‘Focus on’ series
The medical definition of the menopause is the end of menstruation, which results from a reduced production of oestrogen by the body. The term ‘peri-menopause’ is used to describe the time surrounding the last natural menstrual period.
In the UK, the average age at which women go through the menopause is 51 years. Because women’s life expectancy is getting longer – average life expectancy in the UK is over 80 years – women can now expect to spend a third of their lives in the post-menopausal stage.
During the menopause a woman may still have monthly bleeds but the number of menstrual cycles, when no egg is released from the ovaries, increases. The levels of female hormones, oestrogen and progesterone, may fluctuate almost daily around the time of the menopause. Women’s periods then stop due to the consistently low levels of oestrogen.
Fluctuating hormone levels result in a wide range of symptoms, including:
- Hot flushes
- Night sweats
- Mood disturbances / depression / forgetfulness
- Vaginal dryness / urinary infections / pain during intercourse
The menopause occurs when the female reproductive organs, the ovaries, stop producing hormones. The time when this happens is influenced by genetic and environmental factors; for example Japanese women tend to have a later menopause, and women that smoke experience on average an earlier menopause.
A woman is born with a certain number of egg cells, and this number decreases with age until, at the age of around 45-55, very few are left. The ovaries are controlled by the hormones Follicle Stimulating Hormone (FSH) and Luteinising Hormone (LH), and as a woman ages, the ovaries become less and less responsive to these hormones and produce less oestrogen. Over time, oestrogen levels decrease and it is consistently low levels of oestrogen that cause a woman’s periods to stop.
Women lose their fertility much earlier than females of other animal species. Some scientists believe this is to protect women and children from the dangers of late childbearing, as risks of childbirth increase as the mother gets older, whilst others believe it is simply because humans live longer and women therefore run out of eggs sooner.
During the menopause, the drop in oestrogen and progesterone production leads to an increase in FSH and LH. One of the most common tests used to diagnose the menopause checks for levels of these two hormones in the blood.
The menopause is the time when a woman’s monthly periods stop permanently. The menopause is recognised when a woman has not had a monthly period for 12 months, as long as there is no other reason. The average age in the UK for the menopause is 51, and for most women it happens between the ages of 45 and 55 years old.
It’s not always easy to confirm that the menopause has actually happened. Of course, irregular periods and the occasional hot flush is a sign that changes are taking place, but timing the actual menopause is not so simple. And it’s important to know – not just preventing symptoms in the most appropriate way, but also for contraception.
A truly menopausal woman will be infertile and will have no need of contraception. However, most doctors advise menopausal women under 50 to continue with their contraception for two years after their last period and for one year if they are over 50. However, even identifying the last period can be difficult for a woman still taking the Pill (bleeding still occurs every month) or who has just started HRT for the relief of early perimenopausal symptoms. Most doctors will evaluate a woman’s menopausal status according to her symptoms (e.g. hot flushes), pattern of periods, and medical records.
Most women reach their menopause between the ages of 45 and 55. However, for some women it can happen later than that, or considerably earlier. If the menopause happens before the age of 45 then this is known as a premature menopause. Although it is rare, some women experience the menopause in their teens, twenties or thirties.
The cause of a premature menopause can be natural or surgical. Surgically-induced menopause results from removal of both the ovaries. Radiotherapy and chemotherapy can also induce an early menopause. In most cases the cause of an early menopause is unknown.
The fall in levels of oestrogen and progesterone triggers a whole range of symptoms. Around 70% of women experience symptoms with the menopause such as hot flushes and night sweats.
A common early sign of the menopause is irregular periods. Low levels of oestrogen also cause the bladder lining to become thinner, and this can lead to loss of some control of the bladder.
Two of the most common symptoms associated with the menopause are hot flushes and night sweats. Caused by a malfunction in the body’s methods of controlling body temperature, they can occur at any time of day or night and are most common in the year following the final period. The disturbance of sleep patterns as a result of these symptoms can in some cases lead to insomnia, which in turn may cause depression.
Hormonal changes taking place around the menopause may impact on a woman’s sensory perception, leading to sexual problems, difficulty in becoming aroused and inability to climax during sex. Vaginal dryness is also associated with the menopause, caused by lower oestrogen levels, and can make sex uncomfortable or painful.
Whilst there is no scientific evidence to suggest changes in hormone levels result in psychological changes, many women experience symptoms such as mild depression, irritability and loss of interest in sex during the menopause. Such symptoms may be caused by stress due to physical changes taking place, or by the emotions of going through a major time of change.
Long-term effects of the menopause
The short-term effects of the menopause are of great concern to many women. However, there are also long-term symptoms associated with oestrogen deficiency that can cause more serious health problems. Decreases in oestrogen levels result in increased risk of osteoporosis.
Osteoporosis, the thinning and weakening of the bones, is aggravated by the menopause as oestrogen has a protective effect on bones.
How can the menopause be treated?
Each woman will be affected differently by the menopause and management must be defined via a joint approach between a woman and her healthcare team.
Possible treatments include counselling, dietary and exercise regime, anti-depressants and Hormone Replacement Therapy (HRT) for relief of menopausal symptoms.
Treatment and options
Hormone Replacement Therapy (HRT) is a treatment prescribed by a doctor to women going through the menopause. Around the time of the menopause the ovaries gradually stop producing the hormones oestrogen and progesterone. HRT replaces these hormones. It is a proven treatment for hot flushes and vaginal discomfort.
HRT is usually a combination of two types of hormone, oestrogen and progestogen. The role of oestrogen in HRT is to replace the oestrogen lost as a woman goes through the menopause. Loss of oestrogen is the cause of menopausal symptoms, both short and long-term. There are two types of oestrogen most commonly used in HRT preparations; estradiol, and conjugated equine oestrogens.
The role of progestogen is to protect the lining of the womb (the endometrium). Progestogen, the synthetic form of progesterone in HRT, helps to prevent changes in the endometrium which may develop in to cancer.
Women who have had a hysterectomy, and so have had their womb removed, do not generally need progestogen and therefore can take oestrogen only HRT.
Hormone replacement therapy regimens use different types of oestrogens and progestogens. Not all types of HRT will suit all women and it is important for the women to discuss her options with her GP or nurse to find the most suitable form of treatment. For women starting HRT, experts recommend that the starting dose is low, e.g. 1mg estradiol, which will provide relief from symptoms while minimising side effects.
The main types of HRT
Cyclical or sequential
This form of HRT mimics a menstrual pattern. Oestrogen is taken every day and progestogen is taken as well for 10-14 days every month. A bleed usually occurs at the end of the progestogen course. This form of HRT is recommended for women who have had a natural menopause within the last year, or who are approaching the menopause but still having periods and menopausal symptoms.
Oestrogen – only HRT
This type of HRT is used by those women who have had either their ovaries and womb, or just their womb, removed by a hysterectomy, and therefore have no need for progestogen to protect the womb lining.
Continuous Combined HRT or period-free HRT
This is a ‘period – free’ form of HRT. Breakthrough bleeding and spotting may occur during the first months of treatment. Combinations of oestrogen and progestogen are taken every day. This type of HRT is recommended for those women who have not had a period for at least one year and are therefore truly postmenopausal.
This form is used to treat local urogenital problems such as vaginal dryness. Local therapies raise the local hormone levels but do not affect the whole body. This includes tablets, creams, pessaries and rings which are inserted into the vagina, where the oestrogen helps reduce vaginal dryness.
A synthetic form of period-free HRT, which may have similar benefits to oestrogen. It is taken continuously in tablet form.
HRT can be delivered in tablets (orally, or inserted into the vagina), transdermally (through the skin) by skin patch or gel, or directly into the blood stream (parenterally). Parenteral delivery systems include nasal sprays, vaginal rings and implants. There is no clear evidence available to suggest that one system is better than the other, it is more a case of which is most suitable to each individual and a woman’s choice.
When to start HRT?
There is no need to wait until periods stop before starting HRT. Symptoms may start months or even years before periods stop.
Potential side effects of HRT
There may be mild side effects when taking HRT, but these usually resolve within a few months. The common side effects are breast tenderness, irregular bleeding and feeling bloated. Some side effects can be reduced by using a lower dose of hormones. Women should discuss any concerns with their doctors.
Benefits of HRT
The replacement of oestrogen through HRT addresses the complications of the menopause caused by the drop in oestrogen levels and, therefore, reduces menopausal symptoms. Symptoms can respond rapidly to HRT treatment. Relieving hot flushes, particularly those occurring at night, can help to improve a woman’s sleep pattern and hence reduce irritability, insomnia and tiredness. Hot flushes and night sweats usually improve dramatically within a short time of starting HRT. In addition, many women experience an improvement in their psychological well-being after starting HRT. HRT can often dispel a wide range of psychological problems such as disturbed sleep, loss of interest in sex, tiredness, difficulty in remembering things and concentration, over-sensitivity, tearfulness and feelings of irritability, anxiety and depression.
Taking HRT, especially in the longer term helps to reduce the risk of osteoporosis, however, the results of the Women’s Health Initiative Study in the US found that the risk out weighed the benefit. Therefore, HRT can not be recommended as a first-line therapy for the prevention and treatment of osteoporosis except for women requiring treatment for menopausal symptoms (J R Coll Physicians Edinb 2004; 34 (suppl 13) p2).
There may be other long-term benefits of HRT which are less well known. Studies have shown HRT may reduce the risk of bowel cancer; however, this is still an area that requires further investigation. It is now accepted that HRT does not have a benefit in reducing the risk of Alzheimer’s.
The main risks that have been linked with HRT are breast cancer, deep venous blood clots and stroke.
Every woman is at risk of developing breast cancer and that risk becomes greater with age. Many studies have been undertaken to establish the link between increased breast cancer risk and HRT. The absolute risk is small and equates to an extra 2 to 6 cases of breast cancer per 1,000 women treated with combined HRT for five years (J R Coll Physicians Edinb 2004; 34 (suppl 13) p3), and 1.5 cases for women treated with unopposed HRT (Current Problems in Pharmacovigilance, Committee on the Safety of Medicines Vol 29, Sep 2003 p3).
Deep venous blood clots
Venous thrombo-embolic disease (VTE) occurs when veins are blocked by blood clots. As with breast cancer, all women have a very small risk of developing blood clots in the leg whether or not they take HRT. The risk for women between 50 and 59 not on HRT is 3 per 1,000 women. For women on HRT over 5 years in this age group, there is an additional 1 case per 1,000. Risk of VTE increases with age for example 8 cases per 1,000 in the 60-69 age group of non-HRT users, rising to 9 per 1,000 for HRT users over 5 years. (Current Problems in Pharmaco-vigilence, Committee on the Safety of Medicines Vol 29 Sep 2003 p3)
Cardiovascular disease and stroke
HRT increases the risk of stroke and may increase risk of heart attack. It is estimated that about 3 in every 1000 women aged 50-59 years not using HRT will have a stroke over 5 years; this figure rises by about 1 extra case in 1000 in those using HRT for 5 years. About 11 in every 1000 women aged 60-69 years not using HRT will have a stroke; this figure rises by about 4 extra cases in 1000 in those using HRT for 5 years. (Current Problems in Pharmacovigilance, Committee on the Safety of Medicines Vol 29 Sep 2003 p3) A woman requiring HRT for menopausal symptoms should have her coronary heart disease risk assessed. Women already on HRT who have no increased cardiovascular risk or disease have no need to stop. (J R Coll Physicians Edinb 2004; 34 (suppl 13) p2)
HRT in the media
There was widespread publicity, much of it adverse, following the publication of the results of two trials: the Women’s Health Initiative (WHI) 1993–2004 and the Million Women Study (MWS) 1996–2001. Both studies had shortcomings and we suggest that you look at leaflet HRT: Benefits and risks – what you should know. This provides a balanced, current summary of the situation.
How long should I take HRT for?
Although not all women will need or benefit from HRT, many women will benefit from the relief of symptoms of the menopause. The decision to use HRT should be discussed with each woman on an individual basis taking into consideration her history, risk factors and personal preferences. It is important that each woman and her GP weigh up the benefits and the risks of using HRT which will be specific to her own situation, especially if the long term use of HRT is being considered. The lowest possible dose should be used and regularly reviewed.
When oestrogen therapy is not tolerated or is contraindicated, a number of alternative therapies can be considered
Dietary supplements and complementary therapies
There are a huge number of menopausal women taking dietary supplements and complementary therapies today. However, there is little scientific evidence to prove that all complementary therapies actually work. Some dietary supplements, however, may be necessary. Anecdotally, many women find that these complimentary therapies help to relieve menopausal symptoms. Before starting any therapies for the menopause, whether prescribed, complementary or alternative, it is vital that you discuss your intentions with your GP.
Both advancing age and the menopause increase the risk of heart disease and stroke. It is, therefore, a good idea to cut down on other lifestyle factors that are known to increase these risks – smoking, being overweight, a diet high in fat, salt and sugar. Exercise is of benefit both to maintain or achieve a health weight, and also to reduce the risks of osteoporosis. Gentle regular exercise may also help reduce other menopausal symptoms such as hot flushes.
This article is supported by an unrestricted educational grant from Novo Nordisk. It has been produced by Women’s Health Concern and reviewed by one of our Medical Advisory Panel.
Review date: March 2011
© Women’s Health Concern. Charity No. 279651
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