Every adult has been through puberty. It is clear from personal experience that some people have a lousy time, with unpredictable moods, spots, and for women irregular painful or heavy periods. The menopause is simply puberty (or the menarche)in reverse. As with puberty, some women wake up one morning having had little in the way of symptoms and it is all over. In others the menopause goes on for years and can be miserable.

What is the Menopause?

The menopause is triggered by falling levels of oestrogen, the female hormone which is responsible for puberty. The ovaries fail to make enough hormones to trigger the production of an egg and the womb lining does not build up in preparation for a possible pregnancy. As a result bleeding stops. In principle this sounds simple, but as with most things in life, it is more complicated than that.

• Some women's ovaries stop functioning for a short time and then restart. Their periods may be irregular and may stop altogether and subsequently restart.
• Hot flushes occur because the female hormone oestrogen helps to control the function of blood vessels. The hot flush occurs because the vessels suddenly open up. This is the same process which occurs in blushing. A woman may experience hot flushes for a while which then disappear.
• 'Crawling' or 'creeping' feelings in the skin can also occur. These symptoms can range in intensity from mild to disabling.
• Vaginal dryness is common as the female hormone is responsible for maintaining the normal secretions of this area. As a result of dryness lubrication fails and intercourse can become painful.
• Urineary leakage can occur because the tissues around the urethra(where urine comes out) do not support the bladder so well.
• Sleep disturbance is common,not only because of hot flushes but  as a direct effect of the menopause.
• The hair and skin become dryer and mild acne can occur as well as an increase in hair growth in places where it oughtn't.
• As a result of loss of oestrogen, the bones can become more brittle and more prone to break (osteoporosis).

All sounds pretty dreadful, doesn't it? Fortunately not all women suffer from all the symptoms of the menopause. Some escape lightly and cannot see what all the fuss is about, whilst others have such a miserable time that almost no treatment seems to help. The majority are somewhere in the middle.

Diagnosing the Menopause

Doctors are often asked by women 'Am I menopausal?'. There is no simple way of telling but a number of pointers can help.

• Age. It is unusual although not impossible for a woman to continue to make eggs beyond the age of 50 or so. Some women suffer from an early menopause, either naturally or as a result of surgery (usually hysterectomy) or radiotherapy.
• Lack of periods. This is not entirely reliable. A significant proportion of young women taking the oral contraceptive would not have periods if it were not for the artificial bleed caused by the pill. Some women can stop having periods for a while (say due to stress or physical illness) and then restart. With regard to contraception a woman in her 50's who has not had a period for two years is extremely unlikely to conceive.
• Symptoms - such as those mentioned above.
• A blood test can be taken (FSH or follicle stimulating hormone). If the level of this hormone is very high then this can be a useful  indicator.

Hormone Replacement Therapy

Some women are started on hormone replacement therapy before their periods have completely petered out. This is usually in an attempt to smooth the fluctuations in hormone level around the menopause which can result in disordered periods as well as mood changes. Sometimes this works, sometimes not.

• Some women who are around the menopasue (peri-menopausal) find they can be helped by foods containing natural oestrogens or other widely available preparations. There is a herb, Agnus castus, which seems to help some women.
• If menopausal symptoms are severe hormone replacement can be prescribed. This can be either oestrogen only (usually only given in women who have had a hysterectomy) or 'combined'. The combined preparation contains two hormones, oestrogen and  a progestogen. The latter causes the womb lining to be shed on a regular basis which protects against cancer of the womb.
• Some combined preparations are also 'bleed free'. These contain more of the progestogen substance. If women experience any side effects whilst taking combined therapy it is usually the 'progestogen' which is responsible. Side effects might include breast tenderness, spotting and fluid retention for example.
• Preparations are also available which contain hormones which the body converts into the female hormone such as Tibolone which should only be started a year or so after bleeding has stopped.
• Hormone creams are also available - these are useful to treat local symptoms such as vaginal dryness. Some women find they are allergic to the carrier which the hormone is mixed with; it is often worth another try with a different brand if this happens.
• Also available are hormone rings such as the Estring which are like a ring pessary which releases hormone slowly.
• Hormone replacement can also be given by patches and there is a wide selection of these available.

My usual advice to women who are running into trouble with HRT preparations is that it is often better to switch the mode of administration than it is to change the preparation. So changing from a tablet to a patch may work better than changing from tablet A to tablet B.

Some women should perhaps not take HRT although the risks are small. There is some evidence that the incidence of breast cancer is marginally increased although women who develop breast cancer on HRT seem to fare in general better than those who develop the disease and are not taking HRT. There is an increased incidence of thrombosis so women with a strong history of this might be advised to avoid it. Heart disease or high blood pressure is not a contra-indication although women with these problems should have regular checks with their GP.

Other Treatments

Hormone replacement is not a panacea. When a woman stops HRT she will suffer from the same symptoms as first time around. However it may be easier to tolerate these at a later less busy stage of life than say in the early 50's. If hot flushes are a particular problem, a tablet is available (clonidine) which will reduce their severity. This is not a hormone and will not have the same beneficial effects on say bone strength but may be a useful short term solution if flushes are the principal problem.

Sources of Help

There are many sources of useful information on this subject which grows more complex by the year. Organisations such as the Amarant trust and the Osteoporosis society are good places to start.

Amarant Trust (Advice on all aspects of the menopause)

11-13 Charter House Buildings

London

EC1M 7AN

Tel: 020 7401 3855

Fax: 020 7490 2296

 

National Osteoporosis Society

PO Box 10

Radstock

Bath

BA3 3YB

Helpline: 01761 472721

Tel: 01761 471771

Fax: 01761 471104

Email: info@nos.org.uk

Website: http://www.nos.org.uk

 

Solvay Healthcare Web-Site

http://www.hrtinfo.co.uk

Dr Don Grant

 
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