Taking HRT will eliminate night sweats, dramatically improving the quality of your sleep, and with it your level of fatigue and irritability. Sadly, some general practitioners still prescribe tranquillisers and anti-depressants to women who complain of hot flushes and night sweats, and the insomnia and emotional upsets that they cause. This is difficult to justify, as the problem is due to falling oestrogen, and nothing else. Replace the oestrogen with HRT and the flushes and sweats will disappear, and with them the sleep disturbance they cause and its accompanying fatigue, irritability and lack of wellbeing. If you are on tranquillisers or anti-depressants for these particular menopausal problems, talk to your doctor about the possibility of changing to hormone replacement therapy. (If he ‘doesn’t believe in it’, see page 90 for other suggestions.)

Many women feel they want to ‘die of embarrassment’ or ‘disappear into the floor’ when a hot flush strikes them at work or in mixed company. This is largely due to other people’s perception of hot flushes; some men and young women may laugh and make unkind remarks. Perhaps we could bring up our sons in such a way that they become men who will not diminish a female colleague’s self-esteem at work, but will show kindness and sympathy during what is a very uncomfortable few minutes. Once our daughters know more about the menopause and its causes and effects, perhaps they will help to develop a culture that will ensure attitudes have changed by the time their turn comes.

Flushes have been described as ‘something like adolescent acne – an outward sign of natural hormonal changes’. They may be troublesome and embarrassing but (unless you are one of the unfortunate 5 per cent) they do decrease in number and strength, and they will eventually pass as the body adjusts to its lower level of oestrogen. However, just because the menopause is ‘natural’ doesn’t mean you have to put up with its distressing symptoms for months or years, and we are lucky that HRT is now available to relieve them.

*11\42\4*

- I have developed patches of discoloured skin since using oestrogen. Is this normal? Will it go away when I come off hormone therapy?

Many women on oestrogen (in contraceptive pill or HRT form) are dismayed to find that patches of coloured pigment appear on their skin after they have spent time in the sun. This is called chloasma, and is caused by deposits of melanin in the skin. In a small proportion of women, oestrogen seems to stimulate chloasma development. The effect will usually fade when you stop taking oestrogen, but this depends on how much exposure you have to the sun. Always use a sunblock: your doctor or pharmacist may suggest an anti-chloasma type.

- Are lumpy breasts a reason not to take oestrogen?

No . . . but whether you use oestrogen or not, it is important to examine your breasts regularly, have your doctor check them over too (at least annually), have regular mammograms and avoid smoking.

- I have had breast cancer. Is there any form of therapy, including HRT, that might help to control the severe flushes I am having? HRT is sometimes considered for women who’ve had breast cancer, particularly if quality of life is the priority and nothing else works to reduce flushes. In these cases, Provera or low doses of natural oestrogens (and daily progestogen if you have a uterus) are likely to be chosen. If your breast surgeon and oncologist feel you should not use HRT, you might like to try regular exercise, evening primrose oil or pressed linseed oil, vitamin E, relaxation and meditation to control your flushes. The prescription medication clonidine may also be helpful.

- Since starting on Estigyn eleven years ago I have developed benign cysts in one breast. Is it possible that HRT caused this problem? Should I change my therapy or come off HRT altogether?

There is no evidence that oestrogen, even the synthetic form of oestrogen you are on, causes breast cysts. However, oestrogen may stimulate the growth of existing breast abnormalities like cysts or fibroadenomas, causing them to become larger and more obvious. You should certainly consider changing the type of oestrogen you use. Estigyn is a powerful synthetic oestrogen and, as we explained in chapter 2, it is more likely to produce side effects than a natural oestrogen formulation. There is no justification for you to come off HRT in the circumstances you describe.

- The reason I am taking oestrogen is to make sure that my bone strength is maintained. How can I be certain that the dosage of oestrogen is high enough?

The only reliable way is to have two bone density scans twelve to eighteen months apart. This will indicate whether your bone density has been maintained or has deteriorated while you have been on HRT. If the density has fallen, your dose of oestrogen should be increased if there are no medical reasons against this.

*123\38\8*

While women within male-female relationships have been largely overlooked by theorists, homosexual women and heterosexual women without partners have fared even worse, having had almost no attention paid to them in traditional analyses of sexuality after menopause. Simone de Beau voir made the point in her book The Coming of Age that enjoyment of sexual activities takes many forms, has many motivations, and is not necessarily extinguished with age. ‘It is understandable that a man or woman should be bitterly unwilling to give it up, whether the chief aim is pleasure, or the transfiguration of the world by desire, or the realisation of a certain image of oneself, or all this at the same time . . . The old person often desires to desire because she retains her longing for experiences that can never be replaced and because she is still attached to the erotic world she built up in her youth or maturity — desire will enable her to renew its fading colours.’

*89\38\8*

painful than previously. Approximately 7 per cent said they were more sexually interested and active, and some attributed this to a new partner in their lives.

Since sexual activities involve two partners, it is important not to assume that difficulties originate on the female side. As men age they tend to experience increasing problems with libido, erections, orgasmic capacity and penile sensitivity. This may compromise their sexual interest or capabilities. When Leah was fifty-seven, her husband Brian, aged sixty-four, suffered a heart attack. Although he was soon back at work, his sex drive all but disappeared and he had difficulty getting an erection. During counselling sessions he revealed that he feared dying during sexual activity, and that this weighed heavily on his mind.

In other couples, sex literally becomes a bruising experience. Some, but not all, women experience vaginal dryness and thinning of the vaginal lining after menopause, and this may make intercourse painful. This symptom is more frequent among postmenopausal women than their younger sisters, but is not confined to the postmenopause. A study of women in the south-east of England found that 40 per cent had this problem after menopause, but 26 per cent of premenopausal women also did. If the problem of painful intercourse becomes established, it can lead to lack of confidence in both partners and things may go from bad to worse.

This chapter looks specifically at the role of HRT, but hormone therapy is certainly not the whole answer to sexual difficulties around the time of menopause. There is some evidence that sexual problems will respond to HRT by its direct effect on vaginal lubrication, the vaginal lining (causing it to resume its former thickness), blood vessels and blood flow in the vagina, vulva and uterus, and perhaps also transmission of messages along nerve pathways to the genital organs. Oestrogen and testosterone seem to be the only hormone therapies that improve libido in women, although they are not universally effective.

Before embarking on HRT in the hope that it will improve your sex life, it is important that you explain the problem to your doctor in detail. Specialised sex therapy may be required, no matter how good your response to hormones, since the problem may have set in train patterns of sexual behaviour that are difficult to undo.

*54\38\8*

In most women, oestrogen production by the adrenal glands and by fat and muscle tissue partly compensates for the diminished oestrogen output of the ovaries from menopause onwards. Jill is a woman who found the ‘HRT for everyone’ approach worrying. Most of her friends seemed to be on HRT, yet at fifty-seven she was in exuberant postmenopausal health without it. For Jill, fitness has been something of an obsession for many years, partly because she has a tendency to put on weight easily: in spite of vigorous daily exercise and a carefully balanced diet she remains ‘well covered’. After reassurance that her sensible lifestyle was providing protection for her bones and heart, and her fatty tissue was supplying adequate oestrogen for her needs, she decided that HRT was not necessary for her.

The second main challenge to advocates of near-universal long-term HRT has come from those who question the confidence with which clinicians attribute benefits to HRT that are based on specific research findings. The research quoted usually involves the use of oestrogen on its own, rather than the more usual combination of oestrogen and progestogen. These critics also argue that, until the results of long-term studies of current HRT formulations and dosages are available, it is foolhardy to widely prescribe hormone therapy without firmer selection criteria than operate at present.

It makes more sense to identify specific groups for whom menopause is a particularly distressing or potentially dangerous experience; to analyse carefully the immediate and future risks and benefits they face, and the pros and cons of HRT in their situation; to upgrade selection criteria; and to campaign for fair access to screening tests that can assist decision-making. This would help to ensure that women in need of HRT have access to it, while those for whom it is unnecessary do not embark on it. Taking up these challenges is, of course, a matter for the women concerned, as well as researchers.

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