Menopause

Menopause describes the end of a woman's periods. This commonly occurs between the ages of 45-55 years and is a normal process of ageing in women. It occurs when the ovaries stop releasing eggs, which in turn causes a significant drop in levels of the female sex hormones, estrogen and progesterone, in the body. Individuals respond differently to the changes in hormone levels, with some experiencing no symptoms and others being quite severely affected.

It is also common for women to start experiencing symptoms leading up to menopause as their hormone levels start to decline, which is known as perimenopause. Once 12 consecutive months have passed since a woman's last period, the phase is known as post menopause.

Causes

A background understanding of the menstrual cycle and ovulation can help you to understand menopause.

The menstrual cycle

At the time of puberty, each woman has about 400,000 eggs in her ovaries. Over time, this number falls naturally through the process of ovulation. The rate of decline is different for every woman, but is about 1000 eggs a month.

In the ovaries, each egg is contained inside a sac called a follicle. Each month, the brain sends messages to the ovaries, which causes several follicles to begin maturing. As the follicles develop, estrogen levels rise, peaking at the release of an egg. Of these follicles, only one will grow to become the dominant follicle and release an egg at the time of ovulation.

Ovulation occurs when the follicle ruptures and the egg is released from the ovary into the fallopian tube. Following this, the burst follicle collapses, forming what is known as the corpus luteum. This structure produces progesterone, along with a small amount of estrogen. These hormones play an important role in building up the lining of the uterus in preparation for pregnancy.

If pregnancy does not occur, the corpus luteum breaks down over about 10-14 days, which causes estrogen and progesterone levels to fall. In response to this decrease in hormone levels, the lining of the uterus is shed through the vagina, along with the unfertilized egg. This shedding of the uterus lining is experienced as a woman's monthly periods.

The menstrual cycle. 

There are a number of reasons why periods stop and menopause occurs in women, including:

Natural menopause

Menopause most commonly occurs naturally with age, as the function of the ovaries gradually declines and the ovaries stop releasing mature eggs. This also leads to the female hormones, estrogen and progesterone, no longer being produced.

Induced menopause

The surgical removal of both ovaries in a woman, for a wide range of reasons, can cause induced menopause. Chemotherapy and radiation therapy can also bring about menopause in some women.

Premature menopause

Premature menopause is when periods stop before the age of 40. In about 8% of women, this is due to induced menopause caused by chemotherapy, radiotherapy or surgical removal of ovaries. However, periods can also stop spontaneously in about 1% of women, usually due to an unknown cause. This is more accurately known as premature ovarian insufficiency (POI), as the ovaries can begin to function again in a small number of women.

Early menopause

Early menopause is when periods stop between the ages of 40-45. As is the case with premature menopause, it can occur spontaneously or as a result of chemotherapy, radiotherapy or surgery to remove the ovaries. Early menopause affects about 5% of women and is usually permanent, as the ovaries rarely regain function after periods have stopped.

Signs and symptoms

A range of symptoms are associated with perimenopause, menopause and post menopause. Most symptoms are related to a decrease in estrogen levels. Symptoms can be both physical and psychological:

Irregular periods

Leading up to menopause, it is common for periods to become irregular, especially in their frequency, but also they can be lighter or heavier than usual. During this time, fertility becomes reduced and unpredictable, until menopause is reached and it is no longer possible to become pregnant.

Hot flushes

Hot flushes, also known as hot flashes (mainly in the United States), usually occur in the face and neck, and involve a distinct sensation of heat. Hot flushes can also occur all over the body and last for seconds or minutes. They can also involve sweating, headaches, palpitations or fainting, which can become worse with stress, alcohol and hot foods or drinks. Hot flushes are harmless, but can cause embarrassment, sleep disruption and anxiety. Some women may experience up to 10 or more per day, for months or even years after their last period.

Hot flushes are a common symptom of menopause. 

Night sweats

Night sweats cause mild to severe sweating that may disrupt sleep. However, not all women who experience hot flushes will get night sweats. The reverse is also true, in that not all women who get night sweats will necessarily experience hot flushes.

Vagina and bladder problems

It is common to experience vaginal dryness and alterations in bladder function. The skin within the vagina can lose its elasticity, which can make sex uncomfortable. It is also possible to experience a loss of bladder control, also know as urinary incontinence. This is because the pelvic floor muscles, much like muscles in other parts of the body, become progressively weaker around the time of menopause. These muscles help control bladder and bowel function, therefore weakness can lead to urine leakage, difficulty holding wind and even prolapse (falling down) of internal organs.

Psychological issues

Many women will experience emotional changes. These can include irritability, depression, anxiety, loss of concentration, poor short-term memory, insomnia, or low libido.

Other symptoms can include:

• Palpitations;
• Light-headedness or dizziness;
• Joint and muscle aches and pains;
• Dry skin;
• Tiredness, and;
• Weight gain.

Methods for diagnosis

The diagnosis of menopause is usually based on age and the presence of signs and symptoms. As this can feel like, or be, a life-changing experience for some women, you may want to talk to your doctor about any concerns.

Blood tests are rarely used to diagnose menopause. Measuring certain hormone levels that can change with menopause, such as follicle-stimulating hormone (FSH) and estrogen, is not always accurate. However, measuring thyroid-stimulating hormone (TSH) can help identify thyroid disease that causes hypothyroidism (which causes a high TSH), which can mimic symptoms of menopause. If hypothyroidism is present, then treatment of this condition can help to improve symptoms.

Types of treatment

Menopause does not require treatment; however, there are treatment options available to reduce the signs and symptoms associated with it. Your doctor will be able to provide advice on treatment options that suit your circumstances. These may include:

Self care for hot flushes

Cooling gels containing menthol may help to provide relief from your hot flushes. These products are available over the counter without a prescription.

Other non-medical management techniques include:

• Cold drinks;
• Applying a cold compress to the back of your neck;
• Using fans or an air conditioner to keep cool, particularly during hot weather;
• Wearing light, loose clothing at the time of a hot flush, and;
• Relaxation activities, such as yoga and meditation.

Some women report relief from hot flushes from taking natural therapies, such as evening primrose oil, red clover and black cohosh (Cimicifuga racemosa). However, scientific studies have not been able to produce consistent results that support the benefit and safety of these products. If taking natural therapies, it is important to always inform your doctor, to prevent any potential interactions with other medication you may be taking.

Self care for night sweats

Non-medical management techniques for night sweats include:

• Wearing light bedclothes;
• Using light, absorbent bed linen that can be taken off in layers;
• Developing a calm bedtime routine that encourages stress reduction;
• Using fans or an air conditioner to keep cool, particularly during hot weather, and;
• Relaxation activities, such as yoga and meditation.

Hormone replacement therapy

Many of the signs and symptoms associated with menopause are related to decreased estrogen. To rectify this, hormone replacement therapy (HRT), which increases the body's estrogen levels, may provide effective relief from symptoms. This involves either taking an oral medication, wearing a skin patch, using a vaginal ring or applying a skin cream or gel.

If you have had a hysterectomy to remove your uterus, you will only require estrogen. However, if your uterus is still intact, then progesterone is prescribed together with estrogen to reduce the risk of uterine cancer.

HRT has been proven to significantly reduce menopausal symptoms for most women. It is considered to be the most effective treatment for hot flushes and night sweats and can reduce the severity and frequency of hot flushes.

The risks of HRT depend mainly on your personal circumstances, medical history and lifestyle. Risks are considered to increase with age, long-term use and oral forms of HRT (i.e. taken by mouth), and include issues such as a small increase in breast cancer (following the use of HRT that combines both progesterone and estrogen), blood clots and stroke.

Other medications

If HRT is not an option due to personal or medical factors, other non-hormonal medications have been shown to reduce discomfort associated with hot flushes. These include certain medications that are more commonly prescribed for depression (antidepressants) and high blood pressure (antihypertensives).

Potential complications

After menopause, you have an increased risk of developing certain medical conditions, including:

Heart disease

As your estrogen levels decrease during menopause, your risk of heart disease increases. To help avoid this, it is important to eat a healthy balanced diet with lots of fruit and vegetables. It is also important to maintain a healthy body weight and monitor your cholesterol and blood pressure to ensure they are at healthy levels.

Osteoporosis

Osteoporosis is a condition that causes your bones to weaken and become brittle, which can lead to an increase in bone fractures. An increase in the risk of osteoporosis occurs in the first few years after menopause, when bone density may be lost at a rapid rate. This can lead to fractures, which commonly occur in the wrists, hips and spine. These risks can be dramatically reduced with regular exercise and a healthy diet.

Occasionally, medication to improve bone strength can be prescribed to limit further bone loss. HRT used to treat symptoms of menopause can also help to prevent osteoporosis.

Urinary incontinence

Urinary incontinence is the loss of bladder control that results in unintended urine leakage. Incontinence in menopausal women is treated by:

• Pelvic floor exercises that strengthen the pelvic floor muscles;
• Sanitary pads to absorb accidental urine leakage;
• Bladder retraining, aimed at gradually increasing bladder capacity;
• Medications that reduce bladder overactivity, and;
• Surgery to restore normal urinary function.

Prognosis

Menopause is a natural process of ageing. Some women are largely unaffected, while others may have severe or prolonged symptoms. Unfortunately, it is difficult to predict who will develop symptoms, or the severity and duration of symptoms.

Treatments can improve quality of life in those experiencing problematic symptoms. In addition, good eating habits and regular exercise can also help reduce the health risks associated with menopause.