Menopause in the Workplace

Women currently make up a huge proportion of the workforce. For those of us who are 'baby boomers' and are now experiencing the hormonal changes of the perimenopause and of the menopause, demands of work can become even more challenging. Many women report great difficulties coping with what was previously manageable due to sleep disturbance and hence tiredness and, in some cases, exhaustion, difficulty concentrating, lack of confidence, anxiety, joint aches, not to mention the embarrassment of the well-known flushes and sweats. Throw into this the demands from teenage children and elderly relatives, and one might wonder how women cope at this stage at all!

The sad truth is that some really struggle and need help, yet often try to get through in the knowledge that for many, these symptoms will pass. The problem is that there is no way of predicting how long the 'early' symptoms of estrogen deficiency of the menopause will last. Many women report sad tales of significant symptoms which they openly admit have affected their ability to do their job necessitating changes in their role, time off work and even early retirement. Not all have received appropriate support and there appears to be a lack of awareness of the impact that menopausal symptoms can have - “isn’t it just about a few flushes?”!

So what can we do? As a doctor working in the field of menopause, I would wish that all women could receive appropriate advice and information about the effects of estogen deficiency, what simple changes women can make to reduce symptoms and improve long term health and what specific treatments are available. Sadly, this vision is a long way off but meanwhile, if symptoms are affecting you and your work, do seek help; ask your GP or Practice Nurse, make an appointment with Occupational Health, and above all, do not battle on alone!

For more information and for support, visit Menopause Matters and the Menopause Matters Forum.

Please let us know below if menopausal symptoms have affected your working day, and what support you've received from health professionals or colleagues.

Renewed Confidence in HRT

Since July 2002, there has been a huge downturn in the confidence of, and use of HRT. The concern about risks of HRT followed publication of results the Women's Health Initiative trial in 2002 and of the Million Women study in 2003. The massive publicity around the apparent risks shown by these studies understandably led to HRT being viewed as dangerous and that it should rarely be used.

Both these studies have since been reviewed and reanalysed and the revised outcomes, along with new studies which have now been published paints a much different picture - when used appropriately, HRT provides more benefits than risks for most women. Yet this message has not yet been widely circulated and I continue to hear of women who have distressing menopausal symptoms, have read thoroughly, weighed up the pros and cons and know that HRT is the best option for them but have to battle with their doctor to be allowed to take it.

To sort out the ongoing confusion, a global team of representatives of Menopause Societies and organisations associated with Women's Health met in November 2012 and have published a global consensus statement. The conclusions are clear:

• HRT is the most effective treatment for symptoms related to the hormonal changes of the menopause, and is beneficial for bone health and may decrease mortality and cardiovascular disease.

• Risks are acknowledged, but benefits will generally outweigh the risks for women under sixty, or within ten years of the menopause. The risks are generally small.

• Taking HRT is a decision which needs to be individualised, in consultation with a suitably qualified physician.

This statement is extrememly important and must be widely circulated and discussed. Women should be able to be access accurate, non-biased information so that they can make informed choices and in managing the consequences of the hormonal changes of the menopause, HRT should once again be considered as a safe option.

Full statement on menopausal hormone therapy.

Read more about hormone replacement therapy.

What do you think? Have you encountered problems with getting your doctor to prescribe you HRT? Please let us know below.

Vaginal Dryness - Lube or Hormones?

Many women experience vaginal changes and vaginal problems due to the lack of estrogen after the menopause. Initially, this can be in the form of dryness during sex. At this stage, lubricants can be used and many effective preparations are available. Some are applied just during sexual activity, others can be applied regularly to maintain the moisture. It is often a case of trial and error to find what works best.

While lubricants and moisturisers can reduce the dryness and ease the discomfort, to treat the underlying problem of the lack of estrogen and consequent changes in vaginal blood flow, secretions, thickness, elasticity and support of the vaginal skin and acidity level, consideration should be given to replacing estrogen which can either be in the form of HRT (hormones which circulate throughout the body and would be used if other generalised menopausal symptoms are also present) or vaginal estrogen.

The debate around the risks and benefits of HRT continues, but it should be understood that vaginal estrogen provides a very low dose of estrogen which is concentrated in the vagina and bladder with minimal absorption around the body. Therefore, vaginal estrogen can be used by women who either do not want to take HRT, or have been advised not to take HRT.

Various types of vaginal estrogen treatments are available and again, it may require trial and error to find which suits best. Preparations include small vaginal tablets inserted by an applicator, vaginal creams, pessaries and a three monthly vaginal ring. Vaginal tablets, creams and pessaries are used every night for two weeks, during which time there may be a little absorption and some women may notice breast tenderness. This should not cause concern. After the first two weeks, the maintenance dose is twice weekly, during which the absorption is minimal and any breast tenderness should settle. The vaginal ring is changed every three months and produces a small regular amount of vaginal estrogen. Vaginal estrogen used at the maintenance doses can be used long term, there being no known risks with many years of treatment. Indeed, we know that if vaginal estrogen is stopped, the symptoms frequently return and long-term treatment is recommended.

Whatever you choose, be aware of menopausal effects on the vagina and look after your vagina in the happy, healthy years ahead!

See more at Menopause Matters.

What do you think? Is this a problem you've encountered yourself? If so, what impact has it had on your relationship and sex life?

Why Do We Flush?

Flushes and sweats are the classic, well-known menopause symptoms, or can be caused by estrogen deficiency. We have all heard of them, yet we still know relatively little about why they happen and why there is such variation in their severity and duration. From what we do know, it seems that we have a thermostat in the brain which regulates our body temperature. If our core temperature rises, as happens if we have an infection, a fever, then our thermostat triggers cooling down mechanisms such as opening up surface blood vessels (the flush) and switching on sweat production. These measures ensure that our body organs do not become too hot. In the reverse situation, if our core body temperature falls, our thermostat switches on heating up mechanisms such as shivering, in order to maintain temperature.

During every day, our core temperature fluctuates by a few degrees but our thermostat works within a buffering zone, so that we don’t spend the whole day flushing, sweating or shivering. Even additional changes in temperature as brought about by hot or cold drinks, being outside or inside, emotion or stress do not normally lead to triggering by the thermostat. However, with estrogen deficiency of the menopause, the thermostat changes in action so that even the normal daily temperature changes and additional ones described, can lead to unnecessary flushes, sweats and shivers - the thermostat thinks that the body is over-heating, or over-cooling when it is not.

While it appears that estrogen deficiency is a cause of changing thermostat function, it is clearly not the only factor since menopausal women, with the same changing and low levels of estrogen, can have very different levels and duration of symptoms. Diet and lifestyle factors are involved with being overweight, drinking alcohol and caffeine, and smoking leading to worse symptoms. Other chemicals such as serotonin, noradrenaline and gamma aminobutyric acid are also likely to be involved and the recognition of their involvement has led to the development of other non-hormonal drugs which can be prescribed to reduce symptoms in women who are not able or willing to take HRT.

So while research continues into the mechanisms and treatments for flushes and sweats, we should try to maintain a healthy weight, eat a healthy, balanced diet, minimise alcohol and caffeine, not smoke, take plenty of exercise, wear loose layered clothing, and generally look after ourselves whilst considering treatments to minimise symptoms of the menopause and the impact that they may have on our lives.

See more at Menopause Matters.

Breast Cancer and HRT - Fact or Fiction?

While the role of HRT for treatment of menopausal symptoms, treatment of premature menopause and beneficial effect on bones should now be well established, the debate about HRT and breast cancer risk continues.

Following a massive drop in use of HRT after publication of the Women’s Health Initiative (WHI) trial in 2002 and Million Women Study (MWS) in 2003, an apparent drop in rates of breast cancer was claimed to provide further evidence that HRT did indeed cause breast cancer. However, researchers from Cape Town University, writing in the journal of Family Planning and Reproductive Healthcare, state that it is impossible to establish a causal link. Breast cancer rates actually started to fall in 1999, before the drop in use of HRT, and the drop seen in 2002 to 2004 was far too early to be due to the fall in use of HRT.

The same journal, in 2012, published reviews by Shapiro et al of both the WHI trial and the MWS and concluded that these studies did not in fact prove a link between HRT and breast cancer.

So, can we be completely reassured that HRT does not cause breast cancer, and can women go back to using HRT without any fear that it will increase their risk of this tragic disease? It seems that it is extremely unlikely that HRT causes breast cells to become cancerous. But it is possible that, if certain types of HRT (combined HRT containing estrogen and progestogen, rather than estrogen alone) are taken for more than five years after the age of fifty, there may be promotion of cancer cells which are already present in some women, but not in the majority. To add to the complexity, even within types of combined HRT, it appears that different progestogens have differing effects, some types appearing to be “breast-friendly”.

Finally, to try to understand the level of risk, it is known that drinking two or more units of alcohol per day, or being overweight after the menopause both provide a far greater level of risk than taking HRT for five years. Read more about the effects of diet, exercise and lifestyle on menopause.

No medicine is perfect and everything that we do carries some level of risk. It is essential that women who are considering taking HRT, and healthcare professionals who are considering prescribing HRT, should access accurate information to help them make informed choices. Currently, many women are missing out on the benefits of HRT because of fear of risk. But for the majority, when HRT is used appropriately,  the benefits outweigh the risks.

You can see more about balancing the risks and benefits of HRT at http://www.menopausematters.co.uk/pdf/breastCancerRisklinks.pdf

Mental Health and Menopause

Many women notice changes in mood around the time of the perimenopause and menopause.

It can be difficult to know if the symptoms of low mood, anxiety, panic attacks, depression and mood swings are caused by the hormone changes associated with changing ovarian function, or are due to an underlying mental health problem. Indeed, it appears that when presenting with such symptoms, many women have been offered antidepressants when they have wondered themselves if the symptoms could be hormonal.

If these symptoms occur along with evidence of change in ovarian function, from a change in the period pattern with or without other menopausal symptoms such as hot flushes, sweats, joint aches and sleep disturbance, then a trial of hormone replacement rather than an antidepressant, would seem worthwhile. In fact, many women take HRT purely for control of such symptoms, rather than control of the classic flushes and sweats. Such mood, psychological and coping symptoms are often completely unexpected and, when untreated, cause more distress than the expected flushes and sweats.

We know that women who have previously suffered from clinical depression, particularly those who have experienced postnatal depression or premenstrual syndrome, are sensitive to hormonal fluctuations and are at risk of developing depression in the perimenopause, a time of significant hormonal fluctuation. Otherwise, while depressed mood is common around the time of the menopause, new onset clinical depression is not increased purely due to the menopause.

Mental health problems are very common, and can be associated with the menopause so should be treated early.

For more information, visit the symptoms section and psychological section of Menopause Matters.

A Sore Point

In many issues of Menopause Matters magazine we have included articles, results of surveys, research findings and advice about the very embarrassing topic of vaginal dryness and discomfort which is common during the menopausal changes of vaginal atrophy. With a lack of estrogen, many women experience thinning, drying changes, in the vagina which can lead to irritation, pain, discharge, bleeding, soreness and reduced response during sex. This can then also lead to relationship problems.

We know from our surveys that still, in the 21st century, women find it very difficult to discuss this with their partner, let alone a healthcare professional. This results in women often making excuses not to have sex, and putting up with the symptoms for many years. We know that their confidence can be affected, and this common symptom can have a great effect on self-esteem, quality of life and relationships.

Vaginal atrophy often occurs a few years after the menopause, or a few years after stopping HRT. Symptoms can be reduced using lubricants or moisturisers, and the underlying cause of lack of estrogen can easily be treated with vaginal estrogen in the form of small vaginal tablets, cream, pessaries or a vaginal ring. Vaginal estrogen can be used even when HRT is not desired or not recommended since the dose of estrogen is very small and is concentrated in the vagina. Vaginal estrogen can be used for many years and indeed may be required indefinitely.

If you are experiencing vaginal changes, be sure that help is available. See more info on the Menopause Matters website.