To start with, such symptoms as hot flushes, brain fog and poor sleepare NOT the menopause. They are symptoms – in other words they are outward signs, effects - of the menopause, but definitely not the cause. To identify that we need to dig a little deeper into female physiology.
So what actually is the menopause?
As you may already know, a woman carries in her ovaries a set number of unfertilized eggs, a number that is predetermined even before she is born. From the time she reaches puberty she will usually release one egg per month until they are all used up. The release of those eggs (known as ovulation), along with changes to the womb with each ovulation, is controlled by varying levels of the sex hormones estradiol and progesterone, both produced by the ovaries. In turn, their levels are controlled by two other hormones called follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which are released by the pituitary gland at the base of the brain. It's all a cyclical process known as the menstrual cycle.
Once all those eggs are gone, the estradiol and progesterone levels crash. In response, FSH levels go through the roof, as the pituitary gland rather literally screams at the ovaries to make estradiol. Another sex hormone, testosterone, also goes into rapid decline.
Interestingly, the body does respond to some extent to the cry to make more estradiol by creating more fat tissue which produces estrone, a hormone closely related to estradiol but which is significantly less effective. It is also one of the main causes of menopausal women putting on weight, with their associated change in body shape.
So this loss of eggs resulting in a crash in estradiol, progesterone and testosterone levels is the menopause. Everything else associated with the menopause is a secondary effect.
When do we get through the menopause?
There is a common belief that the menopause is simply a phase, that one eventually gets through it and out the other side. Even a lot of doctors still believe this. But it is completely untrue. Given that the end of a woman's eggs is rather a one-way event - you're never going to suddenly get a new supply – it must follow that the loss of estradiol and progesterone that follows this loss of eggs is also permanent. Therefore the menopause is also permanent.
The belief that menopause is only a temporary phase comes about because certain symptoms can fade with time, perhaps as the body adapts to the new reality and finds alternative ways to function. This may be at least partly true for some symptoms in some women, but for most women most symptoms go on for years, often for the rest of life. The term 'post-menopausal' is still widely used, even by the medical profession, greatly adding to the impression that menopause is only temporary. However, such a term only offers a false dawn.
Once it starts, menopause is permanent, and stays with a woman for the rest of her life, which could easily be more than 30 years!
About the outward symptoms of the menopause
There is a long list of potential menopause symptoms, which include:
hot flushes
brain fog
poor sleep
depression and anxiety
loss of strength and stamina
fatigue
loss of libido
weight gain
deterioration in skin elasticity and quality
an increase in urinary tract infections, plus vaginal inflammation and dryness
The list could probably go on, but this is already quite a potentially debilitating and highly varied set of symptoms – the outward, visible effects of the menopause, not the cause.
Notall women get all these symptoms. A few lucky women will sufferalmost none – or at least only very mildly – but a few veryunlucky ones will suffer all of them quite severely. Most willexperience some, and not necessarily at the same time. It is allhugely variable from one woman to another, and at different times.
The hidden metabolic effects of the menopause
So much for the visible, readily recognised symptoms. These are bad enough. But what about the hidden effects, those that – initially at least – have no symptoms? These are the metabolic effects of the menopause, those that affect the body's physiology and which can therefore be a whole lot more dangerous than those outward, visible effects.
In this field we're looking at such risks as:
osteoporosis
diabetes
cardiovascular disease
thyroid issues
Let's take a look at each in turn:
Osteoporosis: We've all heard stories of elderly ladies falling over and breaking their hips. It's a widespread issue. For a younger person a simple fall is not likely to cause any issue, but for an elderly woman the risk of a bone breakage is extremely high. This is because the menopause can cause the bones to become increasingly brittle, with calcium lost and the bone structures being generally resorbed. The bones literally develop holes and become porous. Not all women develop osteoporosis, but most do – it has a very high probability in menopausal and 'post-menopausal' women. Even worse, when breakages occur they often don't heal well, and they can prove fatal.
Diabetes: The loss of estradiol at the heart of the menopause often causes a rise in insulin resistance either directly or due to the knock-on effects of increased body fat that usually comes with menopause. This insulin resistance makes it harder for the body to regulate its blood sugar levels, leading eventually to diabetes. The bad sleep commonly experienced in menopause can also result in poorer blood glucose management, again leading to an increased risk of diabetes.
Cardiovasculardisease: This generally consists of blockage of the arteries, big and small, that supply blood to the heart's own muscles. If this happens, the heart can't beat properly and the result can be a heart attack. It used to be said that women don't get cardiovascular disease (CVD), only men. But over the past 25 years it has slowly been realised that this false belief was because the tests used to measure the problem don't work in women!
In fact, CVD is the number one killer of older women, far outstripping all other causes, including cancers. (For more on this see our blog on heart disease in women.)
Relatively recent research has shown that CVD can start to develop in a woman as a direct result of the loss of estradiol (and possibly of progesterone too) during the menopause.
Thyroid issues: The menopause can lead to an under-active thyroid as a direct result of falling estradiol levels. It can also make pre-existing under-active thyroid issues worse. The thyroid is involved in regulating a number of aspects of the body's metabolism, including bone health. So a decline in thyroid activity can play arole in promoting osteoporosis.
Treatment of themenopause
If all this sounds incredibly depressing, take heart. Help is at hand. At its most basic there is a wide range of supplements and herbal remedies that claim to have all kinds of benefits in helping to overcome menopausal symptoms. Unfortunately, the effectiveness of most is highly questionable, the producers making claims that simply have not been backed up by any testing.
However, a few do seem to help some women with some of their symptoms, which has to be encouraging. However, not a single one of these treatments addresses the central issue of the menopause – that of falling sexual hormone levels. And this is where hormone replacement therapy (HRT) comes in.
Of course, we can't replace the lost eggs, but we can replace the lost hormones, and to date this is by far the most effective way to manage the menopause, treating both the visible symptoms and the hidden metabolic effects.
At its most basic, HRT consists of supplying estradiol as either pills or a skin cream, gel, patch or spray. However, it should also always include progesterone, which has a balancing effect on the estradiol, as well as having many of its own physiological effects.
Unfortunately, progesterone is often supplied by many medical practices as a progestin, a manmade form of progesterone. This has a slightly different biochemical structure from the naturally occurring progesterone, and consequently not quite the same effects, resulting in a treatment that can have some side effects.
Furthermore, in the past estradiol was often given as a pill, but this has been found to lead to increased risk of cardiovascular issues and stroke. Today, it is usual to supply estradiol through the skin, which is known to avoid these risks.
At Hebe Medical, all our HRT programmes use only the skin route for estradiol, while progesterone is supplied in its bio-identical form, ie it is biochemically indestinguishable from the naturally occurring progesterone. This bio-identical form has been shown to be free of any of the side-effects seen with manmade progestins, and to have all the desirable effects of the body's own progesterone.
Ourprogrammes also include a number of hormones that you will rarely find prescribed by an NHS clinic, but which nevertheless have important benefits in helping menopausal women. All these hormones are closely related to estradiol, and are important precursors in the body's production of estradiol. They also all have distinct effectsof their own, which make them valuable additions to any HRT programme. All of them go into a major decline during menopause.
These include:
Testosterone: There are still many medical professionals who fail to recognise the importance of testosterone in women, considering it to be a wholly male hormone. As a result, it is rarely prescribed and is generally not available at the low doses applicable to women. Surprisingly, testosterone is the most abundant sex hormone in a woman's body. It is, however, significantly less potent at achieving the required physiological effect than either estradiol or progesterone, and is only at a tenth of the level found in men.
Aswith men, testosterone in women is important in promoting physicalstrength, libido and mental wellbeing, and so its decline inmenopause has a direct impact on a woman's health.
At Hebe Medical we will usually prescribe testosterone as part of our HRT package, at the low doses applicable to women, and closely tailored to each individual woman's needs.
DHEA: A precursor of testosterone, as well as of estradiol, in the body DHEA has important effects in promoting a sense of wellbeing, vitality and support for the immune system.
Pregnenolone: This hugely important hormone is a major precursor to many of the steroid hormones, including cortisol, DHEA, testosterone and estradiol. It is enormously helpful in those women suffering from brain fog, helping to sharpen thoughts and to promote concentration.
All these hormones, as well as the estradiol and the progesterone, are supplied by us in their bio-identical forms. For this reason, we are able to call our hormone replacement treatment programmes not simply HRT but BHRT, Bio-identical Hormone Replacement Therapy.
Getting onto our BHRT programme
If you are suffering from the menopause or are in peri-menopause (a phase that precedes menopause) and would like help with a BHRT programme, then please don't hesitate to get in touch.
Send us an email at info@hebemedical.co.uk or use our contact form by clicking here.
Our next blog
Our next article will introduce an exciting new development at Hebe Medical, which is the upcoming availability of treatment with the 'feel-good' hormone, namely oxytocin. Keep a lookout for this article in the coming weeks.