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Menopause

Menopause is often referred to as the ‘change of life’ because it marks the end of a woman’s reproductive life. Menopause literally means that a woman has had her last (or final) menstrual period.

Most women become menopausal between the ages of 45 and 60 with the average age for Australian and New Zealand women being 51 years.

Each woman will experience her menopause in her own way. Many will have only minor discomfort but others will experience a range of troubling symptoms. These symptoms are commonly short lived but, for some women, will persist for over a decade.

Knowledge of the menopause and the symptoms is important to help you decide how best to manage your symptoms and maximise your quality of life.
 
Perimenopause
Perimenopause is the time leading up to the last menstrual period and for one year after this.


During this time, menstrual cycles often become irregular and you may start to experience symptoms such as hot flushes, night sweats, muscle and joint aches and pains and breast tenderness.

Premature menopause​
Menopause before the age of 40 is premature and is also called Primary Ovarian Insufficiency (POI).

Women with POI experience a premature menopause either because their original supply of eggs is less than normal or because the rate at which they are used is greater than normal.

This may be caused by genetic abnormalities, autoimmune or endocrine disorder and some cancer treatments, although in many cases the reason is unknown. Removal of the ovaries will cause an immediate menopause.

POI usually results in loss of fertility that may cause great distress to young women still hoping to have children. In this situation the only proven treatment is donation of eggs or embryos. However, almost 50% of women with POI of unknown cause will have periods again and 5 to 10% may become pregnant.

Women with POI usually require hormone therapy until at least the normal age of the menopause is reached. Higher doses of hormones than those prescribed for women in their 50s are often required, although the possible risks of long-term Menopausal Hormone Therapy (MHT) seen in older women do not apply to these young women.

Diagnosing the menopause​
Menopause is diagnosed by the absence of menstrual periods and the presence of menopausal symptoms.

Blood tests are not usually helpful except if you are suspected of undergoing a premature menopause and unless you have undergone a previous hysterectomy when a diagnosis based on symptoms and signs is unclear.
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Menopausal signs and symptoms
Irregular periods are one of the first signs of an impending menopause.

You may notice your periods may be either more or less frequent but, as menopause approaches, they usually become less and less, while the other symptoms become more prominent. These include hot flushes, night sweats, insomnia, muscle and joint pains mood changes, vaginal dryness and discomfort with sex.

Hot flushes
Hot flushes and night sweats are the commonest
menopausal symptom experienced by Australian and New Zealand women.


A hot flush is a sudden feeling of warmth or heat starting centrally and spreading over the face neck and chest. It is usually accompanied by a reddening of the skin, an increased heart rate, palpitations and tiredness. A hot flush may last from a few seconds to a few minutes and may occur day or night with varying frequency. Most women will experience hot flushes for up to five years but for some they will persist beyond 10 years. Hot flushes and night sweats may also lead to disturbed sleep, tiredness and forgetfulness.

Mostly, hot flushes arise spontaneously, however there are a number of known ‘triggers’ including alcohol, caffeine and hot drinks. Avoiding these may help to reduce these symptoms.

Muscle and joint pains
Muscle and joint pains, due to loss of the hormone estrogen, are a common symptom of the menopause and in Asian women they are more common than hot flushes.

Vaginal and urinary symptoms
Estrogen is important in maintaining the health of the vagina and surrounding tissues. Low estrogen causes the vaginal lining to become thinner and dryer and to lose elasticity. This may cause pain with intercourse, an annoying discharge, the need to urinate more often than usual (frequency) and an increased risk of urinary tract infections.

Sexuality
Many women find their sexual feelings and desires change around the menopause. It is normal for both men and women to experience a decline in sexual desire with age; however, the physical changes and symptoms associated with the menopause may make these worse.

Vaginal dryness together with loss of elasticity may cause pain with intercourse. Hot flushes, night sweats and disrupted sleep will also affect sexual desire.

These symptoms are common and you may find it helpful to discuss them with your partner, friends or doctor.

Psychological changes
The hormonal changes and symptoms that occur around the menopause may contribute to mood changes, anxiety and irritability, forgetfulness and difficulty making decisions. Low levels of estrogen are associated with lower levels of serotonin, a neurotransmitter that regulates moods, emotions and sleep.

Although depression is not more common at the menopause, a past history of depressive illness may make a woman more likely to experience mood problems at this time.

The ‘mid-life’ consultation
All women should have regular health checks with their doctor. The ‘mid-life’ check, around the time of the menopause is particularly important. This is a time when your doctor will want to do tests, such as a mammogram, a pelvic examination and Pap smear.

It is also a time to discuss irregular periods, possible menopausal symptoms and the need for contraception.

Even though menopause marks the end of reproductive life, you should still use contraception for 12 months after the LMP if it occurs after age 50 and for 2 years if before age 50.

General health checks such as blood pressure, cholesterol and sugar levels, thyroid function, kidney and liver function, iron levels and faecal occult blood testing are also included.
 
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Heart disease
Heart disease is the commonest cause of death in women in Australia and New Zealand. Heart disease is more common in men but, following the menopause, the risk increases in women.

There are a number of possible explanations for this, including ageing, lifestyle changes and metabolic changes. However, the menopause has a significant impact and the risk of heart disease is always higher for menopausal women, regardless of their age, compared to women of the same age who are still having regular menstrual periods.

Scientific studies have shown that, for postmenopausal women within 10 years of their last menstrual period, estrogen therapy reduces the risk of cardiovascular disease. However, it is not
recommended that hormone therapy be used to prevent or treat cardiovascular disease, instead healthy heart and lifestyle choices should be used to prevent heart disease. 
 
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Osteoporosis
Osteoporosis is a condition where bones become weak and more likely to break due to loss of calcium and other minerals, plus loss of normal bone structure.

Calcium loss is a normal part of ageing but it happens more rapidly after menopause.

Bone is living tissue that is constantly being renewed as old bone is broken down and replaced with new bone. Around the menopause, the rate of breakdown of bone is greater than the rate of replacement, resulting in a loss of bone tissue and an
increase in risk of broken bones.

Avoiding osteoporosis is a life-long task and should begin with a healthy diet, adequate dietary calcium, vitamin D, regular exercise and maintenance of normal weight.

Managing menopause

Menopause is a normal part of ageing. As we age, the risk of many common illnesses increases and optimising health at the menopause may help to improve both physical and emotional health.

Diet and exercise
Diet and exercise, as outlined in National guidelines, will contribute to your optimal health and wellbeing.

Lifestyle changes including stress reduction, regular exercise, optimal weight management, appropriate diet and avoidance of smoking and excessive alcohol and caffeine intake should be considered.

Hot flushes
Hot flushes are the commonest menopausal symptom and often start before menstruation has completely stopped.

Simple measure to manage these include avoiding ‘triggers’ such as caffeine, alcohol and hot environments, dressing in layers and sleeping in a cool room may also help.
 
Hormonal preparations
The primary cause of menopause symptoms is declining levels of estrogen and scientific studies have shown that estrogen therapy eases these symptoms more effectively than any other treatment. Hormone Replacement Therapy (HRT) also known as Menopausal

Hormone Therapy (MHT) comprises estrogen-only for women who have had a hysterectomy and estrogen plus a progestogen for women who still have their uterus.

MHT may be taken as tablets, applied to the skin as a gel or patch, transdermal (placed under the skin as an implant) or applied vaginally as a cream, pessary or tablet if your symptoms are confined to the vagina and bladder.

Risks and benefits of MHT​
Before starting MHT, your health checks should be up to date.

Risks

Short-term side effects of MHT may include breast tenderness, fluid retention, mood changes, menstrual spotting and bleeding. If you are experiencing these side effects, talk to your doctor as they are usually dose-related and easily corrected. MHT does not cause weight gain.

Women who take MHT in tablet form have a small increase in the risk of thromboembolism (blood clots in the veins). The increase in risk is between one and two per 1000 each year for women aged between 50 and 60 years.

This risk is reduced if MHT that is absorbed through the skin (such as patches or gels) is used. If you have had a blood clot in the past, you should not start MHT.

Long-term use of combined MHT may be associated with an increased risk of breast cancer. This risk is less than one in 1000 women, and is not seen for seven years in women using MHT for the first time.

Estrogen-only therapy does not increase breast cancer risk, and the chance of dying from breast cancer is not increased in women using MHT.

Benefits
The reason your doctor may prescribe MHT is to ease troublesome menopausal symptoms and improve your quality of life. MHT is known to improve the density of bones and reduces the risk of broken bones due to osteoporosis.

Women aged 50 to 60 years who use oestrogen therapy after menopause have a reduced risk of cardiovascular disease.

There is no specific length of time that a woman should remain on MHT. Dose and duration of therapy should be consistent with treatment goals and you should have an annual wellness check to determine whether or not to continue.

Many women will consider using complementary therapies such as phytoestrogens. These estrogen-like compounds are found in all plants, but in highest quantities in legumes including beans and soy products. Some women find these compounds beneficial, although scientific studies have found them no better than a placebo.

A lack of response after six weeks should be seen as a reason to stop. Similar data exist for the herb Black Cohosh. Dueto possible adverse effects on the liver, it is recommended that Black Cohosh treatment be ceased after six months.

All complementary therapies may have side effects and may interact with prescription medicines, so it is important that you tell your doctor if you are using these preparations.

DISCLAIMER: This information is intended to be used as a guide of general nature, having regard to general circumstances. The information presented should not be relied on as a substitute for medical advice, independent judgement or proper assessment by a doctor, with consideration of the particular circumstances of each case and individual needs. This information reflects information available at the time of its preparation, but its currency should be determined having regard to other available information. RANZCOG disclaims all liability to users of the information provided. 
 

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