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  • Hormone blood tests at perimenopause and menopause

    Hormone blood tests samples

    I completely understand the rationale to want to have hormone blood tests checked to see where you are in the menopause transition, and understand your experience.

    Unfortunately the tests we currently have available often aren’t that helpful. They give a level at the particular point in time the test was taken, not an average, and those levels can fluctuate significantly during perimenopause.

    Hormone blood tests for menopause diagnosis

    Current guidance is that the FSH blood test is considered for those aged under 45 with symptoms of menopause. This test cannot be done if you are using a method of contraception containing oestrogen like the combined pill. It can be done on other forms of contraception including progesterone pills, the implant and the hormonal coil. With the contraceptive injection it is best timed when the injection is due rather than when it has recently been given.

    Two blood test results showing FSH levels over 30 are used to diagnose menopause. In the perimenopause though the level does not usually reach 30. It can sometimes be normal, sometimes be on the higher side (15-20). Labs often report levels under 30 as being normal to GPs. There is no agreed level of FSH to diagnose the perimenopause. Normal FSH levels do not exclude perimenopause.

    Blood tests can be really helpful if it is difficult to know what is happening because you don’t have a cycle for example after a hysterectomy it is common to enter menopause earlier even if your ovaries are conserved, but without the change in cycle sometimes it is much more tricky to recognise a perimenopause presentation of fatigue, anxiety and poor sleep for example. Similarly if you are using a hormonal method of contraception that changes your cycle like the hormonal coil and you’re experiencing symptoms blood tests can be useful.

    hormone blood tests can be used to assess when to stop using contraception

    Hormone blood tests & contraception

    Blood tests can be used to help us know when we can safely stop using contraception. Using age alone, it is recommended to continue with contraception until age 55. If we are not using a hormonal method and our periods stop, we can stop contraception 2 years after our last period if it occurs under the age of 50, and 1 year after our last period if we are over the age of 50. 

    If we are not having periods, for example with the hormonal coil, and think we are menopausal and do not want to continue with the coil, the FSH level can help in knowing whether that is the case, and so can stop using contraception.

    Hormone blood tests for understanding symptoms

    Blood tests can also be really helpful in assessing symptoms that could have a number of causes. For example, fatigue is a very common symptom of perimenopause, as is a change in cycle towards longer, heavier periods. Blood tests in this scenario could be useful to check for anaemia and low iron levels.

    There are very few blood tests that are routinely recommended in NHS care, they are largely used to assess for specific causes. When screening blood tests are done sometimes we will find results that are not in the “normal” range, which can cause anxiety. In many situations, for example a slightly low vitamin D level, the result may be difficult to interpret and aiming to normalise the numbers does not always lead to any improvement in how we feel or our long-term health or wellbeing. They may be “normal” for us! There are of course other situations where it is certainly helpful to aim to optimise results.

    Hormone blood tests to assess oestrogen absorption from HRT

    The other main reason for blood tests at menopause is to help with understanding how medications are working for us. They are not needed in most cases, as the best way of knowing if HRT is helping is whether symptoms have improved.

    For example, we know approx 20% of people don’t absorb oestrogen well through the skin and blood tests to measure the oestradiol levels can help us know if this may be the case. Blood tests can’t be used to assess the effects of oral oestrogen, only transdermal oestrogen in the gel, patch or spray.

    Hormone blood tests for testosterone treatment

    Blood tests for testosterone levels are important if testosterone is being considered for use as part of HRT. Before starting testosterone baseline blood tests for testosterone levels help to assess whether levels are low and our oestrogen is optimised, and then during treatment we need to make sure that blood tests for testosterone levels are being kept within the usual range to avoid rare but potentially very significant and irreversible side-effects.

    Further info about hormone blood tests

    Women’s Health Concern leaflet Menopause

    Women’s Health Concern Testosterone

  • Non-hormonal treatments for menopause


    non-hormonal treatments for menopause

    Non-hormonal treatments for menopause are sometimes overshadowed, but not everyone can or wants to take HRT. This blog will cover the non-hormonal treatments for menopause that are available, including for those with hormone sensitive breast cancer and menopause.

    I’ll be focusing on prescribed medications, what’s available now and new developments that are coming soon. Much of the available evidence is for vasomotor symptoms like hot flushes and night sweats, but some medications can also help with sleep, anxiety, low mood and pain.

    Antidepressants for menopausal symptoms

    Antidepressants are the most widely used group of non-hormonal treatments for menopause symptoms. Aswell as helping with anxiety and low mood, they can reduce hot flushes by up to 50%. High doses of antidepressants are not usually required to see the benefits. Some women respond better to one antidepressant than others, so it can be a matter of trial and error to see if you respond to a particular medication.

    Not all of the antidepressants are suitable for all women with breast cancer to take. Some (Sertraline, Fluoxetine, Paroxetine) can reduce the effectiveness of Tamoxifen treatment. Others (for example Venlafaxine) are safe with Tamoxifen treatment.

    Antidepressants are recognised for treatment in women with breast cancer and menopause but not licensed for this use. They are included as recommended options in the British Menopause Society consensus statement “Non-hormonal-based treatments for menopausal symptoms”.

    Initial side-effects of antidepressants can include nausea, dizziness and increased anxiety. These effects are usually transient and settle over time. It can help to start with a low dosage. Sexual dysfunction is a recognised possible side-effect of all antidepressants, and unfortunately does not always improve when the medication is stopped.

    Gabapentinoids for menopausal symptoms

    Gabapentin is used for the treatment of epilepsy and nerve pain. It is used for menopausal symptoms in women with breast cancer but not licensed for this use, and can help with vasomotor symptoms, sleep and pain.

    Pregabalin is used for the treatment of epilepsy and anxiety. It is used for menopausal symptoms in women with breast cancer but not licensed for this use, and can help with vasomotor symptoms and low mood.

    Both drugs have been designated as controlled drugs due to the risk of abuse, and the effects can be increased by alcohol, leading to drowsiness and sedation. Side-effects can include weight gain, dry mouth, dizziness and drowsiness.

    Clonidine for menopausal symptoms

    Clonidine is the only licensed non-hormonal treatment for menopausal symptoms.

    It reduces blood pressure, and so is not suitable for those who have a low blood pressure. It is important to reduce the dosage gradually on stopping treatment to prevent a rebound increase in blood pressure. Side-effects can include sleep disturbance (especially at higher doses), dry mouth, nausea and fatigue.

    Oxybutynin for menopausal symptoms

    Oxybutynin is prescribed for urinary frequency, urgency and urge incontinence. In one relatively small randomised controlled trial, oxybutynin improved sleep quality and vasomotor symptoms. It is not currently included in the British Menopause Society consensus statement “Non-hormonal-based treatments for menopausal symptoms”. 

    Side-effects are common, including a dry mouth, constipation, blurred vision and dizziness. Using oxybutynin in the patch formulation rather than the tablet formulation can moderate these effects.

    Neurokinin receptor 3 (NK3) antagonists for menopausal symptoms

    The exciting new development is an entirely new class of drug, the NK3 antagonists, which had remarkable effects for some people in the trials “switching off” their hot flushes within just a few days. Currently they are not able to be prescribed in the UK, but will hopefully be approved for use soon. They have been approved for use by the FDA in America.

    For more info

    Women’s Health Concern

    Complementary & alternative therapies

    MacMillan

    Breast cancer treatment and
    menopausal symptoms

  • Cervical screening, what you need to know.

    Cervical screening ribbon, cervical cancer awareness

    A cervical screen, or smear test, takes just 5 minutes and can help us to know whether we are at risk of developing cervical cancer, yet so many of us put it off. This blog will give you more information about what’s involved, to inform your decision making.

    Cervical cancer

    In the UK <1% people with a cervix will develop cervical cancer. Risk factors for developing cervical cancer include:

    • smoking
    • combined contraceptive pill usage
    • HIV
    • maternal history of DES usage (a medication given to some pregnant women for miscarriage until the 70s)

    Cervical cancer mortality rates have reduced by 70% since the start of the UK screening programme.

    The invite for a smear test

    To receive an invite automatically you need to be registered with a GP surgery, be aged between 25 and 64, and be registered as female with your GP surgery.

    If you have a cervix and are not registered as female with your GP surgery the screening is definitely still recommended and although you will not be sent an automatic invite you can request an appointment from your GP surgery, and ask them to automatically invite you themselves next time. More info is available from Jo’s trust.

    Invites for your screening appointment are sent by post from the screening office, so do keep your address up to date with your GP. If you don’t book after the first invite the screening office will send a reminder 18 weeks later. They then let your GP know if you haven’t taken up the offer, and your GP surgery may well then text you or contact you directly by phone or letter.

    The interval between appointments depends on your previous result, and may be 1 year, 3 years or 5 years. Or you may be invited direct to colposcopy for an additional examination.

    Screening rates are falling, and currently nearly 1 in 3 people eligible for cervical screening don’t take up the invite. There can be many different factors that contribute to this, including difficulties in getting appointments through to experiences of pain with the appointment, embarrassment of the test itself, and fear of what the results may show. Rates of uptake are known to be lower for those with a disability, those who do not have English as their first language and those over the age of 50.

    Symptoms to report

    Any new symptoms such as a change in vaginal bleeding or persistent vaginal discharge should be checked with your GP or ANP. Don’t just book for a cervical screening appointment.

    The smear test itself

    The testing has changed over the last few years, and now in England, Scotland and Wales the cervical screening test checks for the HPV virus. If certain types of the virus are present then checks are made on the cells themselves. This has made the test more accurate for us, and means less of us will need to have further examinations.

    The testing is done via a speculum examination. Depending on the position of your womb (uterus), the clinician may ask you to raise your hips by placing your hands under your buttocks. Our wombs are all positioned differently, and the position can vary through the menstrual cycle, don’t be worried if you are told yours is tilted!

    The sample is sent to the lab and the results are then sent to you directly by post, so do make sure your GP surgery has the correct contact details for you to receive your results. You should get your results within 2 weeks and your GP surgery will receive a copy of the results when you do.

    Jo's cervical Cancer Trust image of a cervical screening examination with a speculum

    HPV

    Human papillomavirus (HPV) is a very common virus, and most of us will have it at somepoint in our lives. It is transmitted through skin to skin sexual contact. HPV can infect the skin and any moist membrane, including the cervix, vagina, vulva, anus and mouth. There are over 200 types of strains of HPV, and <10% of the strains are linked with the development of cancer.

    90% of the time when we have HPV it goes away within 2 years without causing any problems.

    On occasion though it can be persistent, and if this is with a higher-risk strain it can lead to pre-cancerous changes in cervical cells. HPV is more likely to be persistent if we smoke. We don’t know when we have HPV or pre-cancerous changes in cervical cells, which is why the screening test for persistent high risk strains is so useful for us.

    >99.5% of cervical cancer is caused by HPV. Pre-cancerous cell changes can usually be treated effectively.

    Young people are now offered HPV vaccines at school. The screening programme is still recommended even if a young person has received the vaccine. The current vaccine being used protects against 9 types of HPV, which cause >95% of cervical cancers.

    Your cervical screening results

    When you receive your results you may see

    • HPV negative – no further tests needed, “routine” recall e.g. 3 years
    • HPV positive, no abnormal cells present – no further tests needed, “sooner” recall e.g. 1 year
    • HPV positive, abnormal cells present – you will be automatically referred for a colposcopy, an extra examination to further assess (and treat) the abnormal cells
    • Inadequate – the sample could not be analysed well enough to give a reliable result – you will be asked to attend for a further test in 3 months time

    Cervical screening at menopause

    The rate of screening in those over the age of 50 is at an all-time low. A survey by Jo’s Trust of those over 50 reported that 29.1% of women over 50 had found the screening test painful since becoming older.

    The genito-urinary syndrome of the menopause (GSM) can be treated though. For cervical screening the use of local, vaginal oestrogen for at least 2 weeks prior to the test can make a considerable difference. Different labs will have different guidelines about when treatment needs to be stopped before the test – usually a few days. You can check with the practice nurse at your surgery.

    GSM can also mean we are more liekly to receive an “inadequate” result, which can be extremely frustrating, especially if the procedure was painful.

    Top tips if you’re worried about attending for a cervical screen

    If you can, do try to share any worries you have about the test with the clinician. They are very likely to have heard those same worries before, and can give you some personal advice.

    These things sometimes help:

    • You can ask for a chaperone.
    • You can ask for a clinician of a particular gender.
    • You can bring a friend to the appointment
    • You can bring something to listen to during the appointment.
    • Wearing a dress or skirt may help you feel less exposed. It’s fine to keep your socks on!
    • Try to prioritise the appointment in your diary, as you would for a child or partner’s essential healthcare appointment.

    It can be very difficult to attend for a screening appointment if you have experienced any type of sexual violence in the past. You can book an appointment to talk the test through, to see whether there is a way the appointment can go ahead in a manner that works for you. Sometimes people like to see/feel the speculum, sometimes people prefer to insert the speculum themselves with the clinician then taking the test.

    The future of smear tests

    Hopefully soon cervical screening tests will be done at home with a self-sampling kit. The You Screen study trialled this in certain parts of the UK in 2021.

    There are private kits available to buy online, but the results of these are not acted on by the NHS screening programme, so it is best to attend your GP surgery for screening if you feel able to.

    Whether or not to attend is your choice, you can opt in or out of the screening programme at any time.

    Cervical screening is certainly a test I’d recommend if you feel able to attend.

    For more info..

    What is cervical screening – NHS

    Colposcopy information – Jo’s Trust

    Macmillan – Cervical screening awareness week

    HPV vaccine – NHS website

    Vaginal dryness – Women’s Health Concern