Menopause means the stopping of periods and marks the end of a woman’s fertility. It is caused by a drop in the hormone Oestrogen. This can affect women in different ways. A lot of women may have very few symptoms and for some women who have suffered with other traumatic symptoms related to their menstrual cycle, it may be a relief. However, for some women symptoms can be severe and debilitating.

Menopause can start naturally, on average around the age of 52 or it can start early. This is called “premature menopause”, when symptoms begin under age of 45. It can be related to family history, or brought on by surgery or treatments and can also be caused by a certain condition.

Important, if you experience menopause symptoms before the age of 45 please see your doctor.

Causes

Oestrogen and progesterone levels ensure monthly periods happen. As the ovaries get older less oestrogen is produced and this causes the menstrual cycle (periods) to stop. This is normally a gradual process and initially periods may become irregular; the time before periods stop altogether is called the “peri menopause” this can last from a few months to a few years. The peri -menopause is usually when symptoms may start.

Causes of premature menopause:

The early loss of ovary function by removal, damage or abnormality.
 

• Surgery – the removal of ovaries can cause early menopause.
• Health conditions - Hypothyroidism and Addison’s disease can increase the risk of damage to ovaries. A genetic condition can cause the ovaries to stop working, such as Down’s syndrome or Turners syndrome.
• Treatments - certain cancer treatments can cause damage to the ovaries.
• Infection - in very rare cases Mumps or Tuberculosis (TB) can also affect the ovaries.

Diagnosis

Currently there is no accurate test to diagnose the peri menopause symptoms (before periods have completely stopped). A discussion and consultation with the GP should help decide if treatment is needed on an individual basis. For women with premature menopause and fertility concerns, current research is looking at blood tests and ultrasound to predict when a woman will go through the menopause. This could help with planning families.

Symptoms

If you feel that you are experiencing menopausal symptoms you should visit your GP for advice, other symptoms can be mistaken for the menopause.

Lower oestrogen levels are understood to cause the majority of the symptoms of the menopause. At least 80 percent of women will suffer from some menopausal symptoms. Every woman is different and symptoms can vary in strength and numbers. Most women will have some mild symptoms lasting a few years. However, for some women it can be much worse. The most common symptoms are ‘hot flushes’ and ‘night sweats’, again these can vary in strength. Some of the symptoms are listed below:

Early (peri) menopause symptoms can include:
 
Hot flushes
Night sweats
Palpitations
Disturbance in sleep
Period problems
Loss of concentration
Mood swings
Anxiety
Low mood
Dry skin and hair
Formication – a sensation of insects crawling on the skin (rarely)

Vaginal dryness
Soreness with intercourse
Loss of libido (sex drive)
Urinary problems
Prolapse
Weakening pelvic floor
Weight gain

Later on in the menopause women are at more increased risk of developing osteoporosis (weakened bones) and heart disease. These can be caused by low oestrogen levels.

Treatment

For some women treatment may not be required. There are other things women can do to help with symptoms and reduce the risks of the menopause, these include:

Balanced diet- reduces the risk of heart disease. This can also help to reduce risk of osteoporosis, by helping to increase calcium levels– some women may consider calcium supplementation.

Regular exercise- reduces the risk of heart disease and reduces risk of osteoporosis as it can also strengthen bone density. Weight bearing exercise such as walking is most helpful in improving bone density.

Pelvic floor exercises- These are exercises to strengthen the basket of muscles that support the pelvic organs. Strengthening these can help prevent prolapse and urinary problems. Avoid trigger foods- alcohol and spicy food- avoiding this may help to lessen hot flushes and night sweats.

Stop smoking- this reduces the risk of heart disease.

When symptoms are affecting a women’s quality of life or medical circumstances require treatment there are a variety of options which can be considered:

All treatments have advantages and disadvantages, this information is just a summary, please see expert invterview to find out more.

HRT- hormone replacement therapy. This replaces the hormone oestrogen and in most cases progesterone. It is proven to reduce or eliminate the majority of menopause symptoms and can offer some protection from risks of the menopause. This treatment has recently become a contentious issue, as some studies reported the increased risk of certain cancers with the use of this treatment. The actual increase in risk is very small and women should discuss with their GP what is the best treatment for them.

SERMs- selective oestrogen receptor modulators, these occupy oestrogen receptors in cells. Some will prevent osteoporosis.

STATINS– lower cholesterol and reduce risk of heart disease.

DHEA- dehydroepiandrosterone, this a natural substance produced in the ovaries - not advised as it’s long and short-term effects are as yet unknown.

Testosterone- a sex hormone may improve libido. This can only be used in conjunction with oestrogen.

Phyto-oestrogens- derived from plants such as, soya, red clover and yam which are thought to be a natural source of oestrogen.

Transdermal Progesterone- a progesterone cream. Not advised as there is no current evidence of the advantages, and progestogens have been incriminated in the development of breast cancer.

Vaginal Lubricants- help to prevent soreness in the vagina. Some of these lubricants contain oestrogens that are absorbed only locally.

Alternative remedies- such as Kava kava, evening primrose, ginko, dong quai, ginseng, black cohosh, Chinese medicines and homeopathy. There is some evidence that black cohosh may help relieve hot flushes. There is no strong evidence to support the others.

If considering alternative remedies, women need to be aware that they are not medically recommended. Licensing can be variable and some can have adverse interactions with medications or damaging effects. Always ask for advice from your doctor.

Alternative therapies- accupunture, acupressure, tai chi, reflexology and reiki. These may relieve stress and tension.

Daksha's story-

Daksha tells her story about how menopause affects her life both at home and at work.

Daksha first started noticing symptoms of the menopause when she was around 45 years old, working in a pharmaceutical company where she had previously been involved in selling HRT patches, she was well informed about what might be happening.  She also knew that her Mum had started the menopause around the same age and that this was quite common in Asian women.  She knows her two younger sisters will soon be following her!

The first symptoms she noticed were missing periods and then she started having hot flushes, these mostly came at night although she did have some during the day as well.  Daksha describes how she would go to bed and have just fallen asleep when she would be woken up by the very unpleasant sensation of a wave of heat rolling up her body from the tips of her toes to the top of her head.  Although the heat would only last a few minutes it would leave her wide awake, and after it had gone, her body would cool down meaning further rearrangement of the bedding.  For Daksha this disturbed sleep was the most difficult thing to cope with in a busy life where she is wife, mother and career woman.

Quite soon after these symptoms started Daksha went to her GP and he confirmed that she was in the climactory phase and going through the peri-menopause.  He decided that it would be best to monitor her progress and wait until a full year without periods had elapsed (the actual definition of Menopause) before starting her on HRT.

In the meantime she tried a variety of ‘holistic’ remedies, including sage-oil (recommended by her cleaner), black cohosh, ‘flash-fighters’ but with little success.

One of the main symptoms Daksha mentioned is one that many women will relate to, the psychological dread of the menopause, not just because of the symptoms but because it really confirms that we are getting older.  Daksha looks great for her age, she is really young spirited and active (she took part in the Adidas 5k for Wellbeing of Women last September) and having had her son at 39 is used to keeping up with an energetic 9 year old.  But even though she isn’t ageing on the outside she says she really feels she is ageing on the inside and knows that her energy levels have dropped as a result of the menopause.

Last year, even though her periods hadn’t stopped altogether, she went back to the Doctor because she couldn’t bear the constant waking up in the night and was finding it difficult to keep up with being a wife and mother and holding down a full-time job without a decent night’s sleep.  She has now been on HRT for about 6 months and has felt some benefits – she still has the occasional hot flush but is able to sleep through the night.

Daksha says that sometimes she forgets what she is saying half-way through a sentence – and although forgetfulness is a known symptom of the menopause – she does worry that perhaps it is just ‘age’ rather than anything else.

Although the menopause hasn’t really affected her working life (she has still been very successful in her career throughout this period) she does worry that it has affected how much time and energy she has for her family, she is very grateful for her fantastically understanding husband particularly as she feels that she has become more short-tempered (which could be to do with the menopause or just being the mother of a very active 9 year old!) lately.  Daksha is quite philosophical about the menopause, knowing that it is just one of the stages all women have to go through and is very grateful for the support of all her family throughout this period.

If you would like to tell us your story so we can help and inform other women; there is more information available HERE 

This interview was recorded in December 2008.

Menopause and HRT: Text Version

Welcome to Wellbeing of Women’s health podcast, 1 in 2 women in the UK are affected by a reproductive health problem in their lifetime and Wellbeing of women is the only charity dedicated to finding solutions to these by funding medical research, training staff and offering public information.

This month we are looking at the menopause and HRT. Our expert is consultant gynaecologist Peter Bowen Simpkins, currently the Medical Director of the London Women’s Clinic.

Over the years Peter has treated many women going through the menopause and will be able to talk you through this stage of life and its effects along with dispelling some of those myths surrounding breast cancer and HRT.

During this podcast you will hear all of this and more, to help answer your questions and put your mind at ease regarding the menopause.

Good morning Peter.
Good morning.

Thank you for joining me today. First of all, what is the menopause and when does it happen?   

The menopause means that periods stop, it means that the ovaries have effectively run out of eggs and marks the end of the fertile period of a woman’s life. And the average in the UK, Europe, in fact almost the whole world is just over 50 years.

Right and are there any specific tell tale symptoms?

Well, there are many symptoms and most of those obvious ones start before the periods stop … hot flushes and night sweats, people will be very familiar with, poor sleep patterns, it can also affect people’s moods, particularly around period time and sometime people have very labile emotions, in other words they are very up and down. In addition to this there are some rather odd symptoms like itching the skin, sometimes joint pains and occasionally ladies periods become either heavier or longer or sometimes just the opposite they become lighter and further apart.

And can you do anything to put off the symptoms or the menopause for a few years?

Yes, it’s easy to treat the symptoms, hormone replacement therapy is just replacing the hormones that the ovaries produce and if you’re taking that then it will delay the menopause, obviously if you’re taking that and particularly before your natural periods have stopped then you’ll go on having periods whilst you’re taking the treatment.

 Now, just with regards to HRT, obviously it’s attracted quite a lot of negative press recently, especially with links being made with breast cancer, is it a treatment that women should avoid?

Not at all, the first thing that is very important to say is that it must be the woman’s choice as to whether she wants to go on it or not and it’s one of the things that a doctor must explain to them, in terms of its advantages and its risks. Now as far as breast cancer is concerned we’ve known for very many years that there is a slightly increased risk of developing breast cancer if you take long term hormone replacement therapy but to put it in perspective, between the ages of 50 and 70, 45 women per 1000 will get breast cancer. Now if you take hormone replacement therapy for five years there’ll be an extra four cases and for every five years you continue to take it, there’ll be an extra four cases in other words, let’s say after 15 years you’ll have an extra 12 cases.
Now 15 years of HRT then represents an increase in the risk of breast cancer of just 1.2%, a very, very small increase.

So, can you take HRT if you’ve had breast cancer?

That’s much more difficult to answer, there are different sorts of breast cancer and some are what are called oestrogen positive that means the cells in the breast actually latch onto oestrogens and some tumours are oestrogen negative. and many people who are oestrogen positive are put onto a drug called Tamoxifen which blocks these receptor sites. Now, there really is no reason why a woman who is on Tamoxifen who will develop menopausal symptoms can’t take hormone replacement therapy because as I said the Tamoxifen is blocking these receptor sites in the breast. However, because there is a perceived increase in the risk of taking HRT and breast cancer, lots of people are very wary about it but some very good research has been done recently which showed that women who took HRT having had breast cancer actually did better in terms of survival rates than those who weren’t taking it.

And what are the alternative treatments for people who choose not to go with HRT?

Well, there’s no one satisfactory treatment at all, I suppose for most people hot flushes and night sweats are the most troublesome problem and that affects about 90% of women. And, I should say that the oestrogens that we use, largely are derived from plants, from soya and yam and red clover, that sort of thing, they’re called phyto-oestrogens and most of the treatments that are supposedly non HRT that you buy in a health shop are actually phyto-oestrogens. So the products I’ve just mentioned, soya, yam and red clover are readily available and there is good evidence that they will help hot flushes. There’s another substance called black cohosh which is not a phyto-oestrogen which is also effective against hot flushes, but none of these have any effect on the long term problems associated with the menopause.

And what are those long-term problems?

Well, the ones that occur in the five years after periods have stopped, largely on the waterworks and the pelvis, so the vagina becomes dry and that may lead to painful intercourse, the bladder base tends to shrink a little bit and the pipe leading from the bladder called the urethra sometimes gets a little narrower so the bladder has to work harder to push out water and this can lead to what’s called an overactive bladder and people have to go to the loo much more often and get up at night and that’s quite a common problem post menopausally.

And the other one that’s associated more with having babies, putting on weight and being post-menopausal is that the neck of the bladder which controls continence tends to open and so people get what is called stress incontinence which means they can lose water if they cough, sneeze, run, laugh, jump, dance anything like that. Those are things that happen quite commonly in the five years after periods have stopped.

The long term affects are perhaps much more serious, one is what is called osteoporosis, which is a way in which the bones become thinner and their architecture inside breaks down and they become more liable to fracture. In fact by the age of 70, about 50% of women will have osteoporosis in the bones of the spine.

If you take exercise particularly weight bearing exercise, such as walking three miles twice a week, then you’ll protect the bones, there are other substances which you can use as well. But I suppose the major problem is that oestrogens up until the age of menopause protect your heart, the blood vessels in your heart and in your brain and after 50, then the incidence of heart attacks increases markedly so by the age of 70, there are as many women having heart attacks as there are men. And if people take HRT from the time of their true menopause then whilst they’re taking it they will protect themselves from heat attacks in fact it will reduce the incidence by about 50%.

It all sounds quite daunting, is the menopause something women should fear?

No, I don’t think it’s anything to fear at all. Its true to say that some women have hardly any symptoms at all and other women find it an intolerable part of their life because its difficult for them to work, things like loss of concentration and mood changes I was talking about before and of course having flushes and so on make life quite difficult if you’re in a busy job.

And what about premature menopause, do we know why that happens?

Well, that means that the ovaries have failed before their allotted time, there are some obvious reasons like surgery if you have had the ovaries removed or if you have radiotherapy or sometimes chemotherapy that can affect the ovaries and stop them working. For a very, very few there are genetic reasons there’s something wrong with the make up and their ovaries never develop properly but for the most we don’t know. It just happens what it means is periods stop before the age of 45 and there is a slight family tendency so if your mother and sister has had an early menopause, it’s quite likely that you will as well.

And what can be done in terms of treatment fertility treatments for women who do experience it early?

Well, it’s true that the number of eggs in the ovary start declining almost from birth and for some, their fertility reduces much earlier than others and it would appear that this starts about ten years before the natural menopause so if a woman is going to have premature ovarian failure at the age of 40 she’s going to start losing her fertility by the age of thirty surprisingly. There are a variety of blood tests we can do which are readily available nowadays to see what the reserve is in the ovary. So if people are worried about it, particularly if they’ve got a family history, then it’s worth checking on this.

What can be done for younger women now, is that we can remove eggs from them, let’s say in their twenties and we can freeze them, in a process called vitrification and they can then be saved for them for when they want them but this is a very new procedure. At present most of the women we see in our fertility clinics who have got premature ovarian failure become pregnant through the donation of eggs from another person.

Now inevitably there are a lot of old wives tales and myths that have filtered down through the generations, can you help clear some of those up for us please? For example, forgetfulness is inevitable with the menopause.

No that’s not true, forgetfulness is inevitable for everybody and it’s just a process of brain aging and I have to admit that men get it just as badly as women.

Now, what about the next one, this is a worry for many women, the menopause will mean that I am going to put on weight.

Now that’s an interesting one, it is true that women and sadly particularly heavier women will put on up to two or even three kilograms around the menopause and of course those women taking HRT have got something to blame but there have been extensive studies to show that the weight gain associated with taking HRT is no different from those women who go through a natural menopause and don’t take anything.

Flushes and night sweats are an obvious sign but even if you don’t get those, it doesn’t mean to say that your bones area not getting thinner and that your heart is not being affected so these things don’t appear as symptoms but they do have a major affect on your life in your seventies and eighties.

And what about the idea that herbal alternatives are a more natural and safe way to treat the menopause rather than the medical alternatives of HRT?

Well, in the United Kingdom, most if not virtually all of the HRTs we use are derived from phyto-oestrogens which I mentioned earlier, they come from yam and if you go to a health shop and buy phyto-oestrogens there isn’t a huge amount of difference between that and what is commercially available as HRT. So I would say really that there is no evidence that taking phyto-oestrogens is safer or more dangerous, we just don’t have the evidence.

And is there anything you would like to say to women approaching the menopause as a way of easing their minds?

Well, I think there are things that women can do to help themselves, mainly taking exercise, is very, very important in terms of bone health and as I said earlier weight bearing exercise is very, very important. Lots of people say swimming is good for you and of course it is, it’s very good for your heart but it doesn’t actually help your bones because your body is being supported in the water.

Hot flushes can be exacerbated by alcohol, by smoking, by caffeine and by spicy foods so if you don’t want to take treatment and you do have hot flushes, you need to avoid those sorts of things. Other than that, I think that having a healthy diet and a healthy lifestyle is the best advice I can give.

Great. Thank you very much for joining us today. I’m sure that’s helped many women out there. Thank you.

My pleasure.

The menopause is an inevitable stage of a woman’s life, eagerly anticipated by some but feared by many more.

Discover which old wives tales and myths are true and which are false.

The menopause will make me an emotional wreck

Emotional changes are common around the menopause but are more pronounced in those who have previously suffered from PMS or post natal depression.

Some women do not experience any symptoms at all

For a very small group of women, no symptoms will be experienced but that does not mean that long-term effects on the bones or heart are not occurring.

Menopause occurs at 50

The average age of the menopause is now 52.

Forgetfulness is inevitable

Loss of short-term memory is a consequence of aging and is as common amongst men as women.

Menopausal women’s sex lives are over!

Many women, relieved of the worries of pregnancy, find their sex lives improved. For those with vaginal dryness, local creams will usually relieve any discomfort.

The menopause causes weight gain

The majority of women gain 1-2 kg at the menopause whether they take HRT or not.

HRT is one of the most talked about menopause treatments in modern day society.

After being linked to cancer health scares and ongoing media speculation, the subject is a breeding ground for myths and misunderstanding.

The menopause is natural, so is it wrong to interfere by taking HRT

It was not until the 20th century that the average age of death for a woman exceeded 50. It is only now that we have a huge proportion of postmenopausal women. The hormones used in HRT are natural as they are derived from plants.

HRT is unnecessary as menopause symptoms are short term

Menopausal symptoms are largely short term but the consequences of loss of oestrogen have a marked effect on bones and the cardio-. vascular system (CVS). Osteoporosis, heart attacks and strokes become increasingly common in women after the menopause.

HRT is a huge breast cancer risk

The risk of a woman developing breast cancer between 50 and 70 is 45 per 1000. If HRT is taken, there is a small added risk of 4 extra cases every 5 years.

Herbal alternatives are more natural and safer

Some herbal remedies such as soya and red clover contain natural oestrogens but HRT is largely derived from these phyto-oestrogens.

To find out about our research follow these links:
 

• A study looking at the cause of flushing in hormone deficient men and women.

• The Royal College of Obstetricians and Gynaecologists website has a wide range of information and guidelines on many women’s health topics. This can be found at: http://www.rcog.org.uk/womens-health/patient-information 

• NHS Choices website also has a range of health information. This can be found at: http://www.nhs.uk/Pages/HomePage.aspx