Breastfeeding & HRT
As a result of greater awareness about the menopause, more people are beginning to recognise that symptoms of the perimenopause can start in your mid-to-late 30s and early 40s, when you may still be fertile and having periods. This greater awareness has seen more people seek treatment – especially hormone replacement therapy (HRT) – well before the average age of menopause which, in the UK, is 51.
Not only that, increasing numbers of people are starting families later in life, and may also be relying on fertility support such as IVF to help with this. Despite what some graphs may show, your phases of life don’t neatly stop and then another one start, and it can be common for there to be overlap between beginning the perimenopause and pregnancy. In addition, if you choose to breastfeed for more than a year, it is possible you may reach the point where you become perimenopausal or menopausal while you are still breastfeeding your baby.
Dr Wendy Jones, a pharmacist with a special interest in the safety of drugs in breastmilk, runs the website www.breastfeeding-and-medication.co.uk. She says, “As many women now give birth later than in the past, due to changes in work and finance, and feed until they and their infant choose to stop, I have received a substantial increase in questions from mothers experiencing signs of early menopause.”
Premature Ovarian Insufficiency (POI)
It’s important to recognise that no one is ‘too young’ to be menopausal, especially as one in 100 individuals have Premature Ovarian Insufficiency (POI). This occurs when your ovaries stop functioning normally and hormone levels decline. As a result, periods become irregular or stop altogether, and this may also trigger symptoms of the perimenopause and menopause. If you show signs of this happening and are under 40 years, you may be diagnosed with POI.
Sometimes POI can be caused by an operation that removes the ovaries (oophorectomy), or after a hysterectomy – even if your ovaries aren’t removed, it can be common for estrogen levels to decline at an earlier age. POI can also be caused by cancer treatments such as radiotherapy or chemotherapy, an autoimmune disease, or genetic conditions such as Turners Syndrome. In many women, the underlying cause of POI is never known.
If you have POI, ovarian function can fluctuate, occasionally resulting in a period, ovulation or even pregnancy. For this reason, some people don’t realise they have POI, even though they may experience common symptoms of the menopause such as changes to their periods, hot flushes, night sweats, brain fog, mood changes and disturbed sleep. Because of this, anyone under the age of 40 who is having irregular periods (or whose periods have stopped altogether) should consult their healthcare professional and/or someone who specialises in the menopause. It is really important to replace your missing hormones if you have POI to prevent any deterioration in your bone and heart health, as well as help protect against other diseases in the future.
Breastfeeding during the perimenopause
It can be difficult to access effective and safe treatment for your perimenopause or menopause if you have recently given birth or are breastfeeding. In addition, estrogen levels drop after childbirth and during breastfeeding, which can result in symptoms that often mimic those experienced during the perimenopause, such as hot flushes, headaches, or joint pains. The psychological symptoms of perimenopause and menopause such as low mood and irritability, and trouble sleeping are also familiar features in the postnatal period for many reasons.
“Medical understanding of perimenopausal symptoms can be poorly understood, and probably more so if the woman is breastfeeding as well, particularly outside of the perceived ‘normal’ timeframe,” says Dr Wendy Jones.
For this reason, it’s helpful to keep track of your periods (if you have them) and log all your symptoms on the balance app, in preparation for an appointment with your healthcare professional. This will help convey to your clinician the range of relevant information relating to your hormones, especially if your tired and foggy brain might struggle to remember everything in the moment.
Taking HRT while breastfeeding
HRT contains the hormones estrogen and a progesterone (if you still have your womb). These are similar to the hormones found in the combined oral contractive pill, which we know can be safely used while breastfeeding. Crucially, HRT contains much lower amounts of these hormones, and body identical HRT (transdermal estrogen and micronised progesterone) mimics the natural hormones that your body produces. Although there are some studies that suggest the estrogen can pass into breastmilk, there is no evidence that it leads to any effects on the baby.
Dr Wendy Jones says, “There remains no conclusive research on the passage of HRT medication into breastmilk but, anecdotally, HRT has been used by nursing women without impact on the infant or breastmilk supply.”
If HRT is taken soon after childbirth, there is a theoretical chance that this could reduce the amount of milk produced and its protein content, but this very much depends on the type of HRT and the dosage.
Dr Wendy Jones says, “If you take HRT when breastfeeding, there is a possibility of reduction in milk supply as the estrogen content may inhibit the production of prolactin (the hormone that is responsible for the production of breastmilk). However, it appears anecdotally that there is less impact from using transdermal preparations, such as a gel, patch or spray, instead of taking oral HRT. The decision to take HRT should be that of the lactating mother, after discussion with her healthcare professional.”
Using vaginal HRT while breastfeeding
Local estrogen (that is placed directly into the vagina) is often prescribed when breastfeeding, usually to help with the healing of stitches after childbirth, prolapses, or ongoing vaginal dryness. According to Dr Wendy Jones, breastfeeding can affect natural vaginal lubrication for some, so vaginal dryness can become a particular problem for those who are already in the perimenopause.
When vaginal moisturisers like YesVM™, Sylk Intimate, and Regelle don’t provide relief, it can be very effective to deliver estrogen straight to the affected area. For this reason, clinicians may prescribe vaginal estrogen (either estradiol or estriol) in the form of a pessary like Vagifem® or a cream like Ovestin®.