The Last Word: Menopausal Management

By Dr Shirin Lakhani / 26 Jan 2021

Many women are being prescribed antidepressants first line as their hormones shift but Dr Shirin Lakhani calls for urgent change

Let’s talk about menopause. Defined as the permanent cessation of menstruation and reproductive capability, it is an inevitable consequence of growing older and ultimately affects almost every woman.1 Yet, while menopause is a natural stage of life, it’s often not spoken about and, in my opinion, education is lacking. The consequences of the menopause can be absolutely devastating – one in four women will experience debilitating symptoms that can last up to 15 years.2

With the population now living longer, healthier lives, women can spend up to one third to half of their lives in the peri and post-menopausal period. The average age of onset in the UK occurs at 51, with variations between race, ethnicity, demographic and lifestyle, and those at onset of the perimenopause is 47.5 years.3,4 The average duration of vasomotor symptoms (hot flushes) also vary between ethnicities but can last more than seven years.5

For young women who find themselves catapulted into instant menopause due to surgery, medical treatment or a diagnosis of primary ovarian insufficiency (POI), the menopausal chapter can extend even further.

 The misunderstandings of menopause

Lost amongst the myriad acute illnesses and chronic diseases, post-reproductive health does not garner much attention in medical school or post-registration training. In addition to the characteristic hot flush, there are many related symptoms that can have a significant impact on a patient’s quality of life, such as nausea, joint aches, an increase in allergies, memory loss and palpitations, to name but a few.6 The lack of awareness regarding menopausal symptomatology may result in needless anxiety for patients and a feeling of helplessness. An additional challenge is the impact menopause has on long-term conditions such as diabetes,7 an area that is vastly under-researched.

More concerning still, while many women are now finding the confidence to come forward to speak about their health with their GP, thousands of women are finding that their symptoms are overlooked or diminished.4 I’ve found that many are either told that this is a normal part of life and they should just put up with it until the symptoms pass, or are prescribed antidepressants to treat the associated symptoms of the menopause rather than treating these symptoms head on. In my experience, hormone replacement therapy (HRT) is still regularly feared by some healthcare professionals who can actively discourage their patients from taking it, rather than having a balanced discussion, considering up-to-date evidence instead of older flawed studies. In the early 2000s, the results of two large studies (The Women’s Health Initiative in the US and the Million Woman Study in the UK) raised concerns about the safety of HRT, particularly with regards to breast cancer and heart disease, causing widespread panic and confusion amongst patients and doctors alike.8,9 Newer long-running research has found that women taking progesterone plus natural oestrogen does not raise a risk of heart disease or cancer.10

 Antidepressants for menopausal management

Unfortunately, I believe doctors are often too quick to treat patients with selective serotonin reuptake inhibitors as a quick fix alternative; putting a band aid over the issue as opposed to treating it head on. While low dose antidepressants such as SSRIs and SNRIs have been shown to improve the vasomotor symptoms of menopause11 and may be useful in women who are unable or unwilling to take HRT, in my experience treating with antidepressants like this can instead result in side effects that are similar to those associated with the menopause. This includes problems with concentration, problems with sleep and a decreased libido.12 We are forgetting that it is often these symptoms of the menopause that can have resulted in patients suffering with depression and anxiety in the first instance.13 Furthermore, whilst their use may be beneficial in a small cohort of patients, they do not address the actual cause of the symptoms or provide the multiple benefits that other treatments such as HRT would, in my opinion. I strongly believe that this is a complete disservice for the 13 million women in the UK going through the menopause and more needs to be done.14

My experience treating menopausal patients

Over the years, I have encountered numerous cases that demonstrate the need for increased competence in the management of menopause within both primary and secondary care. One patient I cared for recently had suffered from a plethora of menopausal symptoms including mood swings, hot flushes and insomnia, along with debilitating vaginal atrophy. The pain associated with the patient’s vaginal atrophy had ended any intimacy with her husband, pushed the patient to cancel her gym membership and, at its worst, left her struggling to walk.

She became incredibly distant from family, had ceased socialising with friends and dreaded going to work in her job as a civil servant, fearing that she would experience a hot flush. Incredibly unhappy and in pain, she visited her GP who advised against HRT and instead suggested citalopram, which this particular patient refused.

After consultation I suggested bioidentical hormone replacement therapy to address the hormone imbalance that was causing the majority of the symptoms. In September she visited my clinic for radiofrequency tightening with Ultra Femme 360. The patient noticed instant results and now, a few months later, her menopausal symptoms have improved dramatically and, most importantly, her entire outlook on life has completely changed.

She provided the following testimonial to encourage other women to seek alternative treatment to antidepressants, “Most of my menopause symptoms have disappeared or improved dramatically and I want to urge other women like myself not to continue suffering in silence. If you feel like you’ve got nowhere to turn don’t give up. I’m proof that no matter how bad your menopause symptoms are, it doesn’t need to end with antidepressants – there is hope.”

As a woman who hears these stories on a weekly basis, this is yet another heart-breaking instance where menopausal women have been failed due to the lack of specialist knowledge.

Aesthetic practitioners can help

In our industry, where many of our patients are reaching, or are at menopause, they can look to us for improvement not only in their appearance, but also with functional issues. Aesthetics is no longer just about neuromodulators and dermal fillers, but with more practitioners taking an interest in the holistic wellbeing of the patient, there has been an increase in clinics broadening their offering to meet the medical needs of post-reproductive women. I believe with thorough training and understanding, menopausal management is a holistic service that many aesthetic clinics can add. If we do not, I believe we are doing not only our patients a disservice, but also ourselves.

Menopause isn’t a disease, nor is it something that should cause fear, but it can cause untold misery. In a rapidly evolving specialty, not subject to the same constraints as the NHS, we are now lucky to have so many innovative treatments and effective medical interventions available to us that women needn't spend this chapter of their lives in pain or despair. The 13 million women in the UK suffering with the menopause deserve better, don't they?

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