Hormonal

THE MENOPAUSE: HOT FLUSHES AND NIGHT SWEATS (PART 1)

Hot flushes and night sweats belong in a category of symptoms that doctors call ‘vasomotor symptoms’, that is they are concerned with the blood vessels dilating and constricting, and with the flow of blood through these vessels. The symptoms are harmless, but most women greatly dislike having them, and find them uncomfortable, embarrassing and unpleasant. They may also affect a woman’s ability to cope at work and at home, and she may even avoid social contact for fear of feeling ashamed.

The typical hot flush starts as an unpleasant sensation of heat in the face, neck or body. If it starts in the face or neck, it will probably spread down to the main part of the body; if it starts there it will spread up to the face. Often the face becomes red, and sweat appears; but many women find, to their surprise, that, despite the feelings of great heat in their face, there are no outward signs at all, and nobody has noticed.

Flushes may occur at intervals from several each hour, to just a few times each month, usually in the days leading up to the start of a period. There will be times when flushes occur frequently, and times when they do not occur at all. Each flush may last for a few seconds, or for up to half an hour, or more, but most last for about three minutes. After a flush, you may feel sweaty, then cold, and you may seem to be endlessly taking clothes off and putting them on again to get comfortable. Flushes can occur at any time of the day or night, and may be accompanied by heart palpitations, dizziness and feelings of faintness. In America, they are called ‘hot flashes’, but this is a less appropriate name, as it suggests something that comes and goes very rapidly. The British term ‘hot flush’ describes more accurately the feeling of heat that builds up and dies down slowly.

When flushes occur at night, they are called ‘night sweats’. Typically, a woman will wake from sleep to find she is drenched in sweat and has to get up to change her night-clothes, and perhaps even the bedding. Night sweats cause greatly disturbed nights and lack of sleep, for the woman suffering them and perhaps also for her partner who may find himself woken several times in the night as she gets up to wash and change into something dry. Repeated broken nights cause fatigue, loss of concentration, irritability, and a general sense of lethargy.

The underlying cause of a hot flush is a falling level of oestrogen. This is not the same as a low level: girls before puberty and men have low levels of oestrogen, but they don’t suffer hot flushes; women get them when the level of oestrogen in their body has been high and then starts to fall. Women who lose their oestrogen suddenly, as when they have both ovaries removed, tend to get flushes that are particularly troublesome. If the decrease in oestrogen is gradual, the symptoms will be less severe. In most cases, once the body has adjusted to its final low level, the flushes will end.

It is thought that the falling level of oestrogen throws the body’s heat-controlling mechanism into confusion, and the ‘thermostat’ becomes set too low. The result is that the body thinks it is suddenly too hot, so it dilates the blood vessels and sweats to cool itself down. The dilated blood vessels produce redness and a sensation of heat in the skin, but although the skin itself may become several degrees warmer than normal, the body’s underlying temperature remains unchanged. Even if the skin hardly becomes warm at all, the woman will still feel hot – usually uncomfortably and embarrassingly so.

Flushes can be triggered by several things – or by nothing. Common causes of a flush are: anxiety, hot weather, moving from a cold room to a hot one, drinking tea, coffee, alcohol or hot drinks, or eating spicy food. However, most flushes don’t seem to be triggered by anything. As smoking reduces oestrogen, smokers tend to find flushes more troublesome than non-smokers do.

If you get hot flushes, you may feel freakish, and wonder if everyone is staring at you. In reality, the chances are that no one will notice, and, far from being a freak, 75 per cent of women going through the menopause get hot flushes, just like you. Of that number, 80 per cent still have them a year after they first appeared, 25 per cent still have them five years later, and for an unfortunate 5 per cent, they continue indefinitely.

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WHAT SHOULD YOU KNOWABOUT HRT

- I’ve decided to try HRT after discussing my situation with my doctor. Is there any particular time after menopause when it’s best to start?

If you are having menopausal symptoms that interfere with your quality of life, you can start on HRT at any time. If the main reason for HRT is your worry about a high risk of osteoporosis or heart disease in the future, it’s best to start on it within about twelve months of your menopause. It’s also acceptable to begin at any time after the menopausal years. For example, a woman in her late sixties whose bone density is found to be critically low can start HRT to prevent any further loss of calcium from her bones.

- My periods are getting less regular and I’m wondering whether there’s any sense in starting HRT before they finally stop. Could I avoid menopausal symptoms by doing this, for example?

This is not recommended, because many women don’t develop any significant menopausal symptoms and are not at risk of heart disease or osteoporosis, the other main reason for having HRT Another reason why we don’t normally offer HRT before menopause is that women could end up with persistently high levels-of oestrogen, and we don’t know the effects of this yet.

- How long should I stay on HRT?

That depends on why you are having it. If it’s to control symptoms, you’ll probably need HRT for between two and ten years, depending on how long the symptoms last. If it’s for protection of your bones, heart and blood vessels, your doctor will probably recommend that you stay on HRT until your late sixties or early seventies, or for the rest of your life.

- When should I stop HRT for symptom control?

When you feel comfortable about it. If you don’t want to go on any longer because it gives you side effects, or you feel well and are reluctant to continue taking pills, using patches or whatever, it’s a good idea to see how you get on without them. If you do stop HRT, the dose of hormones should be gradually reduced.

- Should I take my HRT pills at the same time each day?

Yes. This seems to give better control of symptoms and reduces the likelihood of spotting.

- Will I need to change the type of HRT I’m on, or the dosage, as time goes by, even though it seems to suit me well?

No. Once a hormone format is found that suits a particular woman’s needs, she is usually advised to stay with that format unless an alternative is developed that is likely to suit her better. Your dosage will probably also remain unchanged unless you have unwanted side effects at some stage.

- Can I use a hormone-based vaginal cream if I’m already using an oestrogen patch?

A vaginal cream used twice a week together with a patch may be called for if vaginal dryness is particularly troublesome and the oestrogen patch on its own does not do the trick.

- Do I need to remove my HRT patch when I shower or swim? Patches are designed to withstand the sorts of activities you describe, but if you find there is a problem, remove it from your skin and replace it on its original backing while you shower or swim. When you’ve dried off, put it back on again.

- Is there any evidence that HRT reduces the risk of bowel cancer?

Several studies suggest that oestrogen confers substantial protection against bowel cancer, while at least one other well-designed study has not reproduced this finding. Various groups of researchers are currently attempting to come up with a conclusive answer to this important question.

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SEXUALITY AND EMOTIONAL GROWTH: EMILLY’S AND NADIA’S STORIES

This was the case until a few years ago for Emily, a sixty-two-year-old who suffered from chronic back pain. Initially she was very concerned to protect her back, and she put sex off limits. But with support and reassurance from various health practitioners, she experimented and found enjoyable ways to have sex with her partner. In particular, she chose times when she was warm, well rested and feeling sexy, and with plenty of pillows available to support her back.

For Nadia, who was plagued by intermittent heavy bleeding in her mid-forties, the problem was finding a time when she could have sex enjoyably. ‘I had never felt like sex during my monthly bleeds, but at least they previously lasted only four or five days. This stage was much worse because I was bleeding for fifteen days without a break and I felt so ugh! My husband didn’t mind having sex while I was bleeding, but I just couldn’t come at it.’ Since Nadia’s menopause at the age of forty-eight, she and her husband have resumed the satisfying sex life they enjoyed in earlier years.

that those who have neither a desire for nor interest in sex, or who have deliberately chosen a lifestyle in which sexual activities play little or no part, have every right to their decision. On the other hand, those older people who enjoy sex or want to enjoy it should be given the information and treatment they need if problems arise.

In attempting to put the presence or absence of sexual intimacy into some sort of general framework of midlife relationships, Hathorn and Bates identified a significant obstacle. ‘One of the major problems was that our interest was in both men and women, yet it seems that most of the well-known developmental theorists of the past have focused only on men. It is as if woman were an afterthought and had to be “fitted in” to men’s cycle of growth

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HRT AND MNOPAUSAL SYMPTOM CONTROL: ENERGY LEVELS

ENERGY LEVELS. Women at midlife sometimes claim that their get up and go has got up and gone. They can’t raise the energy to pursue activities they have enjoyed for years. Such a woman is Bronwyn, whose youthfulness comes from an appetite for adventure that was unquenchable until menopause hit. ‘I don’t have flushes and I generally feel OK, except that I don’t have any energy. I’m working near to home but I find it harder than ever to get up in the morning, and to get moving. The worst thing is that I just want to rest on my days off, instead of visiting friends or taking off for the bush. I haven’t been able to look my hiking boots in the eye.’

If this is your scenario too, it is important — before allowing a doctor to reach for the prescription pad — to establish that your loss of energy has a physical origin and is not explained by job frustration or dissatisfaction, or the need for new challenges in life. Once you are satisfied that there is a physical basis to the problem, it is essential to have a check on your general health, diet, activity levels and lifestyle stresses before even considering HRT. Some women do find that energy levels respond to HRT. It is unclear to what extent this is due to an effect of HRT in settling other symptoms such as night sweats and sleeplessness; a feeling of wellbeing induced by HRT’s action on the brain and other body tissues; or a placebo effect activated by a doctor’s interest in and support of his or her patient.

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THE A TO Z OF HRT: INDEPENDENT STUDIES

Women’s acceptance of oestrogen was helped along by the statements of medical authorities such as Dr Robert Greenblatt, a leading endocrinologist who was president of the American Geriatrics Society. In 1974 Dr Greenblatt claimed that about three-quarters of menopausal women were acutely oestrogen-deficient, and he advocated oestrogen therapy for them all, even in the absence of symptoms. A year later, with prescriptions for oestrogen exceeding 26 million in the US alone (it was the fifth most frequently prescribed drug), and worldwide sales of Premarin surpassing $USioo million in value, controversy erupted.

Two independent studies by reputable US research teams, both published in the New England Journal of Medicine in 1975, reported a link between postmenopausal oestrogen therapy and cancer of the endometrium (the lining of the uterus), the risk increasing with the duration of therapy and its dose. The researchers found that women who had a uterus and used oestrogen preparations without any other sex hormones, such as progestogens (synthetic forms of progesterone), for longer than six months had an increased risk of endometrial cancer -five to ten times greater than was normal for their age.

There followed a period of widespread concern and scientific reappraisal, during which progestogens were teamed with oestrogen, the aim being to protect the endometrium of all women with an intact uterus from the increased risk of endometrial cancer. Subsequent studies have confirmed that progestogen achieves this protection.

Much has been learned from this saga, particularly the need for constant review of present knowledge, and a commitment to ongoing research of the menopause and ageing. What we can say with confidence is that in recent years there has been a resurgence of interest in HRT, together with an acceleration of research and clinical trials using therapies of different dosages in different patient groups, and the development of new ways to administer it. One of the biggest challenges now facing the medical research community is to identify women who need HRT and those who don’t. Women themselves should at the same time be analysing their experience of menopause in the light of their own medical history, weighing up the evidence, and making their own judgement.

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