THE WALL HOUSE SURGERY
Yorke Road, Reigate, Surrey RH2 9HG
Tel: 01737 244325, Email: firstname.lastname@example.org
Menopause Resources to support your
You may find the following websites helpful to review prior to your appointment and when reviewing your HRT:
The British menopause society has a range of really useful videos that discuss aspects of menopause care, testosterone, premature ovarian insufficiency, menopause after breast cancer and much more! https://thebms.org.uk/publications/bms-tv/
Menopause Official Scale: https://assets.jeanhailes.org.au/Health-professionals/Menopause_symptom_scale_Greene_Climacteric.pdf
Remember to book in for an annual review and an annual blood pressure to discuss your ongoing medication.
Don’t forget to attend for regular smears and mammograms.
Information about HRT and breast cancer risks:
This infographic shows the risk of breast cancer and other risks with HRT:
And thinking about menopause after cancer treatment : https://youtu.be/Y456b-Z8oB4
Progesterones and HRT
Taking Progesterone is vital to protect your womb lining from the effects of Oestrogen in your HRT. Oestrogen alone has been strongly linked to the development of endometrial hyperplasia which can then lead on to cancer. See this video by GP Dr Horrocks which explains this:
Progestogens can be provided by combined patches and pills. If your periods have not stopped within a year, you need to take progestogens as ‘sequential HRT’. The regimens can be confusing with this. Sometimes if you have severe PMS / menstrual migraines or endometriosis your GP may advise continuous HRT.
· Sequential patches e.g. evorel sequi contain patches of evorel 50 (estradiol only) to take for 2 weeks of the month AND evorel conti patches to take for the following 2 weeks of the month (containing 50mg estradiol and norethisterone acetate as the progestin)
· Femoston has both femoston sequential tablets 1/10 or 2/10 and also comes as femoston conti tablets for continuous HRT
· In many types of HRT used, the two hormones come separately with the estradiol as a patch, gel or spray and a separate progesterone.
o Utrogestan (‘body identical’ Progesterone) is commonly used for this.
o There are other progestogens that are less commonly used.
o Mirena provides month round protection whether you have stopped bleeding or not and also provides contraception
Utrogestan is a micronized, body identical, progesterone. It is derived from plants including yams. **Do not take Utrogestan if you are allergic to Soya. It contains gelatine. The patient information leaflet that comes with the Utrogestan refers to cycle lengths which can add to confusion around using):
Since natural progesterone can have a mild sedative effect, Utrogestan can cause drowsiness for some women. It is therefore recommended to be taken at bedtime. **If you work night shifts this medication might not be appropriate for you. It can improve sleep quality and doesn’t usually cause grogginess or a hungover feeling the following day. It is best to take Utrogestan on an empty stomach because eating food at the same time as taking this medication can increase drowsiness.
· If you are still having periods you will take sequential HRT:
o Take 2* 100mg utrogestan tablets at night for 14 days in a 28 day cycle.
o Your bleed with usually come as you stop the tablets
o If you have regular periods try to start taking the tablets in the last 14 days of your cycle to help work with your background cycle and reduce break through bleeding
· If you have stopped having periods
o Take 1* 100mg utrogestan tablet every night
· Some women do not tolerate progesterones. Usually these side effects are more to do with changes in hormones on a sequential cycle but if your GP feels that you are not tolerating utrogestan due to side effects they may suggest trying taking your oral tablets vaginally. This is off license but it is regular practice by menopause specialists.
What are the side-effects of Progesterones?
Some women experience side-effects initially which can include erratic vaginal bleeding, abdominal bloating, lower abdominal pains or discomfort and breast tenderness. Bleeding can be intermittent or continual and can last for the first 3 to 6 months. If bleeding worsens or does not improve with time then you should seek guidance from your menopause specialist or your GP. Some women find that they feel lower in their mood when they take progesterones. This side-effect is less common in utrogestan compared with some of the older progestogens but can still occur in around one in ten women.
What are the advantages of Utrogestan compared to other types of progestogens?
As Utrogestan is body identical, women usually experience less side effects compared to the older types of progestogens. The older types of progestogens which can be given as tablets or as a combination patch, can be associated with a slightly higher risk of clot and heart disease. Studies have shown that women who take Utrogestan do not have a higher risk of clot or heart disease.
The small increased risk of breast cancer in women who take HRT is understood to be related to the type of progestogen, and not oestrogen in the HRT. Taking Utrogestan does not appear to be associated with an increased risk of breast cancer during the first five years of taking it. After this time, the risk of breast cancer is very low and studies have shown that this risk is lower than the risk for a woman taking the older types of progestogens.
However, the data on utrogestan shows that it is less good at controlling break through bleeding than other progestogens and may be less good at protecting the uterus from uterine cancer compared to other progestogens. There have also been shortages of utrogestan and it is easier to forget to take an additional tablet than a combined patch thus potentially further increasing the risk of endometrial cancer if a lady forgets to take the utrogestan.
The Mirena IUS
· The Mirena IUS is excellent at protecting the uterus from endometrial cancer
· It is the preferred route of progestogen protection for those who are at increased risk of endometrial cancer (this includes ladies with PCOS and those who are obese)
· The Mirena has a very low level of progestogen and most who cannot tolerate other progestogens are able to tolerate the mirena.
· The data suggests that the mirena does still carry a small increased risk of breast cancer compared to women not using progestogens.
· Please note a Mirena IUS will provide adequate endometrial protection for 5 years (this may differ from your contraception instructions) from the date of fit. It is imperative you keep a track of this date as we do not routinely recall patients – please set up a reminder in your diary for 6 months before it is due to be replaced to give you plenty of time to arrange replacement.
Progesterone Doses with higher doses of estradiol
Women on high doses of oestradiol (100mg estradiol patches, 4 pumps oestrogel, 2mg sandrena, 3 sprays lenzetto) will need to have their progestogen doses increased proportionally to protect from endometrial cancer as per the statement from the British Menopause Society
· Taking 2 evorel conti patches to achieve the 100mg estradiol dose NOT adding an evorel 50 patch to an evorel conti
· Taking 200mg utrogestan every night if on continuous HRT or 300mg 14 days of the month if on sequential HRT (and similar increased doses for other progestogens)
· The mirena provides excellent protection from uterine cancer even on higher doses of estradiol so does not need increasing.
There are some private clinics who do not follow this guidance and suggest ultra low doses of progesterones or do not increase doses of progesterone with high dose estradiol. The BMS has been very clear that off license uses of high dose oestradiol are prescribed at the risk of the clinician and at The Wall House Surgery we will not accept responsibility for regimens which are advised may put you at increased risk of endometrial cancer. If you wish to continue with such regimens you will need to obtain a private prescription for these.
Side Effects on HRT
Side effects are common when you start HRT and usually settle in the first three months
· Bloating/fluid retention-usually settles
· Low mood-uncommon.
· Breast tenderness-usually settles (ibuprofen can be helpful if painful)
· Irregular vaginal bleeding-usually settles within 3 to 6 months of starting HRT. If it persists beyond 3 months you will need to make an appointment to discuss it. Beyond 4 to 6 months, this may need checking at the hospital so an early appointment with your GP is advised.
o Your clinician may recommend an ultrasound scan to check the thickness of the lining of the womb
o If no concerning causes are found your clinician may recommend a change in progestogen or a change in dose of your HRT. They may suggest a mirena coil which is very good at protecting the uterus.
Managing the menopause is about way more than HRT!
It is crucial to look at menopause holistically.
· Consider flush triggers: alcohol, tea, coffee, spicy food are examples.
· Flush friendly fabrics and layers can help.
· ‘Chillow pillow’,
· If you want to avoid HRT there are medications that can be prescribed that can help hot flushes including Venlafaxine
· Some medications such as citalopram and sertraline can actually cause hot flushes (and sexual dysfunction) so speak with your GP if your symptoms started at the same time as new medications (do not stop medications suddenly).
Diet and Nutrition
The Wellness Hub on the BMS website is a useful resource for evidence based videos and leaflets Menopause Wellness Hub - Women's Health Concern (womens-health-concern.org)
Nutrition is important in the menopause: Vit D 400iu per day is advised all year round or 1000iu October to March and adequate calcium in your diet. There are many calcium calculators on line. Here is one:
https://theros.org.uk/ National osteoporosis Society
Karen Newby is a nutritionist on social media and has produced an excellent book about nutrition at this time. ‘Natural Menopause’ https://karennewby.com/
Optimise Gut micro biome-could try a prebiotic such as inulin and cut out all alcohol. Some people find reading the information from the ZOE team about gut microbiome useful.
Wild nutrition, Bare biology, viridian, Biocare, -supplements with ‘Phytooestrogens’ and ‘isoflavones’ are only recommended when not using HRT. The effects on your womb from these are unknown
Myra Hunter books. ‘Living well through the menopause’
Vaginal and Vulval Dryness
Vaginal and vulval dryness is very common. This can be uncomfortable and can increase the chance of urinary tract (bladder) infections occurring as well as affecting your sex life and libido. This is an excellent leaflet:
BMS TV has a useful video to watch on this topic: https://youtu.be/gMbg3p7zue8
It is recommended you use 3 approaches to help:
· Lubricants(oil ones slightly better although will break condoms),
· regular use of vaginal moisturisers bought over the counter help with this along with
· vaginal oestrogen on prescription.
Vaginal dryness can also lead to an overactive bladder:
Background fertility at age 50 is roughly 1:1000 . FSRH guidance is that, even if your periods are still happening, you can stop contraception at 55.
www.contraceptionchoices.org has information about options available. We are able to fit all contraception options at the surgery.
HRT does not provide contraception. You can take the progesterone only pill with HRT or the implant.
The Mirena IUC has transformed women’s healthcare, is excellent for bleeding control, can be the progesterone part of your HRT and provides contraception: https://www.sexwise.org.uk/contraception/ius-intrauterine-system
Video about the mirena fit: https://youtu.be/bIHiZCgr7B4
Sleep problems are common in perimenopause.
Sleep | Healthy Surrey has resources around helping to improve your sleep
BMS TV has a useful video on menopause and sleep https://youtu.be/VeVQDTrrRcM
‘Why we sleep’ by Matthew Walker - highly recommended book and may also give you an insight into your children’s sleep if that would be useful!
Good sleep is key to reduce brain fog.
Also consider checking ferritin level is over 50. This is your iron storage level (not anaemia). Many years of periods can leave women deficient in this. It can cause menopause ‘mimic’ symptoms such as tiredness, poor concentration and brain fog.
Most women gain on average 1 stone of weight through menopause and is one of the most common and distressing symptoms. See the new ‘Wellness Hub’ on the British Menopause Society website with an information sheet on it. Menopause Wellness Hub - Women's Health Concern (womens-health-concern.org)
We have a funded service locally to help with this: One You Surrey | Free Healthy Lifestyle Service
Some people find intermittent fasting useful to help with menopausal weight gain
Anxiety and Low mood
Stress exacerbates all symptoms of menopause. Managing this is key. Local resources:
Mental wellbeing | Healthy Surrey For a range of resources including how to self-refer for talking therapies.
‘Self-guided CBT for the menopause’ Excellent book by Myra Hunter
Migraine and Menopause
Migraine often gets worse through the menopause transition-it is triggered by hormone fluctuations.
‘Managing your migraine’ by Katy Munro-is an excellent podcast. Heads Up: Special Episode: Managing your Migraine (libsyn.com)
She is a specialist in this field and has written an excellent book.
Menopause and the Workplace
Very common and affects at least 50% of women
Advice for Low Libido in the Menopause
Ensure your vulval tissue feels comfortable and not dry. It is very common around the menopause to experience dryness in this area ( at least 50% of us). This can make intercourse seem less appealing.
This website is excellent.
Moisturisers and Lubricants
· Using regular moisturisers (ok to use as much as twice a day if needed) and lubricants is important.
· Try different brands to see which is right for you.
· Coconut oil can be very effective to moisturise this area. Oil based lubricants are more effective.
· Using a combination of oil and water based lubricants can create a ‘double glide’ effect which can help with discomfort during intercourse.
· usually makes a significant improvement to symptoms
· very little of it gets absorbed into the body (using regularly through the year is equivalent to swallowing one HRT tablet per year).
· It can take 3 months to be fully effective.
· Start using it daily until symptoms improve and then maintain with 2-3 times a week
· There are many preparations so if one is not suiting you, it is sensible to try an alternative – there are gels, creams and pessaries
· The pessaries come with a plastic applicator but you can use your finger if the applicator is uncomfortable
Condoms are damaged with anything that contains oil-such as oil based lubricants or coconut oil. Also beware of the friction impact on condoms from dryness. Conception rates are approximately 1:1000 at age 50. Condoms have a failure rate of 17%, this will be higher in the event of breakage.
· It is also very common to experience a low libido around the Menopause (at least 50%).
· This only matters if this is important to you.
· The time of the menopause is commonly a very stressful part of life so this may not be a priority at this time.
· Agnus castus can be helpful for some –look for THR stamp-can help with Libido
· Can help in 1/3 of patients and
· Can take up to 3 months to start working.
· If it has not worked by 6 months it should be stopped
· It is a controlled drug however with limited evidence in research terms for safety so far.
· No data has been published looking at safety of use past 2 years.
· Despite claims in some private clinics the available evidence demonstrates support for use for low libido, some studies show benefit for muscle strength but more studies are needed. Studies have not supported evidence for use for brain fog/cognitive function / overall wellbeing
· The BMS advises for safe testosterone prescribing
o to first ensure a woman is well oestrogenised with other menopausal symptoms well controlled on oestrogen then
o check testosterone levels prior to starting testosterone for baseline levels
o then check testosterone levels at 3-6 months and then
o annually check testosterone levels are not being artificially raised due to the dose you are on
BMS ‘TV’ –Mr Nick Pannay has recorded a video discussing testosterone therapy: https://youtu.be/2AKTgi_nqLM
Testosterone levels actually rise in our 60’s and are very high throughout life for people with certain medical conditions such as PCOS. We do not see this reflected in their libido. The situation is very much more complex than simply replacing testosterone and it is important if considering testosterone to consider
Other resources suggested in Psychosexual clinics which may help:
Films: ‘Hope Springs’, ‘Thank you Leo Grand’. ‘Sex Life’ on netflix
Apps: Furley, Dipsea
Website: OMGYES.com - The Science of Women’s Pleasure. Supported by Emma Watson
Bullet vibrators used as massage to the vulva and vagina can help make the tissue feel more comfortable and flexible which can help if intercourse feels painful.
Pelvic floor physio can also help with this: You can self refer FCHC MSK Self referral form June 2020 Version 7 (1) (1).pdf (firstcommunityhealthcare.co.uk)
Credit to Dr Liz Horrocks who’s leaflet this has been adapted from