What is Menopause?
The menopause is the brief time when a woman’s reproductive life comes to an end. The ovaries stop producing eggs, the hormone “oestrogen” is no longer secreted and the menstrual periods end.
The average age of menopause in developed countries is around 51, with many women beginning to have symptoms from their mid- to late 40s. Some women may face the menopause earlier either physiologically or as a consequence of medical treatment or surgery. Women who smoke seem to reach the menopause earlier than non-smokers.
The symptoms of menopause are primarily a result of oestrogen deficiency; they may be physical but may also affect different organs and systems. They may be temporary (for example, night sweats and hot flushes) or long-term (for example, bone-thinning disease known as osteoporosis).
Common signs of Menopause and symptoms of Menopause
The initial signs of the menopause are erratic menstrual periods, with monthly cycle becoming shorter and the bleeding heavier. Changes to the skin and the urinary system may occur. The sex drive (libido) may change and other psychological changes such as mood swings, depression and anxiety may be experienced.
A decrease in bone density is a natural part of ageing but occurs more rapidly during and after the menopause, progressively continuing throughout this part of life. A decrease in bone density (osteoporosis) puts women at a higher risk of fractures and related long-term consequences. Therefore, post-menopausal women should supplement their healthy diet with extra calcium and Vitamin D in addition to regular weight-bearing exercise. It is important to check the bone density of post-menopausal women every three years.
The use of hormone replacement therapy may be appropriate in certain cases; however specialist opinion has to be sought.
Hot flushes and night sweats (also known as vasomotor symptoms)
These symptoms are the result of the body’s inability to control its temperature due to the lack of oestrogen. Hot flushes and night sweats tend to come mostly in the year following the last period. They can be very uncomfortable, embarrassing and can affect sleep. Apart from self-help (wear cotton, take plenty of cool showers, avoid hot drinks and spicy food) there are several alternatives to minimise the vasomotor symptoms.
It can be caused by a weakening of the pelvic floor muscles. Incontinence is usually characterised by a leak of urine after coughing, sneezing and/or taking physical exercise. During the menopause, the chances of incontinence increase because the tissues supporting the bladder are further weakened due to oestrogen deficiency.
Hormone replacement therapy, bladder self-retraining and regular pelvic floor exercises have been shown to help incontinence, reduce urinary tract infections (water infections) and strengthen the muscles that support the bladder.
Loss of interest in sex (loss of libido)
A drop in sex drive often goes hand-in-hand with other symptoms during and after the menopause. This can be influenced by a variety of factors. The psychological symptoms of menopause — mood swings, depression, sleeplessness and vasomotor symptoms — weigh negatively on sex life. Oestrogen deficiency can also cause vaginal dryness and thinned vaginal walls, which can cause soreness and burning during intercourse, hence in turn affecting sex drive.
These problems are often helped by talking them through. A sympathetic partner (or husband) may be very useful. However, as hormone imbalance and deficiencies are at the root of this symptom, the use of topical hormone therapy (vaginal cream) may be very effective to restore a normal sex life.
Before the menopause, the vagina hosts bacteria and yeasts (unicellular fungi) which form a natural barrier to infection. Oestrogen contributes to provide the correct environment for these organisms. After the menopause, oestrogen levels inevitably fall resulting in a change in bacterial types and promoting an environment more conducive to bacterial growth. This commonly causes vaginal itching, burning sensation and discomfort. Some women might also experience the urge to urinate more frequently.
During and after the menopause is common to experience mood swings, anxiety, depression and irritability. Although it is plausible that fluctuating hormone levels are responsible for these symptoms, however there is no definite evidence for this cause-effect relationship. External stimuli due to changes in career and marriage, children growing up and leaving the home, loss of parents and relatives, and fatigue from other menopause symptoms (for example, sleeplessness) may play a role in the onset of psychological symptoms.
Relaxation therapy, stress reducing measures and regular physical exercise often buffer these and other menopause symptoms. Hormone replacement therapy should not be considered as a first line therapy.
Hormone Replacement Therapy
What is HRT?
Hormone replacement therapy (HRT) refers to the use of oestrogen or a combination of oestrogen and progestogen medication for menopausal and post-menopausal women. HRT replaces the body’s lost oestrogen and often brings great relief of vasomotor symptoms (night sweats and hot flushes) and vaginal atrophy, and reduces the risk of osteoporosis. HRT will not correct any deformity that may have occurred in established osteoporosis.
Different kinds of HRT might be prescribed. There is no “one size fits all” treatment. HRT has varying doses of oestrogen and progestogen, and these can be altered to maximise the efficacy of treatment. A combination of oestrogen and progestogen is generally prescribed except for women who have had a hysterectomy who normally need no other hormone but oestrogen on its own, unless any other coexistent medical problem that require combined therapy.
Further, women who have had a hysterectomy and bilateral salpingo-oophorectomy (removal of the uterus, both tubes and ovaries) may suffer symptoms of “female androgen deficiency syndrome — FADS” which includes loss of libido, loss of energy, loss of self confidence, anxiety and headache. These women may benefit from a combined therapy with oestrogen and low dose testosterone, which may be in the form of tablets or implants. Testosterone will replace the missing ovarian androgens, which are produced during the normal reproductive life and until the menopause, either physiological or surgical.
There are preparations of HRT that combine the effects of oestrogen and progestogen in a single tablet without the need for monthly period (period-free HRT), and forms of HRT where a short course of progestogen is taken each month and periods start after the progestogen is stopped (monthly-bleed HRT). It is recommended that period-free HRT is given only to women who have not had a period for at least 12 months or who are aged over 54 and currently on a monthly-bleed HRT.
Absolute contraindications to HRT are: active deep-venous thrombosis (DVT), active liver disease, recent cardio-vascular event, endometrial cancer and breast cancer.
Different types of HRT
- Tablets (taken orally)
- Implants (a small pellet of oestrogen inserted under the skin and replaced at regular intervals)
- Patches (applied to the skin and allow a smaller dose to be given than by tablets)
- Gel (a daily measure of oestrogen is rubbed on to the skin)
- Vaginal preparations (oestrogen is placed directly into the vagina in the form of cream, tablet or ring device)
- Nasal sprays (delivery of oestrogen in a measured dose via an inhaler)
Potential side effects of HRT
When a woman first starts taking HRT she can complain of some minor transitory side effects such as bloating, headache, vaginal spotting, breast tenderness, leg cramps and nausea. They generally tend to disappear within a couple of months.
Thrombosis (blood clots) — there is a slight increase in the risk of blood clots in women who receive HRT. The risk in the general population is 1:10,000, while in women taking HRT it increases to 2:10,000.
Breast cancer — as suggested by some studies, long-term exposure to HRT increases the risk of developing breast cancer. The estimated increase in risk differs according to the type of HRT taken. Postmenopausal women taking HRT for more than 5 years should be advised to have a mammogram every 18-24 months.