Menopause

What is the menopause?

The menopause occurs when levels of the female hormones oestrogen and progesterone fall and the body stops producing eggs. Menstruation ceases permanently and you're no longer able to conceive. It can be a time of great physical and emotional change that can overwhelm you if you don't know what to expect.

When does the menopause occur?

There's no predicting when the menopause will occur. Generally, it's between the ages of 45 and 55, but for a few women it can start as early as 35 - or as late as 60. This doesn't mean you're in any way abnormal, although an unusually early menopause (before the age of 36, sometimes as young as 18) may have implications that need to be addressed.

Without the previously high levels of oestrogen, your risk of heart disease and osteoporosis (brittle bones) increases. If the menopause comes early - or if there's a high family risk of these diseases - you should see your GP. If they think it appropriate, tests such as a bone-density scan or mammogram will be arranged.

Usually, there'll be some sign that the menopause is approaching. Periods can gradually become further apart, they may be scantier and not last as long. Alternatively, some women experience heavier bleeding with shorter gaps between. Occasionally, menstruation just stops altogether with no warning.

For the majority of women, the menopause will last no more than a couple of years, although others experience symptoms for as long as five or six years or even longer.

Symptoms of menopause

Physical

The decline in the release of oestrogen and progesterone can begin a few years before menstruation stops, leading to some uncomfortable physical symptoms for 80 per cent of women including

• Hot flushes - most women experience these in varying degrees of severity. There can be an all-over hot feeling one minute - enough to make you feel like opening all the windows in the house - and a shivering sensation the next. On average, flushes occur four or five times a day and usually last from a few seconds to a few minutes. They may cause physical sweating or just a feeling of heat, with or without actual reddening of the skin Some women also experience 'crawling' sensations on the skin.
• Night sweats - these are hot flushes that occur at night. If severe, they can drench your bedding, disturbing your sleep pattern and that of your partner.
• Irregular, scant or heavy periods - this is a common sign of the approaching menopause, but it's worth remembering that irregular or heavy bleeding can be caused by conditions other than the menopause (for example, polyps or fibroids), so it's a good idea to get it checked out.
• Dry or itchy skin - as we age, our skin becomes thinner and without oestrogen our skin finds it difficult to retain moisture.
• Aches and pains - low levels of oestrogen can lead to an increase in aches and pains. These can range from joint and muscular pains to backaches or headaches.
• Insomnia - this is caused by low levels of oestrogen, but can be exacerbated by night sweats as these disturb your sleep pattern. It can also be brought on by anxiety or depression.
• Tiredness and lethargy - lack of sleep owing to night sweats can cause you to feel exhausted during the day.
• Bladder problems - these include an increased susceptibility to cystitis or other bladder infections and stress incontinence. Stress incontinence is caused by loss of muscle and tissue elasticity in the pelvic cavity, which leads to a tendency to leak urine on coughing or laughing. Some women also experience reduced bladder capacity.
• Loss of vaginal elasticity - intercourse can become uncomfortable or painful owing to the thinning of the vaginal walls, causing dryness and loss of elasticity. A water-based lubricant can help, although if the pain is severe and persistent it's advisable to seek medical help.

Other symptoms such as dizziness, headaches and swollen ankles and palpitations have been reported but are less common.

Emotional

Some women sail through the menopause with no emotional changes whatsoever, but for others there may be psychological issues to contend with - on top of all the strange physical effects.

Mood swings can range from tearfulness and irritability to depression. Depression may be more likely in the years immediately before the menopause, especially if you've experienced PMS (premenstrual syndrome) in the past.

Your hormones can make life miserable, but oestrogen deficiency alone may not be causing you to feel emotionally out of kilter. It's not always clear whether depression is linked to low oestrogen levels or to the fact that many women face changes during their 40s and 50s, such as pressures of work or marriage, caring for unwell or elderly parents, problems with children and struggling to cope with the altered self-image that can come with ageing.

Emotional symptoms can include:

• Panic attacks - getting older in a society where youth is everything can be stressful and cause increased levels of anxiety. Frequently feeling anxious can lead to panic attack symptoms including palpitations, shortness of breath or dizziness.
• Poor memory and concentration - since oestrogen plays a part in the healthy functioning of nerve cells in the brain, there could be some slight drop-off in concentration when there's less of it.
• Decrease in sexual desire - this may be caused by the decrease in female hormones, tiredness or vaginal dryness, which can cause pain or discomfort. But the reasons aren't always physical. If there are misunderstandings in a long-term relationship that have never been addressed, they may come to the fore now. It could be the menopause is the trigger but not the cause of your loss of libido. Try talking things through with your partner.

On the other hand, some women find they enjoy sex more after the menopause. Freedom from worry about unwanted pregnancy can release your inhibitions, bringing with it spontaneity and an increase in sexual confidence. For some couples, it can be a new beginning.

The extent of menopause symptoms varies from person to person, but with a bit of help you can minimise the effects.

Menopause treatments

Hormone replacement therapy (HRT) can help your body to adjust to lower levels of oestrogen and progesterone, helping to alleviate symptoms such as hot flushes.

Before deciding whether HRT is for you, talk to your GP about the risks of taking it or not. Make sure they are aware of any existing medical problems, such as high blood pressure, liver disease, endometrial cancer or a previous deep vein thrombosis (DVT).

Research has raised concerns about HRT (for example, about a possible increase in the risk of breast cancer or heart disease) and currently it's recommended that HRT is used to provide short-term relief of severe menopausal symptoms such as hot flushes and night sweats, and that HRT drugs should only be offered in the lowest doses and for the shortest time possible.

HRT can take several different forms - tablets, implants, creams, pessaries and patches. The type will be tailored to your individual needs. Some women need specific methods - if, for example, you're an insulin-dependent diabetic, skin patches are preferred. The treatment comes in different combinations of oestrogen and progesterone and in different strengths.

In general, the benefits should kick in within one to two weeks. You'll be monitored by your GP to make sure there are no problems and minimal side-effects. Initial side-effects such as breast tenderness and nausea should settle. Bloating can occur, but changing the type of HRT can help. You may also experience weight gain, although this isn't necessarily due to HRT. There may also be other more transitory side-effects, such as headaches, low backache, irritability or heavy bleeding.

With some types of HRT you have a period, with others you don't. Any bleeding that occurs when it shouldn't, or significant changes in the pattern or severity, should be reported to your GP straightaway, as should any shortness of breath, coughing or chest pains. If you have a painful or swollen red leg, stop the HRT immediately and consult your GP.

Menopause and nutrition

Make sure you get enough calcium and vitamin D in your diet to reduce the risk of osteoporosis. As a general rule of thumb, the recommendation is at least 1,000mg of calcium a day from food or supplements. Your doctor should be able to advise you if supplements are necessary.

Essential fatty acids (EFAs), such as those found in nuts, seeds and oily fish, can be very useful if the skin becomes dry or if you suffer from joint pains. The best EFAs are those from the omega-3 and omega-6 families, which are found in pumpkin seeds, oily fish, walnuts, linseeds, dark green vegetables and oils such as sesame, walnut, soya and sunflower. EFAs can also help prevent vaginal dryness and bladder infections, as well as increasing your mental and physical energy.

Natural plant oestrogens in the form of alfalfa sprouts and linseeds are a useful supplement, as long as you aren't already on an oestrogen replacement therapy. Make sure you get instructions from a reputable source.

Evening primrose oil and vitamin E have been suggested as a preventive measure for hot flushes, but there is little evidence to show they work.

Self-help

There are a number of self-help methods you may find useful:

• Coping with hot flushes - wear layers of clothing, which you can easily peel off and put on again. Wear natural fibres. Use cotton bedding and nightclothes, which absorb moisture more efficiently.
• Avoiding hot flushes - keep hot drinks such as tea and coffee, alcohol and spicy foods to a minimum. Avoiding tea and coffee is also a good idea because caffeine can cause insomnia and lead to calcium being lost from the body. Try a herbal alternative.
• Don't smoke - smoking increases the risk of heart disease and osteoporosis, so if you've been thinking about giving up but never quite got around to it, now is the time to quit for good.
• Stick to a healthy diet and get plenty of exercise - this will help to keep stress levels to a minimum, as well as being of physical benefit. It's never too late to start.
• Drink plenty of water - it's a great cleanser and purifier and can help with many of the symptoms, including hot flushes, headaches and dry skin.
• Continue to use contraception - for two years after your last period if you're under 50, or otherwise a year.
• Try to stay positive - and remember, this is only a temporary phase in your life.
• Get support - having people around you who understand what's going on is invaluable.

Menopause advice and support

The Daisy Network

• A charity and support group for women experiencing premature menopause (before the age of 40).
• Website: www.daisynetwork.org.uk

Women's Health Concern

• Website: www.womens-health-concern.org