Several studies have recognised the menopausal symptoms such as joint pains, hot flushes and low morale impact significantly on the lives of women. Doctors need to appreciate the needs of individual women transitioning to menopause and perimenopause and assist in education, managing symptoms as they age.
“In a small study of 33 healthy premenopausal women, both total and free plasma testosterone showed steep declines with age. According to that study, a woman of 40 would have half the total testosterone concentration of a woman of 21. In those premenopausal women, plasma DHEA and DHEA(S) also declined steeply with age. Clearly, women also pass through an andropause with ageing”. We have also conducted a small local study.
The evolving significant menstrual period has significant impacts on the lives of women and society through economic, social, and physical wellbeing. According to a study by ROCG (UK) 2019, “the menopause affects all women at some stage in their life, but many women do not know what to expect during the menopause nor do they feel empowered to seek help when needed or able to manage their symptoms. This is particularly challenging for the 25% of menopausal women who experience severe symptoms and can lead to the onset of potentially avoidable health problems in the future.”
In The Lancet editorial, its quotes a study of 4000 of menopausal and perimenopausal women “almost half (45%) of women have not spoken to their general practitioner (GP) about their symptoms and 31% said it took multiple appointments with their GPs before they were properly diagnosed”.
Notwithstanding, the Women’s Health Initiative (WHI) study reports that current data supports benefits of HRT, including symptom relief, quality of life improvement, prevention of coronary heart disease and osteoporosis, and mortality reduction. Notably, HRT does not increase all-cause, cardiovascular, or cancer mortality risk.
Variations in HRT efficacy and risks depend on factors such as product origin (body identical or equine), dosage, route of administration, and timing of initiation. Transdermal oestradiol emerges as particularly effective for vasomotor symptoms. While oral estrogen increases venous thromboembolism (VTE) risk, transdermal forms are safer, especially for women at higher VTE risk. Oral estrogen also raises stroke risk, but transdermal options do not.
Natural micronised progesterone (MP) offers advantages over synthetic progestogens, including lower VTE risk, cardiovascular neutrality and possibly lower breast cancer risk, especially when used for over five years. MP also provides effective endometrial protection, making it a favourable choice in HRT. Recommendations favour transdermal estrogen to mitigate side effects, highlighting the importance of tailored treatment approaches in optimizing menopausal symptom management.
We typically observe significant improvement in symptoms within six weeks, with symptoms halving by this time frame, and by three months, patients often score close to zero on their Australian Menopause Society (AMS) Diagnosing Menopause: Symptom Score Sheet. If a woman’s symptoms persist beyond this point, explore other potential causes, with the most common missed diagnosis being ADHD and sleep apnoea.
Hot flushes typically resolve within two weeks. Palpitations, tinnitus, and muscle spasms are among the first to improve. Joint pain and back pain may take six to nine months to significantly improve depending on the underlying pathology. Sleep and mood typically show rapid improvement, with the breakdown product of progesterone, allopregnanolone, exerting a sedating and relaxing effect without causing grogginess.
Around 90% of women experience improved sleep within half an hour to one hour of taking progesterone while a small proportion may report symptoms of intolerance, including bloating, anxiety, headaches, and fatigue.
When topical oestrogen is used appropriately, symptoms of genitourinary syndrome of menopause (GSM) improve within six weeks. Longer and more severe symptoms may take longer. Daily vaginal estrogen for two weeks followed by twice weekly thereafter may not provide adequate symptom control for some women, necessitating more frequent use. Notably, vaginal estrogen is generally safe for use, even in women not on HRT, with gynaecologists often permitting its use in women on Tamoxifen.
Testosterone therapy, typically prescribed for hypoactive sexual desire disorder (HSDD), can improve energy, sense of well-being, and muscle toning, with the aim of achieving a free androgen index (FAI) of 2-3. Testosterone therapy complements estrogen therapy, with the goal of returning symptoms to premenopausal ranges.
Contrary to misconceptions, testosterone therapy does not typically result in masculinising effects like facial hair growth or deepening of the voice. The notion of a three to five-year limit on HRT is not scientifically based, and long-term HRT use has been shown to provide better outcomes for patients in terms of cardiovascular protection and metabolic improvements. Thus, HRT can be used indefinitely to manage menopausal symptoms effectively.
From the viewpoint of a senior GP, the issues that have been identified with this research is that GPs in general are faced with compounding clinical issues based on the expectations of patients. This could also be the result of macro issues dealing with standard MBS consultation criteria, shortage, and turnover of GPs, and reducing number of bulk billing clinics affecting access and affordability.
It is very common for patients to present with the ‘shopping list’ of complaints and this poses many diagnostic challenges for the time pressures for clinicians.
Key messages
- Menopausal symptoms can have significant impact on quality of life
- HRT has a legitimate role in alleviating symptoms
- Individualised care is key.
– References available on request
The authors acknowledge the contribution of Prof Martin Samy and Caitlain Navarra-Babor
Author competing interests – the authors were involved in the study quoted.