Some women breeze through the menopause and hardly notice it's happening - but four in five get hot flushes, and other symptoms including tiredness, disturbed sleep, low mood and vaginal dryness abound. So how do you take the drama out of the menopause?
Half of us go through the menopause if we live long enough - on average at about 52 years old, but anything from 45 is normal and it can happen earlier.
Is HRT right for you?
In years gone by, doctors were quick to recommend HRT as the treatment for menopausal symptoms, on the basis that it relieved menopausal symptoms more effectively than anything else and helped protect against osteoporosis, or 'thinning' of the bones. About 15 years ago, two major studies suggested a link between HRT and breast cancer, as well as a possible increased risk of heart disease. Not surprisingly, prescriptions for HRT plummeted.
Since then, further studies have shown that HRT doesn't carry any increased risk for heart disease for women in their 40s and 50s - in fact, it may even protect your heart at this age.
What's more, the risks of breast cancer with more modern HRTs aren't as high as first thought. The breast cancer risk doesn't apply if you’re under 50, and doctors now recommend all women who go through 'premature' menopause before age 45 should take HRT until at least age 50 to protect their bones. That's because bone density drops more quickly after the menopause, and women who go through an early menopause are at significantly increased risk of osteoporosis, which HRT protects against.
For anyone else, whether or not to take HRT is a matter of choice. It relieves hot flushes, protects your bones and may help with menopause-related mood swings. But unless you've had a hysterectomy, you'll need to take a 'combined' HRT containing the hormones oestrogen and progesterone. Combined HRT is linked to a heightened risk of breast cancer, although the size of the risk depends on how long you take it for and drops off once you stop.
Some HRT can also increase your risk of a clot on the leg (a deep vein thrombosis) or the lung. 'Body identical' oestrogen creams or gels don't, and they may not carry the same risk of breast cancer. Examples include Sandrena gel, Oestrogel or Estradot patches.
Vaginal dryness is a very common side effect of dropping oestrogen levels at the menopause. Unlike hot flushes, it doesn't settle with time. Along with soreness and painful sex, it makes you more prone to urine and vaginal infections.
Topical oestrogen in cream, pessary or hormone-releasing vaginal ring form can plump up your vaginal tissues without any of the risks of 'regular' HRT. Because the hormone is delivered straight where it's needed, the dose is tiny and you can use if for as long as you need.
Non-hormonal vaginal moisturisers are an effective alternative to topical oestrogen. There are several available in the pharmacy and they're different from 'lubricants' designed just for sex. Your pharmacist can advise.
'Body identical' HRT is HRT which mimics your body's own natural hormones - contrary to popular belief, many forms of body identical HRT are available on the NHS.
These are different from compounded 'bio-identical' HRT products, which are only offered by private providers. NICE advises that compounded bio-identical hormones are unregulated (meaning the same checks on quality and safety are not in place) and "the efficacy and safety of unregulated compounded bio-identical hormones are unknown".
However, there have been shortages of many forms of HRT available on the NHS since the end of 2018. That means that your doctor may need to change the form you take if you're already on HRT, and the choice of options they can offer you is currently limited.
What about herbal remedies?
If you're looking for a herbal alternative, there are several on the market. However, because they aren't regulated in the same way medicines are, there have been concerns about safety with some.
Look for a 'Traditional Herbal Remedy' (THR) logo on the packet - your pharmacist can advise - so you know they're safely manufactured. NICE highlights black cohosh (I recommend Menoherb one a day) and Red Clover Isoflavones (I recommend Promensil 40-80 mg a day) as alternatives with the best evidence. Do let your doctor of pharmacist know you're taking these herbal remedies - they can interact with other medicines.
There's also good evidence that increasing the soya in your diet may help with hot flushes. Tofu is an obvious source - and it's also a tasty, heart-healthy, meat-free alternative for stir fries! But soya beans or soya milks and yoghurt can be easily incorporated into your routine, too.
Of course, lifestyle tips can help as well. Wear layers or loose clothes in natural fibres, and keep a sheet under the duvet so you can throw the duvet off in the night. Spicy food, caffeine, alcohol and smoking can all worsen flushes and night sweats, so cut out one at a time to see if you're less troubled. And remember, those hot flushes do usually settle - it just takes a while!
Thanks to My Weekly where this was originally published