of breast cancer will develop as a result.5
Although HRT tablets can lead to a small increase in the risk of blood clots, this does not seem to apply to patch and gel formulations. In terms of cardiovascular health, HRT is not linked to an increased risk of heart disease or stroke if started before the age of 60 years – and may actually reduce risk. HRT tablets do carry a slightly increased likelihood of stroke but, as with blood clots, the risk is small.3
Despite the clear positives of HRT, side-effects can occur and commonly include breast tenderness, nausea, headaches, abdominal discomfort and vaginal bleeding. HRT may not be a suitable option for certain cohorts of patients, including those with a history of breast, ovarian or uterine cancer, prior blood clots, uncontrolled hypertension and liver disease.
Alternatives to HRT
For women unable or unwilling to take HRT, alternative management options for menopause are available utilising both pharmacological interventions and lifestyle measures.
Tibolone is a synthetic oral steroid medication that works by mimicking the activity of female sex hormones and can help to tackle the hallmark symptoms of hot flushes, depressed mood and low libido. Associated risks are similar to HRT and include an increased likelihood of breast cancer and stroke.
Other pharmacological options include selective serotonin reuptake inhibitors and serotonin-noradrenaline reuptake inhibitors which, although not licensed as menopause therapies, may help to alleviate hot flushes – as well as helping with depression and low mood.
Clonidine is another non-hormonal drug specifically indicated for vasomotor symptoms associated with the menopause. Treatment moderates the vascular changes associated with menopausal flushing. Patients should be aware that it can take two to four weeks for the full therapeutic effects of clonidine to become apparent.
Bioidentical hormones, often vaunted by celebrities and popular culture as a ‘safe’ alternative to HRT, are not recommended by the NHS due to a lack of clarity over their benefits/risks, plus complete absence of medical regulation. Similarly, NICE advises healthcare professionals “to explain to women that the efficacy and safety of unregulated compounded bioidentical hormones are unknown”.6
Bioidentical hormones should not be confused with body identical hormones or micronised progesterone, which can be prescribed to treat menopausal symptoms.
Complementary therapies are an important area where pharmacists can provide value-added advice to female customers given the range of menopause preparations available. Although there is some evidence to support a role for St John’s Wort and black cohosh in alleviating symptoms such as hot flushes, the data are not robust and uncertainties over optimal dosing remain.
In terms of lifestyle measures that can improve menopause symptoms, regular physical activity, eating a balanced diet, stopping smoking, maintaining a healthy weight and making efforts to reduce stress levels are all important.
In particular, post-menopausal women should be encouraged to take weight-bearing exercise and strength training activities to build bone strength and combat the effects of declining hormone levels on muscle mass. Caffeine, alcohol and spicy foods have all been linked to hot flushes, so cutting down on these food groups may help. For customers experiencing night sweats, wearing loose cotton clothing and sleeping in a cool, well-ventilated room is recommended.
Pharmacy opportunity
Menopause provides an important opportunity for pharmacists to help female customers. As Boots pharmacist Hala Jawad explains: “I can provide a patient-centred approach to advising women about the menopause that includes advice on health, wellbeing and food, OTC medication, herbal remedies and vitamins. Pharmacists can also provide information about the risks and benefits of HRT that will allow patients to make an informed choice about symptom relief.”
The importance of pharmacy is underscored by the fact that approximately two-thirds of women complain of a general lack of support and understanding surrounding the menopause.1
According to NICE, laboratory tests are not required for diagnosis in otherwise healthy women aged over 45 years with menopausal symptoms.6 Any woman who has not had a period for at least 12 months (and is not using hormonal contraception) or women without a uterus with menopause symptoms can be confidently said to be menopausal.6 Similarly, perimenopause can be diagnosed based on vasomotor symptoms – principally hot flushes and sweats – and irregular periods alone.
In addition to confirming a patient’s diagnosis, pharmacy teams can also help in delivering some of the key pillars of good menopause management in the community setting. These include:
- An explanation of the different stages of menopause and common symptoms
- Advice on lifestyle changes and interventions that can help with general health and wellbeing
- An evidence-based overview of the benefits and risks of treatment for menopausal symptoms
- A frank discussion around the long-term health implications of the menopause.6
Given that the menopause affects half the population and has huge implications for women’s physical and psychological health, there needs to be much greater access to help from their primary care team for women at this crucial time in their lives, reiterates the Menopause Charity.
A plethora of resources are available for pharmacists wishing to educate themselves further on all areas of the menopause.
- The British Menopause Society (BMS) publishes a range of materials aimed specifically at healthcare professions that seeks to dispel common misconceptions and myths around menopause, as well as outlining major clinical guidelines on menopause management and HRT. The society also publishes an evidence-based handbook on the management of menopause.
- The Menopause Charity provides a free Confidence in the Menopause online video course for healthcare professionals, including pharmacists, which is CPD accredited. This menopause educational programme takes around six hours to complete and is aimed at any healthcare professional who sees women and who would like to formalise and accredit their learning and consulting skills in the area of the menopause.
References
- Menopause Support
- The Menopause Charity
- NHS: Menopause
- The Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in health postmenopausal women: principal results from the Women's Health Initiative Randomized Controllled trial. JAMA 2022; 28(3):321-333
- British Medical Journal. 2020. Study provides new estimates of breast cancer risks associated with HRT.
- NICE. NICE guideline [NG23]. Menopause: diagnosis and management. Updated December 2019.
- Medicines & Health Products Regulatory Agency. February 2022.
- British Menopause Society. HRT to be made available over the counter. Press release February 2022.
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