Menopause Transition
The 'menopause' is the cessation of menses. It usually happens between 44-55 years of age. The time spanning either side of the cessation of menses, during which some women may experience symptoms, is called the 'climacteric' and may last 2-15 years. While many women will sail through the menopause without any problems, some will experience distressing symptoms, which result from the lack of oestrogen and testosterone. Prior to the menopause, the ovary produces these two hormones, although the levels of testosterone produced are much less than those found in men. The majority of women with mild menopausal symptoms can be satisfactorily managed in the General Practitioner's surgery. A proportion of women, however, will require specialist management.
Although HRT has recently received publicity, it remains the most effective treatment to prevent osteoporosis (brittle bones) and for symptom relief. Media reports can often lead to confusion as to the costs and benefits of HRT treatment in relation to breast cancer.
We aim to provide a Menopause Clinic at the Parkside Hospital which means the needs of menopausal women.
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Women who might benefit from the Wimbledon Menopause Clinic
- Women wishing to consider taking their HRT in the form of implants, where the GP may be unable to offer this service.
- Women whose menopausal symptoms have failed to respond to to conventional HRT in the GP surgery.
- Women who may have contra-indications to conventional oestrogen therapy.
- Women wishing to explore the treatment of menopausal symptoms without oestrogen.
- Women with libido problems, not responding oestrogen therapy.
- Women uncertain about the benefits and dangers of hormone replacement therapy.
- Any peri-menopausal woman seeking information and advice on matters relating to the menopause or to well-woman assessment. This may include problems with anxiety, lack of confidence, concern over the aging process, lack of concentration, poor memory etc.
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Assessments and Tests Performed in the Menopause Clinic
The aim is to individualise the service to the needs of each women. In general the following may be included:
- A full assessment of symptoms, a breat and gynaecological examination and blood pressure measurement.
- Blood tests which may include hormone analysis, blood lipids (including cholesterol), liver function and thyroid function.
- Mammography
- Bone densitometry
- Pelvic ultrasound scan, examining the ovaries and the lining of the womb
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Conventional Treatments of Menopausal Symptoms
Treatment options include conventional therapies, such as oral oestrogen/progesterone preparations, transdermal preparations (patches) and implants. Other treatments include non-hormonal preparations and natural oestrogens.
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Alternative Therapies
Alternative and complementary medicines for the management of the symptoms of the menopause have seen an unprecedented popularity in recent years. This has been fuelled mainly by the series of 'scares' hitting the headlines about the possible adverse effects of hormone replacement therapy (HRT). Many women perceive alternative therapies as being safer than HRT, and since they are not generally prescribed by doctors, some women report that alternative therapies make them feel they are in control of their health. Other reasons given for avoiding HRT include fear of cancer or side effects (such as vaginal bleeding) and the few that, as the menopause is a natural transition, it requires a more 'natural' remedy.
Menopausal women account for one of the largest segments of alternative medicine users: 80% of women aged 45-60 have reported using non prescription therapies for the management of menopausal symptoms. These therapies include herbal remedies, meditation, traditional Chinese medicine, vitamins and minerals, homeopathy, acupuncture and chiropractic. The regulation of alternative therapies has not kept pace with the fast growth of the industry: For example, the UK has one of the highest sales of vitamins and minerals in Europe, but also the least stringent regulations.
In the USA, large discrepancies have been found between label contents and the active ingredients found in many complementary medicines, most of which are passed off as dietary supplements. Some herbal supplements have been found to contain unreported contaminants, including undeclared pharmaceuticals or heavy metals. In addition, the claims made by manufacturers or dietary supplements do not have to hold up to rigorous clinical standards. The situation in similar in Europe, where the law that should regulate the pre-marketing requirements for proof of safety and efficacy of food supplements and alternative medicines is still in draft form.
Phytoestrogens:
Phytoestrogens are a group of plant-derived molecules so named because they possess an oestrogen-like activity. The major interest in Phytoestrogens in the 1990s arose in part as a result of an observation that Japanese menopausal women suffered significantly fewer hot flushes compared with their western counterparts. They also appeared to have a lower incidence of breast cancer, cardiovascular disease and osteoporosis. The low incidence of these conditions was correlated with the very high levels of Phytoestrogens found in the traditional Japanese diet.
Effects of Phytoestrogens on climacteric symptoms
Soy: Although there have been a few studies that they have investigated the effects of soy on the incidence and severity of hot flushes in perimenopausal and postmenopausal women, there have not been any uniformity in the studies and the conclusions are difficult to interpret. Some of the studies have used soy as whole grains on in flour form, while others have utilised isolated soy protein. The results of the studies so far reported are contradictory. Some failed to observe any effects, while others have observed varying degrees of benefit. Soy preparations appear, at best, to nearly halve the incidence of hot flushes, which is somewhat in contrast with the relatively few hot flushes experienced by Japanese women. There are now available on the market, soy preparations in the form of pills or capsules at doses of 50-100mg per day. Again, at best, the preparations reduce the number of hot flushes by half. This is not an obvious improvement on the treatment effects achieved with whole soy and suggest that the effect of these compounds is small. Thus, it would seem that larger studies with large numbers of women experiencing a high incidence of severe hot flushes are needed to resolve the issue of how effective soy is.
Red Clover: Dietary supplements derived from Red Clover contain additional chemicals that are not present in soy and, therefore, may have different biological activity. A few studies performed using Red Clover at doses of 40-160mg per day found no significant effects on the incidence of hot flushes.
Why are the results conflicting? Many sectors combine to render it difficult to conduct effective research on complementary medicines. Often financial resources are limited, the same product from different manufacturers may not contain similar ingredients, and the way the ingredients are absorbed and/or metabolised by the body may vary between individuals and this may be important in terms of their effects. It is also important to realise that the traditional Japanese diet is not only rich in soy, but also has a low ratio of certain fatty acids due to the high consumption of fish. It may be this combination of fish and other types of diet, rather than just Phytoestrogens themselves, that may be important.
Effects of Phytoestrogens on Bone
The few small studies that have been conducted on the effects of Phytoestrogens on bones have shown a mild but promising effect. In a small study using soy, at a dose of 54mg per day, a highly significant increase in bone mineral density was observed in both the spine and the femoral neck. The increment was similar to that observed with conventional HRT.
Other Remedies Used in Menopause
Black Cohosh: Black Cohosh is a native plant from the east of North America that has been used by Native Americans for gynaecological conditions since before the arrival of European settlers. It was called 'Squaw root' because it was used primarily for female disorders. It was the primary ingredient of a tonic for 'female complaints', which sold widely in the USA for more than fifty years in the early twentieth century. In 1989, the German government commissioned an expert panel to address herbal products, and Black Cohosh was approved as a non prescription medicine for the treatment of climacteric ailments. However, the commission recommended its use for no longer than six months due to an uncertainty about its possible long term side effects.
The treatment of menopausal signs and symptoms has been the primary therapeutic application of Black Cohosh. It is main ingredient in the often used over-the-counter menopausal preparation called Remifemine. The mechanism by which Black Cohosh exerts its effects is unclear. It was once believed to have oestrogen-like activity, but the results of studies have been varied. The biologically active component of Black Cohosh is attributed to a number of special chemicals called tryterpine glycosides. Remifemine is standard with respect to these chemicals. In the two studies that have been conducted to study the effects of Black Cohosh on hot flushes, in only one of them was there a statistically significant reduction in symptoms. A note of caution about the use of preparations containing Black Cohosh has to be made as there have been reports of acute hepatitis in relation to its use.
Don Quai: Don Quai is a herb native to eastern Asia and China. It has been used for more than one thousand years, as a spice, tonic and medicine in traditional Chinese medicine. Don Quai is known as the 'female ginseng' and is currently the second best selling herb in China. It is indicated for painful menses, irregular menstruation, and as a supportive herb for menopausal complaints. In the west, Don Quai has become popular as a herb for treating menopausal symptoms. However, the one well designed study that has been conducted using Don Quai has found no beneficial effects. Don Quai is one of the first alternative therapies to which potentially adverse effects have been attributed, as it potentiates the effects of the blood thinning drug, warfarin. Don Quai contains chemicals that act as blood thinning products.
Evening Primrose Oil: Native Americans consumed the leaves, roots and seed pods of Evening Primose for food, and used extracts from it to treat a number of conditions. Today, the flowers and seeds are pressed to make an oil that is high in the omega 6 fatty acid, gamma linolaeic acid (known as GLA), and essential polyunsaturated fatty acids, which convert into prostoglandins. Evening Primrose Oil also is a good source of linolaeic acid. Although there are a number of good studies in which Evening Primrose Oil has been used to successfully treat eczema and several other conditions with few side effects, it appears to have no benefit of a placebo for hot flushes.
Conclusions
The effects of the most common supplements for the treatment of hot flushes are mild at best. Clinical data about efficacy of these compounds are scarce and contradictory. They are usually sold directly to consumers, and health claims used for marketing purposes do not require any rigorous scientific evidence. Phytoestrogens have the largest amount of data available. This similarity between the isoflavins contained in soy and oestrogen has made the associated between soy consumption and the low incidence of hot flushes in Japanese women easier to understand. This may prove to be too simplistic as it is highly likely that a combination of nutrients, rather than just one compound, may determine favourable health effects of the traditional Japanese diet. The lack of regulation does not facilitate the clarification on the safety of these compounds. Patients tend to associate these products with a lack of adverse events, which tend not to be reported. Further more, given the general laxity in quality control of both doses and contaminants, it is generally difficult to pinpoint the actual substance causing the adverse event. This calls for urgent regulatory attention as food supplements are one of the fastest expanding areas in consumer markets in the western world.
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Media Controversy on Hormone Replacement Therapy
For the past three decades, hormone replacement therapy (HRT) has brought relief to millions of women. However, over the past eighteen months or so there has been a great deal of concern in the popular press raised about the safety of hormone replacement therapy, to a point where the number of British women using HRT has dropped by 30%. In the United
States the fall has been even steeper - HRT use is down by 50%. These figures are the result of two studies that apparently showed links between HRT and breast cancer, heart attacks and strokes. As recently as last week, another report was published which has caused even further confusion. This report suggested that hormone replacement therapy is not, in fact, linked with an increase in breast cancer or heart attacks and that, indeed, there may be fewer incidences of these illnesses. There is, therefore, a great deal of confusion, not only among the women themselves who might be considering HRT, but also within the health profession itself. It is, therefore, pertinent to make a few comments the recent research findings.
The Women's Health Initiative study published eighteen months is considered by some experts to have fundamental flaws for the following reasons:
- The women in the study were too old. In real life, women on HRT usually begin taking it in their early 50s and their dose varies with age. In the WHI
study, the average age of the participants was 63 and a quarter of the women
were over the age of 70.
- Each women was given a standard dose of HRT, whether she was aged
50 or 79, whether she had bone problems or depression, or simply flushes and sweats. Many women were also overweight or had high blood pressure, 8% of them had even had heart attacks before starting on the HRT.
- Most women in this study did not have any menopausal symptoms. It
would seem that the researchers specifically searched for women who were not suffering from hot flushes and similar symptoms - they suspected that anyone having trouble with the menopause would not want to volunteer for research, given that 50% of participants would be given a placebo in
place of real medicine. Thus, women were being given treatment that they did not necessarily need.
- It may not be surprising, therefore, that women did not experience any
improvement in their well-being. There were no problems to resolve.
- It is unfortunate that these findings from the studies were first announced at a press conference rather than being published in research journals to be debated first by scientists and other peers.
- There was also a British study, called the Mirror Woman Study, which was published some three to four months ago. In terms of its design, this was less robust than the American studies and many consider that it was full of errors and discrepancies. It was particularly notable that there was a large increase in breast cancer among in their first year of taking HRT. It would be somewhat surprising to blame HRT in this instance, since it takes several
years before breast cancer is actually diagnosed. This implies that these women, who were found to have breast cancer must have had the breast cancer prior to commencing HRT.
Several years ago when there was the pill scare, many young women came off
the pill and there were large numbers of unplanned and unwanted pregnancies
and, therefore, large numbers of terminations of pregnancy with the attendant
problems. Women coming off HRT will, of course, not suffer the problems of
unwanted pregnancy, but many women now are suffering as a result of having
come off HRT. Even if the results from the WHI and the Mirror Women's Study
were true, the actual risks to an individual women are, in fact, small and the
way they are portrayed in the media is very misleading.
In the Wimbledon Menopause Clinic we would aim to put these issues into
perspective, while respecting that each women is allowed to make a choice.
Whatever the facts or the myths, there will be women who will be very worried
about conventional HRT. For that reason, we also offer alternatives to
conventional HRT in the Menopause Clinic.
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How to Find Us
The Wimbledon Menopause Clinic based at the Parkside Hospital is a purely private service.
Should you wish to make an appointment please contact:
Val Barrett, PA to Mr Isaac Manyonda
Telephone:
020 8947 9877
The other alternative would be to telephone the Parkside Hospital Appointments Desk on
020 8971 8026
Clinics are held on Thursday evenings between
5.30 - 8.00pm.
Costs:
If you are insured and your GP refers you, the cost will normally be recoverable from your insurers. Please note that some insurers will not cover routine treatment of the menopause. It is advisable to check cover before making an appointment. Self-pay patients can be advised of the cost of consultations/treatment by contacting Mr Manyonda's PA, Val Barrett, telephone
020 8947 9877.
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