The Menopause

We mustn’t forget that the menopause comes at the stage of life when physical, psychological and social changes may all be taking place.  Some of these changes may affect the appearance of some of the symptoms.

During the menopause, symptoms include:

• Hot flushes and night sweats
• Insomnia, tiredness and lack of energy
• Aches and pains
• Mood swings and other emotional symptoms
• Loss of confidence
• Loss of concentration
• Forgetfulness
• Skin changes
• Vaginal dryness and soreness making sex uncomfortable
• Bladder problems

The most common symptoms are the vasomotor ones, the hot flushes and night sweats.

• Hot flushes may occur once or twice a day.  Flushes can occur as often as 20 times a day.  When a woman has a flush, she may suddenly feel flushed and hot around the face, next and chest and may sweat.  Her heart may beat faster and she may feel faint or dizzy.
   
• Night sweats are severe hot flushes that occur at night.

Both hot flushes and night sweats are caused by a temporary upset in the body’s temperature control system.  This upset is corrected when it becomes adjusted to the new hormone levels.  This can take months or years.  Women may experience symptoms even into their 60s, 70s and 80s.

Hot flushes occur in 75 per cent of menopausal women in the UK.  Many women go back to having hot flushes when they come off their HRT.  Time and time again when I present talks to women I hear this.  The talks allow women to be interactive because there’s nothing women like better than hearing about each others’ experiences.

Insomnia is defines as ‘inadequate or poor-quality sleep’ and includes one or more of the following:

• Difficulty falling asleep
• Waking up frequently with difficulty returning to sleep
• Waking up too early
• Unrefreshing sleep

Insomnia is a symptom experienced both during and after the menopause.  It can be caused by night sweats which can make women lose a lot of sleep, if they occur several times in one night.  Alyson Huntley, whose personal research interests include complementary medicine and women’s health has written about a UK survey of over 1200 women that calculated that a perimenopauseal woman would be one and a half times more likely (and a post-menopausal women over three times more likely) to experience trouble sleeping that a premenopausal woman’.  However, not all sleep problems at the menopause are of menopausal origin.  Lack of sleep affects function, health and quality of life and can lead to depression.

• How to cope with the menopause

And this means finding the right approach for each woman as an individual.

Many women are coping with the menopause naturally because:

They don’t want to take HRT

3.1.1.1 One of the main reasons why some women don’t want to go on HRT is their fears about breast cancer.  This has been the case particularly since the HRT health scares in July 2002, August 2003 and March 2004.  There is a lot of controversy surrounding there research studies, criticism from experts and uncertainties about the use of HRT amongst health professionals and women.  Fifty per cent of women in the UK stopped HRT after the 2003 scare.

3.1.1.2 Women may make a decision about taking HRT based on the following:

• The type and severity of their symptoms
• How long they’ve had them
• How difficult the symptoms make life for them, that is, how they affect their home life, relationships and their work.
• The benefits that they would derive from taking HRT
• Their risks for taking HRT

Many decide that their risks for HRT outweigh the benefits and they look for alternatives to manage their symptoms.

Another reason why women look for alternatives is because:

• They make a decision to come off HRT.  The reasons for this are:

• It is not helping their symptoms
• They are experiencing side-effects
• They don’t like the withdrawal bleed if on sequential combined or long-cycle HRT
• They don’t want to take it for too long

Of course these decisions have to be made in conjunction with a doctor or other appropriate healthcare professional.

3.1.1 We mustn’t forget that HRT may be contraindicated for some women.

Some women may try prescription drug alternatives to HRT to help their hot flushes.

• How to cope with the menopause naturally

At least 50% of women use alternative approaches for their menopausal symptoms, including sleep problems.

With reference to:

4.1 Complementary therapies

Therapies that can help menstrual symptoms are herbal medicine, acupuncture/acupressure, aromatherapy, homeopathy and relaxation.

4.2 Phytoestrogens

Phytoestrogens have oestrogen-boosting properties.  They are a group of plant hormones that have a chemical structure similar to the body’s natural oestrogen, but they are not as powerful.  Researchers have, in fact, been investigating the lifestyle of Japanese women and Asian women in China because far fewer complain about hot flushes, night sweats and mood swings during the menopause than European and American women.  Compared to about 75 per cent of women in the UK experiencing hot flushes, the figure in Malaysia is 57 per cent and in China it is 18 per cent.  However, Japanese women do still have some menopausal symptoms and report backache and neck ache rather than hot flushes and night sweats.  It is thought that the reason for the lower incidence of symptoms is that these women consume a much greater amount of phytoestrogens in their diet than women in the Western world.  They have lower rates of breast cancer, osteoporosis and heart disease.

There are two types of oestrogen receptors-alpha and beta – with alpha receptors predominating in the breast, uterus and ovary and beta receptors predominating in vascular tissue and bone.

There is some evidence that phytoestrogens may help protect against osteoporosis and heart disease, but more research needs to be carried out.  Phytoestrogens may also help lower cholesterol levels which tend to rise after the menopause by improving the ratio of LDL (bad) versus HDL (good) cholesterol, and there is evidence for soya, which is a phytoestrogen, protecting against heart disease.

One word of caution:  At the moment, it is not clear when phytoestrogens affect the risk of development or growth of breast cancer, but until the research evidence is available, women with oestrogen-dependent breast cancer are advised to be cautious and avoid eating large amounts of phytoestrogens (more than one to two servings a day) or taking phytoestrogen supplements.  Also, if women are taking thyroxin for an under active thyroid, phytoestrogens may interfere with the drug’s effectiveness.   This doesn’t mean that there women need to avoid phytoestrogens, but if they are consciously increasing the amount that they eat they should ask their GP to monitor their thyroxin levels and adjust the dose accordingly.  Similarly, care needs to be taken if women are on anticoagulants.

There are two types of phytoestrogens:

4.2.1 Lignans, which are found in fibre-rich foods including some fruits (dried plums and cherries), some vegetables (red and yellow), wheat bran, rye and seeds such as flaxseed, sunflower seeds and linseeds.

4.2.2 Isoflavones

‘Although research results are not entirely consistent’, it has generally been shown that isoflavones from soya may help menopausal symptoms, particularly hot flushes by reducing the number and severity.  They can help vaginal dryness.

Isoflavones have been shown to have a greater affinity for beta than alpha receptors.  Therefore, they act on bones and the heart and not on the breast, uterus and ovary.

The major isoflavones are genistein and daidsein.  Others are biochanin and formononetin.

Soya is one of the richest food sources.  Soya foods include tofu, soya milk and soya yoghurts.  Isoflavones are also found in beans, pulses and chick peas.

It can be difficult to get enough isolfavones from food sources, which is why many women choose to take phytoestrogen supplements.

There are no drug reactions and phytoestrogens have a good safety profile.  There is no endometrial activity associated with phytoestrogen use.

The response to treatment with the phytoestrogen supplements can take four to eight weeks, but it may take up to 12 weeks to start seeing any beneficial effects.

4.3 Herbal medicine for insomnia

Many women use herbal remedies for their menopausal symptoms.  During the talks that I give to women, I emphasise the fact that it is important that women buy herbal remedies from a reputable place and make sure that they are manufactured by established companies, who use good quality products.  They should ask the advice of an expert such as a pharmacist before buying.  Some herbals may contain oestrogen-like substances that are not recommended for some women.  Some herbals have side effects and some can interact with conventional medicines.  Long-term (greater than six months) continuous use is not recommended.

The main herbs used for insomnia are passion flower, valerian and hops.

4.3.1 Passion flower

There’s a lack of evidence for the effectiveness of passion flower.

4.3.2 Valerian root extract is used for treating sleep disorders.  The extracts contain valepotriates, valernic acid and unidentified aqueous constituents that seem to contribute to its sedative properties.  There is a lack of evidence of side effects in humans and no known interactions with other medicines.

4.3.3 Hops, otherwise called Humulus lupulus

We all know about the use of hops in beer but it has been used in herbal medicine as a mild sedative, hypnotic and anxiolytic for a long time.

Hops are a popular sleep aid.  It is approved by Germany’s Commission E for nervousness and insomnia.

The reputed active ingredients include a volatile oil, valerianic acid, oestrogenic substances, tannins and flavonoids (8-prenylnaringenin).  It has a large amount of measurable oestrogen bioactivity.  It is known to be oestrogenic both from traditional medicine and from anecdotal reports.  Since hops have quite strong oestrogen-like properties, it is classified as a phytoestrogen.  Two clinical studies mentioned in an article called ‘Phytomedicines for menopause’ from Drugs of the future 2007, 32 (10) pages 897-905, have shown that hops has a positive effect on hot flushes and therefore its use as a treatment for menopausal symptoms has been suggested.  Future studies have been recommended.

Side effects are rare, and interactions are generally unknown.  However, care should be taken if taking other drugs for insomnia.  Because it possesses female hormone-like activity, it should not be used by women who have had breast cancer or who are at high risk of breast cancer.  It should also not be used by women with uterine and cervical growths of cancers.

• Some self-help measures for hot flushes, night sweats and insomnia

These should be used in conjunction with complementary therapies, phytoestrogens and herbs.

Some self-help measures for hot flushes and night sweats:

• Avoid hot drinks, hot soup and large meals if these trigger hot flushes and night sweats
• Cut out or cut down on coffee, tea, cola drinks and spice foods, as there can trigger hot flushes or make them worse
• Avoid synthetic fibres for bedding as they increase sweat.  Blankets are better than duvets.  Sleep with the bedding loose.

Some self-help measures for insomnia:

• Develop bedtime rituals by following the same bedtime routing each night
• Take a warm bath or shower at bedtime
• Don’t watch television, eat or read in bed
• Avoid vigorous exercise three hours before bedtime

• So what is the role of the pharmacist with reference to the menopause?

• Response to symptoms
• Advice when dispensing HRT
• Advice on alternatives to HRT
• Opportunistic health promotion advice, for example with reference to smoking which may accelerate the onset of the menopause by about two years
• Referral suggestions to a GP, counsellor or dietician if necessary

It is important that pharmacist receive training on the menopause so as to gain understanding of the symptoms and ways of coping.  The menopause can be a sensitive subject and women may find it embarrassing to discuss their symptoms etc, so it is important for pharmacists to realise this.  Also, pharmacies could offer printed, unbiased information to customers.  I have presented talks on the menopause in pharmacies and they have been well received by customers - this is something that pharmacies could organise.

Examples of case studies:

A woman comes into a pharmacy and says that she wakes up in the night feeling very hot.  This is affecting her sleep.  She wants to speak to the pharmacist privately in the consultation area.  She thinks that she is going through the menopause.  She doesn’t want to go on HRT, has no time to go to the doctor because she’s working and looking after her elderly mother and sometimes grandchildren.

Another woman who says that she is 60 years old has come off HRT and is experiencing terrible hot flushes and vaginal dryness again.  What should she do?

These are examples of opportunities where the pharmacists’ knowledge of the menopause and methods of coping is very important

• Conclusion

An article called ‘Core demographics ripe for picking’ in The Australian Journal of Pharmacy January/February 2008 89 (1054) pages 30-32 says that ‘Many women prefer to explore herbal options to help relieve some menopausal symptoms.’ ‘Pharmacists can be a useful source of professional advice and information.  Women should be encouraged to make lifestyle chances and take action to improve their health and prevent diseases from developing.’  It also suggests that the menopause is one of the areas ‘which pharmacy can specialise in to support the health needs of women.

Copyright Norma Goldman 8^th December 2008