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Menopause mysteries: How we can improve outcomes


Ceri Cashell


18/04/2024 3:02:05 PM

Upskilling in diagnosis and treatment can have profound benefits for patients – including many GPs – writes Dr Ceri Cashell.

GP consultation
Menopause-related symptoms can have serious implications on work performance and quality of life.

More than 50% of Australian GPs are women, of whom 52% are aged 45–64, meaning over 25% of our workforce are women in perimenopause or menopause.
 
Menopause-related symptoms can have serious implications on work performance, and this is no different for female doctors.
 
Nearly three in every four GPs reported feelings of burnout in the past 12 months, but we can often be worse at seeking help for mental health problems than the general population. There is significant overlap between burnout and menopause transition.
 
ABS population data reports that many women reduce their hours or leave their jobs in midlife, earlier than they had intended, and often due to ill-health. The average age of retirement is 52 – one year after the average age of menopause. This is unlikely to be coincidental.
 
My own experience is that many patients still struggle to be ‘diagnosed’ with perimenopause and menopause, and even if they are they often receive incorrect information from their doctor about treatment options, and this includes doctors’ experience as patients.
 
Case illustration
In 2015, a 38-year-old married mum of two, Kate*, came to see me as a new patient. She complained of anxiety, low mood, insomnia, mental and physical fatigue, severe generalised pain and electric shock feelings zapping all over her body.
 
Kate had already been seen by several specialities: endocrinology, cardiology, psychiatry and neurology, including a voluntary inpatient psychiatric stay. Extensive bloods, MRIs of brain and spine, CTs and an EEG were all normal.
 
She had no prior mental health issues.
 
I referred her to another psychiatrist and neurologist. They suggested a trial of low dose amitriptyline which allowed her to gradually function at an acceptable level, albeit with persistent extreme fatigue.
 
In 2018, Kate attended with menorrhagia and mentioned she was divorcing, but amicably. She didn’t want to risk the hormones in a Mirena, as she was ‘sensitive to hormones’ nor the anaesthetic required for an ablation. So, she managed with iron infusions and tranexamic acid, but rarely attended the surgery.
 
In September 2022, aged 44, Kate attended again, six months after I had upskilled in menopause. This time she had night sweats and so the diagnosis would have been easy anyway. Of note, her bloods were still normal.
 
On asking the correct questions it turns out there was a strong family history of premature menopause (more correctly termed premature ovarian insufficiency, POI) in her close family.
 
She decided to have an endometrial ablation and two weeks later we started body identical transdermal estradiol and oral micronised progesterone. In three weeks, Kate said she felt like a new person. Testosterone was added after four months for her loss of libido, persistent fatigue, poor concentration and, 12 months later, she said she was back to her old self.
 
How we can provide better care
As doctors we have been taught very little about the complexities of menopause transition.
 
Early perimenopause symptoms are often neuropsychiatric because of changing levels of sex hormones in the brain including but not limited to, fatigue, irritability, loss of joy, anxiety, depressed mood, intrusive thoughts and insomnia.
 
Other symptoms include, but are not limited to:

  • palpitations
  • menorrhagia
  • recurrent UTIs and vaginal pain (the genitourinary syndrome of menopause/GSM)
  • skin affected by hair loss and itch
  • neuropathic pain or paraesthesia, often prompting a fear of MS
  • dry eyes
  • joint pain or muscle loss
  • snoring and tinnitus
  • a worsening of asthma
  • weight gain, especially central adiposity
  • clinical investigations revealing increasing cholesterol, insulin resistance, osteopenia or osteoporosis. 
Every speciality can be involved in a perimenopausal woman’s care, and often are, as modern medicine is siloed.
 
Vasomotor symptoms of hot flushes and night sweats, the only symptoms we were all taught about, usually only appear in late perimenopause, and 20% of women never have any.
 
It’s important to recognise a significant number of women will be in perimenopause by their late 30s. The normal age range for menopause is 45–55 and perimenopause can begin 10 years before.
 
With such a variety of potential presentations, diagnosis is not simple.
 
There is no diagnostic test for perimenopause – FSH will only rise once there has been persistent failure of ovulation. This applies irrespective of age.
 
Guidelines advising that levels are checked if a woman is under 45 can be confusing. This is important to diagnose early menopause (40–44 years) or POI (<40 years), but does not help diagnose early perimenopause, when levels will be normal whether a woman is 18 or 28 or 38 or 48.
 
Body-identical hormone therapy, ideally transdermal estradiol plus oral micronised progesterone plus/minus transdermal testosterone, remains the gold standard treatment for perimenopause and menopause symptoms but also reduces future risk of premature cardiovascular disease, osteoporosis, dementia and bowel cancer.
 
Vaginal oestrogen is not MHT as it is not absorbed systemically at any significant level. Many women need it in addition to MHT, to treat GSM and all post-menopausal women should be offered it if they have symptoms, not least given its ability to reduce UTIs by 50%. This includes breast cancer patients and breast cancer survivors.
 
The Women’s Health Institute reported an increased risk of breast cancer with MHT in 2002 which saw prescriptions plummet globally, when in fact the risk was not statistically significant at the time.
 
Longer term follow up does show a statistically significant risk, albeit small, using synthetic progestin, MPA, now rarely used in MHT, whereas, conjugated equine oestrogen alone has been shown to reduce breast cancer by 23%.
 
The body of evidence now suggests that body identical hormone therapy – notably the use of micronised progesterone – does not increase the risk of breast cancer, even in women who have a family history or carry a breast cancer mutation gene.
 
My professional experience is women on MHT often find they no longer need to reduce their work demands nor change their job. It improves their personal relationships as partners, parents and unpaid carers of elderly parents. They reduce alcohol, start to exercise and make better food choices.
 
While there can be many areas in medicine that are difficult to treat, this is one where treatment is quite simple, with the potential to transform the health of a huge number of our patients, our own health and that of our profession as a whole.
 
*The name has been changed to protect the patient’s privacy.
 
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Dr Jordana Mariam Rockman   4/06/2024 1:18:35 PM

Excellent article