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Programme 4. - Menopause
RADIO 4
THURSDAY 14/12/06 2100-2130
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
HEATHER CURRIE
PRODUCER:
DEBORAH COHEN
NOT CHECKED AS BROADCAST
MYERS
Hello. Some women swear by it for relieving symptoms such as hot flushes and loss of sex drive. Preventing bone loss is an added benefit. But ever since studies in 2004 showed an increased risk of breast cancer, heart disease and stroke taking hormone replacement therapy is no longer seen as the long term answer to a menopausal maiden's prayer. So just how risky is it and are you prepared to take any small additional risk if your symptoms are particularly severe or if you've had an early menopause, through a hysterectomy, for example? If you do want to take it what is the safest and most effective way of taking it and when is the right time to come off? Medical opinion suggests five years is okay, any longer and the risks may not be acceptable.
And if you have decided against HRT are you trying some of the others? The Black Cohosh, the plant oestrogens, like soya in your diet, some of the things you can find in the health food shop - do they work?
Call us now with your comments and your questions today for Dr Heather Currie, she's an expert in the menopause and she's joined us from Scotland. The number to ring: 08700 100 044 - I've got the number wrong - 08700 100 444 is the number you should ring. You can of course e-mail checkup@bbc.co.uk.
Our first caller is on the line and we're going to be talking to - I think it's Sheelagh, in Wiltshire. Sheelagh, having hot flushes, night sweats - is it getting to be a bit of a pain?
SHEELAGH
Yes, I've been having them for about eight years. I know that if I cut down on alcohol and caffeine they're less intense but I'd like to know really when I can expect them to stop completely or if I can expect them to stop completely?
MYERS
What's the answer to that, it's a straightforward question?
CURRIE
Well good afternoon Sheelagh. It's a very common question, I'm asked that kind of question very often. The average time of the flushes and sweats is about two years but you've obviously proven already that some people go on having symptoms for longer than that. And we do know of some people who have symptoms for up to 20 years and others who don't have any at all. So although we know the reason for flushes and sweats is because with the hormone changes at the menopause the thermostat is reset and basically your body temperature control isn't quite right, there's still a lot of uncertainty about how they affect people so differently. I'm sure they will go. I think you're absolutely right in your finding of reducing alcohol and caffeine can reduce the intensity. Smoking also - I don't know if you're a smoker?
SHEELAGH
No I don't smoke.
CURRIE
Fantastic. So there are other things that we can do that can help. Also exercise is said to help and if we're a bit overweight then losing weight can also help. So these are the general healthy advice things that can be useful. But if they are very troublesome then there are - then obviously considering specific treatments must be an option also.
MYERS
Are you trying to, as it were, sweat it out rather than to try any alternative ways of dealing with it, any particular medications or remedies?
SHEELAGH
I had tried Black Cohosh and Red Clover and Evening Primrose Oil but I didn't find that they had any effect. So yes I guess I'm sweating it out now.
MYERS
I mean is that a reasonable thing to do, is it in fact just part of the way we are and that we're going to have to, some of us, accept that it might be a few uncomfortable years with the hot flushes and sweats?
CURRIE
Well it depends on the severity of the symptoms, I mean if it is just a little bit uncomfortable but not too distressing then many women would probably prefer not to take treatment. But if the symptoms are a nuisance and affecting quality of life, which for many women it can do, there's no need to have to put up with it and sweat it out, as we say. The alternative treatments that you've tried, many women do find that, that they will try alternative treatments before considering hormone replacement therapy, in fact a survey that we have done ourselves showed about 87% of women would try alternatives before HRT. But sadly a lot of them don't have much information available on their effect and also on their safety.
MYERS
And Sheelagh your experience has been that it's not particularly helped with your symptoms?
SHEELAGH
No, they haven't. I considered HRT but I've got a family history of heart trouble, so I decided to try other routes.
MYERS
Okay, well we'll get more into HRT I think in a moment, we've got various callers want to speak about that. But just finishing on this business of when you might expect to, as it were, get over the menopause, how long it might last. Susan, has e-mailed saying, in her case, what she'd like to know constitutes her final period, she says that her periods have taken several years, during which time they've dwindled down to very faint spots of bleeding and she's wondering is she there yet?
CURRIE
The actual menopause does mean the last period, so if there's still some bleeding on a monthly cyclical kind of basis then the actual menopause isn't there yet. But what a lot of people don't appreciate is that they can have a lot of changes before the actual menopause, when the hormone levels are starting to decline, starting to change, and often this can fluctuate from month to month. So there are a lot of symptoms go along with that. People focus on the menopause but that's only a small part in this whole transition, this whole phase of us moving into the next stage of different hormone levels.
MYERS
Okay, thank you very much. I didn't think it would be long before we took a call about HRT. Lee Campbell wants to talk to us, I think has been on HRT and is coming off HRT, what's the story at the minute then Lee?
CAMPBELL
Yes good afternoon. That's correct. I went on to it when I was 48 and I was led to believe by a GP I would stay on it for 10 years, if not longer, because she kept saying that things would change in the future, whatever. I've subsequently moved from the South East to the South West and my new GP was anxious for me to come off it, which I did at the beginning of September because she said - Oh you know now you've been on it eight years your body will have changed, you will have gone through all the different hormonal things and you won't have the symptoms you had before you went on it. But I've not found this to be the case and I'm having horrendous hot flushes and I used to sleep like a top, you know, and now I wake up fitfully every couple of hours and generally I feel exhausted and wish I was back on it basically.
MYERS
Ah right, okay. Well I mean is that the case that it sounds as though the HRT has simply delayed what would have happened anyway and in which case let me ask Heather Currie, our expert here today, what do you do, do you then - okay - accept that these flushes are there, they're going to happen, they're sort of hidden and if you want to keep to keep them at bay you have to go back on the HRT?
CURRIE
Yeah I mean what we don't know is HRT just controlling the symptoms while it's taken and are we going to go completely back to square one when we stop it? Probably not in fact because a lot of women do take HRT just for a few years and then stop it and find that they don't need it, they often find either they don't have symptoms at all or they're not as bad as they were before. Or would - if someone hadn't taken HRT would they have continued having symptoms all that time, that's what we're really not sure about. We are increasingly aware that there are many factors that interact and have an impact on if a woman has symptoms and if she does how bad they are, so that all these interacting factors can change. For example, what else is going on in your life, stressful situations, your diet, your lifestyle, these can all have an effect. But at the end of the day if you've been off HRT for a reasonable length of time, and by that I mean about three months really you need to try before you decide what to do about it, if in that time you feel the symptoms are really troublesome and you felt very well on HRT then it's up to you if you want to go back on it, it should be the woman's choice. And I never tell women what to do, I just try and give them the facts and help them make an informed choice. The other side of it is how you stopped your HRT because a lot of people have, especially over the last few years when there's been concerns about risks of HRT have just stopped it suddenly. If someone's on a high-ish dose preparation then stopping it suddenly in theory is perhaps more more likely to bring the symptoms back whereas if someone does wan to come off HRT we generally advise they wean themselves off it.
LEE
Oh yeah my GP did explain I should wean myself off it over three months, which I did, and then I've been off it for three months altogether, completely now.
MYERS
Is anything you've heard helpful in trying to make a decision about whether you go back on it?
LEE
I understand Dr Currie's point of view in that it's a bit of an unknown quantity, every woman's different, but I just don't know whether I should go back begging to go back on it or not because ...
CURRIE
I mean at this stage, if you're concerned about the risks of HRT, I think we have to come round to thinking that the risks are actually very small and I think the risks that we've been concerned about over the previous years have actually been exaggerated. There's an overall sort of feeling now that women, for example, who have an early menopause - so before the age of 45 and certainly before the age of 50 - would hugely benefit by continuing HRT at least into their 50s. For the women who are between 50 and 60, who have menopausal symptoms, then for them, as with younger ones, the benefits of HRT will outweigh the risks. And the risks are only applied really if someone's been on HRT for quite a long time and then they have to try and balance the risks against the benefits of the HRT in controlling their symptoms.
MYERS
Lee, we may have to leave it at that for the moment but please don't go away because there are other callers, I think, will have something to say about this. Jennifer Jones, for example, is waiting to speak to us, has been on HRT since she was 50 and now reached the age of 71. Wondering whether to come off, is that the case Jennifer?
JONES
Well yes it is, it is really. It was when I got to 70 I thought - I was still bleeding, I was on the dose that I had a bleed and I thought it was quite wrong for this old body to be bleeding. I asked my doctor, being a male he didn't know an awful deal about it. Anyway I heard another programme, way, way back, and it gave a number and I rang them and it was a woman's health concern, and they said to do - I was really wondering how to get off it - for six months go on to an anti-bleed one and then go on to phytooestrogen for another six months. Now I really want to know am I going to get all these symptoms, like that last caller, the thought of that was pretty awful?
MYERS
Heather, what would you have to say on this?
CURRIE
I would - good afternoon, first of all, Jennifer. First of all, I would say that it definitely is worth - is at this stage worth trying to come off your HRT. The biggest concern that we would have with someone who's been on it for sort of 20 years after the age of 50 is the association with a small increased risk of breast cancer. And we have to - we have to keep that in mind when we're trying to balance this out. I think there is no need for you to be on one that causes the monthly bleed, you're quite right about that, and it depends on the dose that you're on, it would be worthwhile changing to a lower dose preparation...
JONES
I was also on a .625, that is fairly low, all this time I've been on .625.
CURRIE
Okay, we do have lower ones than that now, so it's worth going on to a lower dose one and you can have the option of having one that doesn't bring on the monthly bleed. And I don't think you should be worried that the symptoms are necessarily going to come back, I can't say that they won't but hopefully if you've had a lower dose one for sort of three months or so then hopefully you won't find that that is the case. It's definitely worth a try.
JONES
And would you do it alternate days or how would you get off it, you wouldn't just suddenly stop?
CURRIE
You would need to go on to one lower than the .625 first of all and take a lower dose one for about three months. Some people then do go on to alternate days, you can do that, I don't necessarily advise that, often we can just stop from a low dose preparation.
MYERS
Jennifer, I hope that's helpful. You did just mention phytooestogens, and indeed so did I in my introduction - these are the sort of plant oestrogens found in - certainly in soya and other food stuffs.
JONES
Yes, I wrote down Red Clover and Black Cohosh as you said it.
MYERS
Okay, well let's just get sort of expert opinion on some of these alternatives, which certainly many people did decide to try once they decided HRT was not for them, having heard about the possible health risks following that study in 2004. What's the definitive view on some of these remedies?
CURRIE
I don't know if it's the definitive view but the sort of overall view at the moment is that of all of them there is some evidence that the Red Clover phytooestrogens and the Black Cohosh may have some benefit in reducing menopausal symptoms. But the problem is that we don't have a lot of scientific evidence as to their effect. They haven't often gone through the same scientific trials that drugs have to before they can be licensed and be prescribed. But - and we do need more information. So we're not saying that they definitely don't work but we just need more evidence to be able to support that. But certainly of all of them probably the Red Clover phytooestrogens and the Black Cohosh would be worth a try for some women.
MYERS
Well Liz has e-mailed us saying she wanted to share her experience of an alternative. Sage tablets work for me, I know that for sure because I ran out of my HRT while on holiday, the flushes came back with a vengeance and the sage tablets do the trick.
CURRIE
I have heard other women who have found benefit from sage. The problem with controlling menopausal symptoms, there is quite a big effect of placebo and placebo means that it's an inactive tablet, so it means if someone takes something that they believe is going to work then for some women it will. And whenever we're looking for evidence of effect of various treatments we want to know that in any trials that have been done, if they've been done at all, that the active treatment has been compared with an inactive tablet and quite often that isn't the case. And of the trials that have been done some of them haven't shown much difference, compared to an inactive tablet. So I'm not aware of good scientific evidence of sage but if you find it works it's unlikely to be harmful. Except - just to add on from that - some of the alternative preparations we do think can interact with other medications. So it is important, if you have been buying preparations, to tell your doctor if you're also on prescribed medicines.
MYERS
And there was a warning attacked to Black Cohosh.
CURRIE
There was. There has been some concern about the risk of liver damage. However, it's very rare and there are millions of women that have bought and used Black Cohosh, so it does seem to be a very small risk.
MYERS
Let's go to Judith next, she's in Brecon and has given up HRT, in fact gave it up I imagine when that scare hit the headlines, she gave it up in 2004 I think. But she got the hot flushes back. Where are you up to now Judith?
JUDITH
Well, yes I gave it up after 10 years, when I was 62, when the report came out. I gave it up gradually and I persevered for two years, literally the hot flushes came back, they were horrendous, just as bad as they were when I first went on it. I tried sage but that didn't help and so I chatted with my GP and at the age of 64 earlier this year I went back on it. And the quality of my life now is tremendous, I can't - I wasn't sleeping, I don't think I had a good night's sleep in two years. And now it's marvellous. And so I think I feel that you just have to balance the risk.
MYERS
Well it sounds as though you've certainly made a decision that works for you. Let me just ask Heather Currie. I mean is that fine, would you have any concerns about that sort of length of time, given that the idea, at least in our minds now, is that five years is the sort of maximum time that you should take this to be as safe as you can be, particularly if you start taking it over the age of 50, I mean is that right advice, wrong advice, and how does it fit with what we've just heard Judith saying where she's made the decision to go - to press on?
CURRIE
I think Judith has done absolutely the right thing and has made an informed choice and as long as it's an informed choice then it's up to the woman to choose, I can't know how her symptoms are affecting her life and how she responds to treatment, how much that's going to improve life. There is this idea of five years of HRT and no more, but we're now trying to really get away from that because the main reason that HRT is used is for control of symptoms, as Judith and many others have find it very helpful, we don't know how long the symptoms are going to go on for. At the beginning we were unable to tell the lady that phoned how long to expect her flushes because we just don't know and therefore if we don't know how long symptoms will go on for how can we put any time limit on length of treatment. And although there are other options at the moment HRT is still the most effective treatment that we have for controlling menopausal symptoms.
MYERS
Okay we've got a call now from - well it's an e-mail actually from Mary, who says that like millions of post-menopausal women I'm suffering from vaginal atrophy, I don't know if the topical oestrogen cream I need is really safe or, as she says, like HRT has certain risks. HRT was said to be safe, is the cream safe?
CURRIE
That's a very good question. Vaginal atrophy is a really, really common problem and is hugely underestimated, under-reported and under treated and women often do suffer significantly from the vaginal dryness, discomfort during intercourse and bladder problems as well. Using oestrogen into the vagina is a really effective way of treating that and from the information that we have the oestrogen preparations that are currently available are very unlikely to cause any significant risks, the oestrogen is concentrated in the vagina and isn't thought to then increase the risk of breast cancer, for example, it doesn't go through your whole body, it just treats the area in the vagina. The problem with these preparations is that many of them only have a licence for a few months at a time and often doctors will be reluctant to prescribe them for longer but this problem of vaginal atrophy, of the thinning of the tissues and the drying of the tissues is actually a long term problem, so it isn't a menopausal symptom like the flushes that will go away in time, although we often can't say when that's going to be, the vaginal symptoms can actually go on indefinitely and therefore we do need long term treatment.
MYERS
And another e-mail from Maggie, she says 44, going through the menopause and having night sweats, hot flushes, she's about to see her GP but her concern is that she would be reluctant to take HRT because she's particularly concerned about osteoporosis, in fact she has arthritis. So she's raised a very interesting question about the possibility of bone thinning, which of course does come into play after the menopause but in her case HRT, she thinks, is not something she would want to take. So are there any other ways of dealing with the potential risk of bone thinning loss?
CURRIE
The whole area of bone thinning is very controversial at the moment and our practice in managing that is in a state of flux and is very confusing. However, for someone who has an early menopause the loss of oestrogen at a young age does have a detrimental effect or can have a detrimental effect on the bones and can increase the risk of bone thinning. And there are other treatments that can be used when someone is known to have osteoporosis but they are now recommended at much later stage, for example when a bone has been broken. And so in the earlier years HRT is still probably the best treatment we have for looking after the bones as well as controlling the symptoms.
MYERS
The question of knowing whether of course you may be susceptible to bone loss is an interesting one, I think it's going to be raised by Muriel, your concern - Muriel's in Norfolk and she's on the line next, hello.
MURIEL
Hello.
MYERS
Yes Muriel.
MURIEL
Yes I was interested in what you were just saying because I've just been diagnosed with advanced osteoporosis, I'm 55 and I went through an early menopause and I couldn't take HRT because of high blood pressure, so it was never an option and it wasn't until I've just had a few fractures that I actually had to ask for a bone density scan because the question was in my own mind and it's come back as advanced. They've put me on a drug - Actonel - which comes with nasty side effects. But my questions really are one, is there anything else I can do to help myself now and two, are there any GP guidelines for people like me that had an early menopause that could sort of help other women not go through now what I've gone through because it sort of too late for me really but at the time if there had been guidelines could there not be bone density screening, like there is for breast screening and cervical screening?
MYERS
Very good question. Yes Heather what would you say?
CURRIE
Good afternoon Muriel, that's a very, very good question. First of all, what else is there? There are a lot of diet and lifestyle issues that can be really helpful for the bones, so a diet that has plenty of calcium and vitamin D - so plenty of dairy products or oily fish and that kind of thing. Not smoking, not too much alcohol, not too much caffeine I'm afraid, coffee is really bad for our bones and there was a lot of publicity recently about bad - how bad cola can be for our bones. So if you cut all those out ...
MURIEL
Well I don't drink cola or coffee that much really, so that will help even now it's advanced will it?
CURRIE
It's not going to put it back to normal but it's always important with both menopause and osteoporosis to not forget the diet and lifestyle issues. And not smoking also is really important. Actonel, that you're on, is fine, I mean that's one of the recommended treatments. What about GP guidelines? We do a lot of publicity to raise awareness of the importance of early menopause. DEXA scans can be offered and there are guidelines coming out from the National Institute of Clinical Excellence which are specifically aimed at managing and preventing osteoporosis but these are just in the process of being published at the moment. So GPs will have access to know exactly what to do in this kind of situation.
MURIEL
Well I think that would be a good idea really because at the time you're more thinking of the symptoms the other women have been mentioning - the flushes and the sweats - you don't really think when you're in your 40s, for example, of osteoporosis.
CURRIE
No, no.
MYERS
Good point. I'm going to stop you there but a final very good point because that's the damage that's going on sight unseen while, as you say, you're more worried about the flushes. We will have to bring it to an end there, thank you very much indeed to my guest Dr Heather Currie. Thank you to all of you who've called in and have e-mailed. You can listen to the programme again on our website where you can also leave us a message about this or any of our programmes. You can get more information by calling our free and confidential helpline, that's 0800 044 044. And please join me again, if you can, at the same time next week.
Ends
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