Menopause and perimenopause

What is menopause / perimenopause ?

Menopause is a natural life stage that occurs when your ovaries stop releasing eggs and reduce hormone production like estrogen and progesterone. It is diagnosed after you have gone 12 consecutive months without a menstrual period. Most women experience menopause between the ages of 45 and 55 years, with the average age being around 51 years.

Perimenopause, also called the menopausal transition, is the phase leading up to menopause. This transitional period can last several years. The starting point of perimenopause is sometimes hazy and is characterized by declining estrogen levels (with symptoms such as hot flushes, dryness of vagina / skin, sleep disturbances, mood changes and reduced libido) and irregular menstrual cycles. During perimenopause, your periods may become unpredictable — either closer together or further apart — and the flow may vary. If there are erratic bleeding during this period, a gynaecological assessment is necessary to rule out structural abnormalities in the inner lining of the uterus (womb).

Common Symptoms

The symptoms of perimenopause and menopause vary greatly between individuals. Some women experience minimal discomfort, while others find symptoms significantly impact their quality of life.

The most common symptoms include:

·         Hot flushes and night sweats – sudden intense feelings of warmth or heat, often

accompanied by sweating and flushing of the skin, usually starting from the chest, and then going towards the head and neck; may last from 30 seconds to 5 minutes per episode

·         Irregular periods – changes in cycle length, flow, or frequency

·         Sleep disturbances – difficulty falling asleep or staying asleep

·         Mood changes – including anxiety, irritability, or low mood

·         Vaginal dryness – which may cause discomfort during intercourse

·         Reduced libido – decreased interest in sexual activity

·         Cognitive changes – including difficulty concentrating or memory concerns

·         Urinary symptoms – including urgency, frequency, or recurrent infections

·         Joint and muscle aches

·         Fatigue and headaches

You can score your symptom on the chart attached below, and serially monitor the seriousness of the symptoms to see how they progress.

How is Menopause Diagnosed?

The diagnosis of perimenopause and menopause is typically made clinically based on a combination of your age, menstrual pattern changes, and symptoms. Blood tests to measure hormone levels are generally not necessary or recommended for diagnosis, as hormone levels fluctuate significantly during the transition period, and may even be abnormal in different parts of the menstrual cycle in a non-menopausal woman.

When to Seek Help

If you are experiencing symptoms that affect your daily life, work, relationships or wellbeing, you may want to see your gynaecologist. There are many effective treatment options available, including hormone therapy and non-hormonal approaches, tailored to your individual needs and health profile.

Hormone Replacement Therapy (HRT) for Perimenopause and Menopause

Hormone replacement therapy is the most effective treatment for managing bothersome menopausal symptoms, particularly hot flushes, night sweats, and genitourinary symptoms.

Increasingly, it is now recognized that hormone replacement therapy may also improve biomarkers of aging, thereby slowing down biological aging processes.

Treatment Options

1. Transdermal Estrogen + Micronized Progesterone (Bioidentical Hormones)

This combination is one of the most popular combination that uses hormones that are chemically identical (bioidentical) to those your body naturally produces. Transdermal estrogen is applied to the skin (arms or thighs) once daily, where it gets absorbs directly into the bloodstream. This form of estrogen (compared to the oral forms) is more likely to have sustained levels of the hormone in the body and less likely to have complications such as venous thromboembolism (or clots in the leg veins or pelvic veins). Micronized progesterone is taken as an oral capsule, usually at bedtime. This is particularly useful for patients with sleep disorders as the oral micronized progesterone causes sleepiness, and has a more favourable safety profile for breast health than other oral synthetic progestins.

Benefits:

·         Highly effective for hot flushes and night sweats (reduces symptoms by approximately 75%)

·         Improves sleep quality

·         Relieves vaginal dryness and genitourinary symptoms

·         Protects bone health and reduces fracture risk

·         Lower risk of blood clots compared to oral estrogen

·         Micronized progesterone may have a more favorable safety profile for breast health

compared to synthetic progestins

2. Transdermal Estrogen + Mirena (Levonorgestrel IUD)

This option combines a transdermal estrogen gel with the Mirena intrauterine device, which releases a small amount of levonorgestrel (a progestogen) directly into the uterus.

Benefits:

·         Effective relief of menopausal symptoms

·         Provides endometrial protection without daily oral medication

·         Often eliminates monthly bleeding

·         Convenient — Mirena lasts up to 8 years (for contraception) but 5 years for protection of endometrium

·         May be particularly suitable if you also need contraception during perimenopause

3. Femoston (Combined Estradiol and Progestogen Tablets)

Femoston is an oral combined hormone therapy available in different doses to match your symptom severity and individual needs. It contains estradiol (bioidentical estrogen) combined with dydrogesterone (a synthetic progestogen).

Available doses:

·         Lower dose options for milder symptoms or as maintenance therapy

·         Standard dose for moderate to severe symptoms

·         Higher dose for more severe symptoms

Benefits:

·         Convenient single daily tablet

·         Effective symptom relief

·         Multiple dose options allow for personalized treatment

·         Protects the uterine lining

4. Tibolone (Synthetic Steroid with Estrogenic, Progestogenic, and Androgenic Activity)

Tibolone is a synthetic hormone taken as a once-daily oral tablet. It is metabolized into compounds that exert estrogenic, progestogenic, and mild androgenic effects, providing a combined approach to menopausal symptom relief without the need for separate estrogen and progesterone.

Benefits:

·         Improves libido and sexual function due to mild androgenic effects

·         Effective relief of hot flushes and night sweats

·         Helps maintain bone density and reduces fracture risk

·         Does not cause cyclical bleeding (typically results in amenorrhea)

·         Convenient single daily tablet without need for additional progestogen

·         Lower incidence of breast tenderness compared to some combined HRT regimens

Advantages of Hormone Replacement Therapy

When started in women under 60 years of age or within 10 years of menopause, hormone therapy offers several benefits:

• Symptom relief: Most effective treatment for hot flushes, night sweats, and genitourinary symptoms

• Bone protection: Reduces risk of osteoporotic fractures

• Quality of life: Improves sleep, mood, and overall wellbeing

• Metabolic benefits: May reduce risk of type 2 diabetes

• Cardiovascular considerations: In younger menopausal women, may have neutral or potentially beneficial effects on heart health

• All-cause mortality: Considering all causes of death, hormone replacement therapy tends to reduce the rates of dying prematurely.

Risks of Hormone Replacement Therapy

It is important to understand the potential risks, which are generally small for healthy women starting treatment in their 50s:

1)      Blood clots (venous thromboembolism): Small increased risk, lower with transdermal estrogen than oral estrogen

2)      Stroke: Small increased risk (approximately 0.5-1 additional case per 1,000 women per year)

3)      Breast cancer: With combined estrogen-progestogen therapy used long-term (more than 5 years), there is a small increased risk. The absolute risk is similar to that associated with obesity or daily alcohol consumption. Estrogen-only therapy (for women without a uterus) does not appear to increase breast cancer risk.

This is a good illustration to show that the absolute additional risk of breast cancer from hormone replacement therapy (HRT) is only slightly higher than the baseline risk of breast cancer amongst non-HRT users.

4)      Gallbladder disease: Increased risk requiring surgery in some women

The absolute risks are small, particularly for younger menopausal women. For example, the increased breast cancer risk with combined therapy is less than 1 additional case per 1,000 women per year of use.

Who Should Not Use Hormone Therapy

Hormone therapy is not suitable for everyone. You should not use HRT if you have:

·         Unexplained vaginal bleeding

·         History of breast cancer or other estrogen-sensitive cancers

·         History of blood clots, stroke, or heart attack

·         Active liver disease

·         History of venous thromboembolism or pulmonary embolism

·         Personalized Treatment Approach

Duration of Treatment

There is no arbitrary time limit for hormone therapy. Typically, hormone replacement therapy is started before the age of 60 or within the first 10 years after menopause. Treatment should continue if the benefits outweigh the risks for you individually. We recommend regular reviews (typically annually) to reassess your symptoms, health status, and treatment goals.

Next Steps

If you are experiencing bothersome menopausal symptoms or wish to discuss about the pros and cons of hormone replacement therapy, please see your gynaecologist.