Menopause: what you can expect
What is menopause?
Menopause is defined as the time when your periods stop for good. It is a natural part of ageing and happens when your ovaries stop producing the female sex hormones oestrogen and progesterone.
Oestrogen plays a key role in puberty and fertility, including regulating the menstrual cycle. It also has a number of other physiological effects — it stimulates the growth of your skeleton and helps maintain healthy bones, and also helps protect your heart and blood vessels.
At menopause, changes occur in many parts of your body - not just the reproductive organs. This leads to symptoms which can be uncomfortable for some women. For those women who do get significant symptoms, a range of effective treatments is available, so it is important to talk to your doctor about your menopause symptoms.
What is the perimenopause?
The period of time from when you start to get menopausal symptoms to when your periods eventually stop altogether is known as the perimenopause.
During the perimenopause the ovaries start to function erratically and decline in function. Your periods may become irregular and may become lighter or heavier than usual. You may also have symptoms of oestrogen deficiency, such as hot flushes, vaginal dryness and sweats.
The perimenopause lasts about 4 to 8 years on average, until a woman’s very last period.
You are said to be postmenopausal once you’ve had 12 consecutive months of no periods.
When does menopause occur?
Menopause happens between 45 and 55 years of age for most women, with an average age of 51. Menopause that occurs between the ages of 40 and 45 is called early menopause and menopause that occurs before the age of 40 is known as premature menopause.
About one percent of Australian women have spontaneous premature menopause. Premature menopause can also occur if your ovaries are removed surgically, or if you have some types of chemotherapy or radiotherapy for cancer that can damage your ovaries. Sometimes in these cases menopause occurs suddenly rather than gradually and this can be distressing if you have not prepared yourself.
Factors associated with early and premature menopause include:
- being a smoker;
- having a family history of early menopause;
- having previous chemotherapy or radiation therapy for cancer; and
- premature (or primary) ovarian insufficiency (POI), which may be caused by certain genetic abnormalities, autoimmune disorders or metabolic disorders.
What are the signs and symptoms of menopause?
The first thing you might notice is that your periods may become irregular — shorter or longer, with heavier or lighter bleeding, or varying lengths of time between periods. Of course, if you are noticing any changes in your bleeding, it is important you see your doctor to rule out any medical conditions.
You might notice your skin becomes drier or your waistline becomes thicker at the expense of your hips and thighs. Sixty per cent of Australian women will have mild to moderate symptoms of menopause, with one in 5 women having severe symptoms. The symptoms most people associate with menopause include the following.
Hot flushes are the most common reason women seek treatment. They are sudden sensations of heat that often rise from your chest to your face or neck. They can last anywhere from a few seconds to several minutes and often induce a sweat — sometimes they are followed by a chill.
Hot flushes often occur at night and disrupt sleep. Some women have them several times a day and they may go on for up to 5 years or more. They often start occurring before your periods stop and continue for a year or 2 afterwards.
Some women find that hot weather, confined spaces, hot drinks, spicy foods, stress, caffeine, smoking or alcohol make hot flushes worse, while avoiding these things can help.
Other things that may help include:
- wearing layers of clothing that can easily be removed or put back on;
- using a small hand-held fan;
- trying a water spray for the face;
- learning meditation; and
- using relaxation techniques and cognitive behavioural therapy (CBT) techniques.
Hormone replacement therapy (HRT) may be recommended by your doctor if hot flushes and night sweats are frequent and impacting significantly on your life.
Alternatively, medicines such as certain types of antidepressants (e.g. venlafaxine, paroxetine), anticonvulsant medicines (e.g. gabapentin) and some medicines used to treat high blood pressure (e.g. clonidine) have been shown to be effective in treating hot flushes.
Falls in oestrogen levels can cause your vagina and vulva to become drier and the labia to become thinner, which can lead to itching, irritation or pain during sex.
You may need to use a personal lubricant or vaginal moisturiser (available from pharmacies) to make having sex easier and more comfortable.
Hormone replacement therapy (HRT) is useful for relieving vaginal dryness and may be considered if non-hormonal treatments are not effective. As well as oral HRT, there are oestrogen creams (Ovestin Cream) or pessaries (Ovestin Ovula, Vagifem Low) which can be applied directly to the vagina. HRT given in this way can effectively treat many vaginal and urinary symptoms, and reduces the risks of side effects compared with HRT taken by mouth.
Symptoms of itching may be helped by using soap substitutes (such as sorbolene) when bathing your genital area and by wearing cotton underwear.
Weakening of the bladder and thinning of the opening of the bladder (the urethra) can occur with menopause, resulting in leaking of urine when you laugh, cough or sneeze. Or you may get painful urination or the urge to go to the toilet more often. You may also be more prone to urinary tract infections (UTIs).
Your doctor or physiotherapist can show you pelvic floor exercises that should help improve muscle tone and reduce problems with urinary incontinence.
HRT given as vaginal oestrogen (creams or pessaries) has also been shown to be effective in reducing urinary symptoms of menopause.
Menopause may cause mood changes such as increased anxiety, increased irritability and feelings of sadness or depression.
Although many women experience mood changes around menopause, it is not clear whether these changes are linked to lower oestrogen levels or other issues which can coincide with this time in your life, such as career pressures, children leaving home or suddenly finding yourself caring for elderly parents.
While mood may improve with HRT, it is not routinely recommended for preventing or treating depression. Yoga and techniques such as meditation or mindfulness may help improve mood and reduce anxiety.
Other symptoms you may notice are:
- aching joints and muscles;
- disturbed sleep patterns;
- crawling feelings under the skin;
- light-headed feelings;
- weight gain;
- new facial hair;
- loss of hair from the scalp; and
- changes in sexual desire.
However, you may not get all of these symptoms — or even any of them. Some women do not experience these adverse effects and aren’t aware of any other changes in their body. Others may notice these symptoms start before they have any changes with their periods and menstrual cycle.
For most women, symptoms do not last long, but you should be aware that the lower oestrogen levels after menopause do have long-term effects on some parts of your body and can contribute to some health problems.
What health problems are associated with menopause?
Osteoporosis (literally, porous bones) means the loss of bone mass and thinning and weakening of bone.
Bone is a living tissue in a constant state of flux; the state of our bones at any time is a balance between the amount of bone being laid down and the amount of bone being re-absorbed into the body. Everybody has a slight imbalance after about the age of 30 due to the fact that the amount of bone being formed is not as much as the amount that is re-absorbed into the body. This leads to us slowly losing bone density. In women, however, at the menopause, bone turnover increases. This exacerbates the loss and the amount of bone formed cannot keep up with the amount lost and so the bones become thinner.
Other factors that increase your risk of osteoporosis include:
- low calcium intake (for example, if you do not eat much cheese, milk and green vegetables);
- drinking alcohol; and
- a lack of weight-bearing exercise.
Watching your diet and doing weight-bearing exercise such as walking, jogging, and dancing can help prevent loss of bone mass. Getting enough vitamin D through adequate exposure to sunlight with lesser amounts from the diet also helps keep bones strong.
Hormone replacement therapy reduces the risk of osteoporosis and fractures, however, because of the risks associated with its long-term use, it is not a routine treatment for preventing or treating osteoporosis. HRT may be considered for preventing osteoporosis in some younger women who also have troublesome menopausal symptoms.
There are several other medicines that your doctor may recommend for osteoporosis prevention.
Risk of heart disease
Women who have not gone through the menopause have a lower risk for heart disease than men of the same age. This is because oestrogen helps to lower a woman's cholesterol levels and improve the flow of blood through the blood vessels. But this advantage disappears after menopause when women stop producing oestrogen and their risk of coronary heart disease increases. While heart and blood vessel (cardiovascular) disease generally remains uncommon among women in their 50s, it becomes more common after the age of 60 years.
Because of the results of some studies which suggest that HRT may increase the risk of heart disease in some women, HRT is not currently recommended to help prevent heart disease in menopausal women. However, short-term HRT given in standard doses and started within 10 years of menopause or in women younger than 60 years has not been shown to significantly increase the risk of cardiovascular disease, and may perhaps even help protect against heart disease.
It’s important to remember though that HRT is not suitable for women who have known cardiovascular disease. In addition, HRT may increase the risk of cardiovascular disease in older women, and it increases the risk of stroke in all women.
Hormone replacement therapy (HRT)
Hormone replacement therapy (HRT), also known as menopausal hormone therapy (MHT), involves replacing some of the oestrogen (and also often the progesterone) that your body is no longer producing, with pharmaceutical formulations of these hormones.
Doctors may recommend HRT for the short-term treatment of the symptoms of the perimenopause and early menopause. HRT is available in various forms — as tablets or skin patches for general symptoms, or as vaginal cream or pessaries for local vaginal and urinary symptoms.
Because taking HRT can increase your risk of certain health problems such as stroke, blood clots and breast cancer, it is recommended that the lowest dose of HRT is given for the shortest period of time. HRT is not recommended for some women who are already at increased risk of these conditions.
If you are considering trying HRT, you should discuss your individual and family medical histories with your doctor, who will help decide whether treatment might suit you.
Tibolone is an alternative to HRT for women who are postmenopausal. This medicine is a synthetic steroid that has effects similar to various hormones (oestrogen, progesterone, testosterone) in the body. It is not suitable for perimenopausal women.
Tibolone is not as effective as HRT in relieving menopause symptoms. Tibolone is also associated with risks, including stroke and breast cancer in some women - your doctor can talk to you about the risks and benefits of this treatment and whether it may be an option for you.
Bio-identical hormones, made by compounding pharmacists and usually containing oestrogens and progesterone, have been claimed to be safer and more effective than conventional HRT. However, bio-identical hormones are not recommended for the treatment of menopausal symptoms. That’s because in addition to being expensive, there are concerns about their safety and effectiveness due to the fact that they are not regulated.
Complementary and natural remedies
As menopause is a natural event, some women don’t want any medical intervention, while others try complementary and natural remedies. These include:
- phytoestrogens (substances from plants that have oestrogenic properties) including soy extracts or red clover isoflavones;
- foods rich in vitamins B and E;
- black cohosh;
- evening primrose oil; and
Research into the possible benefits of such remedies is ongoing and some may not have any benefit at all. There is currently not enough evidence showing that complementary medicines are effective for doctors to routinely recommend their use. Also, ‘natural’ or ‘herbal’ remedies can have serious side effects just like other medicines. Black cohosh, for example, has been linked with several reports of liver damage.
How can I make my menopause easier?
Each woman will experience menopause differently and there is no one treatment that will suit everyone. Menopause is an entirely natural phenomenon, not a disease, and many women experience no or minimal symptoms and require no specific treatment. However, for some women it can be a very unpleasant time.
There are many things you can do to help yourself and make the transition easier. Here are some of them.
- Understanding that this is a normal part of life and allowing yourself time to adjust, and pamper yourself.
- Relaxing and doing anything which helps cut down stress.
- Exercising regularly and keeping fit. Weight-bearing exercise is particularly helpful for your bones.
- Eating a well-balanced diet and maintaining a healthy body weight.
- Talking to a counsellor if you feel it would help.
Talk to your doctor and ensure he or she understands how you are feeling at this time. If you don’t feel comfortable talking to your usual doctor, you might prefer to visit a women’s health centre or Family Planning clinic. Discussing the options available to you will help you decide on the path that’s best for you based on your symptoms and needs.
Although some parts of the media and TV still seem determined to show menopausal women in a negative light, you should try to see inaccurate stereotypes for what they are and concentrate on taking control of your life. You may well find, as many women do, that you discover a new sense of freedom and enthusiasm at this time.
2. Australasian Menopause Society. What is menopause? (updated Feb 2016). https://www.menopause.org.au/images/stories/infosheets/docs/AMS_What_is_menopause.pdf (accessed Apr 2017).
3. Jean Hailes for Women’s Health. Menopause management (30 Mar 2017). https://jeanhailes.org.au/health-a-z/menopause/menopause-management (accessed Apr 2017).
4. BMJ Best Practice. Patient information from BMJ. Menopause: should I take HRT? (updated 2 Dec 2016) http://bestpractice.bmj.com/best-practice/pdf/patient-summaries/532536.pdf (accessed Apr 2017).
5. Australasian Menopause Society. Menopause and body changes (updated Nov 2014). https://www.menopause.org.au/images/stories/infosheets/docs/Menopause_and_body_changes.pdf (accessed Apr 2017).
6. Kwik M, Baber R. Menopause and women’s health: a quick refresher. Medical Observer (17 Nov 2016). http://www.medicalobserver.com.au/medical-news/obstetrics-gynaecology/menopause-and-women-s-health-a-quick-refresher (accessed Apr 2017).