Menopause: It’s more than hot flashes.

By Elise Dubuc

The definition of menopause is the complete cessation of menstruation for more than a year. It occurs when the ovaries no longer ovulate. The average age of menopause is 52 years old. The period preceding menopause is often called perimenopause. It is characterized by a significant fluctuation in hormonal levels and a decrease in the frequency of ovulation, causing irregular periods which can also be heavy and prolonged.

During perimenopause and menopause, hot flashes can make life difficult for women. Up to 80% of women will experience these vasomotor symptoms, and 20% of them will be up to 20 to 30 episodes per day. These hot flashes are sometimes preceded by anxiety or palpitations. These vasomotor symptoms can persist for an average of 7.4 years. The most effective treatment for vasomotor symptoms is hormone replacement therapy. The safest option is Bio-Identical hormone therapy (i.e. molecules with the same chemical composition as the hormones produced endogenously by the ovaries). Women under 60 or within ten years of post-menopause can safely start hormone therapy. Transdermal estrogen (with micronized progesterone before sleep) is preferred for women with a uterus to reduce the risk of venous thromboembolism (clots in the legs, lungs or brain). For women with no uterus, progesterone can be omitted. Contraindications to hormone therapy include a history of thromboembolism, stroke, hormone-dependent cancer (breast, endometrial or ovarian), coronary artery disease, liver disease, undiagnosed abnormal vaginal bleeding, or known or suspected pregnancy.

Starting hormone therapy must be discussed with a healthcare professional and individualized according to your symptoms and their impact on your quality of life.

Perimenopause is a vulnerability to developing depressive symptoms and major depressive episodes, even in women without a history of depression. Therapeutic options for depression at all stages of life remain the first line of treatment with cognitive behavioural therapy and antidepressants. In perimenopausal women, hormone therapy may have similar efficacy to antidepressants.

Sleep disturbances are prevalent during menopause and can be caused by hot flashes or be independent of them. In cases where hot flashes cause sleep disorders, hormone therapy usually solves the problem. Sleep hygiene should be assessed if sleep disorders are separate from hot flashes. We recommend aerobic exercise, exposure to natural light during the day, stopping looking at screens (phones, tablets, etc.) two hours before sleep, and creating a pre-sleep routine. If sleep doesn’t come after 30 minutes, it’s best to get out of bed and do something quiet like reading. The bedroom should be a space for sleep and sex only. Several therapies are effective for sleep disorders, such as eszopiclone, venlafaxine (an antidepressant) and the natural products black cohosh and valerian.

Other common symptoms of menopause include memory problems and difficulty concentrating, joint pain, vaginal dryness, and urogenital and sexual issues.

Vaginal dryness and discomfort during intercourse respond very well to local estrogen therapy at the vaginal level. Local treatment does not entail any risk and has no contraindications. Local estrogens can be given as tablets, cream or a vaginal ring. For women who cannot or do not want to use local estrogens, other options include vaginal laser or radiofrequency treatment.