BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme 4. - Menopause
RADIO 4
TUESDAY 10/10/06 2100-2130
PRESENTER:
MARK PORTER
CONTRIBUTORS:
HEATHER CURRIE
SARAH JARVIS
THERESA GORMAN
MO AKMAL
JUDITH JOHNS
PRODUCER:
NOT CHECKED AS BROADCAST
PORTER
Hello. Today's programme is all about the menopause and the implications for women's health and wellbeing.
CLIP
You don't know whether you're feeling angry because of a hormonal change in your body or if you're just bloody angry because of what's going on and the way nobody's going to take any notice of it. Oh don't go near her she's going through the menopause! Oh it's a bad time of the month! Yes that was a constant, constant mantra. It's very difficult to counter as well because when you're feeling wobbly and you're feeling insecure and the last thing you want to do is burst into tears and yet you kind of know if you do challenge it that's what's going to happen.
PORTER
Hundreds of thousands of British women have stopped, or been taken off, hormone replacement therapy following the recent scares linking HRT to breast cancer, stroke and heart attack. But looking back some three years later - did we overreact? I'll be finding out the latest thinking on who should be taking HRT, and who shouldn't.
Half of all women who have gone through the menopause will develop the bone thinning condition osteoporosis at some stage during their lives. Spinal fractures can lead to severe pain, loss of height and deformity. Up until recently there has been little that can be done to treat a crumbling spine but I'll be finding out about one new surgical approach that is helping to change that.
CLIP
So I'm now introducing the trocar in the pedicle, the part of the vertebrae which connects the back to the front. Sometimes before you get into the soft part there's the harder shell and that's why I've had to tap it in just to get it through the harder shell.
PORTER
My guest today is Heather Currie, an associate specialist gynaecologist at Dumfries and Galloway Royal Infirmary, and the founder and Managing Director of the Menopause Matters website and magazine.
Heather - what do we mean by the menopause?
CURRIE
The word menopause actually means the last period but people often associate with the menopause with a much longer stage than the actual last period, they associate it with the changes in their hormone levels that leads to all sorts of symptoms leading up to the menopause and then the phase thereafter.
PORTER
And why do hormone levels change at that age?
CURRIE
The reason is that our ovaries were sadly very badly designed and we were only given a finite number of eggs. The egg cells within the ovaries are necessary to go through a monthly cycle whereby each month one or two eggs develop and are then released and as a consequence of this the ovaries produce the hormones oestrogen and progesterone in a cyclical fashion. As our ovaries get older they run out of eggs and not only are there fewer eggs but the egg quality changes, so that they're not able to respond in the normal way, producing the hormones oestrogen and progesterone.
PORTER
So the falling levels of oestrogen result in periods stopping but has lots of other effects too, what might the woman notice herself?
CURRIE
Often the first stages they might notice a change in their period pattern because instead of having a normal roughly four weekly cycle as the levels of oestrogen and progesterone are changing the stimulation of the lining is different and they may have irregular periods, so their periods may become less often or more often and they may start to become heavier. After that the oestrogen level falling can cause the early symptoms which most commonly are the flushes and the sweats and mood changes. And these symptoms can fluctuate, so each month may be different or they may have a few months when there are symptoms and then the ovaries start to have a little better burst of activity and function normally again.
PORTER
That's the medical take on the menopause but what do women going through it notice themselves.
VOX POPS
I'm 55 now, I was 48 when the menopause started. Heavy bleeding was the worst of all and a tremendous amount of pain accompanied it. And the hot flushes, the anxiety, the restlessness, the inability to sleep at night. I used to get terrific headaches, which I'd never experienced or had before. Very painful breasts, which I hadn't experienced before actually. Some vaginal dryness but not to the point where it was causing me sexual problems. I think what I wasn't prepared for was the changes that started happening to my skin and hair and nails. My skin was much dryer than it had ever been before and I noticed very much that my hair was thinning and I've already got quite fine hair, so this was terrifying because I obviously thought my hair was going to be falling out. And in fact when going to the doctors again they said - Oh it might, yes you might lose your hair, that can happen to some people. And this can happen thing was very scary. I was beginning to feel that horrible sort of edge of ageing and decay that was rooting everything that I was feeling and which became almost a sort of psychotic state at one point, I mean I would literally catch myself lying in bed thinking well you're just lying here and you're an old lady and you're going to die. It was the most strange sensation to explain. And I think that what I really struggled with was that normally if you've got something wrong with you you can comfort it - you know a hot bottle or whatever - but this was something you couldn't get at, there was nothing you could do to comfort yourself and I found that very distressing. I just felt that there were huge changes taking place inside me I had no control over and that they felt like they were damaging and detrimental to me both mentally and physically.
I was about 48 actually when I started the menopause and I had memory loss, a bit of anxiety, worrying, confused - slightly confused. And the memory was a real problem for me because I've always had such an excellent memory. I just found all that really difficult to manage with work. I'm very hot - I don't have the flushes that I've seen other people, where the sweat is just pouring off and you know they have to get up and change their sheets in the night, some of my friends are like that but I'm not, I just get very, very hot and uncomfortable, very uncomfortable. And the heat brings sort of an anxiety with it, so I feel very self-conscious and irritated by it, you know. It's very difficult when you're in a meeting and your glasses are sliding down your face and you've got this beetroot look about you and it is a bit embarrassing, I think I'm trying to look young, I'm trying to look in control and here I am looking like this dithering wreck, you know. Sleep is a biggy for me, I don't sleep and I wonder if that's why I don't feel so focused during the day. Waking up every 90 minutes and getting up and wandering around the house. Then you lay there worrying about the children, they're not here anymore, I wonder what they're doing.
I haven't got children and I never wanted children. But I don't think I was prepared for really facing up to the change that was taking place in me. Because it's all very well saying you don't want children when you're still young enough to have them, it's a different matter when you know you're going through the menopause and that's your final chance and you're not going to have them. So yes I found that very challenging.
I felt personally less sexy and I think that's - I don't know whether it's psychological or whether it's about self-confidence and being at a time of life which is not considered sexy, it's not sexy, it's not about - it's about the declining life rather than building life and giving birth and all the sort of PMT stuff is still - we talk about that all the time - giving birth, antenatal clinics, support groups. The menopause - mm don't really want to talk about how sexless I am actually thank you and how flat my stomach is and saggy my bum is you know, it's not really very appealing is it. I think I'm just going to have to go with it and hopefully at some stage it will pass and that's what I've been told, it will pass but it seems endless.
PORTER
You are listening to Case Notes, I'm Dr Mark Porter and I am discussing the menopause with my guest gynaecologist Heather Currie.
Heather, how many of the complaints raised by menopausal women are due to hormone changes, and how many to other factors like just the simple ageing process or where the people are in their particular lives at that stage?
CURRIE
It can be very difficult to separate them because the time of the menopause unfortunately is often also the time that children are leaving home, that elderly relatives are taking extra care and people are worrying over them and that husbands may be having a mid-life crisis. So a lot of these problems can cause symptoms such as mood changes etc.
PORTER
One of the ladies there was talking about her sagging waistline and her sagging bottom, it's a bit unfair to blame that on falling oestrogen levels alone isn't it.
CURRIE
It is really, I mean I think we have to be very precise as what the lack of oestrogen does and therefore what treatment can be expected to help.
PORTER
Because this has been one of the problems historically with HRT is that it's been seen as a panacea for all the ails that might befall a woman in her middle age. Let's move on to what can be done to help women get through the menopause. Explain the principles behind hormone replacement therapy.
CURRIE
Well as we mentioned the problems of the menopause are due to a lack of oestrogen so the principle of HRT is replacing the oestrogen. And there are various types and forms of oestrogen but the oestrogen is the main part that is likely to help the symptoms. If we just give oestrogen on its own it could eventually cause a thickening of the lining of the womb and increase the risk of cancer of the lining and to prevent that we add in the other hormone progesterone. So for women who still have a womb HRT is a combination of oestrogen and progesterone in some form. If a woman's had a hysterectomy - had the womb removed - then all she would need to take would be oestrogen.
PORTER
And it's available in lots of different presentations - pills, patches, gels - but doesn't really make any difference, the basic principle is exactly the same. Before we get on to the benefits let's talk about the downsides. If a woman was to start taking HRT what immediate side effects might she notice?
CURRIE
Often in the first few months they may have signs of breast tenderness, sometimes bloating and sometimes irregular bleeding. Quite often these do settle, so for any treatment that's tried it's worth trying it for at least three months to know if that one is going to suit them or not.
PORTER
What have we learned through studies that have been published in the last three or four years that we didn't know before?
CURRIE
I think the first thing we've learnt is the power of the media because there's been a huge reaction to the scare stories about HRT. But the recent information that we're having that is that in fact if HRT is used appropriately and that's specifically for the woman in the early menopausal years who have reasons to use HRT, especially the menopausal symptoms, then the benefits are far likely to outweigh the risks. And that's a thing that we have to bear in mind.
PORTER
So as with all interventions, medical interventions, it's benefits versus risks.
Well we're joined now by Sarah Jarvis, who's a GP and spokesperson on women's health issues for the Royal College of General Practitioners.
Sarah, how do you think these HRT scares have impacted on your patients' perceptions of the benefits of HRT and how have they affected the way that you and your partners prescribe?
JARVIS
They've had an enormous impact and I think the fact that so many women now are coming in worried about it means that a lot of doctors feel particularly nervous about it. Certainly we're far less perhaps gung ho about it than we were in the past. In the past it was perceived as something that was pretty much universally a good thing, if a woman was having problems with menopausal symptoms like hot flushing, vaginal dryness, we knew that it had a really, really good success rate in helping those. We also thought that it would reduce the woman's chance of heart disease, we know that's no longer the case. We also knew that it would reduce a woman's risk of developing osteoporosis or thinning of the bones in later life. So all in all it seemed an extremely all round good thing for women to have. Now we're getting to the stage where we have to be aware that there is no such thing as a free lunch I suppose and that we have to weigh up the benefits and the risks.
PORTER
Okay, so basically we're essentially targeting the use of HRT now. Are there particular women that either of you would like to see on HRT that you think are very important that they consider HRT. Sarah?
JARVIS
Well I think the first thing we need to bear in mind is that as we've heard it's women after the age of 50 who have this increased risk of breast cancer, so for women who go through a menopause early, especially before the age of 45, they are at greatly increased risk of thinning of the bones later on in life, so I think for them it is important. But the other main group are the women whose lives are being made miserable by having hot flushes every day. And I think what's very difficult for me, as somebody who doesn't personally suffer from hot flushes, is to know quite how important those hot flushes are and I would be the one, if I were taking the HRT, who would have to weigh up this very small increased risk of breast cancer if I took it for more than five years with a very significant improvement in my quality of life.
PORTER
So we're using HRT in at risk women and we're using it in women who are symptomatic, who've got problems with the menopause. What happens if a woman just says well I want HRT because I've heard that it helps me stay young? Do you think all women should get HRT if they want it?
CURRIE
No, I don't think it's appropriate for all women to take HRT. I think in the past, as Sarah said, it was seen as a good thing and many women were taking it for whom it wasn't necessary. So when there are specific indications, the menopausal symptoms, as we've heard about, and risks factors for osteoporosis, then these are the ones that are most likely to benefit. It's not the answer to everything.
PORTER
Well, retired MP Theresa Gorman, now in her mid-70s, has been taking HRT for nearly 30 years. And the title of her recent book - Horray for HRT - neatly sums up her views. She intends to carry on taking it forever and believes British doctors are over cautious.
GORMAN
I became menopausal at a fairly early age, I really didn't know quite the cause. I went to the Chelsea Hospital for Women in those days and they recommended me that I take HRT.
PORTER
What do you think it actually does for you?
GORMAN
Well women are short changed by nature, at around 45 they stop producing eggs and with it they stop producing the vital hormones that keep them healthy and if you like in a condition both to produce children and to raise children. And so all their systems begin to break down. So by replacing these missing hormones you prevent that rapid deterioration. Hormone replacement is used for diabetics and lots of other diseases, so why do we make such a fuss about women and their hormones?
PORTER
What do you think HRT actually does for you though, do you feel - how do you know if you feel any different from how you would do if you weren't taking it - that's a big problem facing a lot of women isn't it?
GORMAN
Well if you're - as a man - you lost your testosterone in around your 40s to 50s, it's very difficult for you to think of how you would feel, you would lose your energy, your basic interest in the opposite sex and particularly I think for women who are still at that stage raising families and often looking after older relatives as well, to have that loss added to their responsibilities in life is desperate. The government tells us we've got to go on working into our 70s, well women because of the loss of these vital hormones simply aren't able to do that.
PORTER
Theresa Gorman speaking to me earlier.
Heather, once a woman has started HRT, how long she should take it for, does it matter if, like Teresa, she takes it forever?
CURRIE
I think it was an informed choice, if she's aware of the concerns, aware of the small risks then it should be her choice how long she takes it for. Though having said that anyone on HRT we do recommend that they're reviewed annually, to go over what they're on, how it's suiting them and if there's new information come about. And after the age of 50 often they would be advised to have a trial off HRT, perhaps every few years, to see if it is still required because the symptoms do go and that's the only way we'll know if it's still necessary.
PORTER
But Sarah presumably on withdrawing HRT those symptoms are likely to come back because all you've done is postpone the fall in level of hormones?
JARVIS
Well of course we need to remember that not all women get the hot flushes after the menopause, so it's entirely possible that a lot of women who've been on it for a long time, started taking it because they were told that it was an all round good thing to do, and that they didn't actually need it, inasmuch as they didn't have symptoms at the time. Now for them there's no particular reason to believe that they'll have problems when they come off it. Certainly for women who've taken HRT because of menopausal symptoms we do know that when they stop the hot flushes and the vaginal dryness and so on tend to recur. Now there's theoretically a view that once you've been off it for a few months and your oestrogen levels have dropped that those symptoms go away, in the same way that round about the menopause they tend to go away within a couple of years. But I think my experience and some of my colleagues in gynaecology are coming round to the view that for some women those hot flushes never really go away and that for them there really isn't a better alternative than long term HRT. But that has to be something you try, you have to try stopping it in order to see if you're one of those women.
PORTER
Well you mention the word alternative there and that's where I'd like to go next. What options are there for women struggling to cope with symptoms, whatever they may be, but keen to avoid conventional HRT?
CURRIE
Well Sarah mentioned there the very important symptom of vaginal dryness and this is incredibly common after the menopause and often starts at a later stage, perhaps a couple of years after the menopause or a couple of years after stopping conventional HRT. And even if women don't want to take HRT in tablet or patch form then they can use vaginal oestrogen which is very, very effective at treating this very common and often very distressing symptom.
PORTER
So creams and pessaries - it's given to where it's needed, and that's presumably not associated with these other risk factors that we were talking about, things like a small increase in breast cancer?
CURRIE
The vaginal oestrogen is thought to be concentrated within the vagina and can help the vaginal tissues and also the bladder but it isn't thought to be absorbed into the system, so shouldn't be associated with the same risks as the conventional HRT.
PORTER
Sarah, like me, I'm sure you get asked by lots of women what alternative herbal remedy would you recommend, there are a few of them out there, any of them have attracted your attention?
JARVIS
Well there are lots of them out there and I think one of the big problems we've heard is that until this controversy arose about HRT none of them had been terribly well researched because apart from women, for instance, who had breast cancer already and who therefore couldn't use HRT most other women, if they had symptoms, were already using HRT. But increasingly I think there's been evidence that perhaps products like Red Clover, which is a natural form of oestrogen, so-called isoflavone form of oestrogen, may help. There are some others out there - Dong Quai, Black Cohosh, Ginseng, Wild Yam - all these have been tried and they do seem to reduce the symptoms. But I think what we need to bear in mind is that in quite a lot of cases they reduce the symptoms in exactly the same way as placebo does. In other words, if a woman - if one woman is taking Black Cohosh and another woman is taking a placebo but thinks she's taking - she's taking a pretend drug - but thinks she's taking Black Cohosh they'll have exactly the same effect on their hot flushes.
PORTER
Dr Sarah Jarvis, thank you very much.
As we have heard osteoporosis is a common problem in women after the menopause. It affects most bones in the body, but the vertebrae in the spine are particularly susceptible. Tell tale signs of trouble include pain, loss of height and curvature of the spine caused by the collapse of the affected vertebrae. Up until recently the standard treatment for this type of osteoporotic fracture was just pain relief and rest, but for some patients a new type of surgery is changing that. Kyphoplasty is an operation to stabilise the vertebra, ease the pain and prevent deformity.
Mo Akmal, consultant orthopaedic surgeon at St Mary's Hospital in London invited me along to watch him perform the procedure.
But first, Judith Johns, who had a kyphoplasty earlier this year.
JOHNS
The pain started about three to four years ago, literally on the bra line. It was extremely annoying and wouldn't go away. I was visiting a specialist osteopath who suggested I had an x-ray, which then showed that I had two broken vertebrae that had fused together, hence causing the pain.
AKMAL
So there we are, this is the MRI scan of this lady, who's 55 years of age. This is a typical appearance of an osteoporotic fracture where the vetebral body collapses and becomes wedge shaped.
PORTER
So instead of being a nice sort of oblong shape, basically what's happening is the front of the vetebrae - that's the bit that faces your tummy button - is collapsed, so you've got a wedge of cheese facing forward.
AKMAL
Yes. Which then increases the stress on the adjacent bones, which then lead to the risk of a further fracture.
PORTER
But it's a chain reaction, potentially, is what we're saying. And it's that chain reaction that results in the sort of classic older lady - stooped old lady - the dowager's hump it's known as isn't it.
AKMAL
Absolutely.
JOHNS
Since the menopause without me realising initially, until I was measured, I have lost half an inch. Because of the two fused vertebrae my right shoulder was lower than the left one because the gap had been taken away.
PORTER
So what are you actually going to do today?
AKMAL
What we aim to do with the procedure is to go in from the back, it's a very small incision, then we will use our instruments to insert a balloon. We then remove the balloon and there remains a cavity within the vetebral body which then can be filled with bone cement.
Proceed countdown from the ribs. And a little bit lower please. Three, four. Okay, so we want L3.
PORTER
So this is presumably quite a recent technique?
AKMAL
Yes the balloon kyphoplasty has been going on now for about eight years. It's becoming more widespread use now because osteoporosis is on the increase.
JOHNS
When I went to St. Mary's Hospital it was suggested I had a bone scan. And the bone scan showed that I had osteoporosis and I was warned that I was in a high risk and falling or carrying heavy weights would make it worse and make me more liable to fracture a bone, which I obviously did.
AKMAL
Okay x-ray please.
PORTER
So we've made the incision in the skin and you've introduced the trocar which is your…
AKMAL
The trocar.
PORTER
… long sharp instrument.
AKMAL
So now introducing the trocar through the pedicle, the part of the vertebrae which connects the back to the front. Sometimes before you get into the soft part there's the harder shell and that's why I've had to tap it in just to get it through the harder shell. So we've got the first instrument in.
PORTER
At the site of the fracture.
AKMAL
That's guided us to the correct place and now we're putting the instruments which are going to be used to insert the balloon. And now we're just creating that cavity in the bone. Now you can start seeing …
PORTER
And the x-ray here, you can just start to see it expanding.
AKMAL
So now we're taking the balloons out. We're going to release the pressure.
PORTER
The balloons are now collapsed, leaving behind them a small cavity.
AKMAL
Yes.
PORTER
You're happy with the results, in terms of the amount of fluid that you've injected in there and simply all you do is pull your trocars out.
AKMAL
Absolutely. Okay good. Let's take all this off.
PORTER
And what happens to the lady once she's had the procedure, how quickly does that set?
AKMAL
The cement hardens in a few minutes but at the moment we keep patients in overnight, just to monitor, but there is no reason why she could not go home this evening.
JOHNS
After the operation I didn't feel any pain at all and since then the pain occasionally recurs but very infrequently. So as far as I'm concerned that is the most brilliant thing anybody has ever done for me.
PORTER
And you don't get much better than that. A very happy Judith Johns talking about her kyphoplasty.
It's an incredible operation - very quick Heather - but presumably not available everywhere, it's certainly not available routinely in my area.
CURRIE
No, it would only be available in specialist centres at the moment.
PORTER
What's the link between the menopause and osteoporosis, why is it so much more common in women who've gone through the menopause?
CURRIE
The link is through the oestrogen, so oestrogen helps the strength of the bones and when we lose oestrogen the bones go through a phase of thinning and there's a rapid loss of bone just after the time of the menopause, the loss of oestrogen. So it's most important for those who have an early menopause, so if someone loses oestrogen before the age of 45 and especially before the age of 40, then they're at an increased risk of bone thinning because they're looking at more years without the effect of oestrogen.
PORTER
Well kyphoplasty may prove a great way to treat people once they get these osteoporotic fractures but we're in the business of preventing them, so how can we identify women who are at particular risk of osteoporosis?
CURRIE
Well the first group would be those who've had an early menopause and this may be a natural early menopause but a very important group are those who've had a surgical menopause, so people who've had hysterectomy. We do far less hysterectomies now than we used to but years ago people often would have a hysterectomy and removal of their ovaries in their 30s, at a time when people didn't know much about the effect of menopause or osteoporosis.
PORTER
But the women could still be at risk of an early menopause even if their ovaries have been left in …
CURRIE
They could because there is thought to be an interference in the blood supply to the ovaries at the time of the hysterectomy.
PORTER
And it might not be that obvious because you've got no periods to stop.
CURRIE
Exactly, these are a group that are particularly important, that should be aware of this issue. And often we would recommend for those people having an annual blood test to check what their hormone levels are doing to look out for an early menopause.
PORTER
And what other risk factors, briefly, might indicate a high risk patient?
CURRIE
A family history's really important, so a lot of our bone density's determined from genetics. So if mum had a history of having had a hip fracture, for example, due to osteoporosis then that would increase the individual's risk of osteoporosis. There's other factors such as heavy smoking, too much alcohol, too much caffeine - believe it or not - is bad for our bones, but that wouldn't be classed as a specific risk factor.
PORTER
Obviously if we're going to identify them we need to be able to do something about it, what can we do?
CURRIE
Well the big group that we talked about there - early menopause - they would definitely benefit by taking HRT, the effect of oestrogen can help to prevent osteoporosis developing. And for anyone having an early menopause, unless there are specific medical reasons not for taking HRT, we would recommend that they take HRT until well into their 50s. So we're really balancing the effect of them having lost the oestrogen at a younger age.
PORTER
We must leave it there - Heather Currie, thank you very much.
If you missed any of the programme, or would like to listen to part of it again, then do visit our website bbc.co.uk/radio4.
Next week's programme is on nausea - less about what makes us tick, and more about what makes us sick.
Ends
Back to main page
|
ÌýPrint this page
