Menopause is a normal event that almost every woman will experience but individual symptoms will vary and could have a physical and psychological impact, writes Kathy Oxtoby... 
 

The symptoms of the menopause can include hot flushes, night sweats. vaginal dryness and discomfort during sex, difficulty sleeping, and low mood or anxiety. 

Guidance on how to best manage these symptoms continues to develop. NICE Guideline NG23, updated in December 2019, advises adapting a woman’s treatment as needed based on her changing symptoms. 

NICE advises that women are offered hormone replacement therapy for vasomotor symptoms “after discussing with them the short-term (up to 5 years) and longer-term benefits and risks”.  

It says that HRT and cognitive behavioural therapy (CBT) can be considered to alleviate low mood or anxiety arising as a result of the menopause. Selective serotonin re-uptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) should not be routinely offered as first-line treatment for vasomotor symptoms alone, the guidance states. 

Vaginal oestrogen can be offered to women with urogenital atrophy (including those on systemic HRT) for as long as needed to relieve symptoms. 
Regarding complementary therapies and unregulated preparations, women should be advised that the “the efficacy and safety of unregulated compounded bioidentical hormones are unknown”, says NICE.  

Risks and benefits of HRT 

In December 2019, in response to an MHRA safety alert on hormone replacement therapy (HRT) and the risk of breast cancer, NICE replaced its recommendations on breast cancer risk from HRT with a link to the MHRA's advice on HRT risks and benefits (see Useful resources). 

The baseline risk of breast cancer for women around menopausal age varies from one woman to another depending on the presence of underlying risk factors, according to NICE guidance. HRT with oestrogen alone is associated with little or no change in the risk of breast cancer. 
However, HRT with oestrogen and progestogen can be associated with an increase in this risk. Any increase in the risk of breast cancer is related to treatment duration and reduces after stopping HRT. 

NICE advises considering transdermal rather than oral HRT for menopausal women who are at increased risk of venous thromboembolism (VTE). 
HRT does not increase cardiovascular disease risk when started in women aged under 60 years. The presence of cardiovascular risk factors is not a contraindication to HRT “as long as they are optimally managed”, says NICE. 

Taking oral (but not transdermal) oestrogen is associated with “a small increase” in the risk of stroke. But the baseline population risk of stroke in women aged under 60 years is “very low”. 

Taking HRT (either orally or transdermally) is not associated with an increased risk of developing type 2 diabetes. HRT is not generally associated with an adverse effect on blood glucose control in women with type 2 diabetes, the guidance says. 

Women’s risk of fragility fracture is decreased while taking HRT. “This benefit is maintained during treatment but decreases once treatment stops, and may continue for longer in women who take HRT for longer,” says NICE. 

Contraception advice 

Advice about contraception for peri- and post-menopausal women can be found in the FSRH Clinical Guideline from the Royal College of Obstetricians and Gynaecologists. Women should be informed that although a natural decline in fertility occurs with age, and spontaneous pregnancy is rare after age 50, “effective contraception is required until menopause to prevent an unintended pregnancy”. 

Health professionals should discuss sexually transmitted infections (STIs) and sexual health with women over 40. “This population should be advised about condom use and protection from STIs even after contraception is no longer required,” the guidance states. 

Women should also be informed that “contraception does not affect the onset or duration of menopausal symptoms but may mask the signs and symptoms of menopause”. Women using sequential HRT should be advised not to rely on this for contraception.  

The FSRH supports extended use of the copper intrauterine device until menopause when inserted at age 40 or over.  

Women aged 50 and over should be advised to stop taking combined hormonal contraception (CHC) for contraception and use an alternative, safer method. A combined oral contraceptive is associated with a reduced risk of ovarian and endometrial cancer that lasts for several decades after cessation, the guidance says. 

In general, all women can cease contraception when they reach the age of 55 as spontaneous conception after this age is exceptionally rare even in women still experiencing menstrual bleeding, says FSRH. 

Managing menopause symptoms OTC 

Menopause symptoms can be managed over the counter (OTC), with support and advice from a pharmacist. Haitham Hamoda, consultant gynaecologist, King's College Hospital, and chairman of the British Menopause Society, says HRT is not suitable for some women, while others may prefer to use natural ways to deal with their symptoms. 

Pharmacists can advise women about lifestyle changes that can ease menopause symptoms overall include cutting down on alcohol and caffeine, and taking regular exercise, he says.  

Mr Hamoda says women looking at herbal remedies such as Red Clover should be advised that they contain oestrogen-like properties - in case they want to avoid taking hormones - and be made aware of the evidence about their efficacy. 

Menopause is associated with mood changes such as increased irritability, anxiety, fatigue, and low mood. “Relaxation and stress-reduction techniques, including deep-breathing exercises and massage, a healthy lifestyle and enjoyable, self-nurturing activities may all be helpful,” advises The North American Menopause Society (NAMS). 

To get relief from night sweats, different strategies to stay cool include dressing in light nightclothes, cooling down with an electric fan, and sipping cold water, says NAMS. Menopause can disrupt sleep patterns, so establishing a regular sleep schedule and routine, including going to bed at consistent times, and keeping the bedroom dark, quiet and cool, can be helpful. 

Menopause contributes to sexual function changes through the decreases in ovarian hormone production and this may lead to vaginal dryness and a decline in sexual function. NAMS suggests vaginal lubricants to decrease friction and ease intercourse when the vagina is dry. It also recommends vaginal moisturisers, which can “improve or maintain vaginal moisture in women with mild vaginal atrophy”. They can be used on a regular basis and offer “a more lasting effect than vaginal lubricants”. 

Whatever a woman’s concerns are about the menopause, Mr Hamoda says the pharmacy has an important role to play in “making her aware of what choices there are, signposting, guiding and providing her with key information to help her make informed decisions.” 

Useful resources 
Menopause: diagnosis and management. NICE guideline [NG23]: https://www.nice.org.uk/guidance/ng23 
MHRA - Summary of HRT risks and benefits: https://assets.publishing.service.gov.uk/media/5d680409e5274a1711fbe65a/Table1.pdf 
FSRH Clinical Guideline: Contraception for Women Aged over 40 Years: https://www.fsrh.org/documents/fsrh-guidance-contraception-for-women-aged-over-40-years-2017 
The British Menopause Society: https://thebms.org.uk/