Published in InterAction 68, Summer 2009
The menopause can present new challenges for a woman with M.E. Thankfully, there are a variety of methods that can help alleviate symptoms.
We regret that our medical advisers cannot respond to individual enquiries.
Dear Doctor: Menopause is making me worse
Since my menopause began two years ago, I have noticed that my symptoms have become more severe and that I constantly struggle with pain, hot flushes and sleep deprivation. At times I am confined to my bed or house, whereas prior to starting the menopause I was able to stick to a pacing programme and go out. Sometimes I feel in so much pain, I worry I’m going to have a major relapse and not be able to come out of it. I’ve thought about taking HRT but have received mixed feedback from people, so I really don’t know what to do. Are there any alternatives?
Professor Tony Pinching responded:
Thank you for your question. Your experiences and worries are very understandable, but there are things that can help and I am sure it will improve. Your account will resonate with the experiences of many women going through ‘the change.’ Indeed, the term ‘change’ is helpful in this case, as people with M.E./CFS generally find that they are sensitive to change, whether these are changes in their routines or circumstances, or in their body’s physiology, as in this case.
For many of the patients I have seen, it has been this process of change that has been the most difficult aspect; and that seems to be your experience too. Once the menopause is established, the stable hormone levels, albeit at different levels from before, are a relief from the cyclical monthly changes.
The female hormones have wide ranging effects on the body’s systems and processes, including the immune and nervous systems, which are where much of the mischief in M.E. itself is happening. The effect on the immune system is connected with the fact that the larger changes in female hormone levels during pregnancy allow the mother to tolerate the fetus, which is a sort of graft. The alterations in various nervous system functions during the menstrual cycle, including PMT, are similarly related to the fluctuations in female hormone levels and their effect on nerve cells.
During the transition to menopause, when the ovaries no longer respond to stimulation from controlling hormones from the neuro-endocrine system, there are surges in the controlling hormones, as if trying to get the ovaries to respond. These are the cause of the hot flushes. Changes in sleep pattern and other body rhythms are similarly a direct or indirect effect of these changes.
People with M.E., who are already experiencing similar symptoms - such as poor temperature control, abnormal sleep patterns and altered cognitive function – will obviously be more vulnerable to such physiological changes. The abnormal ‘tuning’ of the nervous system that leads to most pains in M.E. may also be adversely affected.
Gradually the hormone surges diminish, as the neuro-endocrine system gets the message that the ovaries are not going to respond as they used to and then the menopause itself sets in, with stable levels.
The established menopause generally seems to be much better for people with M.E., probably because things aren’t changing all the time. However, for a few people, the new level seems not to suit their M.E. There isn’t a level of these hormones that is universally right for everyone with M.E.
So what to do? If we see the change as a journey to a probably better destination, then that itself may reduce the worry. Knowing what is going on can help, and I hope this explanation can alleviate some of your understandable concerns.
If the transition to the menopause has changed your sleep pattern and your pain, or if you are experiencing more difficulty with stress, then symptom control measures to alleviate these may be worth considering. They may involve looking at sleep hygiene and relaxation techniques, or medications that can reduce pain and re-establish more refreshing sleep, and so on. The details of these approaches are covered in previous issues and in Action for M.E.’s information resources.
You ask about HRT and I am not surprised that feedback to you was mixed! Quite apart from the more general issues about the pros and cons of HRT, the impact of different types of HRT on different people with different stages of severity, and different symptom mixes of M.E., is indeed highly variable!
If the process of change is turning out to be very hard for you, despite all the other approaches that I have outlined, then it may be worth considering the HRT option with your GP. Similarly, if the effect of the completed menopause hormone levels is not good for your M.E., then you could consider trying HRT. In either case, the choice of agent may be affected by other medical factors, but for the illness, it is essentially trial and error - to see what is best for the individual in their current situation.
The only other thing to bear in mind if trying this approach to the transition is that you would in effect be postponing the transition for later. Because when you come off HRT, the body physiology still has to go through those changes. That may be OK, for example if you feel that you are generally and slowly improving with your M.E., and that you could therefore manage the transition easier at a later date. On the other hand, if you are partway through the change already, then maybe it is better to grit your teeth (only metaphorically!) and complete what has already gone part of the way.
I am aware that various complementary or alternative therapies are sometimes offered. Formal research studies have been published recently with some of these in ‘normal’ people and they did not show any consistent benefits. I am aware that some individual patients have said they have been helped by some such approaches, but there isn’t a consistent story. If you prefer to try such things, then take appropriate advice and see if they help you.
I appreciate how difficult the process of menopausal change can be, especially if your symptoms and function are quite delicately balanced. I do hope that this explanation and these suggestions can help you and others similarly affected to find a way of managing this part of your journey.
GP and homeopath Dr Susie Rockwell commented:
Yes there are a number of alternatives to HRT which may help your symptoms but I would not necessarily discount trying HRT as it can transform women’s symptoms and make the condition much easier to cope with.
Menopausal symptoms may include hot flushes, night sweats, palpitations, insomnia, joint pains, headaches, vaginal discomfort/dryness/soreness, reduced libido, urinary difficulties, problems concentrating, poor memory, mood swings, anxiety, depression, sleep disturbance etc... virtually anything really.
Despite lots of adverse media publicity HRT still has an important role in the management of menopausal symptoms for some women. It is particularly effective at relieving sweats and flushes, mood swings and pains as well as vaginal dryness and reduced libido. It sometimes causes breast tenderness initially but this usually wears off after about six - eight weeks.
Long term use (nine years and over) increases the risk of breast cancer so it is no longer used for the prevention of osteoporosis. It may be used to alleviate menopausal symptoms in women during or after the menopause and for most women can be safely taken for at least five years.
Many women will experience a recurrence of menopausal symptoms for a few weeks/months when they come off HRT even if they are well past the menopause.
Some people with M.E. appear to be hypersensitive to all conventional medications and this may prevent them from taking HRT. If someone has tolerated the contraceptive pill in the past they are very likely to do well on HRT but if previous hormones have caused problems then alternatives such as those listed below may be more suitable.
Numerous clinical trials have been carried out with conflicting results so there is no single evidence-based treatment which works. It is down to trial and error to find what works for each individual woman.
Herbal treatments should not be taken if taking any hormones or warfarin.
Black cohosh, dong quai, red clover and agnus castus may all be helpful with generalised menopausal symptoms. Sage may be useful for flushes. St John’s Wort for depression/ anxiety/mood swings. Ginko biloba for poor memory.
Homeopathy is usually safe, even if you are on medication. Ideally see a homeopath to select the best remedy but some of my favourites include sepia, pulsatilla and lachesis - sepia if you are irritable, weepy, and indifferent to loved ones, have a low libido and/or feel dragged down emotionally and physically; pulsatilla if you have changeable moods and/or crave consolation; lachesis if you are irritable, angry, talkative, jealous and/or suspicious.
Hormonal fluctuation and mood swings are made worse by changes in blood sugar levels so aim to maintain constant blood sugar by eating a high fibre whole food diet composed of foods with a low glycaemic index/load. Artificial sweeteners should be avoided as they confuse the body and aggravate blood sugar fluctuations and flushes. Caffeine and alcohol increase hormonal fluctuation and flushes and should be cut out/minimised. Salt and other additives promote fluid retention and increase in blood pressure so should be avoided.
A balanced diet with plenty of water and fresh fruit and veg will help the body to cope with the stresses of the menopause and minimise symptoms. In particular cruciferous veg such as broccoli, cauliflower, sprouts etc may be helpful.
Phyto-oestrogens are plant substances which have similar effects to oestrogens, for example isoflavones which are found in soybeans, soya milk, chickpeas, alfalfa and legumes. Lignans are found in (flaxseed (linseed)) and whole grain rye and wheat and legumes (peas and beans). Soy isoflavones are available in supplement form eg. Nutri Spectrasoy or Selestro (isoflavones plus black cohosh).
Lifestyle changes, such as smoking cessation, regular exercise and stress reduction are all helpful in reducing menopausal symptoms.
Omega 3 essential fatty acids eg. 1000-3000mg daily of a highly purified fish oil or flax oil supplement is useful to help to stabilise hormones, improve mood and moisturise joints and vaginal tissue. B vitamins can help the body to deal with stress. Magnesium can help bone strength and aids relaxation. Vitamins C and E and zinc can improve immune function and may help with vaginal dryness. Chromium can help to stabilise blood sugar levels if these are an issue.
Natural progesterone cream seems to help some women with generalised symptoms although my impression is that it is not very effective for sweats and flushes. Not usually available on the NHS.
Using KY Jelly as a lubricant during intercourse may make sex more comfortable. Replens, which can be purchased over the counter from pharmacies, gives some women relief from vaginal dryness and soreness. Usually used on alternate days it is worth a two month trial. Not available on the NHS.
Dr Rockwell has suggested a list of useful books and other resources, available from InterAction on request.
Dr Rockwell acts as a medical adviser for the Sussex and Kent M.E./CFS Society.
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