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An estimated 33 million women in the UK will go through menopause, spending about a third of their lives in a post-menopausal state. Many feel unprepared when it happens.
Research carried out by University College London last year on menopause education revealed that only 2 per cent of women felt they were well informed about menopause before they reached perimenopause and almost two-thirds said they were not at all informed. Almost 70 per cent of women said they looked for information once they experienced symptoms and a third said they “dreaded” the menopause.
Another survey, this time carried out by the British Menopause Society (BMS) for World Menopause Day on October 18, 2024, found there was insufficient training and education about menopause for healthcare professionals.
The BMS survey of its members (all healthcare professionals) found that 72 per cent believed newly qualified healthcare professionals were not given enough information on menopause and 55 per cent said there was not enough evidence-based education and training. Despite this, 98 per cent of respondents said more women were seeking treatment for menopause symptoms.
The plethora of unsubstantiated menopause information online is a worrying trend. Almost 80 per cent of BMS members said women were getting their information from social media, while nearly 50 per cent said it came from influencers.
Haitham Hamoda, consultant gynaecologist and clinical lead for the menopause service at King’s College Hospital, London, and a former BMS chair, says: “One reason why many women feel unprepared for the menopause is that there are many varied presentations of symptoms, even though, in general, awareness of menopause is better. There is a lot of misinformation online and on social media.
“Pharmacists can help to raise awareness and improve education by good signposting. They can also help by managing patient expectations – not every woman will experience every symptom, and some that they do experience won’t be caused by menopause.”
Norma Goldman, pharmacist and founder and director of the Menopause Exchange, says: “There is a lack of impartial, well researched and practical information on perimenopause and menopause, and some women do not obtain it from reputable sources. There needs to be an increase in training and education for healthcare professionals, including GPs and pharmacists.”
“There is a lot of misinformation about menopause online”
Menopause explained
Menopause is the stage in a woman’s life when menstruation stops permanently. It is diagnosed after 12 months of no periods. The average age for menopause in the UK is 51 years.
Before this is the perimenopause, where women see changes in their menstrual cycle, with periods typically becoming further apart. Post-menopause is the time after a woman has not had a period for more than 12 months. Early menopause is classed as when periods stop at age 40-45 years and premature menopause is loss of ovarian function before the age of 40 years.
During perimenopause, ovarian follicular activity decreases and oestrogen levels fall. It is this loss of oestrogen that causes menopausal symptoms and long-term health changes to bones and heart health.
Symptoms
Around 80 per cent of women will experience menopause symptoms, with 25 per cent reporting them to be severe and debilitating, says the BMS. “The most common signs you will see reported are hot flushes and night sweats, which affect 80 per cent of women, sleep changes, mood changes, brain fog and low libido,” says Hamoda.
“Pharmacists can help by having a good knowledge of the phases of menopause so they can help women to identify a pattern to see if their symptoms may be caused by menopause.”
Goldman adds: “Pharmacists need to be aware of the long list of possible symptoms and all the ways that women can help their symptoms – not just with HRT.”
Common symptoms are:
- Hot flushes and night sweats
- Disturbed sleep and insomnia
- Low mood and anxiety
- Genitourinary symptoms
- Vaginal dryness and low libido
- Impaired memory and concentration
- Headaches
- Aching joints.
The average duration of symptoms is seven years, but more than a third of women experience long-term symptoms.
“Long-term health issues caused by menopause are important for women to know about,” says Haitham Hamoda. “Bone health and osteoporosis, and increased risk of heart disease, are the main issues to focus on. Talk to women in a holistic way about how they can protect themselves. Weight, diet, blood pressure, cholesterol and blood sugar can be discussed. Where could they make changes and improvements?”
The impact of both perimenopause and menopause on women’s mental health can be considerable. A recent survey from Lanes Health, manufacturer of Kalms herbal remedies, revealed that 72 per cent of respondents reported struggling with their emotional well-being, including stress, anxiety and sleeplessness. Many turn to medications such as antidepressants and anxiolytics for symptom relief, but concerns about their use highlight an urgent need for better support and alternative solutions including OTC options, says the company.
Pharmacists are well placed to talk to women about menopause symptoms and to offer advice on the different ways they can be managed. “Create the right environment in your pharmacy to talk to women,” says Hamoda. “Listen to what they tell you about their symptoms and be aware of where they are in their menopause journey.”
Goldman suggests: “If you see women looking at products related to menopause on the shelves,
ask if there’s anything you can help them with.”
Updated NICE menopause guidelines
Revised menopause guidance from NICE focuses on the importance of an individual approach towards management.
NICE recommends hormone replacement therapy (HRT) for hot flushes and night sweats, and advises prescribers to tailor information about benefits and risks based on the patient’s age, circumstances and other risk factors. It recommends cognitive behavioural therapy (CBT) as an option for vasomotor symptoms, in addition to or instead of HRT.
A discussion aid for healthcare professionals to support conversations about the risks and benefits of HRT with women is available on the NICE website (nice.org.uk), along with the updated guidance (NG23).
There are also new recommendations for the management of genitourinary symptoms including vaginal dryness and discomfort. A choice of vaginal oestrogen should be offered to women, says NICE. It also recommends explaining to women the importance of maintaining muscle mass and body strength through physical activity during the menopause.
Symptom management
- Disturbed sleep: keep bedrooms cool, ideally 18oC. Using a fan can help with night sweats. Recommend a regular bed-time and wake-up time each day
- Low mood, anxiety and stress: cognitive behavioural therapy can help, as can relaxation techniques such as meditation
- Weight gain: this affects around 50 per cent of post-menopausal women. Keeping a food and activity diary over several days can help to highlight where changes could be made to prevent weight gain
- Vaginal dryness: half of post-menopausal women experience vaginal dryness, but only a quarter seek treatment. Local oestrogen treatments can help to ease symptoms, as well as moisturisers and lubricants
- Exercise: isn’t just important for maintaining a healthy weight, but also for building strength, maintaining muscle and avoiding osteoporosis. There are three types of exercise to recommend to women, says Women’s Health Concern, the patient arm of the BMS:
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- Strength exercises (e.g. weightlifting, press-ups and abdominal curls) help to build and maintain muscle and increase metabolic rate
- Steps and walking (10,000 steps a day) can help to strengthen bones and improve cardio- vascular health
- Restorative exercise such as yoga and Pilates helps to increase flexibility
Goldman has these additional tips that can be passed onto women:
- Dress in layers that are easy to remove so body temperature can be adjusted as required
- Avoid synthetic fibres for bedding and use cotton bedding instead
- Take warm showers rather than hot baths
- Cut down on coffee, tea, caffeinated soft drinks and spicy foods as these can trigger hot flushes
- Avoid hot drinks and large meals in the evening as these can trigger night sweats
- Carry a battery-operated fan.
HRT can be the missing piece of the menopause symptomatic jigsaw but
breast cancer risk can be a concern for many women.
Hormone replacement therapy
“Women will want to talk to pharmacists about the risks and benefits of HRT,” says Hamoda. The risk of breast cancer is usually their top concern.
“You can put this into context and look at their overall increased risk. Compare the increased risk with the benefits, and in most cases the benefits will outweigh the risks. HRT is for symptom management. We don’t recommend it for the prevention of osteoporosis or cardiovascular disease if there are no menopause symptoms.
“Women may also ask you about coming off HRT. They can reduce the dose gradually after two or three years and then see if any symptoms return. If they do, they can increase the dose and try again [to come off] after another year or two.”
Norma Goldman says: “The safety and efficacy of HRT will vary from woman to woman, and the HRT chosen will depend on each woman. The decision-making process depends on a woman’s age, the type and severity of her symptoms, and her personal benefits and risks.”
In England in 2023-24, there were 13 million HRT items prescribed – up 22 per cent on the previous year. Latest figures show that the HRT prepayment certificate, introduced in 2023, is used for around 21 per cent of items.
Following a jump in referrals to the Urgent Suspicion of Cancer Pathway for unscheduled bleeding while taking HRT, the BMS issued a new joint guideline in 2024. This states that clinical assessment should start with a review that details bleeding patterns, HRT preparations taken and the patient’s risk factors for cancer. An examination should be offered, if relevant, as well as cervical screening if overdue.
In the absence of risk factors for endometrial cancer, women should be offered adjustments in the progestogen or HRT preparation for six months if the bleeding occurs within six months of starting HRT or persists for three months after a change in HRT dose or preparation.
The new NICE menopause guidelines say that women with genitourinary symptoms and no history of breast cancer should be offered vaginal oestrogen, including those taking systemic HRT.
Prescribable alternatives
- Gabapentin: reduces hot flushes in 50 per cent of women and can also improve sleep
- Pregabalin: similar effects to gabapentin and may be better tolerated
- SSRI antidepressants: for low mood.
Other gynaecological concerns
Painful periods
Around 80 per cent of women experience period pain, says Women’s Health Concern. For 5-10 per cent of women, this pain has a material impact on their lives. There are two types of period pain:
- Primary dysmenorrhoea. Usually begins 6-12 months after the onset of periods and is caused by the production of uterine prostaglandins during menstruation. Cramping pains are caused by the uterus contracting as it sheds its lining
- Secondary dysmenorrhoea usually starts later and is caused by another pelvic issue, such as endometriosis, fibroids, polyps or pelvic inflammatory disease. Women should see their GP for a diagnosis.
Treatment
First-line treatment for dysmenorrhoea is an oral NSAID, unless contraindicated. Paracetamol can be given in combination with an NSAID if required.
A hormonal contraceptive can be prescribed as an alternative and will give pain relief as well as making periods lighter and more regular.
A heat patch or hot water bottle can be used to relieve pain, and a TENS machine may be beneficial. Gentle exercise such as yoga can help relax the muscles and improve blood supply to the pelvic area.
Managing endometriosis
Endometriosis is an inflammatory disease in which cells similar to those that line the uterus are distributed elsewhere. The cells can grow and change in response to hormones in the menstrual cycle, causing pain, inflammation and scar tissue. Endometriosis is commonly found on the lining of the pelvis, ovaries and other pelvic organs, says Endometriosis UK.
The condition affects 10 per cent of women and is usually diagnosed at age 18-29 years. Common symptoms include pelvic pain, painful periods, heavy menstrual bleeding, pain during or after sex, painful bowel movements, pain urinating, fertility problems and fatigue.
Updated NICE guidance (NG73) aims to help improve diagnosis. According to Endometriosis UK, it takes an average of 8-10 years to get a diagnosis, and delays can lead to ill health and risks to fertility. The updated guidance aims to address this by:
- Recommending specialist ultrasound as an alternative to MRI for investigation
- Advising early transvaginal ultrasound for women with suspected endometriosis
- Making clearer recommendations for referral
- Providing greater clarity about care available for women with suspected endometriosis.
Treatment
- Paracetamol or NSAIDs (alone or in combination) are the first-line treatment for pain management. A trial of three months is recommended
- Neuropathic pain treatments (amitriptyline, duloxetine, gabapentin or pregabalin) may be used if analgesics don’t help
- Hormonal treatment (combined contraceptive pill or progestogen) can help to reduce pain
- Heat treatment can ease pain
- TENS use can also provide pain relief
- Physiotherapy exercises can strengthen pelvic floor muscles and reduce pain.
Endometriosis UK offers further information, advice and useful signposting links on its website: endometriosis-uk.org.
Resources and CPD
- Management of Menopause e-learning certificate: the British Menopause Society (BMS) has developed a modular e-learning course for healthcare professionals including pharmacists. thebms.org.uk
- Managing Menopause CPD module: a 10-minute module developed by Bayer, available on the Pharmacy Magazine website. pharmacymagazine.co.uk
- CanesMeno Hub: support for women going through the menopause. Users can track signs of menopause, log changes, and access information and advice from specialists. app.canesmeno.co.uk
- Women’s Health Concern: menopause support for patients. womens-health-concern.org
- The Menopause Exchange: advice and quarterly email newsletters. menopause-exchange.co.uk
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