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Menopause

The menopause represents the beginning of a new phase of your life. 

When does the menopause occur?

In our Australian community the average age of onset of the menopause is 51 years, but this may range from 40 – 60 years. 


If periods cease before 40 years this is considered to be premature menopause and those few women who are affected should consult their doctor if they are concerned. 


If periods continue after 56 years of age there may be other reasons for the bleeding and a doctor should be consulted about this.

What is the menopause?

Literally menopause means the last period. The term “the menopause” is commonly used to refer to the time around when menstrual periods stop or when a woman experiences symptoms associated with the end of menstruation. 


Leading up to menopause the periods may alter, occurring less frequently, irregularly or with increasing frequency. The bleeding may vary, from a darker loss to heavy bleeding with clots and flooding.

Why does the menopause occur?

Changes associated with menopause occur because the number of ovarian follicles (eggs) within the ovary decreases with age and thus less of the hormones, oestrogen and progesterone, are produced. The decrease in hormones leads to the endometrium (lining of the womb) failing to grow and therefore there is no period.

Previously in a normal menstrual cycle the lining cells were shed with the period. This changing time, a climacteric, may take up to, on average, 5-6 years. During this time the body is influenced by the decreasing hormone levels in many ways, both physically and psychologically.

Other events that may occur around the same time

Often this is a time of change in other aspects of a woman’s life: when parents may become dependent or die, or children leave home or return home after a period of independence. These changes may be a source of stress and as such may be a contributory factor to a woman’s experience of the menopause.


Other changes may occur such as independence from the responsibilities of young children, new opportunities in education or career, or new lifestyle opportunities with the retirement of one’s partner from work.


Some women see the menopause as the 'beginning of the end', the beginning of old age, and the end of femininity and sexuality, but this is a myth. It can be the beginning of a new phase of life when a woman has more freedom to develop interests and take up new opportunities

What symptoms may occur?

Many women go through menopause without experiencing any difficulties. Other may experience uncomfortable symptoms such as dryness of the vagina or hot flushes. The frequency and intensity of symptoms vary from woman to woman, so that no two experience menopause in the same way.


The most common symptom experienced is hot flushes. The hot flush may vary from a mild and occasional sense of body heat to a frequent, florid redness and heat of the face and upper body associated with marked sweating, palpitations (racing of the heart), nausea and dizziness. This may occur both during the day and at night. 


When severe flushes are experienced at night, they cause the woman to wake up and often be covered in sweat. She may become increasingly tired and irritable when these flushes and sweats occur at frequent intervals throughout the night.


The vagina may become dry because the natural lubrication no longer occurs. With this dryness, intercourse with one’s partner may become painful and as a result many women become less interested in sex. The skin around the vaginal opening is also dry and with time becomes thin and may narrow. At the same time the urethra (the passage through which urine is discharged from the bladder) may also become atrophic (thinning of the cells). This may lead to passing urine more frequently and being more susceptible to urinary tract infections or ‘cystitis’.


The joints may ache, giving a feeling of being ‘arthritic’. The skin over the body may become drier and thinner, and may itch like ‘ants under the skin’. Hair may also become coarser. 


Unfortunately, weight gain may occur despite no change in diet, with an increase around the abdomen and the upper thighs. The breast shape may alter as breast size decreases.


Around the menopause, some women experience changing moods, decreasing ability to cope with normal life stresses, forgetfulness, and a lessening of self esteem. As these changes occur, tiredness and lethargy may reduce a woman’s capacity to carry out normal life routines and she may become depressed. These symptoms are made worse by physical symptoms such as hot flushes.

What long term effects may occur after the menopause?

Osteoporosis (thinning of the bones)

From the time of the menopause, the bones lose calcium and the internal framework thins. This thinning is fastest in the first five years after the periods stop and in time the bones may become brittle so they may fracture easily, most commonly at the wrist, spine or hips.

A number of factors put a woman a risk of osteoporosis:

Family Factors

  • a thin build
  • European or Asian origin
  • family history of osteoporosis

Lifestyle Factors

  • smoking
  • alcohol
  • caffeine
  • poor diet (particularly lack of calcium)
  • previous long periods of amenorrhoea (lack of periods)
  • Anorexia nervosa, sports amenorrhoea
  • prolonged periods of immobilisation
  • regular use of particular medications, eg. Cortisone, thyroxine

Atherosclerotic cardiovascular disease (a form of heart disease)

This may lead to high blood pressure, with an increase in frequency of heart attacks in women following the menopause. 

Special forms of cholesterol (high density lipoprotein – HDL) protect the body against thickening on the inside of blood vessels (atherosclerosis). These special forms of cholesterol are increased in women in the childbearing years and therefore give protection from atherosclerosis in those years. After the menopause when oestrogen levels are low the same protection does not exist, with the resultant rise in low density lipoprotein (LDL) which increases the risk of atherosclerosis.

How should a woman manage her menopause?

The woman should be aware of what body changes are taking place at this time of her life. It is important to read, talk, discuss and understand the menopause so that the woman may prepare for this new life phase. A healthy diet is necessary, especially of calcium-containing, fat reduced food (eg. milk, cheese, yoghurt). 


Some women are allergic to dairy products, do not like them, find they put on weight, or may be prescribed diets without dairy products for health reasons and therefore should take calcium supplements. Calcium is necessary for healthy bone growth and other body processes and is lost from the bones after menopause. About 1000 – 1500 mg of calcium per day is a recommended dose.


Diets with foods containing phytoestrogens (plant oestrogens) may be beneficial in providing heart disease protection and perhaps cancer protection. These foods include linseed alfalfa, soybean foods, cabbage, peas, beans and grains.


A woman should improve or maintain her body fitness by regularly exercising. Walking is best form of exercise as it has a positive effect on the weight-bearing bones (spine and legs) and may stimulate bone growth. Brisk walking three or four times per week for about 40 minutes appears to maintain fitness. Swimming, aerobics or other exercise programs will also improve fitness.

Should a woman see her doctor when the menopause occurs?

A woman should have a regular check-up, preferably every year. She should have her blood pressure and breasts checked and a vaginal (internal) examination and a regular cervical (Pap) smear (usually recommended every 2 years). If she is distressed by menopausal symptoms she should tell her doctor, so that together they can decide on an appropriate course of action.


A mammogram (X-ray of the breasts) should be recommended, especially if a woman has a history of breast lumps or a family history of cancer of the breast. 


A simple blood test may be performed to measure whether the ovaries have ceased to produce oestrogen, however, before the periods have stopped this may not be helpful. This test, which is called serum FSH (follicle stimulating hormone), measures a hormone of the pituitary gland in the brain. This hormone, FSH, rises at the menopause as the ovaries cease hormone production. Another test may also be recommended, a serum oestradiol, which measures the level of one of the oestrogens produced by the ovary. 


A serum cholesterol test may be performed to assess the risk of heart problems, particularly atherosclerosis. The blood samples for both of these tests can be taken at the same time.


A bone density test can be performed to measure how dense the bones are, how much calcium they contain and whether there is an increased risk of osteoporosis. This test, which is non-invasive, can be performed in three ways: a measurement of the density of the forearm, the hip or spine.


Depending on the result of these tests and the distress caused by the symptoms, the doctor may suggest; a) lifestyle changes such as increasing exercise, change of diet, losing weight, or b) Hormone replacement therapy (HRT). Alternatively HRT, may be recommended in the absence of any symptoms, to prevent long term problems of osteoporosis or atherosclerotic cardiovascular disease.

Therapies

Hormone replacement therapy, what does it do?

Hormone replacement therapy is the most common medical treatment for menopausal symptoms. Women who have had cancer of the breast or thrombosis may be advised to have alternative treatment, although in certain cases they may still be prescribed HRT. 


As the name suggests, HRT, replaces the hormones that the body is now producing in lesser amounts and so reverses the effects of low oestrogen on the body. HRT is prescribed to treat many of the symptoms previously described. Although mood change and depression may be helped by HRT this is not always so. HRT will protect against, or stop, the progress of osteoporosis, and will protect blood vessels against developing atheroma (thickening).


Most women, however find they feel better when taking HRT, their symptoms diminish or cease, they sleep better, have more energy and their quality of life improves.

What about ‘natural’ medicines?

Diet and exercise may be used to diminish symptoms but evening primrose oil capsules and vitamin E are sometimes recommended to reduce hot flushes as an initial treatment. Complementary therapist may prescribe a combination of herbs to reduce symptoms and increase well-being.

 

All herbal preparation are also medicines and should only be used as prescribed and under the supervision of a registered naturopath or complementary therapist. Prolonged unsupervised use of herbs eg. Ginseng can lead to abnormal vaginal bleeding as it may stimulate growth of lining cells in the uterus, which may be adverse effects.

Summary

The symptoms associated with the menopause may be quite incapacitating for a small number of women. Hormone replacement therapy is available to all women who symptoms are troublesome, to those with a risk of osteoporosis and those who choose HRT for its protective capacities on bone and blood vessels. Women should feel free to seek advice from their doctor about what options are available for treating menopausal problems, so that she may have a fulfilling life in good health, physical fitness and with a positive attitude to life in the post menopausal years.