During June 2022 the NCSEM-EM ran a series of online talks discussing various aspects of menopause. The series myth busted and outlined what the evidence says around menopause.
The talks were delivered by three leading experts in the field. Recordings of all three talks can be found below.
Menopause and your heart
Presented by Dr Emma O’Donnell – Senior Lecturer in Exercise Physiology, Loughborough University
Menopause and the brain
Presented by Professor Eed Hogervorst – Professor of Psychology, Loughborough University
A life course approach to menopause: what it is and why it is important
Presented by Professor Rebecca Hardy – Professor of Epidemiology and Medical Statistics, Loughborough University
During the talks a number of themes and discussion points around menopause came up. We have collated a number of the questions that were asked and these have been responded to by our experts below. We hope that you find these responses helpful but the advise below does not replace that given to you by a clinician. If you have personal concerns or questions around menopause or its symptoms please speak to your GP.
Menopause and other medical conditions
Dr Emma O’Donnell: Good question! Ultimately, if you are looking for a medically based treatment, and there are several, please do have a discussion with your GP. However, studies identify that non-hormonal methods to manage hot flushes include cognitive behavioral therapy, hypnosis, selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors, clonidine, and gabapentin. Vaginal estrogen may be useful to address vaginal dryness. A link to a recent peer reviewed article that talks about these options can be found here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6445536/
In general, if hot flushes are your main symptom, try to maintain a healthy body weight (obesity is linked with more severe and more frequent hot flushes), exercise regularly (3-4 x/week of moderate intensity aerobic exercise, or yoga, or resistance training are associated with improvements in hot flushes after 12 weeks or more), avoid triggers of hot flushes, such as spicy foods, smoking, and alcohol, and wear clothes that are breathable. At work, have a fan on your desk and use at will! At home, keep your bedroom cool at night – use a fan if you need one – and wear light, breathable nightwear. I hope this helps.
Dr Emma O’Donnell: The short answer to this is, having cardiovascular disease risk factors does not necessarily preclude you from taking HRT. However, this will depend on your individual circumstances – which your doctor will be able to carefully review. It is possible that you may be able to use one of the many different type of HRT (eg skin patch or gel or pessary), depending on what your symptoms are and what your cardiovascular risk factors are. I hope this helps.
Dr Emma O’Donnell: Endometriosis is very painful, and is also hormone sensitive. You would do best to have a chat with your doctor if you are experiencing unmanageable menopausal symptoms. There are a number of non-hormonal medically based options for the management of symptoms, but these may not have the cardiovascular benefit you are hoping to gain, in which case lifestyle choices can really help – such as regular exercise, maintaining a healthy weight, decreasing alcohol intake, giving up smoking and having a healthy diet. This article on medical non-hormonal options may be of interest: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6445536/
Dr Emma O’Donnell: There is no real evidence to support that HRT leads to weight gain or weight loss. Sorry.
Dr Emma O’Donnell: Speak with your GP about this. They will have the necessary information to be able to give you the best advice as to whether HRT is right or you. Also, you might want to ask about other medical therapies that are non-hormonal – there may be other, preferable options available to you.
Dr Emma O’Donnell: This is an interesting question. However, I’m not sure if I can answer this as I really do not have expertise in this area. However, the following link to a recent scientific paper on this topic may be of interest to you: (it does suggest a correlation between sex hormones between vestibular migraine in postmenopausal women – I never knew! So thank you for enlightening me on this). https://journals.sagepub.com/doi/full/10.1177/03000605211016379#:~:text=Conclusion,the%20disease%2Dfree%20survival%20time.
Dr Emma O’Donnell: I’m sorry you are suffering with these menopause symptoms. I’d go back to the GP and have a discussion about how you are feeling and to talk about what your best options might be to help alleviate these symptoms. You could also ask about non-hormonal medical treatments – there might be something else you can take if there are any concerns about the dose of HRT (or if you’d rather try something other than HRT).
Dr Emma O’Donnell: I’m not sure what the cause of your increase in body weight might be, but it is known that estrogen (and progesterone) have important effects on body fluid regulation, meaning that fluid retention may occur with higher levels of these hormones. It may be possible this is contributing to some of your weight gain. However, it is worth having a discussion with your GP about this to discuss this further. You could also ask about non-hormonal medical treatments – there might be something else you can take if there are any concerns about the HRT being the cause of your weight gain.
Professor Eef Hogervorst: It would seem really important to try to work on improving your sleep, which can cause brain fog, concentration, memory and mood issues. This website has evidence-based tips that may work for you: https://www.sleepfoundation.org/sleep-hygiene, If it does not help, have a discussion with your GP or Dr Louise Newson https://www.balance-menopause.com/
Professor Eef Hogervorst: That is so unfortunate, I am sorry to hear it. Many women can have symptoms for years. You could start with sleep hygiene tips (https://www.sleepfoundation.org/sleep-hygiene) but might in discussion with your GP also think about HRT? Depends a bit on why the ovary was removed and other possible contraindications (i.e. reasons why you should not get HRT) but that would be a conversation to have with your GP.
Professor Eef Hogervorst: That is very difficult. As far as we know, soy products like tempe do not increase risk for breast cancer (as they act on other oestrogen receptors) but could have benefits for brain and heart function. We have seen some benefits of this. This area is currently being investigated.
Professor Eef Hogervorst: Some data suggested that menopausal women were more affected by covid. There is definitely some evidence to show that long covid can affect the brain. I guess you could try exercise, food, sleep, then maybe phytoestrogen supplements then HRT to see if this helps. It may.
Professor Eef Hogervorst: There is, but unfortunately not something I am involved in or review. Joints and muscle pains are frequently complained about during perimenopause and post menopause.
Professor Eef Hogervorst: I am so sorry to hear that, you have really not had an easy time and continue to have such bad symptoms. Eating more soy could help, especially tempe (fermented soy) and as this (older) review showed did not lead to increased risk of recurrence https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2981011/#:~:text=In%20summary%2C%20human%20studies%20that,not%20alter%20breast%20cancer%20risk. In fact, this more recent review suggests soy may reduce cancer risk https://www.frontiersin.org/articles/10.3389/fnut.2022.847421/full. We found mainly benefits of soy in middle-aged East Asian women on brain function who eat this is larger quantities and who may process this food differently in their guts.
Dr Emma O’Donnell: There is no recommended st(age) to start using HRT, but it is recommended that HRT not be started more than ten years after your final menstrual period, or after the age of 60. HRT is indicated for the management of menopause related symptoms. If you hare having unmanageable symptoms during perimenopause, menopause or postmenopause, talk to your doctor to determine if HRT is right for you. I hope this helps.
Dr Emma O’Donnell: The quick answer is, it depends. How do you feel you are coping with your symptoms? How severe are they? Are they impacting your quality of life? If so, speak with your doctor about this and discuss what the right options are for you. I hope this helps.
Professor Eef Hogervorst: The jury is still out there, some treatment data suggest that for older women, say 15 years after the menopause who are not in great cardiovascular health, it may not be a good idea to start HRT but if you still have flushes and other symptoms you could perhaps discuss this with your GP.
Professor Eef Hogervorst: I would not think that has long term benefits from the scarce data we have. In fact, this may confer (a small) increased risk for dementia and heart disease, especially if combination treatment (oestrogen and progesterone) is taken.
Professor Eef Hogervorst: It is very hard to translate individual risk from population risk. It also depends on a woman’s health status, possible genetics, other lifestyles (e.g. diet, exercise, smoking, alcohol) etc so unless you use a computer algorithm (and even then) you cannot really make a judgement for an individual.
Professor Eef Hogervorst: Even men can have flushes and night sweats and they can be caused by other hormonal changes (e.g. thyroid), some diseases or stress/hot weather etc. It may be a good idea to ask your GP and have your bloods checked.
Dr Emma O’Donnell: Testosterone supplementation in postmenopausal women is considered/indicated for low sexual desire after other factors have been ruled out (eg relationship issues, psychological and medication related matters). Beyond libido, randomised clinical trials of testosterone to date have not demonstrated beneficial effects of testosterone therapy for cognition, mood, energy and musculoskeletal health. As such, the NICE guidelines (2015 – currently the most recent guideline, but a new guideline is currently being developed) state that due to the limited availability of evidence, testosterone should only be offered as an option of improving low sexual desire for women in menopause when HRT is not effective.
Professor Eef Hogervorst: Personally on the basis of the data I reviewed, I do not think so for brain function. Some women and some clinicians/researchers say it helps with libido, skin and muscle strength maybe even memory but more research needs to be done in this area.
Professor Eef Hogervorst: It depends what people want hormones for. If it is for menopausal symptoms, such as hot flushes and night sweats, not necessarily based on the data I know of but I think this area (of testosterone addition) does not have very good and well controlled studies available.
Professor Eef Hogervorst: Data are very scarce on that, some women like it a lot but I do not think there is very good evidence for it at this point.
Natural remedies for menopause
Dr Emma O’Donnell: While HRT is recognised as the most effective treatment of hot flushes, and other menopausal symptoms, this is a personal choice for women, and for some, may not even an option due to contraindications (eg high risk of blood clots, known cancer risk etc). While there are other non-hormonal medical treatments that have been reported to help (see article here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6445536/ ), there are also many natural remedies that are suggested to help with hot flushes (it’s a long list!). However, evidence is mixed with regard to the efficacy and safety of these ‘natural products’. You might find the following recent review of the literature on these natural remedies of interest. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6419242/ I hope this helps.
Dr Emma O’Donnell: While I can’t say specifically why this happens, it sounds like sugary foods may simply be a trigger for your symptoms. At least you know that if you stay away from these types of foods you can manage your symptoms, which is great!
Professor Eef Hogervorst: There are no good data to support that claim I think but some women say it helps for them. The data available are usually from not very scientifically robust studies, meaning the quality of evidence is low. However, some women mention benefits, but others absolutely not. Most guidelines do not give recommendations about use of these types of treatments.
Professor Eef Hogervorst: That has not been investigated but women in Oxford who had high folate (I presume from other sources) and high oestrogen had a lower risk for dementia whereas the older women with high oestrogen levels without adequate folate were more at risk. Folate is found in oranges, lentils and green leafy vegetables.
Professor Eef Hogervorst: Spicy food can give you hot flushes by opening your blood vessels. Great if you want to sweat in a hot country, not so good if you do to not want to have hot flushes.
Dr Emma O’Donnell: This is a difficult one to answer, quite simply because we still do not know what the exact cause of hot flushes are. It remains a bit of a mystery! However, we understand that hot flushes are multifactorial, with ethnicity, smoking, obesity or body mass index, levels of follicle stimulating hormone, socio economic status all playing a role, with estrogen thought to play an integral role. Some adjustments in thermoregulation at the level of hypothalamus is also thought to be implicated (estrogen plays a fundamental role in this regulation). I hope this helps.
Dr Emma O’Donnell: The bloating and GI issues you are experiencing with your transdermal patches is not uncommon, and these are recognised side effects of transdermal HRT. Changes in hormone levels due to menopause and due to HRT can influence the amount of bile produced, which changes the way your body digests fats and, in turn, makes it produce more gas. Estrogen (and progesterone) also has important effects on body fluid regulation, meaning that fluid retention may occur with higher levels of these hormones. While it’s not possible to determine exactly what is going on with you and your gastrointestinal issues, I hope this answer helps in some way.
Dr Emma O’Donnell: You may not be able to tell if you’ve reached menopause if you’re still on birth control. Hormonal birth control may hide some of the symptoms of menopause, such as an abnormal period, hot flushes, or night sweats. Your doctor may ask you to come off the pill if you are near to the average age of menopause (50 or so), and in doing so, you may experience menopausal symptoms (most likely hot flushes). If not, you may not have yet reached menopause, or you just might be incredibly lucky! There are some blood tests that your doctor can do to see where you are in the menopause.
Professor Eef Hogervorst: That depends on what is meant by ‘older’. On the basis of the data, I would not think that giving oestrogen to women over 65 years of age for a prolonged period of time (more than a couple of months) is a good idea. Brain cell studies by Roberta Brinton-Diaz have shown that oestrogens can accelerate adverse changes in brain cells that are common in dementia and some treatment studies also showed an increased risk for dementia with oestrogen combination treatment in women over 65.
Professor Eef Hogervorst: Not necessarily, it depends on the type and how long ago it was when you had your menopause. Some women will show spotting, others a small withdrawal bleed, some nothing.
Professor Eef Hogervorst: The difficulty is that some newer products have less research done and lots of studies were done in the US where Premarin was most frequently used. That is a conjugated equine (horse) oestrogen often in combination with medroxy progesterone acetate which had been known in the late 80s (studies by Sarrel) to be associated with negative effects on blood vessels and so could confer risk on heart but brain function too.
Professor Eef Hogervorst: No not necessarily. A complaint is different from an actual objective memory or concentration test result. Many more women complain of brain fog (around half of women in perimenopause) than actually show lower test performance (about one in five women). In meta-analyses we only found benefits of HRT on objective cognitive tests for a couple of months and women then went back to baseline objective memory function. If they were over 65 some studies showed a dip under their baseline function with more risk for dementia. Most important without treatment several studies following women over time showed that many women revert to normal brain function a couple of years after the menopause.
Professor Eef Hogervorst: That is something you would need to discuss with your GP. If you feel happy taking it and are fit and healthy, you may have different risks (or even benefits) compared to someone who is not in such a good health state. Some studies found that taking HRT for more than ten years was associated with a tiny increase in dementia risk, but others did not.
Professor Eef Hogervorst: Yes this is the case for most women, but other women can have flushes for up to 12-14 years after their menopause.
Professor Eef Hogervorst: As long as you are healthy, there is no real reason for you to stop now. The data show that taking HRT over 5-7 years may start affecting your risk for breast cancer but I do not think that is the case for transdermal as much as it is for oral treatments. Some data suggest that taking HRT for over 10 years may affect dementia risk slightly, but other data suggest that is not the case.
Professor Eef Hogervorst: Personally I think (but not a medic) that this is the best time to start taking HRT to regulate your fluctuating hormone levels which can cause flushes and other symptoms. If your symptoms are proving challenging, speak to your GP about your options.
Professor Eef Hogervorst: That depends, in women with higher body fat oestrogen can be formed from androgens. It also depends on the stage you were at when you started taking it, whether you are postmenopausal or perimenopausal.
Professor Eef Hogervorst: Personally I stopped taking estrogel after doing this for a couple of years when perimenopausal and I feel absolutely fine now. Better than I did for a long time. I no longer have periods but also no hot flushes and night sweats (they were horrible!!) and my memory – like the data show – is coming back online (hurrah!). Avoiding stress and working on your sleep hygiene with good nutrition, exercise and stress management can really help as well. I think it is a period of transition, change for the body to adapt to. Many women I spoke to who did not take hormones told me how eventually they came back to themselves and everything calmed down, memory came back, concentration, no more mood issues etc. However, if you have bad symptoms and no contraindications, take hormones to help you through it. Maybe first try the lifestyle changes (light exercise, sleep hygiene, good food, not smoking, light clothes, little alcohol and caffeine, no spicy food etc) then supplements (e.g. sage etc worked for me for a couple of months), then transdermal, gel or patches of oestradiol with a bioidentical progesterone if you have a womb.