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Lyn has been a university lecturer for many years. With a husband, two children and a dog, she also has a busy time at home. She always seems to take things in her stride. So I was rather surprised when she came in one day looking really upset and agitated. " I just feel awful," she said. " I'm 51 and I think I'm packing up." 

We spoke for a while about how she was feeling, and how things were going at home and at work. Apparently, for the last six months she had been getting hot flushes. " They even come over me while I'm giving a lecture," she said. " I feel like I am absolutely glowing at times." 

" But it's not just the hot flushes," she said. " My periods are all over the place, and I just don't feel well." Lyn went on to explain that she had become moody at home, to the point of getting quite teary at times. Her relationship with her husband had also lost its spark, and she had not been enjoying sex like she used to. " We seem to pass like ships in the night," she said. " And when we do get around to having sex, it hurts anyway." 

Although there are several other things going on in Lyn's life, there seemed little doubt that she was having quite a few menopausal symptoms. I offered her a booklet and a video about the menopause and the various treatment options. Lyn was already well read on the subject and she had already been looking into the pros and cons of hormone replacement therapy. 

She agreed to come in the following week for a general check and a Pap smear. Examining her, everything appeared quite normal. We arranged for her to have a mammogram and a basic blood test, including a hormone assay and a cholesterol level. 

Earlier this century, menopausal symptoms were of little relevance. Many women died before reaching the menopause, or shortly afterwards. And for those who did make it into their 50's or 60's, there was no effective treatment anyway. 

These days the menopause and hormone replacement therapy (HRT) seem to be continually discussed, in the media, the medical journals and over the dinner table. Doctors are recommending HRT more widely and it is likely that there will be a steady increase in the proportion of women on HRT. 

Strictly speaking, the menopause means the time when periods cease. However, symptoms like hot flushes and tiredness can be present for months or years before the periods actually stop. Most people use the word menopause to describe the time when these changes are going on; sometimes it is still referred to as " the change of life". The menopause and its associated changes are due to the ovaries winding down in function. 

Throughout the reproductive years, the ovaries cyclically release oestrogen and progesterone. These hormones protect women to some degree against illnesses like heart attack and stroke. With the menopause the output dramatically drops and an oestrogen deficiency state inevitably follows. It usually occurs in women in their late 40's or early 50's. Sometimes it happens at an earlier age. 

A number of menopausal symptoms can occur... 

  • Hot flushes, sweats, headaches and palpitations. 
  • Psychological symptoms like mood changes and depression. 
  • Vaginal dryness and irritation, sometimes making sexual intercourse very uncomfortable. This might be associated with a loss of interest in sex. 
  • Weakening of some of the body's tissues, leading to problems such as thinning of the bones, or osteoporosis. 

Contrary to what was thought years ago, the postmenopausal years can be the most productive years of a woman's life. Likewise, women can enjoy sex as much after the menopause as before, without periods and without the fear of becoming pregnant. But perhaps more importantly, we now understand that menopausal symptoms are not something that women have to put up with as their mothers and grandmothers did. 

When a woman asks for advice about menopausal symptoms or HRT it is a good opportunity for a full medical check, including a Pap smear and internal examination. If there is doubt whether symptoms relate to the menopause, a blood test might be arranged. Many doctors have hand-out booklets or videos about the menopause. It is very helpful for the woman to discuss this information with with her partner or husband. 

Every menopausal woman should be offered HRT as an option. As well as relieving symptoms like hot flushes and vaginal irritation, most women just feel better. It also offers considerable protection against osteoporosis. More recent research suggests that HRT may, in the long term, reduce the risk of heart attack and stroke. 

Modern HRT consists of a daily oestrogen dose, and cyclical progesterone for about 12 days of the month. The progesterone balances the stimulant effect of oestrogen on the lining of the uterus, removing the concern about an increased risk of cancer of the uterus in women taking oestrogen alone. The cyclical progesterone is usually followed by a monthly bleed. Should bleeding occur at other times, a full gynaecological check is necessary. If women have had a hysterectomy, oestrogen alone is the usual recommendation. 

The oestrogen is administered by daily tablets, stick-on skin patches or topical gels. It is also available in a pellet form that can be inserted under the abdominal skin. The progesterone is usually given as tablets. Several oestrogen and progesterone combination calendar packs are also available. Oestrogen and lower dose daily progesterone is another option if women have troublesome bleeding and prefer to have no further periods at all. Some women find oestrogen vaginal cream by itself is enough to control local vaginal symptoms. With so many alternatives these days HRT can be tailored to suit most patients. 

Side-effects from HRT are relatively few. Symptoms like headaches, breast fullness and nausea can usually be relieved by a dosage adjustment. If women have had previous problems like breast cancer, or clots in the legs, HRT is generally avoided. Because there may be a slightly increased incidence of breast cancer in women on HRT, regular checks by the doctor including routine mammograms are essential. 

The choice about HRT is an individual one. Some women have very few symptoms of the menopause and prefer not to be on medication. Other women might elect to take a daily tablet of isoflavones, naturally occurring plant phyto-oestrogens. All women should be given accurate information so that they can make their own informed choice. If conventional HRT is chosen it can be continued for many years. Some women decide to take a break from HRT every now and again. This is also quite reasonable; the HRT can always be restarted at a later date. 

Health Tip:
* HRT offers excellent control of menopausal symptoms and a number of other benefits. If you are in the menopausal age-group discuss the options in detail with your doctor, and anyone else you wish...but ultimately the choice is a personal one.


Dr. Andrew Pattison: Common Consultations
North East Valley Division General Practice, Melbourne, Australia.   Disclaimer
  - Last modified: August 18, 2001