Menopause Treatment in Antalya

What happens at a menopause consultation in Antalya?

The aim of the first consultation about menopausal symptoms is to understand whether the symptoms are related to the menopause and to choose a treatment that suits you safely. According to guidelines, the assessment consists of the following steps:

• Detailed history: you are asked about your menstrual pattern and the date of your last period; hot flushes, night sweats, sleep, mood, vaginal dryness and urinary symptoms. Personal and family risks are assessed for breast cancer, blood clots, heart and blood vessel disease and osteoporosis (bone thinning).
• Examination: blood pressure and weight are measured; a gynaecological examination is done if needed.
• Screening tests up to date: if breast screening (mammography, an X-ray of the breast) and cervical screening (a smear or HPV test) are not up to date, they are completed. For heart and blood vessel risk, blood fats and blood sugar are checked, and because the symptoms can be confused with thyroid problems, a thyroid test is requested when needed.
• Bone density measurement: not every woman needs it at the start; it is done in situations such as early menopause, a high risk of fracture or a treatment that affects the bones.

Is a blood test needed for the menopause?

In women over 45, a hormone blood test is not needed to diagnose the menopause. The diagnosis is made from the symptoms and the change in the menstrual pattern; hormone levels in the blood fluctuate from day to day during this time, so they can be misleading. Between the ages of 40 and 45, if there are irregular periods and menopausal symptoms, a follicle-stimulating hormone (FSH, the hormone that stimulates the ovaries) test can help with the diagnosis. If periods have stopped before the age of 40 (premature ovarian insufficiency), blood tests are needed and are repeated a few weeks apart — see what the menopause is and early menopause.

Check-ups after treatment has started

When hormone therapy is started or changed, the first check-up is usually after 3 months; how much the symptoms have eased, side effects and the bleeding pattern are assessed. After that, once a year, blood pressure, weight, whether screening tests are up to date and the balance of benefit and risk of the treatment are reviewed. For details of screening tests during the menopause see menopause check-up.

Common symptoms of the menopause

The menopause is not only the end of periods; each symptom has its own treatment options. They are described in detail on the following pages:

• Hot flushes and night sweats
• Brain fog: forgetfulness and difficulty concentrating
• Vaginal dryness and pain during sex
• Urinary incontinence (leaking urine)
• Osteoporosis (bone thinning)
• Heart and blood vessel health

Hormone therapy: a short guide

Menopausal hormone therapy (often called HRT, hormone replacement therapy) replaces the hormones that the ovaries no longer produce. For detailed information see Body-Identical Hormone Therapy. The points that guidelines highlight:

What is it used for?

• Troublesome hot flushes and night sweats
• Sleep, tiredness and mood problems related to the menopause
• Vaginal dryness, pain during sex and recurrent urinary symptoms
• It prevents bone loss and reduces the risk of fractures — see Bone Loss in the Menopause

Types

• In women who have had their womb removed: oestrogen alone is usually used.
• In women who still have their womb: a progestogen (a progesterone-type hormone) must always be added to the oestrogen. Oestrogen alone thickens the lining of the womb and increases the risk of womb cancer; when a suitable progestogen is added, this risk is removed.
• Cyclical use: in women who have recently entered the menopause, a progestogen is given on certain days of the month; there is a period-like bleed every month.
• Continuous use: in women whose menopause is established, both hormones are given together every day; the aim is treatment without bleeding.

Tablet, or patch or gel?

Oestrogen taken by mouth passes through the liver, so it affects blood clotting and can increase the risk of a blood clot. Oestrogen given through the skin (patch, gel, spray) bypasses the liver and, according to guidelines, does not increase the risk of clots or stroke. For this reason the route through the skin is the first choice for people with a history of clots, marked excess weight or who smoke.

Vaginal (local) oestrogen

For women who have only vaginal dryness, pain during sex or frequent urinary symptoms, low-dose oestrogen applied inside the vagina is used. Very little of it passes into the blood; according to guidelines it does not create a whole-body risk in terms of breast cancer, clots or the heart and blood vessels, and it does not need a progestogen even in women who have a womb. It can also be used in addition to systemic (whole-body) hormone therapy.

Risks

• Breast cancer: in women taking oestrogen plus progestogen, the risk rises slightly the longer it is used, and falls over time after treatment is stopped. In those taking oestrogen alone, any increase is so small as to be almost none. The size of the risk may also vary with the type of progestogen used.
• Blood clots and stroke: the risk increases with oestrogen taken by mouth; it does not increase with oestrogen given through the skin.
• Womb cancer: in women who have a womb, it is prevented by adding a progestogen.

When should it be started, and for how long?

• The balance of benefit and risk is most favourable when it is started before the age of 60 or within the first 10 years of the menopause. If it is to be started later, the decision is made individually.
• Current guidelines set no arbitrary time limit for hormone therapy; the rule "it must be stopped after 5 years" does not apply. The decision to continue is made each year by reviewing benefit and risk.
• No clear difference has been reported between stopping treatment suddenly or gradually in terms of symptoms returning in the long term.

In early menopause

In women who lose ovarian function before the age of 40, and in those who enter the menopause before 45, guidelines strongly recommend hormone therapy. The aim here is to replace the hormones the body would normally produce, and it is recommended that treatment continues at least until the age of natural menopause (on average 51) — see early menopause.

Follow-up

A first check-up is recommended 3 months after starting treatment or changing medicine, then a review once a year: symptoms, side effects, blood pressure and weight, and whether breast and cervical screening are up to date. Unexpected vaginal bleeding needs to be assessed.

First: who cannot be given hormone therapy?

Systemic hormone therapy is not used in the following situations:

• Past or active breast cancer
• Other hormone-sensitive gynaecological tumours — a history of womb cancer, certain ovarian tumours, uterine sarcoma
• Vaginal bleeding of unexplained cause — treatment is not started until the cause of the bleeding has been established
• Active or past blood clot (deep vein thrombosis, pulmonary embolism)
• Active liver disease
• A recent heart attack or coronary heart disease
• Past stroke or transient ischaemic attack
• High blood pressure that is not under control

Non-hormonal medicines

Guidelines describe several groups of medicine for these women. It is stated clearly that none of them is as effective as hormone therapy; even so, they can reduce symptoms appreciably.

Neurokinin receptor blockers

This is the newest group. They act in the brain's temperature control centre by directly blocking the signal from nerve cells that become over-active as oestrogen falls.

• They have been reported to reduce the frequency of hot flushes by more than 50% compared with placebo, with the effect beginning within the first week.
• In a large network meta-analysis this group was found to be significantly more effective than the other non-hormonal options, and at 12 weeks its effect was close to that of standard hormone therapy.
• Liver safety: cases of liver toxicity have been seen after these medicines came to market. Liver function tests are therefore needed before treatment and at regular intervals during it.

Antidepressant-group medicines (SSRIs / SNRIs)

They produce a moderate reduction in hot flushes, of between 20% and 66%. They may also help mood and quality of life.

Possible side effects: nausea, dizziness, a temporary increase in anxiety at the start, sexual difficulties, and withdrawal symptoms when the medicine is stopped.

Gabapentin and pregabalin

These reduce the frequency and severity of hot flushes, and may also improve sleep quality and the muscle and joint pains associated with the menopause. Some people are reported to tolerate pregabalin better.

Side effects are dose-related: drowsiness, dizziness, dry mouth and weight gain. These medicines are in a controlled class and, because they can cause dependence, caution in prescribing is advised.

Other options

• Oxybutynin: originally a medicine for overactive bladder; it has been found effective in reducing hot flushes and general sweating. It is used with care because of dry mouth, constipation and, particularly in older people, a risk of cognitive decline.
• Clonidine: slightly more effective than placebo, but clearly weaker than the other options. It should not be stopped abruptly but tapered, and it is not suitable for people with low blood pressure.

Cognitive behavioural therapy (CBT)

Among non-hormonal approaches this is the method recommended in international guidelines with the strongest level of evidence (Level 1).

In studies, group or self-help programmes of 4–6 sessions, once a week, clearly improved the distress caused by hot flushes, sleep problems, anxiety and mildly low mood, and this effect persisted at 26-week follow-up. It has been reported to improve quality of life both in women in natural menopause and in those being treated for breast cancer.

Lifestyle and herbal products: an honest account

Exercise and yoga

In a randomised controlled trial, aerobic exercise, yoga and omega-3 supplements could not be shown to be superior to placebo for the frequency of hot flushes.

That does not mean exercise is unnecessary — it is always recommended for muscle mass, mood and bone health. It should simply not be undertaken with the sole expectation of reducing hot flushes.

Herbal products

• Black cohosh: a Cochrane review found no clear superiority over placebo, though some recent meta-analyses report a general easing of symptoms. The important point is that cases of serious liver toxicity have been reported.
• St John's wort: not recommended, because it causes very serious interactions with chemotherapy and many other medicines.
• Phytoestrogen / isoflavone supplements: not recommended in women with a history of a hormone-sensitive tumour.

In summary, the sources say this: non-hormonal methods show limited benefit over placebo and are most likely less effective than hormone therapy; but in people who cannot or do not wish to take hormone therapy, they may help.

If your symptoms do not settle

If non-hormonal treatments do not relieve your symptoms, or troublesome side effects persist, guidelines recommend referral to a health professional experienced in the menopause.