What is the menopause?
The menopause is defined as the last menstrual period. Periods happen due to hormones produced by the ovaries – oestrogen and progesterone. There is a natural reduction in hormone production as a woman gets older. The falling level of hormones, particularly oestrogen, is thought to cause the menopausal symptoms that many women experience.
When does it happen?
The average age for the last period is between 50 and 51 years old but there is a wide variation with an early menopause occurring in some women under forty five years old and some women continuing to have periods up to age 56 or 57. Premature ovarian failure may cause women as young as thirty or less to become menopausal.
What are the symptoms?
Early symptoms of the menopause include:
- Night sweats
- Heart palpitations
- Shortness of breath
- Chest tightness
- Decreased sex drive
- Poor sleep pattern
- Difficulty concentrating
As time goes on, other symptoms may develop due to the lack of oestrogen in the tissues surrounding the bladder and vagina. These include:
- Increased frequency of passing urine
- Discomfort when passing urine
- Urine infections
- Leakage of urine
- Vaginal dryness
Other effects of low oestrogen levels include dry skin and hair, and brittle nails.
What can I do to help myself?
Look at your lifestyle and try to become more health conscious. Stop smoking, reduce alcohol intake, increase the amount of fresh food in your diet, take regular exercise and try to lower your stress levels.
Many women find that lowering caffeine and alcohol intake helps reduce the number and intensity of hot flushes. Sleeping in a cool room may reduce night sweats.
How long will symptoms last?
The time scale varies between individuals. Typically, women will start to experience some menopausal symptoms up to two years before periods stop. This can mean a few days or weeks of flushes and night sweats interspersed with weeks when no symptoms occur. After the last period, women continue to have menopause symptoms for at least two years. It is not uncommon for women to continue having occasional flushes or night sweats well into their sixties and sometimes seventies.
What medical treatments are available?
Hormone Replacement Therapy (HRT) is the most effective prescription medication. It relieves many of the symptoms associated with altered temperature regulation. Hot flushes and night sweats often improve dramatically. If an altered sleep pattern is due to night sweats then sleep will return to near normal. Some of the lack of concentration and forgetfulness is due to tiredness so again there may be an improvement in those symptoms. Vaginal and urinary problems will gradually improve with systemic HRT (tablets, gel or patches,) but local oestrogen treatment in the form of vaginal pessaries may be more effective and work more quickly.
In women who cannot take HRT clonidine tablets may be used to reduce hot flushes. However, this medication has no effect on other menopausal symptoms. Side effects include dry mouth and dizziness. Some antidepressant medications also reduce hot flushes.
What are the side effects of HRT?
Fluid retention is a common effect seen at the start of treatment. This can cause headaches, breast tenderness and bloating. Nausea can also occur. These side effects tend to disappear as the body adjusts to the medication. Usually within two to three months, the woman will be free from side effects.
More serious side effects can occur. HRT increases the risk of blood clots developing in the legs or lungs and there is also a higher risk of stroke in the first year of taking it. There is also an increased risk of breast cancer but this tends to be in women who have been on HRT for more than four years.
The risk of serious side effects is low. For example, in the 50 –65 year age group, it is estimated that about 32 in every 1000 women will develop breast cancer. If the same group of 1000 women is on oestrogen for five years, then 34 of them are likely to get breast cancer. If the same group of women take combined HRT, i.e. oestrogen and progesterone for 5 years, then 38 per 1000 will develop breast cancer. It is well recognised that women on HRT who are diagnosed with breast cancer tend to have a better prognosis than those who have breast cancer and have not been on HRT. This may be because women on HRT have routine breast examinations by their doctor.
Is all HRT the same?
There are different types of HRT. Combined preparations contain oestrogen and progestogen. This is the most common type and is used in women who have an intact uterus. Pills may be either cyclical, in which case the woman will have a monthly (artificial) period, or continuous in which case there are no periods. There are different types of progestogen and some have lower risk of side effects than others.
Women who have had a hysterectomy do not need to take progestogen so they are usually prescribed oestrogen-only preparations.
HRT is usually prescribed in tablet form but patches are also available. If the main symptoms are urinary/vaginal then local treatment with vaginal pessaries may be the best option.
How long should I stay on HRT?
For the average woman who is getting menopausal symptoms around the age of fifty, HRT will generally be needed for three or four years. After this, most women will find that when they stop HRT their own hormone levels will have stabilised and symptoms will not warrant taking treatment.
Occasionally a woman may find that all her symptoms return and then she should discuss going back on HRT again for another year to eighteen months before trying to stop it again.
Young women who experience an early menopause should stay on HRT until they reach the age of fifty and then discuss with their doctor stopping HRT. This group is at increased risk of low bone density (osteoporosis) and HRT has an important protective effect on bone.
What non prescription alternatives are there?
There are a number of herbal, homeopathic and dietary remedies that claim to help various symptoms. Soya products, black cohosh and red clover are often tried. There are no controlled trials to prove that any of these work. Having said that, most are harmless and may be worth a try, particularly in women who cannot take HRT. It should be noted that black cohosh has been known to cause liver damage.
What about contraception?
Fertility decreases rapidly from mid 30s on. However, it is not zero until well after the last period.
The rule is that contraception must be continued until:
- One year after the last spontaneous menstrual period if over aged 50 years
- Two years after the last spontaneous menstrual period if under 50 years.
Using the rhythm method of contraception in the perimenopause is difficult because cycles tend to be erratic. Many women are suitable for normal combined hormonal contraception. If they do not wish to take this or have a medical reason why they cannot take it, then there are several other options available.
Other medical conditions to consider
As we get older, many medical conditions tend to become more common. It is worthwhile getting a general check up to exclude high blood pressure, diabetes, high cholesterol and possibly thyroid problems. Your doctor will also discuss family history, for example for heart disease and osteoporosis, do a breast examination, cervical smear test if needed and perhaps refer you for a mammogram and bone density scan.
Menopause Fact Sheet - Hot Flushes
This Fact Sheet focuses mainly on Hot Flushes, because when we see menopausal women in our three Well Woman clinics, most of them tell us this is the symptom which most concerns them.
Menopause Fact Sheet - Sleep Disorders
This Fact Sheet focuses mainly on Sleep Disorders that can be a result of the Menopause.
The National Institute for Health and Care Excellence (N.I.C.E) in the UK issued a comprehensive review in November 2015 of current management of the menopause. It is aimed primarily as a guideline for doctors but the information is presented in such a way that people with no medical background can clearly see the risks and benefits of treatment.
Please visit www.nice.org.uk for more information.