VOL: 96, ISSUE: 42, PAGE NO: 11
Lesley Woodward, RGN, HealthEdCert, is menopause adviser, Dorset Community NHS Trust, and a nurse counsellor, Women's Health Concern, Menopause Educational Resource Centre, Blandford Community Hospital, Blandford ForumWomen can now expect to live one-third of their lives after the menopause. But for many the cessation of menstruation, the result of a decrease in circulating oestrogen levels, can bring distressing physical and emotional changes.
Women can now expect to live one-third of their lives after the menopause. But for many the cessation of menstruation, the result of a decrease in circulating oestrogen levels, can bring distressing physical and emotional changes.
Concerns about the side-effects of hormone replacement therapy (HRT) mean that only 17% of postmenopausal women try HRT, and that more than half of them stop taking it within a year (Hope et al, 1998).
An increased risk of breast cancer is one of the main concerns associated with HRT. But about 45 in 1,000 women aged over 50 who are not using HRT develop breast cancer within 20 years (British Medical Association and The Royal Pharmaceutical Society, 2000).
The increased risk of breast cancer associated with HRT is related to how long a woman takes it. Those who use it only for a short time around the menopause have an extremely low excess risk, and any increase in risk disappears within five years of the end of therapy (British Medical Association and The Royal Pharmaceutical Society, 2000).
Women who are considering HRT should be told about all the risks and benefits involved so that they can make an informed choice.
Women are becoming increasingly knowledgeable about health issues and more are seeking symptom relief from their GPs during and after the menopause. They are also more aware of the long-term effects of hormone deficiencies and are more likely to take steps to prevent osteoporosis and cardiovascular disease.
Nurses, particularly those in menopause clinics and GP surgeries, have an important role to play in informing women about the menopause and the treatments available. Before the start of treatment it is important to emphasise the wide variety of HRT options on offer and that each has slightly different effects.
As women's natural hormone levels vary, they must be prepared to fine-tune doses or switch between different formulations before finding their ideal therapy.
The menopause is the culmination of several years of declining ovarian function and usually takes place between the ages of 45 and 54. As oestrogen levels fall, menstruation typically becomes heavy and irregular. Eventually, the ovaries stop functioning and periods stop. Falling oestrogen levels result in unpleasant symptoms for up to 95% of women. These may include:
- Irregular periods;
- Hot flushes;
- Night sweats;
- Bladder infections;
- Vaginal dryness;
- Changes to the skin and hair;
- Stress incontinence;
- Joint and muscle pains;
- Loss of interest in sex;
- Poor memory;
About a quarter of the women going through the menopause will have severe symptoms. They may also notice emotional changes, such as mood swings, anxiety and depression.
Untreated menopausal symptoms usually settle within two to three years, but they can persist for a decade. However, declining oestrogen levels also increase bone resorption, particularly in the hips, wrists and spine, which can lead to osteoporotic fractures in later life.
Another consequence of the menopause is an increased risk of cardiovascular disease. Oestrogen protects the heart, so when levels fall the risk of coronary disease and stroke increases.
How HRT works
HRT, which combines oestrogen replacement therapy with synthetic progesterone, replaces the hormones that a woman's body stops producing during the menopause. As such it is the only treatment to relieve the symptoms of the menopause and provide long-term protection against osteoporosis (Barlow, 1993) and cardiovascular disease (Van Baal et al, 2000).
Oestrogen replacement therapy alone would effectively achieve these aims, but it stimulates the growth of the endometrium, which increases the risk of endometrial cancer. To prevent this, women must also take a course of synthetic progesterone, known as progestogen.
The progestogen component of HRT creates an artificial bleed that is similar to a period. It can be taken on a monthly or quarterly basis or as continuous combined therapy.
Postmenopausal women could be offered a continuous combined low-dose oestrogen-progestogen preparation. Because of the low dose, this does not encourage the growth of the endometrium.
A synthetic, period-free HRT is available which improves libido and enhances mood.
Women who have had a hysterectomy are not at risk of endometrial cancer so they can safely take unopposed oestrogens.
HRT can be administered in several ways, depending on personal preference and the possible side-effects. These methods include:
- Oral therapy;
- Transdermal HRT;
- Oestrogen implants;
- Vaginal creams, pessaries and rings.
There are many different brands of oestrogen tablets. Some are fixed-dose regimens while others mimic the menstrual cycle by changing the dose throughout the 28-day course. Women with a uterus also need to take a course of progestogen tablets for about 12 days each month.
The tablets are easy to take and their effects can be reversed quickly, but they can cause side-effects. Altering the dosage often alleviates the side-effects, but if they persist some women may need to switch to a different form of HRT.
There are two forms of transdermal HRT: skin patches and oestrogen gels. Both are absorbed through the skin directly into the bloodstream. This bypasses the liver, giving them an advantage over oral treatment.
Rapid absorption provides fast and effective symptomatic relief (Sturdee, 2000). And women using transdermal HRT require lower doses to achieve natural physiological levels than those using oral HRT, which should limit the side-effects.
A wide variety of HRT patches are available. Some contain oestrogen alone while others are made up of a combination of oestrogen and progestogen. Most have to be changed twice a week, but some seven-day systems are available. They are usually well tolerated but can cause skin irritation. Some women also find them unsightly.
There are two oestrogen gels. One comes in a pump-action canister, making it easy to adjust the dose, and the other comes in sachets. Oestrogen gels are spread onto the arm, shoulder or inner thigh daily. They are alcohol-based, so they are not greasy or messy, and seldom cause skin irritation.
Women who have had a hysterectomy can use unopposed oestrogen gels. All others need to take progestogen tablets or patches as well.
Implants are small pellets of oestrogen inserted into the fat under the skin. They last six months and their main advantage is that women do not need to remember to take tablets or change patches.
They are difficult to remove if they are not suitable, which means that many women have to wait until they dissolve. They can also remain in the system for some time. Women with a uterus need additional progestogen.
Vaginal creams, pessaries and rings
These are local therapies that can be useful to women who are affected only by genital symptoms, such as a dry vagina. If vaginal dryness is a continuing problem they must be accompanied by a cyclical progestogen because systemic absorption can stimulate the growth of the endometrium.
Indications for treatment
Oestrogen deficiency is by far the most important cause of long-term complications during and after the menopause. Oestrogen replacement therapy is therefore the only treatment that addresses the cause of the problem rather than providing only symptomatic relief (Rees, 1999).
HRT should always be considered for:
- An early menopause;
- Those who have had a hysterectomy, even if the ovaries remain;
- Any woman who requests or shows an interest in HRT;
- Menopausal women with a high risk of osteoporosis or coronary heart disease, which includes smokers, stabilised hypertension or a family history of Alzheimer's disease;
- Long-term users of corticosteroids or thyroid replacement drugs as both could lead to a loss of bone density.
HRT is contraindicated in women with:
- Acute-phase myocardial infarction, pulmonary embolism or deep-vein thrombosis;
- Endometrial or breast cancer;
- A pregnancy;
- An undiagnosed breast mass;
- Uninvestigated abnormal vaginal bleeding;
- Severe liver disease with abnormal liver function tests, although if the symptoms of the menopause are severe a non-oral route should be considered.
Many of the contraindications described in prescribed data sheets are based on those for high-dose combined oral contraceptives and are not applicable to hormone replacement therapies. The following are no longer considered to be contraindications for oestrogen replacement therapy (Rees, 1999):
- Controlled hypertension;
- Angina or previous myocardial infarction;
- A family history of ischaemic heart disease;
- Varicose veins;
- Previous superficial thrombophlebitis;
- Heavy smoking;
- Malignant melanoma;
- A previous abnormal cervical smear;
- Previous cervical cancer;
- Previous ovarian cancer;
- Benign breast disease.
Duration of treatment
It is never too late to start HRT, but most specialists recommend that women begin treatment at or shortly before the menopause to gain maximum protection against osteoporosis and cardiovascular disease (Barlow, 1993; Van Baal, 2000).
It is generally accepted that women seeking only symptomatic relief should take it for two to three years, while those who want long-term protection against osteoporosis and heart disease should continue for at least five, and preferably 10, years.
Postmenopausal women who have been counselled on the risks and benefits of HRT and the options available to them are more likely to have realistic expectations of the treatment and therefore to persevere with it.
Nurses have a vital role to play in helping women to cope during and after the menopause, offering individual assessment, education and support. All those involved in counselling such women must ensure that they know where to get up-to-date information and where to direct clients who are in need of further information.
Nurses should explain all aspects of the menopause to each woman and ensure that she is aware of all the available options. This will enable women to make informed decisions on appropriate treatment and encourage them to be active rather than passive recipients of care.