Wine can be a bigger cancer risk than HRT & other menopause facts
Menopause awareness has thankfully grown in recent years, but so too have a confusing array of claims and counterclaims. There are many factors that can affect a woman’s health in this time of life, but luckily many are under our control, an expert in women’s health tells Gemma Fullam
In 2009, I was blindsided when a routine blood test revealed I was “well into menopause”. I was 38. The news, broken to me abruptly over the phone, left me crying in the toilet at work, feeling confused, scared and deeply sad. My experience of menopause hitting so early is unusual — premature ovarian insufficiency under the age of 40 affects just 1pc of women — but enduring debilitating symptoms for years is commonplace. Back in 2009, the topic of menopause was taboo, with information thin on the ground. While I found ways in which I could ameliorate my physical symptoms, nothing I read really reflected how I was feeling — anger, emptiness, grief — and I largely coped through those years alone. In recent times, thankfully, things have changed utterly and menopause is now out in the open, thanks in no small part to, among others, Joe Duffy and Davina McCall, who both platformed discussions around the topic in the mainstream media and gave women’s voices an outlet. It’s about time.
There’s so much support and information available now, and while I am out the other side, so to speak, I’m keenly aware that menopause is a stage of life that is multifaceted and
can have significant health consequences and challenges through all of its iterations. Also: knowledge is power. In advance of the upcoming ‘Menopause in Motion’ conference, I spoke to Dr Breffini Anglim O’Regan, a consultant obstetrician gynaecologist at the Coombe Hospital. Her topic on the day is ‘The Science Behind the Menopause’.
In addition to her obstetrics and gynaecology work, Dr Anglim O’Regan’s subspeciality is urogynaecology, which covers pelvic organ prolapse and urinary incontinence, both serious issues that often arise in menopause.
Menopause is a natural part of ageing, and a woman is considered officially in menopause one year after her final menstrual period. The World Health Organisation defines the cause as “the loss of ovarian follicular function and a decline in circulating blood oestrogen levels”. Progesterone drops too, but the decrease in oestrogen levels is the cause of most of the troublesome symptoms of menopause and of perimenopause (the period leading up to menopause during which symptoms first become apparent, and which can itself last for several years).
“Most women go through menopause at age 51, 52. Oestrogen levels can start to decline four to eight years before menopause, [that’s when] women can become symptomatic. Fluctuating oestrogen levels cause the erratic bleeding you get before you hit the menopause. Your periods can get heavier, more spaced out and last longer or be shorter,” Dr Anglim O’Regan says. Her interest in menopause came about when she experienced a “mini menopause” when breastfeeding.
“When I was breastfeeding my first baby, I was like, ‘why am I so achy? Why am I so irritable?’. It wasn’t lack of sleep, because my baby was sleeping. The second time around, I realised, ‘those are menopausal symptoms because my oestrogen levels are suppressed from breastfeeding’.”
All women have low oestrogen levels after birth and breastfeeding prolongs this. As Dr Anglim O’Regan explains, in menopause, low oestrogen levels can impact the body in myriad ways long after other menopausal symptoms are but a distant memory, so it is important to be aware of the potential long-term effects.
“By the time the lack of oestrogen hits the vaginal tissues, women are more likely to become symptomatic of prolapse and incontinence,” she says. “Ten to 15pc of people will have stress incontinence — leaking [urine] when they cough and sneeze, or prolapse. Prolapse is like a hernia of the vaginal tissues.
“Low oestrogen levels in your vagina make your tissues weaker. Usually women have symptoms of this when they’re 55, 60, so five to 10 years after their last period. [As well as prolapse and incontinence,] Urgency, rushing to get to the toilet, can be due to low oestrogen. Hormone replacement therapy doesn’t really effectively reach the vaginal tissues. It’s not as good, treatment-wise, as local oestrogen — a cream or an applicator with a tablet that you put into your vagina.”
During perimenopause and menopause, low oestrogen in the vaginal tissues can make sex a sore and uncomfortable experience, but the desire to have sex can often be affected too.
“In menopause, testosterone levels go down too — your ovaries also secrete testosterone. There’s not a huge amount of evidence for [testosterone supplementation], but it could be used for women who are having sexual dysfunction or disinterest in intercourse. If low libido is your only symptom, you don’t have to go on HRT first — you can try testosterone. Then it’s very important to monitor your testosterone levels and to calculate your free androgen index.”
Dr Anglim O’Regan is an avid runner, and is passionate about the benefit of running and the importance of exercise generally in menopause.
“I run every day. I love running, that’s my thing. Running is higher impact, so it’s better for your bones. Do whatever [exercise] you enjoy doing. When you are menopausal, there’s more bone reabsorption and you’re more likely to get osteoporosis, meaning you’re more prone to fractures. Your muscle mass over time gradually declines from about age 30, 35. Once you hit menopause, it goes down significantly, again because of the effect of low oestrogen. So if you’re building up muscle, you’re less prone to fractures if you fall. The importance of doing weights, particularly when you’re menopausal, is huge, and most people who run may not want to do any weight training. That’s a big thing I’m going to be talking about at the conference — the importance of doing your weight training as well.
“Also, if you’re exercising regularly, if your weight is well controlled, that’s better, cardiovascularly. If you have a BMI over 30, you’re at a significantly higher risk of stroke, heart attacks, etc, whereas if your BMI is in the normal range between 18.5 to 24.9, then, cardiovascularly, you’re going to be better, feel better and be healthier.”
Dr Anglim O’Regan acknowledges the fact that we are all busy people, but believes it is vital, nonetheless, that women make health and wellbeing an integral part of their daily routine. “I have two small kids. I get up at half five, I go for a run before my kids wake up. You can always make time for yourself if you want to, be it in the morning, evening or during your lunch break. You have to prioritise your health. I think there’s nothing more important as you get older. We’re all living to 80, 90 now, so 30, 40 years of your life are in menopause.” Forty years — it’s a sobering thought, and underlines the need to future-proof our bodies against preventable conditions such as osteoporosis and mitigate the risks of heart disease.
Cardiovascular effects
“When you’re menopausal [because of low oestrogen] the elasticity of your arteries is reduced. You’re more prone to getting a build-up of plaques in the lining of the arteries [atherosclerosis]. Your ‘bad’ [LDL] cholesterol goes up. The risk of a stroke in a woman is far lower up until the point that they hit menopause, then, after that, their risk is equal, if not worse, than a man’s. Oestrogen is very cardioprotective.
“The preventative effects against osteoporosis kick in if you start hormone replacement therapy [HRT] before the age of 60. So if you start HRT before you’re 60, it can reduce your risk of getting osteoporosis. After that [age] there’s not as much evidence for its bone-protective properties. Similarly with cardiovascular disease — strokes, heart attacks, etc. If you start HRT before the age of 60, you’re lowering your risk of having cardiovascular disease later in life. Whereas if you started at the age of 60, it doesn’t have a negative impact, but it doesn’t have that protective effect either — however, symptom-wise, it can make you feel better.”
Mention HRT and the words ‘breast cancer risk’ will inevitably follow. HRT and an increased breast cancer risk first came to light in the early 2000s, when a trial in the US — the Women’s Health Initiative — was halted prematurely when “overall risks [of breast cancer in those taking HRT] were thought to exceed benefits”. However, “subsequent publication of the full findings from the same WHI Study showed different effects”. In other words, the initial findings relating to HRT and breast cancer risk were inaccurate and overstated. Scaremongering reporting at the time resulted in countless women abandoning their HRT.
The advice nowadays is for a woman to consult her GP to weigh up the pros and cons of starting HRT. As the Irish Cancer Society’s website states: “Some types of HRT may increase the risk of breast cancer, but the increased risk is small and the benefits may outweigh the risks.”
What is important to be aware of, as Dr Anglim O’Regan points out, is that there are myriad factors that can increase a woman’s risk of breast cancer, many of which are controllable.
Risk factors
“If you’re drinking an ‘Irish’ glass of wine a day, that’s equivalent to taking HRT in terms of increasing your risk of breast cancer. If you drink more than two drinks per day, your risk of breast cancer is five per thousand. So you need to put these things into perspective. If your BMI is over 30 [which is within the obesity range], your risk of breast cancer goes up by 28 per thousand. If you are doing two and a half hours of exercise a week, you can reduce your risk of getting breast cancer by seven per thousand.”
Dr Anglim O’Regan directs me to an excellent graphic on womens-health-concern.org, titled ‘Understanding the risk of breast cancer’. It clearly illustrates these statistics in a visual format and is well worth a look.
She is an avowed advocate for future-proofing your health from the earliest opportunity, taking back control if perimenopause or menopause has already hit and implementing practical changes that will result in tangible benefits.
“Yoga, mindfulness — those kinds of things are really important and will help with stress levels and sleep. Sleep has a huge impact on everything. Sleep gives you the ability to do the other things that will make you feel better overall. If you’re not sleeping well, you’re going to be tired and irritable. If you’re drinking [alcohol], you don’t sleep as well. Also, tea and coffee have huge impacts on sleep, particularly if you’re drinking caffeine in the afternoon. Drinking a lot of tea also stops you from absorbing iron properly.
“The big thing in menopause is hot flashes during the night [which affect sleep]. Hot flashes can be managed with HRT, doing cognitive behavioural therapy or doing things like mindfulness and yoga, and these will allow you to sleep better. With better sleep, you’re more likely to exercise. If you’re exercising, then you’re more likely to sleep better and to keep your weight in a lower range.”
In addition to physical symptoms, women’s mental health is often profoundly affected during menopause, and it is vital that women share their symptoms — be they low mood, anger, depression, or a ‘flat’ feeling — with their health practitioner.
“I have a screening tool I use in clinic. I say, is your mood lower? More anxious? More irritable? Do you feel overwhelmed? Have anger or aggression outbursts? Have you noticed joint pain, brain fog or memory issues?” Dr Anglim O’Regan says. “Your oestrogen levels, when you’re hitting menopause, they go up and down and, as a result, you get mood [swings] and irritability. There’s also the brain fog aspect. Hormones can be a big part of overall mood in terms of depression, anxiety, etc, and it’s probably overlooked to some degree.”
She says if you are under 50, in perimenopause and suffering with your symptoms, the solution can be very simple.
“A lot of people with perimenopause, if you, having checked for contraindications, put them on the pill, it can regularise their hormones.”
Dr Anglim O’Regan is in agreement that the conversation around menopause has changed.
“I think people are becoming more and more aware of it. I was talking to an older lady yesterday, and she said, ‘gosh, we would have just never talked about menopausal symptoms. It was taboo’. It’s not anymore, people are openly talking about it and I think it’s a good thing. It’s normalising it because it is normal and there are things you can do about it.”
Indeed. Now that the conversation around menopause is, finally, flourishing, it is up to us as women to keep it going and to absorb the knowledge from allies and experts such as Dr Anglim O’Regan whose mission is to keep us thriving, not just surviving, in every aspect of our lives as we age.
You have to prioritise your health. I think there’s nothing more important as you get older. We’re all living to 80, 90 now, so 30, 40 years of your life are in menopause