All women go through the natural process of menopause. When a woman's menstrual periods stop, her ovaries stop producing eggs and her oestrogen levels gradually decline.
In the UK, 51 is the average age for a woman to reach the menopause and the entire process can last anywhere from 2-10 years.
Unfortunately for many women, this is a time of anxiety and distress due to the various symptoms that can accompany the drop in oestrogen
BUT WE STILL DON'T KNOW ENOUGH.
The challenge of menopause is increasing. In 2011, there were 11.6 million women over 50 in the UK and with increasing life-expectancy, British women can expect to live for more than 30 years post-menopause.
On top of this, adverse publicity surrounding the use of HRT, the most effective treatment for oestrogen loss, has led to a major drop in its prescription. Without viable alternatives to HRT, health care professionals worldwide are limited in their ability to help women suffering from menopausal symptoms.
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The menopause is part of the natural ageing process and is caused by a change in the balance of the body's sex hormones.
Oestrogen levels decrease, which causes the ovaries to stop producing an egg each month.
Most women experience the menopause when they are 45-55 years of age. The average age for the menopause is 52.
It is rare for some women to experience the menopause before they reach 45 years of age. This is known as premature ovarian failure. Premature ovarian failure can occur at any age and in many cases there is no cause.
If you experience symptoms of menopause younger than 45, please see your GP. You should also speak to your GP if you have menopausal symptoms that are troubling you.
Possible causes of premature ovarian failure:
· surgery to remove ovaries or womb (hysterectomy)
· certain types of radiotherapy or chemotherapy
· rare cases: infections, such as tuberculosis, mumps, malaria, varicella and shigella (a type of bacteria that causes dysentery)
· medical conditions: enzyme deficiencies, Down's syndrome, Turner syndrome, Addison's disease and hypothyroidism (an underactive thyroid gland).
The menopause can cause a wide range of physical and psychological symptoms. The first symptom is usually a change in the pattern of your monthly period.
The start of the menopause is known as the perimenopause. During this time periods may become lighter or heavier. The frequency of periods may also be affected.
Other menopausal symptoms include:
· hot flushes and night sweats
· loss of libido (sexual desire)
· vaginal dryness and pain, itching or discomfort during sex
· palpitations (changes in heart rate)
· mood changes, such as depression, anxiety or tiredness
· sleeping problems, such as insomnia
· urinary tract infections
If menopause occurs suddenly rather than gradually, symptoms may be worse.
Symptoms will usually last for two-five years before disappearing, although in some cases they can last longer. Vaginal symptoms, such as dryness, can sometimes persist and get worse as you get older.
Hot flushes and night sweats
A hot flush is a sudden feeling of heat in the upper body, which can start in the face, neck or chest, before spreading upwards and downwards.
The skin may become red and patchy and you may start to sweat. The heart may feel that it’s rate has increased, or it may be irregular and stronger than usual (palpitations).
Hot flushes that occur at night are called night sweats. Most hot flushes only last a few minutes and they are most common in the first year after the final period.
Women have trouble sleeping due to night sweats, but sleep disturbances may also occur as a result of anxiety.
The lack of sleep can cause irritability and problems with short-term memory and ability to concentrate.
Dryness, itching or discomfort can make sex difficult or painful (dyspareunia). These symptoms combined are known as vaginal atrophy.
A third of women experience the symptoms of vaginal atrophy shortly after the menopause, with slightly more women having them later on. In some cases, vaginal atrophy can persist for more than 10 years after your final period.
Vaginal symptoms are likely to continue or get worse over time unless they are treated.
During the menopause recurrent lower urinary tract infections, such as cystitis are more common.
Loss of bone bulk and osteoporosis are natural features of ageing, but a decrease in oestrogen accelerates the process in post-menopausal women.
Weight-bearing exercise, eating foods rich in calcium, giving up smoking and consuming moderate amounts of alcohol can reduce the risk of osteoporosis.
Many women do not need treatment for the menopause. If symptoms are mild, they may be able to be self-managed.
If symptoms are more severe and interfering with day-to-day life, medication may be recommended.
· hormone replacement therapy (HRT)
· tibolone (similar to HRT)
· vaginal lubricants
HRT and tibolone do not provide contraceptive protection, and although fertility does decrease during the menopause, it may still be possible to conceive.
Contraception should therefore be used for one year after the last period (if over 50 years of age) and for two years after the last period (if under 50 years of age).
Hormone replacement therapy
HRT is effective in treating a number of the most common menopausal symptoms, including hot flushes and night sweats, vaginal symptoms and urinary tract infections, such as cystitis.
In the long-term, HRT can also reduce the risk of osteoporosis (weak and brittle bones) and combined HRT (see below) can reduce your risk of developing bowel cancer.
HRT works by replacing the female sex hormone, oestrogen, which naturally begins to decrease as the menopause approaches. There are three main types of HRT:
oestrogen-only HRT –for women who have had their womb and ovaries removed; if oestrogen is taken on its own it can thicken the womb lining, increasing your risk of cancer
combined HRT – for women who are experiencing menopausal symptoms but are still having periods (you take both oestrogen and progestogen)
continuous HRT – for post-menopausal women
HRT is available as a cream or gel, a tablet, a skin patch or an implant.
A number of side effects are associated with HRT:
· weight gain
· tender breasts
· headaches and mood changes.
Tibolone is a man-made hormone that acts in the same way as HRT. It may be recommended as an alternative to combined HRT for post-menopausal women who want to end their periods.
It is effective in treating menopausal symptoms such as hot flushes and night sweats and it can also help prevent fractures of the spine. It may also improve sexual problems, such as a decreased sex drive.
Tibolone carries some small risks, including a small increased risk of breast cancer, cancer of the womb and stroke. It is not suitable for women over 60 years of age.
Clonidine was originally designed to treat high blood pressure, but it has been found to reduce hot flushes and night sweats in some menopausal women.
Clonidine can cause unpleasant side effects including dry mouth, drowsiness, depression, constipation and fluid retention.
Your GP can prescribe a vaginal lubricant or moisturiser that can be used for as long as you like.
Although they are not licensed for treating hot flushes, there are several antidepressant medications that may be effective, including venlafaxine, fluoxetine, citalopram and paroxetine.
Potential side effects of these antidepressants can include nausea, dizziness, dry mouth, anxiety and sleeping problems.
If you are taking HRT, you will need to return to your GP for regular follow-up.
Your GP will refer you to a gynaecologist for treatment and to discuss your fertility if menopause has occurred under the age of 40.
Treatment may be needed to ease symptoms and prevent osteoporosis (brittle bones) which is more likely to occur as the level of oestrogen decreases.
HRT and the combined contraceptive pill are recommended treatments because they both contain oestrogen and progestogen.
There is little scientific evidence to show that complementary therapies are effective in reducing the symptoms of the menopause.
Herbal remedies, such as evening primrose oil, black cohosh, angelica and ginseng are not recommended because they may interact with other medications and cause side effects.
Some women have reported that relaxation therapies, such as yoga, aromatherapy and reflexology help to reduce their menopausal symptoms, but there is no scientific evidence to show that they are definitely effective.
Medication may not be necessary if symptoms are not severe.
Many women are able to ease their symptoms by making simple changes to their lifestyle and diet.
To improve hot flushes and night sweats:
· take regular exercise
· wear light clothing
· keep your bedroom cool at night
· try to reduce your stress levels
· avoid potential triggers, such as spicy food, caffeine, smoking and alcohol
To improve sleep:
· avoid exercising late in the day
· go to bed at the same time every night
To improve mood changes:
· make sure that you get plenty of rest
· take regular exercise
· try relaxation therapies, such as yoga or tai chi
WELLBEING OF WOMEN WORKS WITH PIONEERING EXPERTS TO ENSURE THE RESEARCH WE FUND MAKES A DIFFERENCE
We recognise the importance of understanding both the mechanics of the menopause in order to treat its symptoms and in helping women deal with their impact. *We focus on* Our work focuses on:
· Basic science to understand the menopause
· Improving current treatments for the symptoms of the menopause
· Disseminating up to date knowledge to women and their doctors and nurses
In 2009 we funded key work by Professor Mary Ann Lumsden to study the causes of flushing with the aim of developing new treatments. It had always been assumed that the brain was responsible for hot flushes, but Professor Lumsden's ground breaking study proved her theory that it is actually abnormalities in the blood vessels that trigger the reaction. Her work investigated the important role of the brain chemical seratonin in this process and its ability to reduce the overactivity of the blood vessesls. The family of anti-depressants known as SSRIs are commonly used to improve the levels of seratonin uptake in the brain and Professor Lumsden proved this also helps flushing by decreasing the activity of the blood vessels.
We hope that this work will now provide a basis for much needed future research into non-HRT treatments for hot flushing.
You can read more about Professor Lumsden's project here.
Recurrent urinary infection is another common symptom of the menopause and like the hot flush, its causes are surprisingly little understood. Current treatment consists primarily of antibiotics, which offers limited relief and encourages resistance, or the use of oestrogen cream, which although effective, has been linked to a possible increased risk of cancer. Consequently, In 2011 Professor Robert Pickard began work focused on understanding the underlying causes of recurrent urinary infection with the ultimate aim of developing new and safer treatments based on increasing the body’s own natural defences. Results to date have thrown up exciting possibilities for vaginal therapies with potentially rapid translation to patient use.
You can read more about Professor Pickard's project here.
Menopausal symptoms, particularly hot flushes and night sweats, together with poor memory, tiredness and reduced confidence are particularly problematic for women in work settings. In 2015, Professors Myra Hunter and Amanda Griffiths began work to develop cognitive behaviour therapy (CBT) based self-help tools to be used by companies to support menopausal women in managing their symptoms and to increase awareness of the menopause amongst their managers. Her team is collaborating with three large employers to determine the best form and delivery of these tools, with the ultimate aim of rolling them out nationally.
You can read more about Professors Hunter andGriffiths' project here.
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.
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.
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.
Page last updated January 2013