An exciting close to 2019 was the opening in Cork of a clinic dedicated to POI & Menopause. It is great to see more clinics and GP's expanding their knowledge and spreading their wings throughout the country. I was thrilled to finally met Brenda after months of emails as she prepared to open her clinic in Cork.
Brenda is a UCC graduate and qualified GP - during her GP training she became interested in the area of sexual & reproductive healthcare and went on to study a Diploma of the Faculty of Sexual & Reproductive Healthcare (UK). It was while working in London as a portfolio GP encompassing part-time GP and part-time work in King’s College Hospital in the area of sexual health and forensic medicine ( sexual assault), that Brenda met Mr Haitham Hamoda (current Chairman-Elect of the British Menopause Society, consultant Gynaecologist and sub specialist in Reproductive Medicine). Keen to gain practical hands-on experience in menopause Brenda worked under the tutelage of Mr Hamoda at King’s Hospital. (King’s College Hospital is a large Tertiary Referral Centre in South London which has a long-running and comprehensive Menopause Clinic). Brenda was determined to bring this knowledge back to Ireland.
‘Over the past few years, I have observed the menopause getting much more well-deserved exposure in Ireland with regular media articles, on-line resources such as My Second Spring, menopause advocates such as Catherine O’Keeffe (Wellness Warrior) and there has been great initiatives by the Irish College of General Practitioners (ICGP) to improve menopause care by GPs and I think the message is getting through slowly. Every woman’s menopause transition and journey is different and it’s important that readily available access to up-to-date information in all aspects of menopause care is available so that women are well-informed and can avail of treatment options (if any) that most suit them.’ Dr Brenda Moran
Below you can read the interview with Dr Brenda Moran on discussing her new clinic, POI & Menopause.
Brenda talking POI:
Premature ovarian insufficiency (POI) refers to onset of the menopause or oestrogen deficiency under the age of 40. Early menopause refers to the onset of menopause or oestrogen deficiency between the age of 40 and 45. POI has a prevalence of 1%. Genetic factors, autoimmune factors, infections and iatrogenic causes such as chemotherapy, radiotherapy and surgery are reasons why women might have POI. However, in most cases no cause is identified.
In addition, there is an increasing prevalence of childhood and young adult cancer survivors following the advancements made in cancer treatments over the past 2-3 decades. Risk-reducing surgery such as bilateral oophorectomy (removal of both ovaries) to reduce the risk of ovarian cancer is on the rise following advancements in genetic testing resulting in the identification of BRCA carriers (BRCA carriers are at a very high risk of developing breast and/or ovarian cancer). Therefore, the number of women with POI is increasing.
The long-term complications of POI have been well documented in medical literature. These include reduced bone mineral density with resultant increased risk of developing osteoporosis and fractures, an increased risk of cardiovascular disease, reduced cognition and decreased life expectancy.
Hormone replacement has a beneficial role in maintaining bone and cardiovascular health as well as cognitive function in addition to symptom control and has been approved by the NICE guidelines as the treatment of choice for women with POI.
There is currently no national referral guideline or recommendation regarding the treatment of POI in Ireland. It is not uncommon to find women with longstanding POI not taking HRT, nor advised about HRT, nor linked with either a gynaecology or endocrinology clinic or closely monitored by their GP. It is essential that women with POI get access to the most up-to-date, evidence-based treatment and appropriate psychological support.
There is a clear lack of resources, support and awareness of this important condition which can have life-altering physical and psychological consequences for some women, especially when it impacts on fertility when a woman would like to conceive. We need to continue to advocate to improve resources for women with POI in Ireland, especially when it comes to accessing proper medical care, appropriate psychological support and access to funded assisted reproductive technology for fertility treatment.
The Daisy Network is a UK based charity dedicated to providing information and support to women with POI. It’s wonderful to now have an Irish representative for the Daisy Network in Catherine O’Keeffe. Catherine is now the Irish link to the Daisy network and can help to provide grass root support to women who need it. (See more details here.)
I am very happy to see and treat women with POI in my clinic. However, it’s important to note that I will be focusing solely on menopausal symptoms and consequences of POI and am not a substitute for one’s regular endocrinologist if there are other associated endocrine conditions albeit I can happily liaise with them in relation to POI.
You can contact Brenda at her clinic or through her website : www.danuclinic.ie.
When Menopause happened for you (if applicable)
I have yet to go through the menopause. However, one of the most challenging periods of my life to date has been the experience of 1st trimester pregnancy when I felt so generally unwell, and frankly didn’t recognise myself. I was expecting to be nauseous (and I didn’t have hyperemesis)– but I was not expecting to feel that I had lost complete control over my own body. I lost any extra reserve that I had, felt I was sub-performing in all aspects of my life and it was an acute personal realisation of the effect that hormones can have on a person’s body, and how the physiological response to the same type and level of hormone can differ hugely from person to person.
What are the most common issues women experience in menopause?
Menopausal symptoms: I am not going to list all the symptoms as they are listed on this website and elsewhere, but the most common ones I encounter in clinical practice are: (*of note, some women might have no symptoms; others might have 1, others might have several – it’s hugely variable)
The last few years has seen the advent of changes in clinical practice when it comes to HRT prescribing taking into consideration the cardiovascular “timing hypothesis”, “window of opportunity”, the role of transdermal oestrogen (oestrogen via the skin) as well as body-identical hormones.
The “timing hypothesis” and “window of opportunity” relate to the theory that if HRT is started within 10 years of the menopause or before the age of 60, the advantages generally outweigh the risks, particularly in terms of benefit to the heart, as well as bone protection and cognition (the latter only for women who are symptomatic in this regard, for example, are experiencing brain fog, forgetfulness and poor concentration which started around the menopause. It is not a treatment for dementia) as well as improving menopausal symptoms. Studies have shown that when HRT is started at a time interval of more than 10 years following a woman’s last menstrual period or over the age of 60, the same cardiovascular (heart) benefit doesn’t apply, although it still may improve symptom control.
Studies have also shown that transdermal oestrogen (oestrogen HRT via the skin) does not increase the risk of a venous thrombo-embolic event (VTE) or stroke. VTE is a clot in a vein, commonly the leg or the lung. Therefore, it has a lower risk of blood clots and strokes than oral HRT.
Prior to the publication of the Lancet Study during the summer, HRT use had increased again following the negative media publicity it had received following the publication of the WHI Trial in 2002 when it was associated with an increased risk of breast cancer, cardiovascular disease, stroke and clots ( of note, the majority of women enrolled in this trial were much older than the average woman starting HRT in the perimenopause and early menopause and therefore it wasn’t an accurate reflection of the usual cohort of women who start HRT under the age of 60).
Evidence from studies does suggest a small increased risk of breast cancer with HRT use which increases with duration of use and reduces on stopping. This came to light again with the publication of the Lancet Study in 2019 which concluded there were an extra 2 cases of breast cancer for every 100 women of average weight using continuous combined HRT (daily oestrogen and progesterone) for 5 years. The study suggests that the additional risk associated with combined oestrogen and progesterone may continue for longer than was previously thought after HRT is stopped.
However, it’s important to note this is a 2% absolute increased risk and the majority of women taking HRT will not go on to develop breast cancer as a result of taking HRT. In addition, the figure of 2% was lower for that of oestrogen-only HRT, sequential combined HRT (daily oestrogen and intermittent progesterone use) and no increased risk was seen with vaginal oestrogens. In addition, women should be counselled that other factors, including body weight and alcohol consumption, have a greater effect on breast cancer risk than HRT (NICE 2015).
In conclusion, HRT remains the most effective treatment option for severe menopausal symptoms. In general, the benefits outweigh the risks when started within 10 years of the last menstrual period or below the age of 60 when it comes to symptom control, reducing the risk of cardiovascular disease and for bone protection. There is a small increased risk of breast cancer which increases with duration of use and depends on the type of HRT used. This risk needs to be acknowledged but the overall benefits of HRT need to be taken into consideration. For every woman, it should be an individual choice.
Your treatment choice and reasons - please give as much detail as you can, to help other women consider their decisions
I discuss all treatment options with women and then it’s the individual woman’s decision as to which option she chooses. Often, it’s trial and error and women respond differently to different treatment options. Some women might just want advice on lifestyle changes, others are interested in non-pharmacological interventions such as psychological therapies and acupuncture, others might want advice on supplements or non-hormonal options and others want HRT. Sometimes people might start with non-hormonal options, and then build up to hormonal options if symptoms are not controlled with these measures.
Lifestyle changes. The perimenopause and menopause is an opportunity for every woman to look at their general lifestyle and consider introducing different habits and changes which will benefit their health in general, and often can help with mild to moderate menopausal symptoms.
Diet. Discussed ad nauseum and already mentioned on this website so I am not going to go into too much detail. Main take-home messages:
- Regular balanced meals.
- Complex carbohydrates such as whole grains, oats, beans and root vegetables. Avoid fast releasing high-GI carbs which give an initial burst of energy followed later by a slump caused by a reduction in blood glucose levels causing fatigue and lack of energy.
- Plenty of fruit and veg.
- Plant-based fats such as nuts, seeds and avocados.
- Plenty of fibre such as whole grains, brown rice, beans, bran.
- Plenty of protein such as lean meat, eggs, yoghurt, cheese, seeds, nuts, hummus, tofu.
- Two portions of oily fish per week or supplement with omega 3 fatty acid or algae-derived EPA+DPA (250mg daily) if you don’t eat fish.
- Minimise refined/ processed carbohydrates, red meat or processed meat, junk food, take-aways, caffeine, alcohol.
- Avoid hot spicy foods if prone to hot flushes.
Vitamin Supplements - There are lots of vitamin brands targeting the menopause on the market. I would always advise supplementing if confirmed deficient in certain vitamins. Any vitamin deficiency should be corrected (B12, folic acid, vitamin D, magnesium) along with iron (which is a mineral). Even with normal vitamin D levels, I would recommend supplementing over the winter months, and taking extra amounts if confirmed to have low bone mineral density. Magnesium supplements can help sleep symptoms in some women.
Will help to reduce the risk of cancer, cardiovascular disease and has been shown to improve vasomotor symptoms in some women.
Any form of aerobic exercise has been shown to improve psychological health, mood, quality of life, poor sleep - all areas that can suffer around the menopause.
Weight-bearing exercise (for example: brisk walking, running, dancing, resistance training, weights, tennis) is particularly good for bone health which can be affected by the menopause.
Moving and exercise have also been shown to reduce frailty which has a significant effect on general ageing. Exercise is a drug. Now is the time to consider taking up a new hobby or increasing your amount of exercise.
Stress Reduction (easier said than done) but taking a spotlight view of one’s typical work schedule and lifestyle can sometimes highlight where changes can be introduced. It might be a good time to consider changes in work practice or changing aspects of your life that are increasing stress (if possible, to do so).
Pilates and/or Yoga: may help with flexibility, muscle strength and toning. Yoga particularly can help with stress-reduction. Pilates can help with pelvic floor exercises which can help genitourinary symptoms as discussed previously
Mindfulness: Learning to live in the present moment.
Sleep Hygiene. Reducing screen time and stimulants such as caffeine and alcohol in the evening time, try to get up at the same time each morning including weekends aiming for 7-8 hours of sleep per night. Treat the bedroom as a sanctuary and remove all electronic devices. Consider the use of blue-light blocking glasses in the evening.
Paraphernalia such as fans, facial water sprays, loose-fitted cotton clothes and underwear. There are lots of small fans on the market that can help with vasomotor symptoms at home and work. Promensil do a good instant relief cooling spray for hot flushes and night sweats
What are your thoughts on complementary therapies?
There is more of an evidence base for phytoestrogens, black cohosh and St. John’s Wort (NICE guidelines 2015) than other complementary therapies but there can be variations in standards between different products. St. John’s Wort in particular, may interact with certain types of conventional medicines and should be avoided in these cases.
Phytoestrogens are naturally occurring substances that are present in plants which have similar but less potent effects to conventional oestrogens. They occur naturally in enriched foods and are available as supplements in health stores. They are divided into 2 main types (isoflavones and lignans). Isoflavones can be found in soybeans, chickpeas and red cover. Lignans can be found in oilseeds such as flaxseeds, bran, vegetables, legumes and fruit. If taking a supplement, I would advise getting a product with a traditional herbal registration as approved by the HPRA in a health store rather than an unregistered product over the internet as this product would have needed to meet certain standards in order to be registered.
It’s also important to note that the efficacy of these products would not have been tested in a similar manner to conventional medications via clinical trials and there is no guidance on whether these products should be used in women with a previous history of hormone-sensitive breast cancer and there have been reports of liver and kidney toxicity in rare cases.
CBT (Cognitive Behavioural Therapy) can be a very useful tool for those who want a more natural non-pharmacological intervention. It’s a form of psychological therapy focusing on challenging and changing your thought processes and behaviours and aims to help a person manage a problem by changing how they think and act. Unlike other forms of psychological therapy, it focuses on problems and difficulties you have now, rather than issues from the past. Some women report improvement in their menopausal symptoms, and ability to cope with their symptoms via this method.
Acupuncture may improve hot flushes, night sweats, mood irritability and increase general well-being in some women.
Non-hormonal oral medication is an option for women who want a prescribed medication option but where HRT might be contra-indicated or not desired. Examples include gabapentinoids, SSRIs, clonidine, propranolol which can improve vasomotor symptoms in some women. Melatonin can sometimes help with sleep problems and insomnia. I don’t recommend sleeping tablets such as the Z drugs or benzodiazepines. If no improvement is obtained after a few weeks, I would recommend stopping these medications.
Hormonal therapy, HRT (as discussed above) which remains the most effective treatment option for women with severe symptoms impacting significantly on quality of life and has other benefits including bone protection and reducing the risk of cardiovascular disease.
Vaginal moisturizers and lubricants, vaginal oestrogens and pelvic floor exercises can with genitourinary symptoms.
Vaginal dryness is a big issue in Ireland - do you feel women are tackling this or being shy to discuss it
Yes, most definitely - I think both women and doctors are shy in discussing it and it’s frequently not discussed or brought up by both women and doctors during consultations despite it being an important and common symptom of the menopause. Up to 1 in 2 women will suffer from what we call in medical terms “Genitourinary syndrome of the menopause” which means symptoms affecting the vagina and bladder. Vaginal dryness is one of the commonest genitourinary symptoms.
The reduction in oestrogen around the time of menopause can cause vaginal dryness resulting in painful sex, as well as an overactive bladder and recurrent urinary tract infections. This is because there are oestrogen and progesterone receptors on the musculature of the genital and lower urinary tract organs that are no longer activated by oestrogen, especially, causing the vagina to become thin, dry, itchy and less elastic. Vaginal mucus production decreases, further exacerbating symptoms, and causing reduced lubrication during sex. The lower urinary tract may also be affected causing symptoms such as an overactive bladder and recurrent urinary tract infections.
It responds well in particular to topical oestrogen which is taken vaginally via a pessary, cream or ring. Vaginal oestrogens are very effective at relieving symptoms and can be safely used in women who do not wish to take, or can’t tolerate, the usual methods of HRT. There is no need for womb protection with progesterone in this instance as vaginal oestrogens act on the vagina and lower urinary tract directly with minimal absorption into the bloodstream thereby not affecting the lining of the womb. It has also been endorsed by the Nice Guidelines as a treatment for genitourinary syndrome of the menopause.
Non-oestrogen-based treatments are also available for vaginal dryness. Lubricants (examples YES and Sylk) are applied before sexual intercourse, but it’s important to note that oil-based lubricants reduce the integrity of condoms. Vaginal moisturisers are longer acting, deliver continuous moisture, can be applied every few days, and don’t cause condoms to break (examples Replens, Regelle and Hyalofemme).
Please don’t be shy to speak about this important symptom with your doctor. Lubricants and vaginal moisturisers can be bought over the counter, vaginal oestrogens need a prescription from your doctor.
At what point should a woman talk to her doctor about vaginal problems she’s experiencing? Are any of these potentially dangerous?
A woman should be able to discuss any vaginal symptom with her doctor at any time. Vaginal symptoms are common around the menopause, especially vaginal dryness and itch.
Don’t be afraid to report any unusual changes in your menstrual cycle, particularly new bleeding in between your periods or bleeding after sex to your doctor at any time.
Postmenopausal vaginal bleeding should always be reported to a doctor – an episode of bleeding after an interval of 1 year for women over the age of 50, and for 2 years under the age of 50 as this will need further investigating in the form of a physical examination and potentially hospital based investigations to rule out endometrial (womb cancer), cervical cancer and vaginal cancer as a cause of this symptom. The incidence of endometrial cancer is increasing in Ireland. However, in most cases, a sinister cause for postmenopausal bleeding is not found.
What other areas of health should women in peri/menopause be aware of?
We have touched on some of these areas in previous questions but:
Cardiovascular disease – there is an increased incidence in CVD in women post-menopause, and indeed it is the leading cause of death in women.
Attending your GP annually for a BP check and blood test (to check glucose, HBA1C and lipids) can reduce your risk of getting CVD if abnormalities are picked up that can be addressed.
Lifestyle factors such as a healthy diet, exercise, maintaining a healthy weight, reducing alcohol intake, quitting smoking are also important modifiable factors that can reduce the risk of CVD.
Osteoporosis is a skeletal disorder caused by low bone mass resulting in increased bone fragility and susceptibility to fractures. Prevalence increases with age. Every person has a unique peak mass and “threshold value” under below which a bone can fracture after minor trauma. The inter-play between vitamin D, collagen and oestrogen receptors determines bone peak mass.
Peak bone mass usually occurs around the age of 30 years and begins to decline thereafter from mid 40s onwards. Menopause is associated with an accelerated period of bone mass of 2% annually. This rate of bone loss declines with age.
Women should consider getting a DEXA scan to assess their bone mineral density, particularly before their late 50s or early 60s when the accelerated level of bone mineral density around the time of the menopause begins to level off.
Adequate Vitamin D, calcium and plenty of weight-bearing exercise is important to maintain bone health (see the section above under lifestyle changes).
Calcium, unlike vitamin D can usually be obtained from dietary sources in adequate amounts, especially in dairy products. However, vegans and non-dairy eaters can also obtain adequate amounts of calcium via other dietary sources such as fortified cereals, tofu, leafy greens, seeds, beans and lentils. Consider calcium supplements if you don’t consume the mentioned dietary sources in moderate amounts.
Oestrogen is known to be protective to bones and one of the benefits of HRT is the protective effect that oestrogen has on bone mineral density which can protect against osteoporosis. It is also a treatment option for osteoporosis for women diagnosed around the time of the perimenopause or early to mid-menopause.
Sexual dysfunction is more prevalent in women than men, and this tends to increase around the menopause and perimenopause with women reporting problems with libido, vaginal dryness and inability to climax. Painful sex can then lead to avoidance of sexual activity, and anticipation of pain prior to sex can lead to lack of arousal. Women who are going through their menopause transition and women who are postmenopausal should be able to participate in an active sex life. Maintaining sexual health in the peri-and post menopause is an important part of menopause management by treating genitourinary syndrome of the menopause ( discussed previously) and addressing psychological problems which might also be contributing to symptoms. Perimenopausal and menopausal women deserve to have an active, fulfilling sex life.
During the perimenopause when a woman is still getting periods (even if infrequent), there is still a risk of pregnancy, albeit it is very low. The current recommendation is for women to continue with contraception for 1 year after the last menstrual period if aged 50 or older, and for 2 years after the last menstrual period if under 50 years of age. However, the last menstrual period is a retrospective diagnosis. Some women do not get menstrual periods with certain contraceptives, conversely, some contraceptives and HRT regimens will give women a monthly hormone withdrawal bleed. Hence it can be difficult to accurately determine the last menstrual period. Therefore, another recommendation is for women to continue with contraception regardless up until age 55 whereby most women will be postmenopausal. HRT (apart from the Mirena coil or IUS if used as the progesterone component of HRT), is not a contraceptive, and women are still advised to use a method of contraception until they are postmenopausal.
Safe sex principles still apply and it’s important to avail of STI screens if embarking on a new relationship and to use barrier contraception to reduce the risk of STIs.
Jo Divine’s website has helpful online articles exploring many wide-ranging aspects of women’s sexual health, including sex after cancer, vaginal dryness, low libido and painful sex: https://www.jodivine.com/articles/womens-sexual-health.
Engaging with Cancer Screening. Of note, there are limitations to screening. It won’t pick up all cancers and changes can start in between screening
Most women diagnosed with breast cancer are between the ages of 50-64 at diagnosis. It is common, affecting 1 in every 8 women. It’s important to make sure you are registered with Breastcheck in order to attend your free screening every 2 years from the age of 50 to 67. Also report any breast changes or areas of concern to your GP.
Women are also entitled to a free cervical smear with Cervical Check every 5 years from the age of 45-60 as cervical cancer can still occur in this age group. Make sure to report any concerns such as pelvic pain, bleeding in between your periods and bleeding after sex to your GP.
Bowel cancer is the 5th commonest cancer affecting women in Ireland. Screening involves taking a sample of your stool at home with a kit that’s posted to you which you then post back in a sealed envelope for testing in a laboratory. If the amount of blood found in your stool is above the screening limit, you will be referred for a colonoscopy. Free screening is available every 2 years from the age of 60-69 for both men and women.
Always make sure to report any blood in your stool or prolonged changes in your bowel habit to your GP, especially over the age of 50.
Increasing frailty is one of the biggest challenges of ageing. Good nutrition, exercise, and good cognitive health (keeping your mind active and staying connected with social activities, especially important after retirement) can all help to reduce the onset of frailty.
Do you think doctors should ask women about their sex lives, or is it better to wait for the woman to bring it up?
I ask women about their sex lives when discussing the menopause as menopausal symptoms often impact on women’s sex lives and I want to explore all potential symptoms that might be affecting women. However, I don’t persist if women feel uncomfortable.
I think any focused menopause consultation should always involve questions about genitourinary symptoms and lack of libido which are relatively non-invasive questions but might lead to more direct questions about sex if the woman feels comfortable. Women should never feel embarrassed to bring up the topic of sexual health with their doctor.
Do you think menopause should be covered in the secondary school curriculum and covered in more detail in medical school? If so why
Yes. Yes. Yes. Yes! X 100,000,000. For too long, the menopause has been one of the Cinderella’s of reproductive health, especially in Ireland. As the life expectancy for women in Ireland continues to increase, most women can expect to be postmenopausal or in a post reproductive stage for at least one-third of their life. Albeit the last part of a woman’s reproductive journey, it is still a significant part and deserves the same amount of education, attention and awareness as any other area of reproductive health and should be given equal status to that of other more prominent areas such as pregnancy and puberty. The WHO (World Health Organisation) states that good Sexual and Reproductive Health is a state of complete physical, mental and social well-being. The same should apply for women undergoing their menopause transition and women who are postmenopausal.
Best menopause resource or piece of advice and why?
Don’t be afraid to ask for help and there’s no such thing as a stupid question.
British Menopause Society
Brenda is working with women with POI, Menopause & PMS related issues. In Brenda's clinic she will be focusing solely on menopausal symptoms and consequences of POI and as such an endocrinologist is still required ( where there are other associated endocrine conditions).
You can contact Brenda at her clinic or through her website : www.danuclinic.ie.
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