When Australian writer Germaine Greer extolled the arrival of the menopause as the "end of apologising" and a time for women to take stock, one of its more severe symptoms was regarded as an awkward inconvenience.
Now, however, there is a growing awareness of “hot flushes” being a problem for both men and women – and new research suggests the symptom has both medical and quality of life implications.
“Flashes”, as they are known in some jurisdictions, are caused by declining oestrogen levels and are experienced by the majority of African, American and Caucasian women during the “climacteric” – as Greer preferred to call the transition for women.
Men with severe testosterone deficiency can also experience these “flashes” due to changes associated with the “andropause” – the male menopause – or during treatment for prostate cancer.
There is no term for the condition in Japanese, and the fact that they are less frequent in Asia may be due to genetics or diet – for instance, soy, which is present in the daily diet in Japan contains phytoestrogens.
The intense heat and flushing that can occur without warning, and which is associated with disturbed sleep, irritability and depression, is cited as the main reason people seek medical help.
Prof Mary Ann Lumsden, professor for medical education and gynaecology at the University of Glasgow, has been exploring the reasons why flushes occur and the link with cardiovascular disease.
The consultant gynaecologist, who spoke at symposium for medical practitioners hosted by Irish Menopause Society president Dr Barbara O'Beirne in Dublin last week, cautions that the link is not a cause for alarm.
Cardiovascular risk
Rather, she views it as a marker for possible future poor health if not acted upon, and says it is an opportunity for women to check out their cardiovascular risk.
“I live and work in Scotland, which is the heart disease capital of Europe,” Lumsden explains. “I started becoming interested in this link in 1989, when I was running a clinic in Edinburgh, and when I moved to Glasgow as a consultant and senior lecturer in 1993.”
“When I see a woman with severe flushing, I will discuss cardiovascular risk factors with them,”she says. “These include weight, fitness, general health and what medication they may be on,”she says.
“Routinely, we would look at blood pressure, weight and other symptoms,”she explains, and in the context of this work a pattern began to emerge.
Research published in 2008 as part of the US Study of Women’s Health Across the Nation examined the health of women during their middle years. This study noted that hot “flashes” were associated with significantly altered structure and function of blood vessels which would increase the risk of heart disease.
Cardiovascular disease – mainly heart attack and stroke – is the biggest killer of women in Ireland, according to the Irish Heart Foundation. Women are also seven times more likely to die of cardiovascular disease than breast cancer, but tend to present later, and with symptoms which can differ from those in men, as Galway Clinic consultant cardiologist Dr Blaithnead Murtagh noted during an awareness campaign run by Croí, the west of Ireland cardiology foundation.
“The fear of breast cancer is so huge that heart disease was largely ignored as a risk for women until about 20 years ago,” says Lumsden.
“However, women will live for 30 years, potentially, postmenopause and so they need to be in the best health possible to enjoy this to the full,” she says.
“It is important, therefore, that we have research into new treatments that are not necessarily pharmacological, and that include lifestyle and general health.”
Lumsden, who is president of the International Menopause Society, is acutely aware of the ongoing debate over hormone replacement therapy (HRT) – which is prescribed as a medical option for treating symptoms associated with declining oestrogen.
As chair of the relevant British National Institute of Health and Care Excellence (Nice) guideline development group for “menopause: diagnosis and management”, she has worked on recommendations published last year on HRT use.
The treatment fell out of favour after two major studies. Preliminary results from the US Women’s Health Initiative 1993-2002 suggested links between HRT and stroke, breast cancer and blood clots, although they also noted a decrease in osteoporotic fractures and colon cancer.
The British Million Women Study of 1996-2001 found that oestrogen-only HRT posed a small risk of breast, womb and ovarian cancer, while combined oestrogen/progesterone HRT increased the risk of breast cancer.
The Nice guidelines that Lumsden was involved in developing advise that oestrogen-only HRT causes little or no increase in the incidence of breast cancer. The guidelines advise that HRT with oestrogen and progesterone can be associated with an increase in the incidence of breast cancer while taking the medication.
On heart health risk, the British guidelines advise that this only applies to women over 60 years of age when they start taking the hormone treatment, and that younger women with cardiovascular risk factors should not automatically be excluded.
“I think our view as a group is that HRT is a very effective, often the most effective, option for a symptomatic woman,” says Lumsden. “Women need to be given the benefits and the risks to make an informed choice, however.”
British Menopause Society chair Dr Heather Currie says that the Nice guideline is a "really useful document", which should dispel what she describes as "some inconsistency in provision of advice to women".
“We did a survey for a conference we were hosting last May, and found that only 3 per cent of women questioned had heard of the Nice guideline six months after its publication in 2015,” sys Currie.
“That is worrying, as is the fact that about half of women who have significant symptoms associated with declining oestrogen fail to seek medical help – perhaps believing they will only be prescribed something they don’t want, without having the full information.”
Informed choice
“Menopause does not have to be so depressing and scary, as it is a natural event, and the fact is that we are now living much longer without oestrogen,”Dr Currie says. “So we want women to have the information, and know that care is individualised, and to be able to make an informed choice.”
“It is an important time in our lives, and there are really useful dietary and lifestyle measures that can help,” Dr Currie says. “HRT is an option but not necessarily one for every woman.”
One aspect of HRT is that it is not a “cure”, but postpones symptoms in some women. However, a gradual reduction in medication can ease the impact of symptom return, Prof Lumsden points out.
“For some, a postponement to a more convenient time – as in, to near or after retirement from a career – is worth it in terms of quality of life,” she says.
While there are anecdotal reports of cognitive decline during menopause, data linking this to “flushes” is “not so strong”, Prof Lumsden notes.
“Cognitive decline worries women enormously, and there are some studies suggesting that HRT has benefits for cognitive function,”she says.
“It could just be that women on the medication are sleeping better at night, and that would improve memory,” she says.
