This blog is written by our clinicians and aims to keep patients informed with up to date information on medical conditions.
Hormone Health for Women after 40
Oestrogen and COVID
All women should monitor for changes in our emotional and physical wellbeing from our thirties onwards. Oestrogen affects every single cell in our bodies, and begins to decline during our mid-thirties. Symptoms can linger into our seventies, and can be individually investigated and treated by clinicians at every stage, so it is very important that you don’t ignore or tolerate them.
COVID 19 has had a definite impact on women’s health within the NHS. There has been limited access to contraception consultations, fertility care, menopause care and community staff training. At ROC, there has been no change to our services offered during the pandemic, so we can see you in person for a full discussion and examination. If you prefer, we can arrange a phone call or video consultation.
Studies suggest that oestrogen is possibly COVID protective, which might explain the 3:1 male to female mortality rate in COVID. It is already known that male and female immune responses are different, due to genetics and oestrogen. Animal studies have shown that blocking oestrogen receptors in the body appears to increase the effects of COVID. Women in China with more severe responses to COVID had lower oestrogen levels. In a separate study, menopausal women are more likely to develop symptoms compared to women who were still having periods, regardless of age.
How to recognise the Peri-menopause
It is important for immediate and long term health to pay attention to any signs of dropping oestrogen levels as you become closer to peri-menopause.
The signs can be subtle, such as a change in premenstrual syndrome (PMS) symptoms, period flow, length or timing. Other symptoms include insomnia, tiredness, skin and hair changes, poor concentration, memory or decision making, joint aches, low self-esteem, weight gain, headaches, changes in emotions and mood swings, low libido and pain during sex.
Perimenopause is diagnosed when periods become irregular and vasomotor symptoms start. Vasomotor symptoms are hot flushes, night sweats and palpitations. Unfortunately, in 50% of cases, symptoms last for 7 years, and 42% of post-menopausal females aged 60-65 years continue to have these symptoms.
A drop in oestrogen alone is not enough to explain vasomotor symptoms because there is so much variation between them.
Lifestyle and general health such as exercise, caffeine, body weight, dietary content of phytoestrogens and smoking can have an impact on the intensity of the symptoms. This illustrates the importance of having a well woman check or medication review to make sure you are maximising your health. Treatment can be started at any stage, and will depend on the symptoms you describe.
Hormone Replacement Therapy
Decisions regarding Hormone Replacement Therapy (HRT) are complicated and must be made on an individual basis.
The main factor for deciding on any drug or non-medical therapy is guided by you and how you are feeling, as well as your chances of developing side effects.
We will perform a full history and general examination, can provide general lifestyle advice as well as calculate your risk of cardiovascular events in the future. The risk of heart attack or stroke increases following perimenopause and menopause. HRT is known to provide cardioprotection and can help to reduce your long-term risk of vascular disease in the future.
HRT can slightly increase your risk of breast cancer, particularly if you have other risk factors, as well as an increase in your risk of thromboembolism (blood clot).
However, it is known that HRT lowers the risk of cardiac events and bowel cancers, and providing treatment in the form of patches or gels can reduce or eliminate the chances of adverse effects.
Alternative Treatments available
We are happy to discuss alternative treatments to traditional medical hormone replacement.
Herbal alternatives to HRT include Phyto-estrogens (e.g Red Clover) and Agnus Castus. Other medications such as Gabapentin and Pre-gabalin were developed as anti-epileptics but are now commonly used for pain control as well as other conditions. Studies have shown that women with breast cancer who did not wish to use HRT and took Gabapentin instead, reported a 50-75% in reduction in hot flushes.
Venlafaxine, an anti-depressant, can reduce hot flushes by 50%. Oxybutynin, developed to aid bladder issues, can also reduce hot flushes. It is important to remember that all of these drugs have potential side effects, therefore an individual consultation to discuss them is recommended.
Acupuncture is also very effective, although the effects are temporary, but may be used on continuous basis.
How can Testosterone therapy help women?
You might not be aware that testosterone is needed by women just as much as men.
Low testosterone levels include fatigue, irritability, low libido, loss of orgasm and headaches. It is thought that testosterone increases dopamine release and serotonin release, so can reduce anxiety and depression.
Testosterone also increases bone and muscle strength, and is cardioprotective. Low levels of testosterone in men and women are associated with increased risk of stroke or heart attacks. If you have ongoing menopausal symptoms despite having oestrogen replacement therapy, testosterone therapy can be considered.
At the moment, testosterone gel and creams are unlicensed for women in the UK, which means that you might have difficulty accessing them from NHS primary and specialist care. However, given their safety in research and success in improving symptoms, this is something we are able to prescribe and monitor at ROC.
HRT and Migraine
You might think that you are not a candidate for HRT due to having migraines. Migraine is associated with more frequent vasomotor symptoms, and frequency of migraine usually gets worse during the peri-menopause or post-menopause.
Taking HRT oestrogen tablets is not recommended in women with migraines, but oestrogen patches or gels are not associated with any increase in the frequency of migraine attacks.
Alternatives to HRT can also help migraine – Escitalopram and Venlafaxine are anti-depressants which have been shown to reduce migraine frequency. Clonidine, an anti-hypertensive can also help.
Urogenital Atrophy or Dryness
A drop in oestrogen causes Urogenital or Vulvovaginal atrophy which can cause urinary tract infections, vaginal dryness and discomfort.
You may have had previous treatment for thrush but noticed no improvement with anti-fungal treatments such as creams or pessaries. In this case, it is possible that you have vulvovaginal atrophy.
Treatment with vaginal oestrogens can reduce the number of urine infections you have and increase bladder capacity, as well as treating dryness and discomfort. Vaginal oestrogens come in the form of gels and pessaries. There is no whole body absorption, so no increased risk of thrombosis, breast cancer or endometrial cancer.
Contraception
It is important to remember that you will still need contraception for some time after the menopause. We are here to assist you with making these difficult decisions by providing information about different options.
Homework for you…
Please have a look at the Menopause Matters and British Menopause Society websites to begin considering whether some of the above changes might be happening to you. We always recommend keeping a note or diary of your symptoms to help us get a better picture of any patterns.
Get in touch for Well Woman Medical or a personalised consultation to meet your needs. Our GPs and Menopause Specialists are here to help.
References
Dr E Morris, President of the Royal College of Obstetricians and Gynaecologists. Post Reproductive Health conference RCOG/British Menopause Society Meeting October 2020.
T Spector et al, Zoe App, UK COVID-19 Symptom Study,
MacGregor EA, Barnes DS, Climacteric 1999; 2: 218-23
E. Anne MacGregor – Menstrual and perimenopausal migraine: A narrative review. Maturitas 2020; 142:24-30.
