Menopause

Menopause is the natural transition that occurs when a woman reaches the end of fertility. Technically, menopause occurs when a woman has stopped ovulating and her periods have ended. More broadly, people use the term ‘menopause’ to refer to the months or years around this time, during which women may experience other symptoms associated with this change.

Menopause is different for every woman. While the average age for menopause in Australia and New Zealand is 52, menopause typically occurs anywhere between the ages of 45 and 60. Some women do not experience any discomfort, while others have a difficult time and experience a number of unpleasant symptoms. It is normal to experience a range of different emotions as you approach menopause. Knowledge about the physical changes and symptoms that may occur, and awareness of your treatment options, can be empowering as you approach this time of life.

What causes menopause?

The ovaries are two organs – one on each side of the uterus – that contain eggs. A woman is born with all the eggs she will ever have, and the ovaries begin to function at puberty, releasing one egg each month. The ovaries also produce the hormones oestrogen and progesterone, which governs both their function and the rest of the menstrual cycle.

Each month, oestrogen and progesterone cause the uterus lining (endometrium) to thicken in preparation for a fertilised egg to implant. An egg is released by the ovaries each month (ovulation), and if it is not fertilised, the thickened lining is shed, resulting in a menstrual period. If pregnancy has occurred, the cycle ceases until after the pregnancy is complete.

As a woman gets closer to menopause, her ovaries slowly begin to produce less oestrogen and progesterone. Once oestrogen levels dip below the level required to thicken the endometrium each month, periods cease. This is menopause. Menopause is confirmed when a woman has not had a menstrual period in 12 months.

This decline in the production of oestrogen can bring other physical changes which are considered symptoms of menopause

Normal anatomy of uterus.

Normal anatomy of uterus

Signs and Symptoms of Menopause

Every woman has her own unique experience of menopause. There are a number of symptoms and signs of menopause that may occur, but they don’t occur in every instance and don’t always occur in the same intensity or for the same amount of time. Some common symptoms are listed here.

Changes in the menstrual cycle

As hormone levels change, women often begin to notice changes in their menstrual cycle. Bleeding may become lighter or heavier. You may experience irregular periods, or there may be more or less time between your periods.

Hot flushes

The most common symptom of menopause is the experience of hot flushes (sometimes called hot flashes). When a woman experiences a hot flush, she feels a sudden warmth or heat in the face, neck or chest. This can occur at any time of the day or night. The feeling may move or spread, and lasts anywhere between a few seconds and several minutes. This can be unpleasant, and can be accompanied by other symptoms like sweating, heart palpitations, redness, nausea, and tiredness.

Most women experience hot flushes in the years after menopause, and sometimes in the years before as well. Hot flushes normally cease over time, but there are things you can do to help manage them:

  • Avoid hot or spicy food
  • Avoid caffeine and alcohol
  • Sleep in a cool environment
  • When a hot flush starts, go somewhere cooler
  • When a hot flush starts, have a cold drink
  • Dress in light layers so you can remove clothing when hot
  • Dress in cotton clothing or other breathable material
  • Carry a fan or something else to fan yourself with
Vaginal symptoms

Decreasing levels of the hormone oestrogen can lead to symptoms such as vaginal dryness, thinning of the vaginal walls, and a loss of elasticity. This can lead to discomfort or pain during sex. Some women also experience general vaginal irritation and an increased vulnerability to certain infections.

If vaginal dryness is causing pain or discomfort, a cream or pessary containing oestrogen may be prescribed. If sex is painful, lubricant is recommended. There are a number of different types available, and they are readily available in the supermarket or chemist.

Urinary symptoms

Low levels of oestrogen can also cause changes in the urinary tract, which can lead to more frequent urination and sometimes an increased vulnerability to urinary tract infection. Over time, some women experience decreased bladder control and incontinence. Pelvic floor exercises can help prevent this, or treat the problem if it already exists.

Sleep disturbance

Some women experience difficulty sleeping during menopause. This might include insomnia, difficulty falling asleep, or finding sleep unrefreshing and waking feeling unrested. This symptom may present on its own, or it may be a result of other symptoms such as night sweats and more frequent urination. Lack of sleep can exacerbate other symptoms like emotional changes and fatigue.

Emotional changes

Women may experience emotional changes during menopause, including mood swings, irritability, and difficulty with concentration and memory. There are a number of things that may contribute to this, including changes in hormone levels, lack of sleep, and life changes that occur with age. Major emotional changes should be taken seriously, and a doctor should screen for symptoms of depression. Clinical depression is not a normal symptom of menopause.

Sexuality

Women often experience changes in their sexual desire as they go through menopause. It is common to become less interested in sex during this time. This loss of libido may be related to fluctuating hormone levels or other physical changes like vaginal dryness or fatigue from lack of sleep.

Other changes

Other changes can occur during menopause, including weight gain, bloating, dizziness, headaches, joint pain, aching muscles, dry or itchy skin, and hair loss, thinning hair or hair texture changes. Some women experience problems with their dental health during menopause, which may be related to bone loss and osteoporosis.


Talk to your doctor if you find any of these symptoms distressing. There are treatment options available to relieve any pain or discomfort.

Health and wellbeing during and after menopause

Women’s experiences of menopause vary, but certain lifestyle changes and healthy habits can make the experience easier.

Diet

Eating a healthy diet is important at every age, including during menopause. Calcium and Vitamin D intake become particularly important at this time, as they strengthen bones and can help prevent osteoporosis. The recommended dose of calcium during menopause is 1,000 to 1,500 milligrams per day. Dairy foods are naturally rich in calcium (milk, cheese, yoghurt, etc.), and prepared foods like breakfast cereal are often fortified with calcium. If you are struggling to get enough calcium, calcium tablets can be taken instead.

Some women find that it helps their menopause symptoms to eat soy-based products, which are rich in phytoestrogens, and to limit caffeine and alcohol.

Exercise

Like diet, exercise is important at every stage of life. Regular exercise improves general health and fitness, helps maintain a healthy weight, and is good for mental health. Weight-bearing exercise like walking, jogging, or using weights can also play an important role in preventing osteoporosis.

Relaxation

Relaxation is important for health and wellbeing. Allowing time for relaxation can prevent mental health issues like anxiety and depression, or help manage them. It can also help you sleep better and assist in the management of other physical symptoms of menopause. Meditation is a common technique for relaxation, but simply taking a walk or reading a book can help.

 

Hormone therapy for menopause

Hormone therapy (sometimes referred to as hormone replacement therapy, or HRT) can be useful in the treatment of menopausal symptoms. Hormone therapy involves supplementing the decreasing levels of oestrogen in the body with a combination of oestrogen and progestin, a form of progesterone. Sometimes oestrogen is used alone, usually when women have had a hysterectomy (had their uterus removed). This is known as oestrogen therapy.

What does hormone therapy do?

Hormone therapy and oestrogen therapy can help relieve the symptoms of menopause, and may help protect against the progression of osteoporosis and against bowel cancer.

It was previously thought that hormone therapy reduced the risk of heart disease for menopausal women, but recent clinical trials have not found evidence of this. There continues to be research done on this topic. If you were considering hormone therapy as a means of reducing the risk of heart disease, consider other proven methods instead, such as: quitting smoking; maintaining a healthy weight, healthy cholesterol level, and healthy blood pressure; eating a balanced diet; and getting regular exercise.

How is hormone therapy delivered?

Oestrogen is available in a number of forms, including:

  • Tablets
  • Patches
  • Gels
  • Nasal sprays
  • Vaginal creams
  • Implants (placed under the skin by a doctor)

Progestin is available as a tablet or a patch.

Women who have menopausal symptoms but are still having periods (known as premenopausal) may be prescribed oestrogen continuously, with progestin added in for 10-14 days a month. Periods will continue, but may become lighter over time using hormone therapy. This may also be the prescribed treatment in the first two years after menopause.

Women who have reached menopause may be prescribed oestrogen and progestin to be taken every day. Spotting may occur as a side effect of continuous hormone therapy, but stops in 80% of women within six months.

An oestrogen cream, vaginal tablet or pessary may be prescribed specifically for vaginal and urinary symptoms.

Testosterone therapy is sometimes prescribed, particularly for women who experience early menopause, or who have low levels of testosterone.

Sometimes a drug called tibolone is prescribed as an alternative to hormone therapy, particularly if that has been tried and side effects have been a problem.

Risks and possible side effects of hormone therapy

There are a number of side effects that may be experienced by women on hormone therapy. These include:

  • Sore breasts
  • Nausea
  • Weight gain
  • Irritability
  • Spotting
  • The return of monthly bleeding
  • Increased vulnerability to thrush (candidiasis)

Side effects usually ease after a few months, and can be managed by adjusting the dose and timing of hormones given.

Some more serious risks of long-term hormone therapy may include:

  • Increased risk of uterine cancer
  • Increased risk of breast cancer
  • Increased risk of blood clots (venous thromboembolism)
  • Increased risk of heart attack and stroke for women with existing heart disease or risk factors for heart disease.

Despite these risks, no increased mortality has been shown. If you are concerned about these risks, discuss them with your doctor. While all studies show that hormone therapy relieves symptoms of menopause, there remains debate over whether the benefits of long-term use outweigh the risks. This is something to decide in consultation with your doctor.

 

Natural treatment options for menopause

Some women choose to use natural remedies to help them manage menopausal symptoms. Some natural treatment for menopause may include:

Phytoestrogens

Phytoestrogens are substances that are similar to oestrogen, and are found in foods like soy, vegetables, cereals, beans, and some herbs. Many women report relief of some menopausal symptoms by using phytoestrogens, but scientific studies have not shown this to be any more effective than a placebo.

Black Cohosh extract

Black Cohosh extract may be effective in relieving hot flushes, when used short-term (for less than six months), however there has not yet been sufficient evidence to support a medical recommendation.

Herbal remedies

Some women choose to try other herbal remedies to manage their symptoms. The effects of these herbal remedies are not well studied, but adverse side effects may occur. Talk to your doctor if you are thinking of using any herbal preparations for menopause.

 

Early or premature menopause

Most women reach menopause between the ages of 45 and 60, and the average age in Australia and New Zealand is 52, but menopause can occur earlier. Early menopause or premature menopause usually refers to menopause that occurs before the age of 40. About 1% of women experience early menopause.

Sometimes the reason for premature menopause is clear. surgical removal of the ovaries, a hysterectomy (surgical removal of the uterus), radiotherapy to the lower abdomen, and chemotherapy can all bring on menopause. In other cases, the cause of early menopause is unclear. It may be caused by genetics or by a multiple hormonal gland failure, causing the supply of eggs to run out early.

There are a number of risks associated with early menopause, including osteoporosis and heart disease. Early menopause can also be distressing to younger women who may still be planning to have children.

Women who experience premature menopause are usually prescribed hormone therapy to replace the hormones that are no longer being produced naturally. This does not reverse menopause but can relieve some symptoms.

Treatment of early menopause

Women experiencing premature menopause are usually treated with hormone therapy to replace the oestrogen, progesterone and testosterone that their ovaries are no longer producing. As younger women require higher amounts of these hormones, higher doses are usually prescribed. Hormone therapy is usually continued long-term. There is no increased risk of breast cancer brought about by long-term use of hormone therapy in women who experience early menopause.

Treatment of early menopause should go beyond simply prescribing hormone therapy. There should be an assessment to determine the cause of early menopause, long-term follow-up care to manage symptoms and treatment options, and counselling to process feelings of grief or depression.

 

Examinations

There are a number of health checks that women should have regularly, particularly as age progresses. These include:

  • An annual check-up should happen every year, especially once over the age of 30
  • A pap smear should take place every two years (some countries recommend three), and can usually stop at age 70. Discuss this with your doctor.
  • A mammogram should be performed every two years, or more regularly for women with family history of breast cancer, or other risk factors.

Other tests, such as cholesterol testing to determine the risk of heart disease, may be done at the discretion of your doctor.

 

Birth control during menopause

Menopause is confirmed when a woman has not had a period for at least 12 months. Until this time, it is recommended that normal birth control methods are continued to prevent pregnancy. Doctors can recommend other birth control options if current methods are unsatisfactory.

 

Osteoporosis

During our lives, bones are continuously being renewed as old bone breaks down. As part of the aging process, this renewal slows down and more bone is lost than is replaced. After menopause, this loss speeds up, which can lead to osteoporosis. Osteoporosis is a condition where the bones become weak and brittle, becoming more vulnerable to fractures.

Women considered at risk of developing osteoporosis may be given a bone-density scan.

Factors that can increase a woman’s risk of osteoporosis include:

  • Age
  • Being Caucasian or Asian
  • Being thin or small-boned
  • Lack of exercise
  • Family history of osteoporosis
  • Lack of calcium
  • Lack of Vitamin D, which helps the body absorb calcium
  • Early menopause
  • Smoking
  • Long-term use of oral corticosteroids

Talk to your doctor

This article is not a substitute for personalised medical advice. It does not contain all known information about menopause and does not take into account your individual history or health. Please discuss any questions or concerns with your doctor.