Definitions

Menopause – this has occurred when you have not had a natural period for one year (if you are not on medication that stops your periods). The average age for this in the UK is 51 but any time between 45 and 55 is considered normal. You are then described as postmenopausal.

Perimenopause – this is the time when you develop menopausal symptoms but are still having periods although they may be more frequent, irregular, lighter or heavier. This phase can last up to 10 years.

Postmenopausal bleeding – a vaginal bleed when your last period was at least one year ago. THIS NEEDS URGENT ASSESSMENT WHICH IS ARRANGED VIA YOUR GP.

Surgical menopause – your ovaries are removed during a surgical operation (bilateral oophorectomy). This causes a rapid onset of menopausal symptoms due to the sudden loss of oestrogen (and testosterone).

Medical menopause – can be caused by chemotherapy, radiotherapy and some other drugs.

Early menopause – the menopause occurs before the age of 45.

Premature ovarian insufficiency (POI) – the menopause occurs before the age of 40 (about 1 in 100 women).

If you have been diagnosed with an early menopause or POI it is very important to take HRT until at least your early 50s unless there is a specific contraindication. Many women in this age group have been put off taking HRT by media scares but they do need to replace the natural hormones they have lost to protect their heart and bones for the future. Young women with a surgical menopause need to start HRT as soon as possible after their operation. They often benefit from testosterone replacement as well.

What symptoms may I get around the time of the menopause?

We have oestrogen receptors all over our bodies, including our bones, brains, heart, joints, skin, bladder and vagina. There are many possible symptoms related to the menopause, some more commonly talked about than others. Symptoms vary a great deal between women and can change with time. Some women never have the well known hot flushes or night sweats. Vaginal symptoms can come on first or not develop until much later. Symptoms can be very brief or last for decades, the average is about 7 years. A few lucky women ‘sail through’ with no problems but are still left with the effects of a long-term lack of oestrogen.

Physical symptoms can include irregular periods, hot flushes, night sweats, difficulty sleeping, migraines and other headaches, palpitations, lack of energy, feeling faint or dizzy, aching muscles, painful joints, vaginal dryness or burning , urinary frequency, pain and incontinence, loss of libido, breast pain, dry eyes, dry or burning mouth, indigestion, altered sense of smell, tinnitus, restless legs, weight gain around the abdomen, thinning and drier hair, brittle nails, increased facial hair, spots and dry, itchy skin.

Psychological symptoms can include brain fog, loss of confidence, anxiety, low mood, depression, mood swings, irritability, crying easily, poor concentration, lack of motivation, poor memory, loss of joy and low self esteem. Many women are given antidepressants at this stage of life when they really need HRT. When you consider that many of us are also coping with at least one of the stresses of looking after a partner, children, elderly relatives or work issues it is amazing that we manage to keep going at all!

What type of HRT can I have?

If you have had your whole uterus removed (total hysterectomy) you only need oestrogen HRT. This option has little or no increased risk of breast cancer.

If you still have your uterus you need both oestrogen and a progestogen (combined HRT) to stop the lining of the uterus building up and in rare cases developing endometrial cancer. This is divided into continuous combined or sequential combined HRT and we can discuss which is best for you during your consultation.

Some women will also benefit from testosterone.

Oestrogen can be delivered by tablets, patches, gels or a spray. Progestogen can be delivered via tablets, patches (only if in combination with oestrogen) or via the intrauterine system (Mirena). Testosterone can be delivered via gel. We can discuss the most suitable options for you.

What about side-effects and risks of HRT?

There are so many myths about HRT that are still being perpetuated and many doctors are still very cautious about prescribing it despite the proven benefits. Typical misconceptions are that it makes you put on weight, that you can’t have it if you get migraines or blood clots or have a family history of breast cancer, that it just delays your menopause and that you should only be on it for the shortest possible time. You do not have to have stopped your periods before you start HRT. We can discuss any such issues that concern you at your consultation. SEE MY PAGE ON MYTHS FOR MORE DETAILS.

The biggest worry for most women is the risk of breast cancer but this does not apply to all types of HRT and for the types it does apply to the risk is much smaller than we have been led to believe. It does not apply to women needing HRT for POI or early menopause until they reach their early 50s. I can discuss the research and look at this risk in relation to other risk factors for breast cancer you may have and how you can reduce your personal risk.

UPDATE JULY 2020 A recent research paper from the Journal of the American Medical Association (JAMA) published on July 28th 2020 confirms that women who have taken oestrogen only HRT (because they have had a hysterectomy) for more than 20 years have little or no risk of both developing or dying from breast cancer compared to women who had never had HRT. Taking oestrogen and a synthetic progestogen did increase the risk slightly as we already knew but there is no increased risk of death from breast cancer. Those on the body identical micronised progesterone (Utrogestan) rather than the synthetic form have an even lower risk of breast cancer. This small risk has to be considered in context with all the long-term benefits of HRT such as reducing the risk of endometrial cancer, bowel cancer, dementia, cardiovascular disease and osteoporosis as detailed below.

There is a small increased risk of blood clots and ischaemic strokes with the oral forms of oestrogen but not with the patch, gel and spray forms of oestrogen, absorbed through the skin. The body identical progesterone capsules are the safest form of progestin for those at risk of blood clots.

Unfortunately most of the patient information leaflets that are provided in HRT packaging give out of date information and list risks that do not relate to the newer HRT preparations and most recent research analysis.

What are the long-term benefits of HRT?

Every woman needs to know about the long-term benefits of HRT which are not publicised enough.

Heart benefits

Before the menopause women have a much lower incidence of cardiovascular disease (heart attacks and blood vessel disease) than men but after the menopause we gradually catch up with them. If started within 10 years of your last period or below the age of 60 and continued long-term, HRT can significantly reduce your risk of cardiovascular disease.

Bone benefits

We all start losing bone density in our 40s and this accelerates during and after the menopause. Certain lifestyle factors such as smoking and heavy drinking can put you at higher risk and it can also run in families. Osteoporosis has no symptoms until you start getting fractures after only minor trauma and it can lead to the classic stooping posture of some elderly people due to fractures in the spine. Fractured hips after falling are a common cause for hospital admission in the elderly, often leading to the loss of independence. Life-style factors such as weight-bearing exercise and a good diet are important in both preventing and helping with thin bones but HRT can also significantly reduce the risk of developing osteoporosis and is an effective first line treatment if you are diagnosed with it under the age of 60.

Studies have also show HRT reduces the risk of developing dementia, colon cancer and Type 2 diabetes. Women on combined continuous HRT have a lower risk of cancer of the lining of the uterus than those not on any HRT. Unfortunately this type of cancer is increasing in incidence as it is related to obesity.

How long can I take HRT for?

Although symptoms of the menopause such as hot flushes and night sweats do eventually go, your body is still left without oestrogen for the rest of your life unless you are taking HRT. The NICE guidelines say that women can take HRT for as long as the benefits outweigh the risks. For the majority of women this means they can continue it into old age, as long as they are having transdermal oestrogen and an annual review to assess their individual benefit:risk ratio. The dose of oestrogen can be gradually reduced as we get older as a low dose can still protect bone health into old age. If you decide to stop HRT we recommend doing this gradually.

A common myth is that you have to stop HRT after 5 years or at the age of 60. This is not the case.

What is the difference between body identical and bioidentical HRT?

I encourage the use of body identical hormones which have the same molecular structure as the hormones we produce and are derived from a chemical extracted from a tropical root vegetable (the yam). Ongoing prescriptions can be via the NHS or from the clinic.

I do not prescribe the compounded bioidentical hormones that some private clinics offer at vast expense together with unnecessary monitoring via blood or saliva tests. These can include hormone combinations that are not necessary and some of the types and doses of progestogen offered may not fully protect the lining of the uterus. These hormones are not regulated or licensed and are not recommended by the British Menopause Society.

Do you prescribe testosterone?

Yes. Many people don’t realise that testosterone is a really important hormone for women as well as men. We produce it both in our ovaries and via our adrenal glands and production naturally declines with age. Our levels reduce more dramatically if our ovaries are removed or stop functioning at a young age. I can prescribe testosterone if indicated, mainly to help with libido. Some women find it can also improve motivation, mood, energy levels, concentration, muscle strength and stamina. You would normally have a trial of an adequate dose of oestrogen (with a progestogen if you still have a uterus) for at least 6 months before considering whether testosterone is also needed to help with your symptoms. Younger women with a surgical menopause are most likely to need testosterone supplementation.

There are clear guidelines for prescribing testosterone and this does require regular monitoring and blood tests. Many GPs are not able to prescribe this on the NHS and if this is the case you will need to be seen privately for ongoing monitoring and private prescriptions.

Do I need a referral from my GP to come to the clinic?

No, you do not need a referral from your GP. Please fill in the online medical questionnaire and submit it before your appointment. All information is transmitted and held confidentially in a secure medical records system.

Most GPs are very happy for their patients to get expert advice on the menopause and have a specialist work out the best HRT option for their patients. They are usually able to take on further prescribing on the NHS although this doesn’t tend to apply to testosterone prescribing.

Will I need a physical examination?

COVID-19 update – please have any recent blood pressure, height and weight measurements available for your video consultation, thank you.

If you decide to start HRT you will need a blood pressure check and weight at 3 months and then annually. Home blood pressure monitors can be bought fairly cheaply online, I recommend the Omron brand.

Do I need any blood tests?

Blood tests are not usually needed to confirm your menopausal status, especially if you are aged 45 or above. They are indicated for anyone under 40 as it is very important to make a definite diagnosis of POI. However hormone levels can be very variable so a normal result does not necessarily exclude the diagnosis of the perimenopause. Blood tests are needed for the monitoring of testosterone treatment. They are occasionally used to check how well you are absorbing your HRT if you are not getting the desired effect. I have listed the most frequently requested test profiles below but other blood tests can also be arranged at the clinic if required. They are sent to the Nationwide laboratory. You will be able to access your results and my comments easily via the computer system used by the clinic. Alternatively your own GP may be happy to arrange for blood tests on the NHS. If you have had any recent blood tests it would be helpful to bring the results to your appointment.

Blood tests that can be taken by Dr Balfour at the clinic

PROFILE 1: full blood count, ferritin, folate, B12, kidney and liver function, lipids, thyroid function (TSH, T3 and T4), HbA1c (diabetes), vitamin D, oestradiol, sex hormone binding globulin (SHBG) and testosterone £200

PROFILE 2: oestradiol, SHBG and testosterone £82

PROFILE 3: SHBG and testosterone £62

PROFILE 4: oestradiol, SHBG, testosterone and thyroid function £120

PROFILE 5: thyroid function £80

Can I ask for sexual health screening?

This can be arranged if attending a face to face appointment in Wells via urine and blood tests (with an extra charge from the laboratory). There has been a rise in STDs in older women due to the new found freedoms some women have at this stage of life.

Am I covered by my private health insurance?

Menopause consultations are not usually covered by private insurance companies as it is considered a natural part of life. Dr Balfour is not registered with any insurance company.

If I start medication from the clinic what follow-up do I need?

Anyone starting or changing their HRT needs a follow-up appointment after 3 months (ideally including blood pressure and weight). Once on a suitable preparation and dose you need an annual check up but some people find they need to be seen more often initially to fine tune their HRT. Review appointments can be made at the clinic or with your own GP if you prefer.

How can I improve my vaginal or urinary symptoms?

As we lose oestrogen we all develop thinning of the tissues of the vagina, vulva and bladder. This is not something that settles after the menopause but steadily gets worse, often leading to vaginal burning and itching, painful sex, urinary frequency and recurrent urinary tract infections. It can easily be prevented by the regular, long-term use of vaginal oestrogen which is very safe and effective. It has no risk of causing breast cancer. I can discuss the different ways of applying this as well as advising on vaginal moisturisers and lubricants.

Vaginal oestrogen can be used with HRT or on it’s own as a long-term treatment. Most women on HRT find their vaginal symptoms are greatly improved but about 20% find they need to add in long-term vaginal oestrogen. If you are having bad symptoms when you are first seen you can start both HRT and vaginal oestrogen at the same time and then have a trial off vaginal oestrogen once the HRT has started to work.

Can I request repeat private prescriptions from you?

Yes, I can send you a private prescription for up to 6 months of medication once you are on the right regime for you and as long as you are getting the correct monitoring. I can either post the prescription to you or send it directly to the Independent Pharmacy. There is a charge of £20 for this service if it is not part of a consultation.

Do I still need contraception?

HRT is not a contraceptive. Some women with menopausal symptoms will still need contraception as well as HRT and this can be discussed at the clinic.

Can I have the intrauterine system ( Mirena)?

This is a great option for both contraception and/or the progestogen element of HRT. Although I’m a qualified and experienced fitter I’m not currently able to offer a fitting service at this clinic but I can advise you on the pros and cons and explain your options for arranging the procedure.

What about the HRT shortages?

This is causing a great deal of stress to lots of patients and indeed their doctors too. I can advise you on up to date availability and alternatives if your usual HRT is not available. There is also an issue with some batches of certain preparations being less effective than expected.

Is the clinic wheelchair accessible?

Please email me if you have any mobility problems and would like a face to face appointment.

Where can I park?

There are several pay and display car parks close to Rock House Dental Practice, including one just across the road from the practice.