Peri menopause - At a complete loss

[WutheringShites]

Hi there,
I've been experiencing signs of the peri menopause for the past 18months, which include monthly hormone related migraines, hot flushes, tiredness and mood swings.
Far the past few months these symptoms have been getting worse, particularly the mood swings. For around 10 days leading up to my period I am ragey, irrational and basically a nightmare to live with. As you can imagine it's beginning to take its toll on my DH.

After a horrible weekend, this morning I made an appointment to see a GP and am now at a complete loss. After a few basic questions I was offered antidepressants or group talking sessions for anger management.

I really don't know what to do next as neither of these approaches seem to address my problems. What I really want to know if there are any supplements or lifestyle changes that I can implement and was wondering if anyone had any suggestions?

It sounds like this GP is pretty unknowledgeable about the menopause OP. Is there someone else that you could see?

Why would anyone want to take ADs if they weren't the right treatment and just a sticking plaster? ADs have many side effects too. They are very powerful, mind altering drugs that can be addictive. Most women who are having emotional problems due to low oestrogen won't recognise that some of their physical symptoms are also due to loss of oestrogen.

A HUGE amount of work went into the NICE guidelines by practising gynaecologists with decades of experience treating women.

I'm really shocked tbh that some people want to dismiss the guidelines and even encourage women to use treatment that is not necessarily right.

You'd have to ask the patients Polly.

Fear, lack of scientific understanding, not trusting doctors even if they are providing up-to-date information that doesn't tie in with their preconceptions or narrative. Or as I said previous experience of ADs while HRT is an unknown.

No one on this thread wants women to have treatment that doesn't help them Polly.

What people are saying is that women should have a right to express their views and concerns about possible treatment options and make an informed choice.

Not just all be treated the same way or as per the guidelines.

All treatment for the menopause is a sticking plaster if you want to ser it that way. Nothing can stop the menopause occurring, but there are treatments including HRT and ADs that make the symptoms much more manageable for some women.

All treatment for the menopause is a sticking plaster if you want to ser it that way

No they aren't. HRT can help prevent bone loss, bowel cancer, pelvic organ prolapse, arterial disease and possibly dementia. Short term symptoms of menopause are the tip of the iceberg. Oestrogen deficiency is for life and many women suffer worse things decades after their flushes have stopped.

If you think people should have a choice, I agree with that, but why would you say people should be able to choose from something that is off the menu as being the right treatment?

Do you think people ought to be given antibiotics on demand too even though GPs are told to cut back on them? It's the same argument.

Anyway- I'm not going to argue with you. Wait till you get there, then talk to your own dr about the options. It's all academic for you at the moment.

I agree with polly
I don't like taking medication. But I've spent years trying to "cure" my peri symptoms.
I've tried the mirena. Was awful.
Tried the pop pill. Made me sick.
Tried the depo...I put in 2 stone and the mood swings were hideous.
I take supplements and they have helped a small amount.
But now I'm on hrt and I'm hoping that I will feel better in a couple of months. (Been on it 3 weeks!)
If it helps I will happily take it forever!

From NICE

Psychological symptoms

1.4.5 Consider HRT to alleviate low mood that arises as a result of the menopause.

1.4.6 Consider CBT to alleviate low mood or anxiety that arise as a result of the menopause.

1.4.7 Ensure that menopausal women and healthcare professionals involved in their care understand that there is no clear evidence for SSRIs or SNRIs to ease low mood in menopausal women who have not been diagnosed with depression (see the NICE guideline on depression in adults).

The reality of most people's jobs differ from guidelines.

Gynaecologists deal with people who are happy to have hormonal treatment so of course that's their area of expertise.

People walking into their GP are an undifferentiated mass of illness and problems. A nice neat consultation on the menopause or HRT is a rarity.

Do we just stick the rest on a CBT waiting list? Even if they are happy to go back on a treatment which previously helped them with hormonal mood swings/PND?

I am pretty unconvinced about the success of talking therapies for menopause-related depressive and anxiety symptoms. They often seem very biological yet can be compounded by stressful life circumstances.

There is no problem with resistance to ADs so no public health issue like with ABx. Long term they are very safe drugs.

Patients want to feel listened to. Refusing a valid treatment for at least some of their symptons in favour of guidelines is not very fair imo. Since menopause often starts gradually it is often impossible to say when depressive symptoms started exactly. Worsening PMT is common as women go through late 30s and 40s. ADs are a valid treatment option for this. Since there is no blood test to indicate the stage in perimenopause where a women is it is a diagnosis which emerges over time. Since the length of time a patient is on HRT for has a bearing on breast cancer risk, and since nobody has a crystal ball, ruling ADs out of the game completely seems unreasonable to me. If they 'buy' you a couple of years before HRT gets started then that is potentially a good thing.

Women are sick of hormones being foisted on them - see multiple Mirena coil threads (scuse the pun) for evidence of the same.

You put it very well effiel. No one has suggested that anyone should be able to demand any drug that they want from their GPs, Polly.

Some women find ADs a helpful treatment for symptoms of the menopause. There may be reasons that they are happier to take these drugs than HRT.

This has been the situation since SSRIs came into the market. Women's lived experience hasn't suddenly changed since the new guidelines were issued.

TBF my GP offerered me ADs for hormonal depression today as she has seen women who have been helped by it. But it was all part of a long discussion about my mood generally, HRT as the first option and a low dose. It was very much in context.

I'm going to change to a new HRT and see if it helps my mood. But I accept that I may at some point find ADs of more use as hormonal intervention doesn't appear to be agreeing with me.

So....as part of a dialogue and in the context of a full discussion about options - I can see how a GP might use them.

As a - oh, god, it's you crying again - here have some ADs - not so helpful.

Eiffel You make some very wide ranging assumptions and I can't see where the foundation for them is.

The reality of most people's jobs differ from guidelines
Where is your evidence for this? What do you mean? Are you saying that in medicine, guidelines by consultants and professors should be ridden over roughshod by GPs who are non-experts?

Gynaecologists deal with people who are happy to have hormonal treatment so of course that's their area of expertise

Sorry but where is your evidence for this? Have you spoken to dozens of gynaecologists or their patients? Or is this your own opinion? (It also contradicts your other opinion that women are sick of having hormones foisted on them.) Most top gynaecologists are willing to offer all kinds of treatments but only if they are proven to be of benefit.

There is no problem with resistance to ADs so no public health issue like with ABx. Long term they are very safe drugs.

Where is the evidence for this? Can you link to research? (Some people need stronger and higher doses which do have very serious side effects.)

Patients want to feel listened to. Refusing a valid treatment for at least some of their symptons in favour of guidelines is not very fair imo

But the NICE report says that ADs are not a valid treatment because there is not enough evidence they work! (see quote I left.)
.
Worsening PMT is common as women go through late 30s and 40s. ADs are a valid treatment option for this.

But the research shows it is NOT a valid treatment! (valid means it doesn't work so should not be used.)

Science is not about opinions or beliefs. It's about facts. Research on thousands of women. The facts are that if anxiety and depression start with a fall in hormones, the treatment is hormones, not antidepressants. And HRT does not cause breast cancer- it may in some women promote cancer already there to grow. So delaying the use of hormones for a year or so if not really relevant.

This is worth reading if anyone is interested in the causes of depression linked to hormones.

www.studd.co.uk/reproductivedepression.php

If you don't already know, John Studd is one of the UK's foremost consultants whose life's work is on women and hormones.

He's not the only consultant saying this, by any means, but his website is very informative.

I am basing my practice on a mixture of guidelines and clinical experience not assumptions.

Any job involving people presents daily (probably hourly) scenarios which are simply not covered by guidelines. We can shrug and wish patients who aren't 'playing ball' good luck or try to find a mutually acceptable way forward. I think most patients would prefer a humane approach. Many aspects of modern medicine are not evidence based - the therapeutic value of being listened to, taken seriously, shown empathy, having anxieties contained in a safe space, offered treatment options and empowered to take part in decisions about their health- none of it can be measured which is why medicine is both an art form and a science.

NICE states clearly that ADs are fine for PMS. Also states transdermal oestrogens, diuretics, danazol shouldn't be used in primary care. I've never seen a gynaecologist prescribe most of the things Prof Studd mentions - the usual gap between MN and RL no doubt applies. I'm glad more options are hopefully becoming available though it sounds like he is still researching options. It is easy to offer hormones if you have ready access to scanning, not so much in primary care.

I don't agree with how you phrased the information on breast cancer and think it is a bit misleading.

It is easy to cut and paste guidelines but RL isn't so simple. I'm unsure why anybody would object so strongly to a well-informed woman who declined hormonal treatment being offered a 2-3 month trial of an AD. I'm not proposing treble dosing her with an antifungal and advising her to rub a boiled egg over her scalp.

Recently it was in the news that UTIs can exist in the abscence of a positive lab culture - this information is far from surprising to many GPs, ER doctors and nurses. There have always been patients who the standard guidelines 'let down'.

Guidelines are there to advise, not to dictate.

I personally am willing to try anything that will improve my quality of life, the benefits are more important if they outweigh the possible side effects. I agree the talking therapy wasn't particularly helpful for me - it addressed some ongoing themes/triggers and gave me some reassurance but i don't feel any better for it because I know or I can feel that it's all caused by hormonal ups and downs. No matter how many psychological coping strategies you have sometimes you just feel really shit physically and mentally and there's nothing you can do about it but accept it and stick it out til it passes. I know it's hormonal because the symptoms fluctuate and yet are repetitive, each one comes round every few weeks, one after the other. Anything that can regulate things a bit so I can feel human again most of the time I will try, whether it's ADs or HRT. In fact this discussion has made me think I should discuss trying both/either or even ADs first for a bit with my GP. I think it's probably a case of finding what works best for each person as everyone's different.

I would have no issue taking ADs if I were depressed
But I'm not
I'm peri menopausal and having lots of nasty symptoms
I'm treating that because 44 is too young to feel like this!

OP was talking about horrific mood swings though, which makes ADs a feasible option.

If your mental health isn't suffering then there's little sense in considering a mental health treatment.

For the last year my perimenopause symptoms made me think I was going mad. Anxiety, flushes, muscle aches, foggy brain. After 5 months on oestrogen patches, I feel ten years younger. I was already on the mirena coil.

One of my symptoms is mood swings

I am basing my practice on a mixture of guidelines and clinical experience not assumptions

You are a GP or a consultant? Be good to know if you are a professional rather than a random poster!

. It is easy to offer hormones if you have ready access to scanning, not so much in primary care.

I don't understand this Effiel- many women take HRT but never ever have a scan. What do you mean? Pelvic scans or mammograms?

Outside the NHS women can access scans. They can and do pay. I pay for mine. I know of other women who do the same.

I think it would be helpful to put your posts here into context so readers know if you are a doctor, a nurse or whatever, so we can pick your brains further and benefit from your knowledge.

I'm just coming back to you Eggiel on your comment about my post on BC being misleading.

I'm not sure which comment it was now, (the one about oestrogen/ HRT promoting not causing BC?)

If it were, here are the views of Dr Heather Currie, Chairman of the BMS, practising gynaecologist- on her blog on Menopause Matters. I was quoting her and my own eminent gynae- they are not my opinions.

"For women who take combined HRT, NICE confirms that this can be associated with an increase in the incidence of breast cancer. The absolute figure given is 5 more cases of breast cancer in women taking combined HRT per 1000 menopausal women over 7.5 years, baseline risk as noted. This increase in risk appears to be associated with the length of time that HRT is taken, the risk being higher when combined HRT is used for more than 4 years. However, the risk reduces and returns to each woman’s baseline risk after HRT is stopped. Another important point highlighted is that the mortality from breast cancer does not appear to be increased compared to women who develop breast cancer and are not taking HRT. The conclusion from these two points is that combined HRT may, in a small number of women, stimulate the growth of cancer cells which are already present, rather than cause breast cells to turn into cancer, and the natural history of disease for each woman is not altered."

Polly you've made your stance as being very pro HRT clear.

You can trawl the web to your heart's content finding guidelines and blogs to support your views.

The point that Eiffel and others are trying to make is that some women may prefer to try ADs as a treatment for their menopausal symptoms. Some women find these to be helpful.

OP has long since gone, but from the info she gave it does sound like her HP should have discussed HRT with her, as am option, not the only course of action as this is what the latest NICE guidelines say.

Do you mind me asking what scans you pay for privately and why? Are they to provide information and hopefully reassurance about the side effects of HRT?

Christina - there are two issues here!

First is my own circs. I am happy on HRTand it seems to work for me, for many reasons, (other health issues linked to falling oestrogen .) My dr BTW is open to all kinds of treatments for menopause and doesn't 'push' HRT.

I'm not exactly 'trawling the web'' for the purpose of MN! My work has involved interviewing consultants on menopause.

The second issue is nothing to do with my circs, but NICE recommendations. I've never come across anyone anywhere - real life or forums- who is questioning the guidelines re. ADs in the way they have been here. ADs have a role but are usually now only used for women who cannot use HRT for medical reasons, not for otherwise healthy women whose symptoms are improved with HRT. You seem to be implying women ought to be offered the choice of ADs or HRT whatever, and I don't understand where this opinion's coming from, That's all!

Scans- like many women using a longer cycle HRT regime, I have a pelvic scan annually or biannually organised by my dr just to check the thickness of the endometrium, and it also checks the ovaries at the same time.

polly, neither I nor anyone else has said that women should be offered the choice of 'ADs, HRTs or whatever', simply that some women would prefer not to take HRT and do find ADs help their symptoms.

It's great that HRT is working for you, and that you feel comfortable taking it, and I'm simply saying that all women should have the same degree of imput and choice about their medical care as you have had, even if they make different choices to you.

Guidelines are continually being questioned - that's why they're revised regularly. You probably haven't met many endocrine consultants who know much about any other branch of medicine or other treatments for HRT, so it doesn't surprise me that you haven't heard much debate about them tbh.

And regarding the breast cancer risk, maybe some women would rather not take a drug that accelerates their already existing risk, especially is there is another treatment available that helps them? Treatment for breast cancer isn't exactly lightweight, even if the cancer isn't actually fatal.

Well, your post give the very strong impression that women ought to have a choice of ADs or HRT. If you weren't saying that, then it's confusing as to what you were saying!

I agree about guidelines being reviewed. Exactly. That's why the new NICE guidelines are important as they are NEW and correct some of the incorrect treatment offered before.

. You probably haven't met many endocrine consultants who know much about any other branch of medicine or other treatments for HRT, so it doesn't surprise me that you haven't heard much debate about them tbh

I beg your pardon?? :) How can you know who I've spoken to or what their expertise is? And what do you mean by I won't know of any other treatments for menopause?

Not sure what you mean about 'other treatments for HRT'?

Sorry Christina but you're beginning to border on being a bit personal and confrontational, so I'll leave you to you to your own research and opinions on this as you are so keen to have the final word!