What is the menopause?
Menopause is when you stop having menstrual periods. This is usually around the age of 50, but it can happen earlier. It is usually a gradual process, with periods becoming irregular before stopping completely. You are classed as having been through menopause (be post-menopausal) when you have not had a period for 12 months.
You may experience menopause symptoms for several years before your periods stop. This is known as perimenopause (meaning around the time of menopause.) During the perimenopause your periods may become more frequent, irregular, lighter or heavier before they stop completely.
What causes the menopause?
As you get older, the number of eggs in your ovaries reduces and ovulation and menstruation become less frequent. As a result, your ovaries make less oestrogen (the main female hormone). After the menopause, your periods stop and you are no longer able to get pregnant naturally.
You may go through menopause earlier if you have a hysterectomy (the removal of your womb). Your ovaries will continue to make oestrogen, but at lower levels than before. If you have your ovaries removed as well, you will go into menopause immediately – this is known as surgical menopause. Going through menopause before the age of 40 is known as premature ovarian insufficiency.
How is menopause affected by CKD?
Some research suggests that women with CKD may go through menopause slightly earlier than the general population, but this is still being investigated. If your periods stop while you are on dialysis this does not necessarily mean that you are going through menopause, and they may come back if you have a transplant.
Women who go through menopause early (before the age of 45) may have an increased risk of developing CKD in later life, but this has not yet been proven conclusively.
Menopause may affect the severity of some kidney conditions, such as autosomal dominant polycystic kidney disease (ADPKD), which is influenced by hormonal balances that are disrupted in menopause.
What are the symptoms of menopause?
Most women will experience some menopausal symptoms. These may be minor or can have a big impact on your life. The menopause can cause both physical and psychological symptoms.
Physical
- hot flushes
- night sweats
- difficulty sleeping
- headaches
- thinning hair
- dry skin
- heart palpitations
- aching muscles and joints
- changes in body shape and weight gain
- reduced sex drive
- vaginal dryness, which can cause itching and discomfort during sex
- urinary symptoms such as increased frequency and urgency, and urinary tract infections
Psychological
- low mood
- irritability
- anxiety
- forgetfulness
- difficulty concentrating (‘brain fog’)
These symptoms may start several years before your periods eventually stop and can carry on afterwards. They may vary in intensity and can affect people in different ways. Talk to your GP if you are concerned about any of these symptoms, especially if you are under the age of 45 and your periods have stopped.
How will I know if I am going through the menopause?
Hormone tests can confirm menopause. However, these can be misleading if you have advanced CKD, as your hormone levels are affected by your drop in kidney function.
If you are over 45 and are experiencing some of the symptoms above, along with a change in your periods that is not caused by pregnancy, it is highly likely that you are in perimenopause and hormone tests are not needed.
What are the long-term effects of menopause?
As your oestrogen levels continue to drop, you may find that your skin and hair become dryer and thinner.
The reduction in oestrogen levels that occurs during menopause may increase your risk of osteoporosis (thinning of the bones). This risk increases if you are on dialysis, which can also lower your hormone levels. The risk also increases if you are on steroid treatment for your kidney condition or if you have had a transplant, due to the anti-rejection drugs that you must take.
The risk of developing heart disease also increases once you go through menopause, as you lose the protective effect of oestrogen. This risk is already higher in those with kidney disease and increases further if you are overweight, have high blood pressure or smoke.
Because of these long-term effects and the pre-existing risk of bone problems and heart disease that comes with CKD, it is important that women with CKD are monitored as they go through menopause.
Do I still need to use contraception after the menopause?
It is very rare for women over the age of 55 to become pregnant, even if they have not yet gone through menopause. It is recommended that you continue to use contraception for 12 months if you are over 50 when your periods stop, or for 24 months if this happens below the age of 50.
This advice can vary if you go through the menopause at a younger age however, so it is best to discuss whether you still need contraception with your healthcare professional.
Barrier methods of contraception, such as condoms, should still be used to prevent sexually transmitted infections (STIs), even after menopause.
How is the menopause treated?
Menopause is a natural process that all women go through. Some women will only have very mild symptoms and will not need any treatment. For others, the symptoms can be very severe and have a major impact on their quality of life.
There are a variety of treatments for menopausal symptoms.
The most commonly used and effective treatment is hormone replacement therapy (HRT), which works by replacing the hormones that your body has stopped producing. HRT is an effective treatment for most of the physical and psychological symptoms of menopause. It can also help to keep your bones and heart healthy.
Oestrogen is available as tablets, skin patches, sprays or gels. Local oestrogen therapy is also available as a vaginal tablet, pessary, cream or ring. This helps to manage vaginal dryness and improves the tissue of the vulva, vagina, bladder and urethra. It can also reduce urinary frequency and prevent recurrent urinary tract infections. Vaginally delivered oestrogen is not absorbed systemically (throughout the body), so it does not provide the other benefits of HRT such as bone and heart protection. Vaginal oestrogen can be used in addition to systemic HRT or on its own. Vaginal lubricants and moisturisers may also be used.
Women with a womb (those who have not had a hysterectomy) or with a history of endometriosis, need to use an additional hormone called progestogen, as well as oestrogen. This can be taken as capsules which contain body identical micronised progesterone. This is made from plants (usually yams) and has the same structure as the progesterone that humans produce. Synthetic (artificial) progestogens are also available and may be combined with oestrogen as tablets or patches, or used separately as a tablet, capsule or through a hormone releasing intrauterine device, which gradually releases progestogen.
Talk to your GP about the best HRT option for you.
Avoid using compounded “bioidentical hormones”, which may be prescribed through private clinics. These are not recommended as there is not enough evidence on how well they work or how safe they are.
What are the side effects of HRT?
Like all medicines, there are some potential side effects associated with HRT, including breast tenderness and headaches.
The most serious complication is an increase in the risk of blood clots with oestrogen tablets. There is no increase in blood clot risk with the oestrogen patch, gel or spray. However, it is still important that your blood pressure is well controlled and checked regularly in order to protect your kidneys.
There is a small increased risk of developing breast cancer for women taking combined forms of HRT (which contain both oestrogen and progestogen).
- The background risk is 23 new cases of breast cancer for every 1,000 menopausal women aged between 50 and 59.
- For those on combined HRT this increases to 27 cases (an extra four cases per 1,000 women). This is the same increase in risk as for those who are overweight or drink more than four units of alcohol a day.
- It is likely that these cancers were already present but developed more quickly due to the influence of the HRT.
- This increased risk decreases after you stop taking HRT.
It is important to check your breasts regularly for lumps and attend all your breast cancer screening appointments (mammograms).
Oestrogen-only HRT is associated with little or no increase in the risk of breast cancer, but it is only recommended for women without a womb. There is an increased risk of uterine (womb) cancer in women who have a womb if oestrogen is used without progestogen.
How long should I take HRT for?
There’s no fixed time limit for how long you can take HRT, as long as the benefits outweigh any risks. You will usually have a review of your treatment every year. If you go through the menopause early (younger than 45) you will likely be advised to stay on it at least until you reach the normal age of menopause, which is around 50.
Vaginal oestrogens can be used for as long as needed and ongoing treatment is important to maintain any beneficial effect that is achieved. There is no need to combine vaginal oestrogen with a progestogen if you have a womb.
Is it safe to take HRT if I have CKD?
Yes in most cases, unless you have uncontrolled high blood pressure. In this case, your blood pressure will need to be controlled before you can start HRT.
HRT may not be suitable for you if you have a history of breast, ovarian or endometrial (womb) cancer, unexplained vaginal bleeding or ADPKD. Nonhormonal treatments may be recommended instead. Talk to your doctor or other menopause specialist about your options.
Women with a history of blood clots in their legs or lungs may be able to use HRT, but it should be delivered through the skin as a patch, gel or spray, rather than taken as tablets. This also applies to women with stable liver disease. The progestogen component can be safely taken by mouth in both cases.
If you have medical problems in addition to CKD, you should discuss suitability for HRT with your healthcare professional, who may need to discuss your care with a specialist.
What other treatment is available?
As well as medical treatment, dietary and lifestyle changes can help to improve menopausal symptoms.
Eat a healthy balanced diet, including plenty of fruit, vegetables, calcium and fibre.
You may be prescribed calcium or vitamin D supplements to protect your bones and reduce the risk of osteoporosis. Always speak to your kidney healthcare team before starting to take any vitamins or supplements.
Reduce the amount of caffeine that you drink to help prevent hot flushes and night sweats.
Give up or cut down on your alcohol intake.
Give up smoking. Your GP can help you with this.
Take regular exercise. Your bones need regular weight-bearing exercise to stay healthy. Impact and muscle-strengthening exercises are best. This can be as simple as increasing the amount of walking that you do each day. Activities such as running or swimming are also good for strengthening your muscles. Doing any amount of exercise is better than none. Your GP can give you advice about how to exercise safely.
If the psychological symptoms of menopause are having a major impact on your life, you may wish to try cognitive behavioural therapy (CBT). Your GP can discuss local providers.
Non-hormonal treatment options for vasomotor symptoms (hot flushes and night sweats) include medicines prescribed out of license (those that are licensed to treat other conditions). They include:
- anti-anxiety medications (gabapentin and pregabalin)
- antidepressants known as selective serotonin reuptake inhibitors (SSRI) (fluoxetine and citalopram)
- serotonin and norepinephrine reuptake inhibitors (SNRIs) (venlafaxine).
Antidepressants may also help to manage the psychological symptoms of the menopause. Clonidine is a medicine used to treat high blood pressure and is also licensed to treat hot flushes and night sweats.
A new non-hormonal medication fezolinetant (a Neurokinin 3 receptor antagonist) has recently been approved for use in the UK. This is not yet available on the NHS but it is likely to become available in due course and offers a further choice to women who cannot or do not wish to take hormonal treatment to manage hot flushes and night sweats.
Some herbal medicines such as red clover and sage are marketed to help with menopausal symptoms. However, these plant-based oestrogens (isoflavones) have not been subjected to robust clinical trials in the same way as the licensed medication that your doctor can prescribe. In addition, herbal medicines can have serious side effects and can react with your other medicines. This includes medicines that you have bought over the counter and those that have been prescribed by your doctor such as anti-rejection drugs if you have had a transplant. There is also the risk of causing inflammation and damage to your kidneys. You should always check with your kidney doctor before taking any herbal treatments.
The menopause is a natural stage of life. Every woman experiences it differently and it is important to ask for help if you need it. Ask your GP to refer you to a menopause specialist if you would like more specialist support.
Where can I find more information?
- NHS - Menopause
- Women’s Health Concern - the patient arm of the British Menopause Society
- Patient Info - Menopause
- Royal Osteoporosis Society - Exercise for bones
Menopause and kidney disease: download or order Kidney Care UK's information leaflet
You can download our Menopause and kidney disease leaflet for free.
Publication date: 11/2024
Review date: 11/2027
This resource was produced according to PIF TICK standards. PIF TICK is the UK’s only assessed quality mark for print and online health and care information. Kidney Care UK is PIF TICK accredited.