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Menopause

Medically reviewed by M. Puckey, BPharm Last updated on Oct 15, 2019.

Menopause is a natural event that normally occurs between the ages of 45 and 55.

As a woman transitions from her fertile years to non-fertile years there is a decline of the hormone levels of estrogen (estradiol, estrone and estriol) and an increase in follicle-stimulating hormone (FSH). 

The perimenopause stage is when your menstrual periods generally become more irregular, either more closely or more widely spaced.  This stage may last for 1 to 5 years before menstruation finally ends completely (menopause). During these changes the gradual decrease of hormones generally allows your body to slowly adjust to the hormonal changes.

Menopause is when you have not had a period for 12 consecutive months.

Postmenopause are the years after menopause.

In some women their menstrual flow naturally comes to a sudden halt when hormone levels drops suddenly, or this can occur when the ovaries are removed surgically (called surgical menopause) and in these cases menopausal symptoms can be more severe.

The specific symptoms of perimenopause and menopause that are experienced, and whether the symptoms are mild, moderate, or severe varies from woman to woman.

Symptoms


Symptoms of perimenopause and menopause

    • Hot flashes and skin flushing
    • Night sweats
    • Insomnia
    • Mood swings including irritability, depression, and anxiety
    • Irregular menstrual periods
    • Spotting of blood in between periods
    • Vaginal dryness and painful sexual intercourse
    • Decreased sex drive
    • Vaginal infections
    • Urinary tract infections
    • Joint pain

In addition, the long-term effects of menopause include:

    • Bone loss and eventual osteoporosis
    • Changes in cholesterol levels and greater risk of heart disease

Exams and Tests

Blood and urine tests can be used to measure hormone levels that may indicate when a woman is close to menopause or has already gone through menopause. Examples of these tests include:

    • Estradiol
    • FSH
    • LH

A bone density test may be performed to screen for low bone density levels seen with osteoporosis. A pelvic exam may also required.


Helpful Tips

Lifestyle changes that can help mild symptoms during menopausal transition are:

    • Dress lightly and in layers
    • Reduce caffeine, alcohol, and spicy foods
    • Practice slow, deep breathing whenever a hot flash starts to come on 
    • Use relaxation techniques like yoga, tai chi, or meditation
    • Eat soy foods
    • Perform Kegel exercises daily to strengthen the muscles of your vagina and pelvis
    • Use water-based lubricants during sexual intercourse
    • Exercise regularly
       

Non-Hormone Medication Treatment

There are non-hormone medications available to help with mood swings, hot flashes, and other menopausal symptoms. These include low doses of antidepressants such as paroxetine (Paxil), venlafaxine (Effexor), bupropion (Wellbutrin), and fluoxetine (Prozac), or clonidine, which is normally used to control high blood pressure.

Hormone Treatments

Menopause is a natural process and may not require treatment unless the symptoms, such as hot flashes or vaginal dryness, are particularly bothersome.

For years, hormone replacement therapy (HRT) was the main treatment for menopause symptoms. Many physicians believed that HRT was not only good for reducing menopausal symptoms, but also reduced the risk of heart disease and bone fractures from osteoporosis. However, the results of a major study -- called the Women's Health Initiative -- showed that by taking HRT there was also an increase in risks of breast cancer, heart attacks, strokes, and blood clots.

More recent recommendations look at the risks and benefits for each individual woman depending on their personal circumstances and the severity of their symptoms.

Hormone therapy is approved by the FDA for prevention of bone loss, estrogen deficiency, moderate to severe vasomotor symptoms  (hot flashes, night sweats and skin flushing) and vaginal or urinary symptoms, if these symptoms are caused by reduced levels of hormones related to menopause.


The benefit of HRT is more likely to be greater for those women who are 

    • suffering from moderate to severe symptoms
    • who start hormone treatment within 10 years since the start of menopause
    • that are younger than 60 years old 
    • providing that they do not have any contraindications to hormone therapy. 

To decide if HRT is appropriate personal risk factors need to be taken into account including

    • age
    • time since menopause
    • risk of venous thromboembolism, stroke, ischemic heart disease, and breast cancer 

Women who should not take are women who have: 

    • a history of breast cancer or endometrial cancer
    • liver disease
    • coronary artery disease
    • triglyceride levels are elevated
    • history of hormone related thromboembolism or arterial thromboembolic conditions
    • vaginal bleeding of unknown cause
    • pregnancy
    • endometriosis
    • fibroids

Individualization of HRT is important for each patient as the most appropriate treatment option will maximize benefits while minimising risks, while meeting the patients preference. It is important to consider: 

    • Type of hormone (estrogen, or estrogen with progestin)
    • Dose (strength of medicine)
    • Route of administration (oral, transdermal, vaginal)
    • Formulation (tablets, capsules, gels, sprays, patches, injection, suppository, rings etc)
    • Duration of use (regular re-evaluation of the benefits and risks, and reassessment of continuation or discontinuation treatment)

Hormone Types 

Estrogens:

Estrogen or a medicine that has an estrogen-like effect, is prescribed to treat the symptoms and issues associated with menopause. Estrogen is used on its own if you have had a hysterectomy (your uterus has been removed). 

Types of Estrogen: 

    • estradiol
    • conjugated estrogen 
    • estropipate


Medicines used for their estrogen-like-effect:

    • ospemifene - a selective estrogen receptor modulator (SERM)
    • prasterone  - a dehydroepiandrosterone (DHEA)

Progestins:

If you have not had a hysterectomy (therefore still have a uterus) you need to take progestin, in addition to estrogen, as progestin reduces the risk of cancer in the lining of the uterus. 

Types of Progestin: 

    • progesterone 
    • medroxyprogesterone
    • norethindrone
    • drospirenone
    • norgestimate

Bazedoxifene can also be in combination therapy with estrogen for women who have a uterus.   Bazedoxifene is a selective estrogen receptor modulators (SERM) and like progestin reduces the risk of cancer in the lining of the uterus.


Forms of HRT

Hormone therapy can be delivered to the body in a number of forms:

Oral (tablets, capsules): 

    • have a whole-body affect therefore treats hot flashes, night sweats, bone density issues, and vaginal and urinary symptoms.
    • as the hormones reach the whole body oral medications can have more side effects

Transdermal (patches, gels and lotions):

    • are also absorbed into the whole body and therefore treats hot flashes, night sweats, bone density issues, and vaginal and urinary symptoms.
    • products that are absorbed through the skin do not have to pass through the liver so reduce some side effects such as venous thromboembolism when compared to oral medicines

Vaginal products (suppositories, tablets, creams and rings):  

    • these have a local effect and are used to treat  vaginal or urinary symptoms 
    • very little is absorbed into the body so they have reduced systemic side compared to oral hormone therapy

Hormone Treatments for Postmenopausal Symptoms - Tables 

ESTROGEN TYPE PRODUCTS

Estrogen- Oral Products

Estrogen type Brand Names

Strengths

Conjugated estrogen Cenestin 0.30 mg, 0.45 mg, 0.625 mg, 0.90 mg, 1.25 mg
Enjuvia 0.30 mg, 0.45 mg, 0.625 mg, 0.90 mg, 1.25 mg
Premarin oral tablets 0.30 mg, 0.45 mg, 0.625 mg, 0.90 mg, 1.25 mg
estradiol (17B-estradiol) Estrace oral tablet 0.50 mg, 1.0 mg, 2.0 mg
esterified estrogens Menest 0.30 mg 0.625 mg 1.25 mg 2.5 mg
estropipate Ogen 0.75 mg 1.5 mg 3.0 mg*
ospemifene** Osphena 60 mg

*0.625mg  sodium estrone sulfate is equivalent to 0.75mg estropipate

1.25mg  sodium estrone sulfate is equivalent to 1.5mg estropipate 

2.5 mg  sodium estrone sulfate is equivalent to 3 mg estropipate

**ospemifene is a selective estrogen receptor modulators (SERM) so it is a non hormonal drug that acts like or has the effect of estrogen

Estrogen -  Vaginal Products

Estrogen type

Brand Names Product Strength
conjugated estrogen Premarin vaginal cream  vaginal cream 0.625 mg/gram applicator delivers 0.5, 1, 1.5, and 2 gram doses
estradiol Estrace vaginal cream vaginal cream 0.01% applicator that delivers 1, 2, 3, and 4 gram doses
Estring vaginal ring vaginal ring contains 2 mg of estradiol (approximately 7.5 mcg per 24 hours of estradiol over 90 days)
Femring vaginal ring vaginal ring. 0.05 mg/day ring, 0.10 mg/day ring
Imvexxy vaginal insert vaginal insert 4mcg, 10mcg estradiol
Vagifem vaginal tablet vaginal tablet 10 mcg estradiol
Yuvafem vaginal tablet vaginal tablet 10 mcg estradiol
prasterone* Intrarosa vaginal insert 6.5 mg prasterone

* prasterone is an inactive hormone which is converted in the body to active androgens and/or estrogens

 

Estrogen -  Transdermal

Estrogen type Brand Name Product Strength
estradiol patches Alora Patch 0.025 mg/24 hour, 0.050 mg/24 hour, 0.075 mg/24 hour, 0.10 mg/24 hour
Climara Patch 0.025 mg/24 hour, 0.0375 mg/24 hour, 0.050 mg/24 hour, 0.060 mg/24 hour, 0.075 mg/24 hour, 0.10 mg/24 hour
Dotti Patch 0.025 mg/day, 0.0375 mg/day, 0.05 mg/day, 0.075 mg/day, and 0.1 mg/day

Menostar (only for prevention of postmenopausal osteoporosis)

Patch 0.014 mg/24 hour
Minivelle Patch 0.025 mg/24 hour, 0.0375 mg/24 hour, 0.050 mg/24 hour, 0.075 mg/24 hour, 0.10 mg/24 hour
Vivelle-dot Patch 0.025 mg/24 hour 0.0375 mg/24 hour 0.050 mg/24 hour 0.075 mg/24 hour 0.10 mg/24 hour
estradiol gels and sprays Elestrin gel Gel pump 0.06% gel. Each pump is 0.87 grams and contains 0.52 mg estradiol. Contains 30 metered doses
Estrogel Gel pump 0.06% gel. Each pump delivers 1.25 grams of gel which contains 0.75 mg of estradiol. 50 gram pump that delivers 32 doses
Divigel Gel packets. Individual packets. Available in 3 doses 0.25 mg, 0.50 mg, 0.75 mg, 1.0 mg. 30 packets per carton
Evamist Spray. Each spray is 1.53 mg of estradiol. Each bottle contains 56 sprays

Estrogen -  Injections

Estrogen type Brand Names Product Strength
conjugated estrogens Premarin injection 25mg per vial
estradiol cypionate Depo-Estradiol injection 5 mg/ml. 5 ml vial
estradiol valerate Delestrogen injection 10 mg/ml, 20 mg/ml, 40 mg/ml. 5 ml vial

 

PROGESTIN PRODUCTS

Progestin -  Oral

Progestin type Brand Names Product Strength
progesterone Prometrium capsules 100mg capsules, 200mg capsules
medroxyprogesterone Provera tablets 2.5mg, 5mg, 10mg tablets

 

COMBINATION PRODUCTS

Estrogen and Progestin - Oral 

Estrogen type Progestin type Brand Name Product Strength
conjugated estrogens medroxyprogesterone Prempro

0.3mg conjugated estrogens/1.5mg medroxyprogesterone. Take 1 tablet daily

0.45mg conjugated estrogens/1.5mg medroxyprogesterone.

0.625mg conjugated estrogens/2.5mg medroxyprogesterone
0.625mg conjugated estrogens/5mg medroxyprogesterone
Premphase
14 maroon tablet 0.625 mg conjugated estrogens, 14 light blue tablets 0.625 mg of conjugated estrogens and 5 mg medroxyprogesterone. Take 1 maroon tablet daily for 14 days, then 1 light blue tablet daily for 14 days.
estradiol norethindrone Activella, Amabelz, Lopreeza, Mimvey 1 mg/ 0.5 mg (1 mg of estradiol/0.5 mg of norethindrone acetate)
Activella, Amabelz, Lopreeza, Mimvey Lo 0.5 mg/ 0.1 mg (0.5 mg of estradiol and 0.1 mg of norethindrone acetate)
estradiol drospirenone Angeliq

0.25mg drospirenone/0.5mg estradiol
0.5mg drospirenone/1mg estradiol
estradiol progesterone Bijuva 1mg estradiol/100mg progesterone
estradiol norgestimate Prefest

peach tablet 1mg estradiol, white tablets 1mg estradiol/ 0.09mg norgestimate

1 tablet is taken daily. Alternating between 3 days of white tablets and 3 days of peach tablets

ethinyl estradiol norethindrone Femhrt, Fyavolv, Jevantique Lo 0.5 mg norethindrone acetate / 2.5 mcg ethinyl estradiol
Fyavolv, Jinteli 1 mg norethindrone acetate / 5 mcg ethinyl estradiol

 

Estrogen with SERM - Oral

Estrogen type SERM type Brand Name Product Strength
conjugated estrogens bazedoxifene (Selective estrogen receptor modulators -SERM)* Duavee 0.45 mg conjugated estrogens/20 mg bazedoxifene

*Bazedoxifene is an estrogen agonist/antagonist that reduces the risk of endometrial hyperplasia that can occur with the conjugated estrogens component.

 

Estrogen and Progestin Combinations - Patches

Estrogen type Progestin type Brand Name Product Strength
estradiol levonorgestrel
Climara Pro
0.045 mg estradiol/0.015 mg levonorgestrel per day
estradiol norethindrone Combipatch 0.05 mg estradiol / 0.14 mg norethindrone per day
0.05 mg estradiol / 0.25 mg norethindrone per day

 

 

Side effects of Hormone therapy


Like any medicines hormone replacement therapy can cause side effects the more common ones being

    • breast tenderness
    • nausea
    • bloating
    • leg cramps
    • irritability 
    • depression
    • weight gain
    • breakthrough bleeding

Long term side effects are increase risk of 

    • thromboembolism,  stroke or cardiovascular disease 
    • breast cancer 
    • ovarian cancer
    • endometrial cancer, depending on hormone regime 
    • dementia 
    • liver disease

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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