Menopause - A natural Life Change

This information has been written to help you understand what happens at the menopause and how you may be helped at this time should this be required.

The menopause, a natural life change, represents the beginning of a new phase of a woman's life in which, with a positive attitude, she may fulfil many life ambitions that she has previously not had the opportunity to pursue.

When does the menopause occur?

In our Australian community the average age of onset of menopause is 51 years, but this may range from 40 to 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 there may be other reason 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. During this changing time of climacteric, which may take up to 5-6 years, 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 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. Others 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 say.

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 shrink. At the same time the urethra (the passage through which urine is discharged from the bladder) may also become atrophic (a 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 also thinner, and the hair may 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.

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

2. Atherosclerotic cardiovascular disease (a form of heart disease). This leads to high blood pressure, and heart attacks increase in frequency 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 child-bearing years and therefore give protection from atherosclerosis in those years. After the menopause when oestrogen levels are low the same protection does not exist.

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 (e.g. milk, cheese, yoghurt or ice-cream). Some women are allergic to dairy products, do not like them, find they put on weight, or women may be prescribed diets without dairy products for health reasons. Calcium is necessary for healthy bone growth and is lost from the bones after menopause. About 1000-1500mg of calcium per day is a recommended dose.

Diets with foods containing phyto-oestrogens (plant oestrogens) may be beneficial. These food include alfalfa, soybean, cabbage, peas, beans and grains.

A woman should improve or maintain her body fitness by regular exercise. Walking is the best form of exercise as it has a positive effect on the weight-bearing bones (spines 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 programmes 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 cervical (Pap) smear. 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 breast) may be recommended, especially if the 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 ( an oestrogen produced by the ovary), which measures 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 increase 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 Hormonal 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.

1. Hormone Replacement Therapy, what does it do?

Hormone Replacement Therapy is the most common medical treatment of menopausal symptoms but 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 changes 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 type of oestrogens and progesterones are prescribed?

Natural oestrogens are preferable, because they break down in he body normally with no adverse effects on clotting factors and cholesterol. Natural oestrogens increase the protective part of cholesterol in the blood, high density lipoprotein (HDL), and therefore give protection against thickening of the arteries and the increased risk of heart attack and high blood pressure.

Natural oestrogens may be taken in tablet form, by implants, or through a skin patch. The tablets are usually taken continuously without a break, otherwise symptoms return. I plants are small pellets about 1/2 cm long containing natural oestrogen. These are inserted in the fat underneath the skin through a small incision. A local anaesthetic is required. Depending on the dosage inserted the implants may last up to 12 months or longer. The patch is applied to the skin and releases small amounts of hormone to be absorbed through the skin in a continuous controlled way. Unless a woman has had a hysterectomy (removal of the uterus), progesterone is necessary to protect the living cells of the uterus against cancerous change. Only synthetic progestogen in tablet form are presently available and are recommended to be taken for about 12 days each calendar month. This medication causes withdrawal bleeding (a period) that may vary from slight spotting to a heavy period lasting for up to one week. Bleeding at any other time must be reported to the doctor. Progestogen may be prescribed continuously in smaller doses without a regular bleed but may have the side effect of irregular spotting during the first six months.

The longer a woman is taking HRT the less her menstrual flow is likely to be. The side effects of HRT may include weight gain, sore breasts and pre-menstrual like symptoms.

2. What about natural therapies?

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. Natural therapists prescribe a combination of herbs to reduce symptoms and increase well-being.

All herbal preparations are also medicines and should only be used as prescribed and under the supervision of a registered naturopath. Prolonged use of herbs such as Ginseng can be lead to abnormal vaginal bleeding as it may stimulate growth of lining cells in the uterus.

The symptoms associated with the menopause may be quite incapacitating for some women. Hormone replacement therapy is available to all women whose symptoms are troublesome, to those with a risk of osteoporosis and those who choose HRT for its protective capacities on bone and blood vessel, so women should feel justified in seeking their doctor's help if they so wish. Good general health, physical fitness and a positive attitude to life are essential for a woman in the menopausal years.

For further information:

North East Valley Division General Practice, Victoria, Australia, Disclaimer
Level 1, Pathology Building, Repatriation Campus, A&RMC, Heidelberg West VIC 3081. .. map
Phone: 03 9496 4333, Fax: 03 9496 4349, Email: nevdgp@nevdgp.org.au,
Please note: NEVDGP does not provide an on-line consultation