MENOPAUSE- a patient's guide
Abstract
Overview:
- Menopause can start between the early 40s and late 50s.
- Menopause starts when there are not enough hormones(oestrogen and progesterone) for regular periods
- Menopause is complete when a woman has not had a period for one year
- Women are advised to continue contraception until menopause is completed.
- Menopausal symptoms include hot flushes, night sweats and vaginal dryness
- The majority of women have no major problems with symptoms
- One quarter of women develop osteoporosis after menopause
- Women have a higher heart attack risk following menopause
- Women can take hormone replacement therapy for difficult symptoms
What is menopause?
Menopause is when a woman stops having regular periods. It is normal for a woman's periods to stop anywhere between her early 40s and late 50s, with an average age of 52. Occasionally women in their 30s can experience early menopause.
Periods tends to tail off gradually because the ovaries can no longer make enough oestrogen and progesterone hormones to grow the lining of the uterus, which is normally shed once a month during menstruation.
Ovaries start to reduce their production of these hormones during the mid-thirties, with marked decreases about three to five years before the final menstrual period. Menopause is believed to be over when a woman has not had a period for one year, and only small amounts of the sex hormones are being produced.
It is unlikely you will get pregnant during menopause but if you are still getting periods, you are still fertile, and it is recommended you use contraception for one year after your last period.
Younger women who have both their ovaries surgically removed will experience menopause immediately afterwards and may have worse symptoms than women who reach menopause naturally. Women who only have one ovary removed are still likely to have a natural menopause. Women who have a hysterectomy tend to experience menopause on average a couple of years earlier.
On average, cigarette smokers undergo menopause about 2 years earlier than non-smokers.
What are the symptoms of menopause?
Irregular periods are often the first sign of menopause. Your periods may be shorter, lighter, heavier or longer. Some women also experience flooding.
Menopause can be an emotional time for many women. They may enjoy no longer having periods or using contraception, but may get depressed that they have reached this change in their life. They may believe their sex life has ended and worry about the effects of less oestrogen being produced in their body. Irritability and mood swings may be common at this time, although this may relate to other life changes at this time of life as much as hormonal changes.
Low levels of oestrogen affect several parts of the body - the vagina, the vulva, breasts, hair, skin and the bones.
Many symptoms are attributed to the menopause transition, including anxiety, memory loss fatigue, headache, joint pains and weight gain.
However, the only symptoms that have been clearly shown to be associated in longitudinal studies are
A hot flush is a sudden intense feeling of warmth and heat sensation usually felt most intensely over the face ,neck and chest. Average duration is around 4 minutes .This can cause sweating followed by chills. About 65 percent of menopausal women experience hot flushes, particularly in the later phase of menopause.
Some women feel embarrassed about having a hot flush because they think it may signal their menopause to others. However, it's more than likely to go completely unnoticed because there is actually little change to the colour of the face during a flush.
In most women ,hot flushes are transient and improve within a few months in up to 50 percent of women and in 85 to 90 percent have resolved in 4-5 years.
There is a small group of women (around 12 percent)who have ongoing troublesome hot flushes
Low levels of oestrogen cause the vagina walls to become thinner. This can make a woman more prone to vaginal infections. Intercourse can become painful because the vagina may feel dry during sex. However, frequent sexual intercourse is believed to help reduce this problem. The use of lubricant is also advised if needed.
Some women report a lack of interest in sex following menopause and there may be several physical and emotional factors involved in a decline in libido.
It is generally believed menopausal women are more prone to mood swings and depression. However, one study has found that menopause does not cause stress or mood swings among most women. Other studies suggest that major life changes at this time such as children leaving home may aggravate depression and not menopause itself.
About one quarter of women develop osteoporosis after menopause which can cause the bones to become brittle and more prone to fractures. Women need a higher calcium intake after menopause. Bone loss can be rapid in the years following menopause.
Women's heart attack risk also becomes as high as it is for men after menopause. Women are about 10 times more likely to die of heart disease than breast cancer.
It takes about five years for a woman's body to adapt to less oestrogen, though some people have trouble with symptoms for 10 years or more.
When to seek medical treatment?
If symptoms like hot flushes, night sweats and vaginal and bladder problems become troublesome, talk to your doctor about treatment options.
See your doctor if you think you may be at high risk of osteoporosis. Women at high risk are those with a small statue, a family history of the disease, getting little exercise, smokers, and not having enough calcium in their diet.
It is important to seek medical treatment if bleeding happens more than once month, the amount of blood loss increases instead of decreases, or if your periods stop for more than six months and then return.
Urinary incontinence also responds to medical treatment. Most cases are successfully treated by bladder training, medication or surgery.
Some women like to see their doctor just to confirm they are starting menopause and that there are no other medical problems causing symptoms.
Women should also consider having regular breast screening mammograms from the age of 50, or sooner in some cases .
Treatment options
Estrogens: May studies have shown that oral oestrogen replacement markedly reduces the frequency and severity of hot flushes by around 80 to 95 percent. The benefit is dose related ,but even very low doses may be effective.
For a detailed discussion of the pros and cons of hormone replacement therapy see our article on this (HRT).
Topical vaginal oestrogen creams are highly effective at relieving vaginal symptoms and when used at recommended dosages ,they have a minimal effect on serum oestrogen levels .
It is worth noting that unlike hot flushes, the vaginal related symptoms tend to worsen and progress.
A variety of prescription drugs have been studied for the treatment of flushing(vasomotor symptoms) ,including several SSRIs(serotonin re-uptake inhibitors).Two trials with paroxetine showed modest benefit ,particularly in breast cancer survivors.
Clonidine has been used and suggested for vasomotor symptoms, but trials have not suggested any substantial benefits.
An over the counter polycarbophil –based vaginal moisturiser (Replens) has shown benefits similar to vaginal oestrogens .
Future trends
Scientists are continuing to study the biology of menopause and the long-term effects of HRT to treat it.
Researchers are also studying whether hormones are responsible for depression and mood swings around the time of menopause.
Getting help
Your doctor or practice nurse will help able to help.
Local Family Planning Clinics run courses about menopause and can provide information and support.