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WOMEN of all ages should be made aware that vasomotor symptoms associated with menopause may last for several years, says a leading women’s health expert who has called for greater recognition of menopause as a normal transition in life.
Professor Martha Hickey, director of the Women’s Gynaecology Research Centre at the Royal Women’s Hospital, Victoria, said the traditional notion that vasomotor symptoms (VMS) — hot flushes and night sweats — lasted for about a year had been overturned as recent, longer-term studies found that symptoms could persist for many years.
Professor Hickey was commenting on US research, published in JAMA Internal Medicine that found frequent VMS lasted for a median of 7.4 years during the menopausal transition, with symptoms persisting for a median of 4.5 years after the final menstrual period. (1)
The researchers analysed data from the US-based Study of Women’s Health Across the Nation (SWAN), an observational study of menopausal transition in 3302 women from 1996 to 2013, which included 1449 women with frequent VMS.
An accompanying editorial said the findings overturned the “dogma” that VMS have a short duration, minimally affect women’s quality of life and could be addressed by short-term approaches. (2)
Professor Hickey told MJA InSight awareness that these symptoms may last for many years might help to lessen their impact.
“The environment that women are in can contribute to the stress around these symptoms, so I think an important message … is the wider recognition and acknowledgement that these are normal symptoms for women”, she said.
“We know that the more anxious women are about menopause and its symptoms, the more troublesome their symptoms are, so if we can normalise this in the same way that we normalise pregnancy in women and breastfeeding … then I think that will make it easier for women, particularly in the workplace.”
Associate Professor John Eden, associate professor of reproductive endocrinology at the University of NSW, said the US findings were “no surprise”.
“We have known for ages that [12%‒25%] of women will ‘flush forever’. That is why any ‘debate’ about HRT [hormone replacement therapy] is silly. Most women don’t need it, but for some women, if they are not treated they will be miserable forever. Thus, my goal for these latter women is to find the safest regimen for them.”
Professor Eden said most women experiencing symptoms ended up taking HRT, although he considered transdermal oestrogen safer than oral in the long term because it has less effect on clotting.
HRT alternatives included clonidine, selective serotonin reuptake inhibitors and gabapentin, he said.
Professor Henry Burger, clinical endocrinologist and emeritus director of the MIMR-PHI Institute of Medical Research, told MJA InSight the advice to doctors to prescribe HRT at “the lowest possible dose for the shortest possible time” was problematic given evidence that symptoms could last for much longer than the 5-year putative window of safety.
“There has been a lot of discussion about 5 years being a time during which hormone therapy is generally safe, usually with the qualification [that] hormone therapy is initiated in women under 60 or less than 10 years since menopause”, said Professor Burger, who is also a consultant to Jean Hailes for Women's Health.
He said a “rough rule of thumb” was that about 10% of women experienced hot flushes for more than 10 years, and a handful of his patients had required treatment into their 70s and 80s because of persisting and disabling hot flushes.
Professor Burger said that when the risks and benefits were properly explained to these patients, they would usually opt for hormone treatment.
“The bottom line is that appropriate use of relatively low-dose hormone therapy, particularly given through the skin, [combined with the minipill for progestogen] seems to be pretty safe”, he said, adding that a 2012 Danish study provided some reassurance regarding the safety of longer-term therapy when started early after menopause. (3)
Professor Burger said the US approval of a combination of conjugated equine oestrogen with bazedoxifene (a selective oestrogen receptor modulator) seemed promising as an alternative treatment, although long-term safety data were not yet available.
The latest US study comes on the heels of a UK study published in The Lancet of menopausal hormonal use and ovarian cancer risk, which found that hormone therapy in women for 5 years from about age 50 years was associated with one extra ovarian cancer per 1000 users. (4)
Professor Hickey welcomed The Lancet findings. “The more high-quality information we have about HRT, the easier it is for women and health care providers to make informed decisions about what they take”, she said, adding the “very small increase” in this rare condition was something that women and their doctors should take into consideration when making decisions.
1. JAMA Intern Med 2015; Online 16 February
2. JAMA Intern Med 2015; Online 16 February
3. BMJ 2012; Online 9 October
4. Lancet 2015; Online 12 February
(Photo: Rob Bayer / shutterstock)
Sorry for the delay Sue.
Yes quite a few published papers. Laser seems to set of the same chemical cascade that estrogen does resulting in the increased glycogen and normalized mucosa. See –
Menopause. 2015 Jan 20. Histological study on the effects of microablative fractional CO2 laser on atrophic vaginal tissue: an ex vivo study.
Climacteric. 2014 Aug;17(4):363-9. A 12-week treatment with fractional CO2 laser for vulvovaginal atrophy: a pilot study.
Female Gyno,
Please speak to Dr Eden. Or simply visit his waiting room.
You will see slim women who look after themselves. In fact, to end up in his waiting room, often these women have to go above and beyond to get there. These women invariably care deeply about their health and are actually more aware that things simply are not right, through no fault of their own, only their parents’ genetics.
It is important to define what we mean by “HRT”.
Ask Dr John Eden! It can mean progesterone, oestrogen and testosterone TOGETHER. GPs prescribing oestrogen alone can lead to bad outcomes.
My point is not to plunge headlong into treatment but to CONSIDER the possiblity of (peri)menopausal issues of that small minority and to REFER TO A SPECIALIST.
Ask Dr Eden about thyroid issues. Many of his patients had a hyperthyroidism dx, often subclinical. His treatment often ameliorates these symptoms along with the (peri)menopausal symptoms. Isn’t medicine more about ruling out possibilities?
Please let’s not allow this small minority women to suffer when there is effective treatment. Their families also end up suffering…
In 25 years of solo private practice, I have never met a woman with bad VMS who was also physical fit, pursuing happines, and content with her life. Clearly, this is not evidence-based medicine, but there must be something in it…
As a Respiratory and Sleep physician, most of my sleep referrals are for sleep apnoea, although I am trained in other areas too. Until recently, I had thought that VMS related to menopause should be should be within the scope of General Practice. However, there is one patient whom I treat for sleep symptoms, who had very distressing VMS disturbing her sleep, which we identified from the start. That is, she told me, it’s my hot flushes that cause my sleep distrubance. She was absolutely right, diagnosis and effective treatment of her severe OSA didn’t help symptomatically at all. I suggested to her GP that she might benefit from treatment for her VMS but after several follow ups with no new treatment tried (and no relief), it became my role to do something. She’d had past breast cancer and so HRT was not considered safe. We trialled a couple of alternatives and eventually had resounding success with venlafaxine!
Thanks for your response, Jayson. How does laser restore post-menopausal tissue to glycogen-rich ”young/estrogen supplied vagina”. It is interesting that you say ”It would be interesting to hear more about it.” when you already use it. Are there trials published somewhere?
Any woman who presents in the approx. 40+ (usually 45-50+) age group that may have classical menopausal symptoms or just any of : depression/anxiety/aches/pains/sweating/flushing/low libido/headaches/palpitations/urogenital problems etc etc etc – especially if these do not “add up” to any obvious diagnosis then we should consider menopause and treatment for this.
Of course a history is useful eg DVT/Breast cancer/Uterine cancer etc etc.
Some testing is also appropriate eg FBP, Iron Studies, TFT, LFT , Lipids etc. PAP and Mammogram
After this if the woman and I think it appropriate, I will offer a course of HRT for 1-2 months with a view to seeing how well she responds. So many of the symptoms are not “provable” with testing and the only way to determine this is with a trial. At the end of the trial, so long as the woman is properly informed of the risk/benefits of HRT then she can make an informed decision as to whether she wishes to continue. As prescriptions last for about 6 months then they can be reviewed then and I consider a trial off HRT at about 2 years or less if the woman prefers.
Vaginal Oestrogen preparations can be very effective if there are significant concerns in that particular area.
Some women are happy to know that most of the symptoms that might have disappeared are due to menopause and not cancer, dementia, old age etc. This can be very reassuring. When the symptoms come back as the HRT is ceased it adds further evidence to the idea that they are menopause related.
I think that all of this is in the scope of any average GP and I only send the occasional patient to a specialist.
Sue – yes we do. The lining of a young/estrogen supplied vagina is glycogen rich – which sheds and feds the natural microbiom which includes lactobacilli. They produce lactic acid which is a humectant, slippery and keeps the pH low. There is also a normalized lamina propria with increased vascularity and GAG’s.
Do you use Laser for this indication, Jayson Oates? How would Laser fix vulv0-vaginal atrophy from oestrogen decline?
The oldest patient that i have treated for a disturbed sleep pattern due to severe flushes and sweats was 90 years old. This had been going on for 40 years. She had aquired a new husband and he did not like being disturbed by her restless sleeping pattern.
Not part of the VMS symptoms, but vulvo-vagina atrophy – burning, dryness, itching, discomfort, dyspareunia etc is a major issue that is often not brought up. A new laser treatment has good support in the literature and is just becoming more widely available in Australia.It would be interesting to hear more about it.
Certainly vasomotor symptoms can last for years, but here’s an instructive anecdote. My mother had symptoms ON HRT, mistaken for ongoing symptoms of menopause, which turned out to be hyperthyroidism. All that ails the middle aged woman isn’t menopause.
Great comment Elizabeth. I agree with you wholeheartedly. There’s a lot more to menopause than VMS, HRT certainly has my vote!
This article didn’t mention the increased incidence of breast cancer associated with HRT. Instead it reported the much less frequent increase in ovarian cancer. It is unbalanced in its presentation of the risks and benefits of HRT.
Nooo…don’t tell me this information… this is when the hypochondriac in me takes over from the health professional. As a women experiencing mild VSM but yet to experience any other symptoms of note, I don’t want to even consider the possiblility of years of VSM. Ignorance was bliss!!
Dr Eden says 12-25% of women “will be miserable” if left without any intervention.
Professor Burger says about 10% of women suffer chronic disabling symptoms for over ten years.
Is this large minority of women receiving the medical advice that could help them to live productive, healthy and happy lives?
Sampling by age, if we compared the proportion of female doctors on HRT to the proportion of the general population on HRT, would we see a significant difference? My money is on Yes! Doctors know the benefits, while most women opt for money-wasting bogus CAM therapies and baulk at the mention of HRT.
When female patients over 40 come to their GPs with the onset of sleep difficulties, mental health issues and other possible perimenopausal symptoms, they should be considering the possibility that these patients may be a member of the 12-25% who will be miserable if left untreated! These women should be referred to a gynaecology/endocrinology specialist who can investigate whether an intervention such as HRT could be an effective option. No intervention could also leave these vulnerable women at a higher risk of further health problems which in turn can affect family dynamics and lead to relationship breakdowns.
Be mindful of the possible underlying factors triggering problems in your over 40 patients. In this group of women the benefits of HRT can be so profound that you may even save a marriage or two…