MASTERING THE MENOPAUSE

by Mr John Studd MD, FRCOG
Mr Rod Baber MRCOG, FRACOG

What brings about the menopause?

The menopause occurs when a woman's ovaries cease to function and there is a decline in the levels of two hormones produced by the ovaries (oestrogen and progesterone). This is a gradual process which takes place over a number of years - a time known as the "peri-menopause". During the peri-menopause, menstrual cycles are often irregular in both frequency and flow, and oestrogen hormone levels fluctuate. it is this fluctuation in the levels of oestrogen which causes symptoms like hot flushes and other body changes associated with the menopause.

The occurrence of symptoms and particularly the development of irregular vaginal bleeding are signs that a woman should consult her doctor to discuss the problem. Although some women do go through the menopause without experiencing any symptoms at all, we know that almost all women will experience the longer term problems of oestrogen deficiency unless they receive treatment.

What symptoms may occur?

Symptoms may be divided into long term and short term, with effects on blood vessels, bone, skin and reproductive organs.

Short term symptoms

Vasomotor

• Hot flushes
• Night sweats

Musculo-skeletal

• Thin dry skin
• Painful joints and bones

Genito-urinary

• Painful intercourse
• Urinary frequency

Psychological

• Insomnia
• Tiredness
• Depression and irritability
• Reduced libido

Short term symptoms

Vasomotor
Hot flushes and night sweats.

These are the best known menopausal symptoms. Three out of four menopausal women experience sudden unpleasant sensations of heat spreading over the face, neck and chest - and occasionally over the whole body.

These sensations may be accompanied by sweating and shivering. The attacks can occur at any time of the day or night, from once to 100 times a week, for a few minutes or even a half hour. Most attacks last for about three minutes. These symptoms can persist for years and be severe enough to interfere with sleep and everyday life.

Some women also describe an unpleasant prickling sensation over their body. Both this and hot flushes can be relieved by hormone replacement therapy (HRT).

Musculo-skeletal

Skin. During the menopause skin becomes thinner, drier and more wrinkled due to the loss of a protein called collagen from the underlying connective tissue. Loss of shape and firmness is apparent on oestrogen dependent tissues such as the breasts. Skin in exposed areas will be more likely to bruise and tear. Underarm and pubic hair may thin, but there is sometimes an increase in facial hair growth. HRT helps to maintain collagen and therefore slows down these processes.

Painful joints and bones.

A number of women complain of aches and pains in their joints during the menopause. This may be associated with the tendency for bones to become more brittle at this period of life. (See also the section on osteoporosis.)

Genito-urinary

Like the breasts, the skin of the vagina becomes thin and dry after the menopause, leading to pain during and after intercourse which in turn can often cause a reduction in the frequency of sexual relations. These symptoms may be treated locally with lubricating creams but are better treated with HRT, which overcomes the cause of the problem. Because the tissues of the urinary tract and its supporting structures also become thin, post-menopausal women are often troubled by disorders of bladder function, such as sudden urge to pass water (urgency) or by the loss of water on coughing, sneezing or straining (stress incontinence). These symptoms may also respond to HRT.

Psychological

Many emotional problems which occur around middle age are wrongly attributed to the menopause. At this time other domestic and emotional problems may arise - such as children leaving home, dissatisfaction with social or work circumstances, or declining general health. These problems are often helped by talking them through. A sympathetic doctor and supportive husband and family are far more use to women with personal problems than tranquillisers. There is no doubt, however, that the menopause can lead to mood swings, forgetfulness, loss of concentration, sleeplessness and depression, all of which will often respond to HRT.

Reduced libido.

Most surveys show that at least one third of post-menopausal women experience a declining interest in sex. Most of this is related to the bodily changes associated with the menopause (thin skin, dry vagina, etc) and some to the effect on sex drive of decreased hormone levels. Both these factors may be improved by the use of HRT.

Perimenopausal women, who ovulate occasionally, may still become pregnant if no contraceptive precautions are taken. However, once periods have ceased permanently, pregnancy cannot occur because the ovaries no longer function - even when some types of HRT cause regular monthly bleeding.

Long term effects

Osteoporosis. Perhaps the most serious long term consequence of the menopause is osteoporosis, or brittle bones. Bones reach their peak density in the fourth decade of life, after which there is a gradual loss of bone mass. This is much more rapid in women than in men and occurs at a rate of 2-3 per cent of bone mass per year from the time of the menopause. The end result of this process is an increased incidence of fractures, particularly in the bones of the spine (vertebrae), the wrist, and the hip (neck of femur). if untreated, almost 50 per cent of women will have sustained a fracture in one of these sites by the age of 70. Fractures of the vertebrae lead to disabling pain, considerable loss of height and the deformity known as 'dowager's hump'. Fractures of the neck of femur in post-menopausal women are 12 times higher than in old men and are the third highest cause of hospital admission in this country. They lead to death in 25 per cent of cases and long term disability in a further 25-30 per cent. Although it is difficult to predict which women will develop brittle bones in later life, new techniques of bone scanning enable us to measure bone density and plan treatment. We now know that hormone replacement therapy can prevent the onset of osteoporosis and may even reverse bone loss.

Heart attack and stroke.

Prior to the onset of the menopause, women enjoy a significant advantage over men with regard to the risk of heart attacks. This is thought to be due to the effect of oestrogen on certain fats in the blood which are responsible for the removal of cholesterol. After the menopause, this protective effect is lost and the risks even out as the walls of small arteries harden. These risks may be reduced by exercise, proper diet and HRT.

Hormone replacement therapy (HRT)

Gynaecologists now agree that HRT provides the most effective way of managing problems associated with the menopause. It gives dramatic relief of symptoms and protection from heart disease, stroke and osteoporosis.

Treatment consists of administering hormones in the form of tablets, by the application of creams or patches, or by the use of long-acting pellets which are implanted just below the skin and allow a continuous slow release of hormone over several months.

Most of the hormones used are natural hormones, and are thus quite different from those used in the contraceptive pill. just because women were unable to take the Pill does not mean they can't take HRT!

Oestrogens are the principal hormones used in HRT. Women who have had a hysterectomy do not usually need any other hormones; however, those who have not had a hysterectomy must take a short additional course of progestogen tablets each month. Progestogen causes the lining of the womb to be shed after each course (a withdrawal bleed) and helps protect against any cancer developing in the womb.

The very latest forms of HRT tablets combine the effects of an oestrogen and a progestogen in a single tablet. Studies show that in post-menopausal women these new tablets control their symptoms and protect their womb without the need for a regular withdrawal bleed.

How long do women take HRT?

Some women only take HRT for a short time - between six months and two years perhaps - to overcome their initial symptoms of the menopause. However, we now know that, when properly administered, HRT is free of major side effects and, if used for at least five years, will halve the rate of hip fractures in post-menopausal women. It therefore seems more appropriate for women to take this therapy for a longer rather than a shorter period of time providing, of course, that they are seen regularly by their doctor.

What are the side effects?

Approximately one in ten women develop slight nausea and breast tenderness when they start treatment. This is caused by the increasing levels of oestrogen in their blood and soon disappears when levels become stable once more. Fluid may be retained initially, causing a slight increase in weight, but it is usually less than three pounds.

Thrombosis, heart attack and stroke?

Because of an association between older high dose oral contraceptives and thrombosis there was an early concern that HRT might behave similarly. However, comparison of the Pill and HRT is inappropriate since the doses are quite different and modern HRTs use oestrogens similar to natural oestrogens. Research has shown that HRT may reduce the risk of heart attack and stroke by as much as 50 per cent.

Any other risks?

Fewer women who take HRT develop cancer than would be normally expected among this age group. This is because HRT actually protects against cancer of the uterus (womb) and ovaries when administered in the correct manner. Furthermore, HRT does not appear to cause any increase in the incidence of cancer of the breast or cervix - although it seems to offer no protection against these diseases.

Can all menopausal women take HRT?

There are a few women with certain medical conditions whom doctors consider unsuitable for HRT. These would include women with oestrogen-dependent cancers (such as cancer of the breast or womb-lining), women with high blood pressure, or women who have had previous heart disease, stroke or blood clots. Severe varicose veins and heavy smoking are thought by some doctors to be reasons for not prescribing HRT.

How widely available is HRT?

A woman's own doctor can prescribe treatment for her on the NHS. HRT has been available for over 20 years and is a well accepted and effective treatment, although some doctors still have reservations. If a woman feels she requires HRT and her doctor says no, the reasons should be fully explained.

Looking younger?

Not even HRT can stop the ageing process. What it can do is slow down some of the signs of ageing, preventing thinning of the skin and bones and loss of mental capacity.

It also reduces the risk of heart disease and stroke.

Too good to be true?

The answer is no. HRT has many benefits both long and short term. It represents one of the most significant advances in preventive medicine this century and may be safely used by most women, providing they do so under medical supervision.

The principal complaints of women receiving long term HRT are the need for regular withdrawal bleeds and the presence, in some of them, of side effects similar to premenstrual syndrome (PMT). Both these symptoms can often be remedied by varying the type and dose of progestogen, although in a small number of cases a hysterectomy may be necessary. The latest HRTs provide the protection of a progestogen but remove the need for withdrawal bleeding in women after the menopause.

Diet and lifestyle

It is important to maintain a healthy lifestyle and diet at the menopause as at all other times in life:

Exercise.

Exercise keeps the heart and circulation in good order and helps keep bones sturdy and strong. Physically active people are usually more energetic and also have fewer heart attacks and strokes. Those who do are more likely to recover. Any amount of exercise is better than none, but one hour of brisk walking, jogging, dancing, swimming or cycling three or more times a week will help keep the body in good shape. Activities should be varied so that the three risky bone areas - the forearm, spine and thigh - are strengthened. For example, swimming is good for the arms; walking for the legs and spine. Exercise should always be enjoyable.

After exercise, even when tired, a rise in the levels of certain chemicals in the brain will lead to a feeling of wellbeing. For those not in the habit of taking regular exercise, it is sensible to start gradually:

• Walk short distances instead of taking the car
• Take the stairs, not lifts
• Walk up stairs instead of taking escalators, or walk the escalator
• Try to take a short walk at least once a day
• If any exercise hurts, stop

Smoking and drinking.

The health risks from smoking are well known and cannot be overstated. Smokers should try to give up the habit completely. If this is too difficult, cutting down as much as possible will be of some benefit. Alcohol should only be taken in moderation, as excessive drinking can cause weight gain and damage to the liver, brain and heart. Alcohol prevents calcium from being absorbed into the body, thus increasing the risk of osteoporosis.

Diet and health.

As men and women grow older they tend to eat more than their bodies need - so they put on weight. Often, they eat convenience foods, which may not provide them with the balanced diet necessary for good health. A varied diet should contain balanced amounts of fats, carbohydrate and protein, with adequate minerals and vitamins.

• Dairy produce is rich in calcium, but some products are also high in fat content. Low fat cheeses and cottage cheese are better than hard cheeses, skimmed milk is better than full cream milk, and unsweetened low fat yoghurt is better than full fat varieties.
• Protein intake can be varied by eating less red meat and eggs and more fish, chicken, beans and nuts. Any visible fat should be trimmed from meat before cooking and, whenever possible, food should be grilled rather than fried.
• A diet rich in fats is associated with cancer of the breast and large intestine, whilst a diet rich in fibre or roughage is thought to protect against cancer. Vegetables, fruits, whole grain cereals and foods such as wholemeal bread and pasta are good sources of fibre.
• The recommended daily requirement of calcium for young people in the United Kingdom is 500 milligrams. This is roughly equivalent to one pint of milk. Women over 50 need double this amount per day. Calcium is readily available in dairy products, leafy green vegetables and small bony fish such as sardines. Calcium may also be taken in tablet form if the dietary intake is inadequate. It is also important to remember that vitamin D is needed to absorb calcium; exposure to sunlight helps the production of vitamin D by the human body. Dietary sources include dairy food, fish oil and good quality margarines. However, remember that calcium alone will not treat or prevent osteoporosis and that HRT is still required.
• Diets rich in fats, particularly animal fats, can cause fatty deposits in the arteries. These can make them narrower and eventually cause high blood pressure, heart disease and stroke.

The risk of such problems occurring increases after the menopause, when oestrogen deficiency causes alterations in circulating cholesterol. Oestrogen replacement in the form of HRT may help correct this, but it is still wise to adopt a healthy diet.

Other health tips

Some women assume that once they have passed the menopause they are no longer at risk of cervical or breast cancer. This is not true, and women should continue to have cervical smears every three years. Regular self-examination of the breasts is also important and should be supplemented by formal medical examinations. There is now good evidence that mammograms performed regularly after the menopause will reduce mortality from breast cancer. Any unexpected vaginal bleeding after the menopause is abnormal and a doctor should always be consulted if this happens. Blood pressure should be regularly checked.