WDH Guide to Menopause

Introduction

Menopause is a natural event. It occurs when the ovaries cannot consistently make the hormones of reproduction called estrogen and progesterone. There is no predictable menopause journey. Each person will experience it differently and individually. Some may transition quickly with minimal support. Others may need more support personally, professionally or medically. In this document we highlight common symptoms, standard potential treatments, as well as concerning symptoms which should be discussed with your healthcare provider. 

Note - Members have the right to privacy and medical confidentiality. Menopause transition is no exception. The decision to share information about your experience with colleagues or chain of command is up to you.

Perimenopause

Perimenopause is also known as the menopausal transition period. It is the time when your periods start to change. The majority will experience perimenopause between ages 40-50, which can last up to 10 years. Perimenopause ends when you have not had a period for 12 months, at this point you have transitioned into menopause. It is normal during perimenopause for periods to become less predictable, the flow may be heavier or lighter, and may last more or fewer days than before. Physical vasomotor symptoms, such as hot flashes and night sweats, often appear during this phase and continue into the menopause and postmenopause phases.

If you are experiencing ANY of the below symptoms, you should speak to your healthcare provider:

• If you are under 40 and experiencing irregular periods or perimenopause symptoms
• If you are experiencing heavier periods, or bleeding during or immediately after having sex, or having unexpected bleeding in between your periods
• Any time you need support to manage your symptoms.

Perimenopause is a time of transitions, not just for the body, but also in all aspects of your life. Perimenopause may also coincide with big life changes. This can be in your personal and/or professional life. For example, you may be deciding to retire, changing professions or being promoted into a demanding new position. When unmanaged perimenopausal symptoms are thrown into the mix, it may be difficult to make decisions with clarity. In some instances, people have ended their careers early because of severe unmanaged symptoms (such as hot flashes). If you are experiencing perimenopause symptoms that are disturbing your life, please consider discussing it with your healthcare provider. 

During perimenopause, you are still fertile and at risk of unplanned pregnancies. Have a discussion with your healthcare provider about safe contraception options personalized to your health history.

Menopause

Menopause occurs when menstruation has stopped for 12 consecutive months. The average age of menopause in Canada is 51 years old. At this point, the natural decline in estrogen may lead to a range of symptoms. Symptoms may be vague, confusing, or difficult to distinguish from age-related changes or other mechanisms such as thyroid disorders and social changes mentioned above.

To clarify, perimenopause describes the months/years of irregular periods, inclusive of the 12 consecutive months without a period. When looking back, if you have not had a period for 12 months, at this point, you have reached menopause. Strictly speaking, menopause is a day in time, then immediately after this point you enter the postmenopausal phase for the rest of your life (Figure 1). The terms perimenopause, menopause and postmenopause are often used interchangeably, adding to the confusion. See Table 1 for a list of changes that may be experienced during peri/menopause

Figure 1: Graph displaying hormonal changes over time before, during and after peri/menopause. Points in the graph highlight the following: A. Start of puberty; B. Start of perimenopause (Average starting age of perimenopause is 45 years of age); and C. Menopause (Average age of menopause is 51 years of age).

Table 1: Changes that may be experienced during Peri/Menopause

Common symptoms of menopause

Hot flashes are the most common symptom of peri/menopause, affecting up to 80% of women studied.

• They begin as a sudden feeling of heat in the upper chest and face. The hot feeling spreads through the body and lasts for two to four minutes.
• Some sweat during the flash, followed by chills and shivers. Some will feel anxiety or heart palpitations described as “heart beating out the chest”.
• Hot flashes may occur once or twice a day, more often at night, or maybe as often as once per hour. It is not clear what causes these episodes.
• On average, hot flashes will recur  for years, some have reported these well into their 60s.
• Drinking hot beverages and eating hot or spicy foods, caffeine and alcohol can make hot flashes worse and more frequent.

Night sweats are hot flashes that occur at night. These can cause you to sweat through your clothes and disrupt your sleep, which can lead to fatigue, irritability, trouble concentrating and mood swings.

Sleep issues are common. Falling asleep or staying asleep becomes disrupted, contributing to fatigue, irritability and brain fog.

Vaginal dryness occurs as estrogen decreases in the body. The tissue inside the vagina and urethra (tube carrying urine from bladder to the outside) becomes thin and fragile. This may lead to discomfort, itching, or pain during sex.

Depression can manifest as sadness, difficulty focusing, disinterest in enjoyable activities, and sleeping too much or too little. Those with a history of depression or anxiety are at higher risk of worsening mood.

Symptom Management

Some may seek professional treatment, others may not. If you would like to try to manage your symptoms on your own or while you wait to see your healthcare provider, see table 2 for ideas on self-management tips.

Table 2: Self-management support for menopausal symptoms.

Treatments

Treatments for menopause symptoms can be broadly divided into hormonal and non-hormonal options.

Hormonal

Hormone Therapy (HT; previously known as Hormone Replacement Therapy) replaces estrogen and progesterone hormones, relieving the bothersome symptoms of menopause.

Estrogen is available in many forms, such as a patch on the skin, oral pills, gel, or a ring, cream or tablet inserted into the vagina. For those with only vaginal dryness or painful sex due to menopause, a low dose of local (stays in the vagina) vaginal estrogen often provides relief. This type of local estrogen can be in ring, cream or tablet form and has low (if any) absorption in the body. Progesterone is not needed when using this form of estrogen.

Progesterone must be paired with estrogen for people with a uterus (unless it is used locally in the above example). It protects the uterus against estrogen-induced growth of the lining of the uterus, which overtime could increase the risk of uterine cancer. Progesterone comes in pill form or as an intrauterine device (IUD).

HT is not for every peri/menopausal situation. Please have a conversation with your healthcare provider if you fall into any of these groups:

• Active or history of breast cancer
• Diagnosed coronary heart disease
• Previous history of blood clots, heart attack or stroke
• People at high risk of the above conditions
• Unexplained vaginal bleeding
• Acute liver dysfunction
• Any estrogen-dependent cancer 

Non-hormonal

For those who cannot or do not want to try HT, the below treatments provide some relief but in general are not as effective as HT.

For hot flashes and nights sweats, medications originally made for mood symptoms, at low doses show benefit for hot flashes in those who cannot or do not take estrogen. These generally fall into two classes of medications called selective serotonin reuptake inhibitor (SSRI) and serotonin/norepinephrine reuptake inhibitor (SNRI).

Gabapentin, originally for neurological conditions, may have some success at improving hot flashes/night sweats.

Consumer accessible supplements

These have found popularity in social media, and are available at supplement stores, not pharmacies. As with all unregulated supplements we cannot be confident in what they contain. The evidence that these supplements improve peri/menopause symptoms is limited. In addition, we cannot be certain that they are not potentially harmful.

Plant derived estrogens, also known as phytoestrogen, are found in soybeans, chickpeas, lentils, flaxseed, whole grains, fruits, vegetables and red clover. They are marketed as natural or safer alternatives to HT. However, these supplements are unregulated (which means there is no Health Canada oversight), and studies have not found plant derived estrogens to be of benefit to peri/menopause symptoms. That being said, eating a diet high in fruits, vegetables, legumes and nuts is always beneficial to overall health.

Bioidentical hormone therapy (BHT) has been promoted as natural remedies for hot flashes. These are compounded by local pharmacies into various forms such as capsules, creams, sprays and suppositories. As with all non-standardized compounding preparations, consumers cannot be confident that the preparations contain the correct purity, quality, and ingredients. Have a conversation with your healthcare provider if you would like more information. 

Postmenopause

Post menopause refers to the time after menopause. It starts when periods have ceased for 12 months and lasts until the end of life. The terms can be confusing since this is how menopause is defined. Think of menopause as a point in time, whereas post menopause describes a span of time. At this point, you are no longer ovulating. Say goodbye to the need for contraception! The menopausal symptoms you are experiencing may become milder or go away completely. However, some people continue to experience menopausal symptoms during this phase.