Understanding Perimenopause and Menopause with Mr Joseph Onwude


The change of life or climacteric or perimenopause might precede, include or overlap different types of menopause. The average duration is 4 years but can last between 5 and 10 years. Most of the disturbances associated with the menopause are actually associated with the perimenopause. This means that you can have these disturbances when you still have periods when it is likely that you are having irregular periods or after you stop having periods but still have your ovaries.

The definition of the perimenopause is often confused with the definition of the menopause. As the disturbances in the perimenopause are related to wide and/or wild fluctuations in a woman’s Estrogen levels and not her periods, the definition of perimenopause has to do with a woman’s ovaries which make the Estrogen hormone that is fluctuating. Menopause on the other hand has to do with cessation of periods.  


Types of Menopause

Natural menopause is when the periods have actually stopped for one year. In the UK this occurs at 51 years of age. When a woman has had a hysterectomy, she is in surgical menopause. Medical menopause describes cessation of periods that follows medicines that a woman is using, for example chemotherapy or ovarian suppression drugs.

Therefore a woman in surgical menopause can still be perimenopausal if her ovaries are retained because she could still have disturbances of the retained ovaries despite absence of her uterus and therefore no menstruation.


Disturbances of Perimenopause

Vasomotor: Hot flushes, night sweats, sweating and sleep disturbances.

Feelings: nervous, anxiety, depression, impatience, accomplishing less, wanting to be alone,

Collagen: Dry skin, thinner hair, brittle nails or increased facial hair

Energy: tired and worn out, decrease in physical strength, decrease in stamina or feeling a lack of energy

Memory: experiencing poor memory, cognition and moods

Physical: aching in muscles and joints, aches in back of neck or head

Urinary: frequent urination, involuntary urination with cough or laugh

Vaginal: change in sexual desire, vaginal dryness and avoiding intimacy


Hormone Replacement Therapy (HRT)

HRT is an important issue for women and their families. It has been around since 1938. Like the combined contraceptive pill, it has been studied, praised, maligned, loved and feared. And the potential harm of HRT is discussed almost daily.

Some women go through natural menopause without problems, while others need support for symptoms and disorders in the late stages of life.

However, whilst most women know that Estrogen in HRT is the hormone that needs to be replaced, many women do not know that Estrogen in HRT is, in fact, far weaker than Estrogen of the ovaries or Estrogen of the combined contraceptive pill. There might also be a fear that Estrogen of HRT is actually stronger than natural Estrogen. It is not.

Secondly Progesterone, the second hormone of HRT is only necessary if a woman who received Estrogens (from the ovaries, the contraceptive pill or HRT) has a uterus. When there is no uterus, then Progesterone hormone is not necessary.

The main benefits of HRT depend on which Estrogen replacement is included in the HRT. Nearly all Estrogens forms, tablets, patches, gels and implants, will improve hot flushes, sweating and night sweats. Estrogen implants more than tablets, patches or gels will improve physical well-being (like tiredness, lack of energy or stamina, decease in physical strength, joint and muscle aches, better sleep), improvements to psychological well-being (like moods, temperament, memory, anxiety and depression) and collagen effects (like unwanted changes to hair, nails, skin and breasts). These benefits are well established.

There is a wide gap in how different people appreciate HRT. Most women will soon tell you that ‘they will never use HRT’ and this sits well with the view that most doctors are uncomfortable about prescribing HRT. The minority of women think it is one of the best decisions they have made, and damn the risks!


Hormone Replacement Therapy (HRT) versus Estrogen Replacement Therapy (ERT)

A woman who has had a hysterectomy no longer requires progesterone protection of the womb. Therefore her HRT becomes Estrogen Replacement Therapy only or ERT.


Risks of HRT and ERT

It is often said that doctors are confused about the risks of HRT. We should not be. It is quite clear that HRT (Estrogen + Progesterone) has a different risk profile from ERT (Estrogen alone in women who have had a hysterectomy).

It is also quite clear that oral Estrogens and oral Progesterones in HRT have a different risk profile from patch, gel and implant Estrogens or Progesterones inserted into the womb as a Mirena coil.

In HRT, oral Progesterones increase the risk of breast cancer. This is logical in many levels – action of tablet progesterone on the breasts in causing division which can lead to cancer of the breasts but which naturally stops at menopause because progesterone is no longer produced. This is also minimised when this progesterone is inserted into the uterus in HRT to protect the uterus or abolished when there is no need to protect the uterus in women who have had a hysterectomy.

In HRT or ERT, oral Estrogens increase the risk of thrombosis in the legs, the lungs and the brain. However this risk is not associated with patch, gel or implant Estrogens.

Therefore the risks of HRT or ERT depend on whether you use tablet form or other forms. 


Perimenopause Clinic

At this clinic, these and other issues can be discussed and appropriate treatment offered. Contact us on 01245 253760 to arrange a consultation or enquire online here.


Mr Joseph Onwude, Consultant Gynaecologist and Medical Statistician

Date: 12/05/2017