As women move towards the menopause menstruation becomes erratic and eventually stops. There are a number of secondary effects described as ‘menopausal symptoms’.

The climacteric, menopausal transition stage, or perimenopause, is the period of change leading up to the last period. The menopause itself is a retrospective diagnosis of the time when menstruation permanently ceases. It can only be defined with certainty after twelve months’ spontaneous amenorrhoea.

 Factors which can affect the age at which women have their final period include age at menarche, parity, previous oral contraceptive history, BMI, ethnicity and family history.

Many women do not seek medical advice for menopausal symptoms. Variations in consultation patterns for menopause depend on many factors, including cultural and educational differences as well as psychosocial difficulties.

Why it happens? 

The menopause is a natural phenomenon which occurs in all women when their finite number of ovarian follicles becomes depleted. As a result, oestrogen and progesterone hormone levels fall, and luteinising hormone (LH) and follicle-stimulating hormone (FSH) increase in response.

The menopause can be ‘induced’ by surgical removal of the ovaries or by iatrogenic ablation of ovarian function by chemotherapy, radiotherapy or by treatment with gonadotrophin-releasing hormone (GnRH) analogues.

What it does to you? 

The menopausal transition stage usually begins when women are in their mid-to-late 40s. The final menstrual period (FMP) usually occurs between the ages of 45 and 55. The average age of the menopause in women is 51 years.

Around 80% of women going through their menopause experience symptoms and around a quarter have severe symptoms, but only a small proportion of menopausal women take hormone replacement therapy (HRT) Symptoms of the menopause last far longer than most women anticipate; frequent menopausal vasomotor symptoms, including night sweats and hot flushes, persist in more than half of women for more than seven year.

Menstrual irregularity

• The majority of women notice irregularities to the menstrual cycle, which may last for up to four years.
• The cycle may lengthen to many months or shorten to 2-3 weeks.
• An increase in the amount of menstrual blood loss is common.
• Approximately 10% of women have an abrupt cessation of periods.

Hot flushes and sweats

• These are hallmark symptoms.
• Hot flushes commonly affect the face, head, neck and chest and last for a few minutes.
• They are caused by a loss of homeostasis by the central thermoregulatory centre.

Urinary and vaginal symptoms

• Urogenital symptoms arise directly from loss of the trophic effect of oestrogen.
• These may include dyspareunia, vaginal discomfort and dryness, recurrent lower urinary tract infection and urinary incontinence.
• Urinary symptoms may not manifest until 5-10 years after the menopause.

Sleep disturbance

• This is a common symptom reported by women.
• Symptoms may be secondary to vasomotor symptoms, are affected by psychosocial factors and may contribute to depression, irritability and poor concentration.

Mood changes

• These may include anxiety, nervousness, irritability, memory loss and difficulty concentrating.
• Perimenopause is accompanied by an increased risk of new and recurrent depression.
• There is some evidence that those women who have a history of premenstrual and postnatal depression have a higher risk of depression during their menopause. These women are typically well during pregnancy.  

Loss of libido

• This can be caused by a number of hormonal factors; oestrogen, progesterone and testosterone have all been implicated.
• Vaginal dryness, loss of self-image and other psychosocial factors also play a part.

Other changes

These may include brittle nails, thinning of the skin, hair loss and generalised aches and pains. These are due to falling oestrogen levels.

Investigate or not to? 

The diagnosis in the majority of women is a clinical one and investigations are usually not recommended.

Laboratory tests are not required in the following otherwise healthy women aged over 45 years with menopausal symptoms:

• Perimenopause based on vasomotor symptoms and irregular periods.
• Menopause in women who have not had a period for at least 12 months and are not using hormonal contraception.
• Menopause based on symptoms in women without a uterus.

Tests which may be undertaken in some women

 

• FSH levels:
• No need for the FSH level to be tested in most women.
• A raised FSH is not diagnostic for the menopause. It just indicates a lack of ovarian response at a point in time.
• FSH testing could be considered to diagnose menopause in women aged 40-45 years with menopausal symptoms, including a change in their menstrual cycle.
• FSH testing should be undertaken in women aged under 40 years in whom POI is suspected.
• TFT– to differentiate thyroid disease symptoms from menopausal symptoms.
• Blood glucose– may be considered in some women, as diabetes can cause similar symptoms.
• Blood cholesterol and triglycerides– consider if the woman has any cardiovascular risk factors.
• Cervical screening and mammograms– ensure the woman is up to date with her cervical screening and also mammograms (if appropriate).
• A pelvic scan– may be considered for those women with atypical symptoms.

Associated diseases

• Cardiovascular disease: increase significantly after the menopause.
• Osteoporosis
• Urogenital atrophy
• Redistribution of body fat: fat tends to be redistributed around the abdomen with age. This is recognised as being an independent risk factor for cardiovascular disease and diabetes.
• Alzheimer’s disease: women have a higher incidence of Alzheimer’s disease than men, indicating that the declining estrogen levels during menopause may influence.

How to manage?

• Healthy lifestyle

Encourage a healthy lifestyle like Stopping smoking, losing weight and limiting alcohol, to take regular aerobic exercise and to ensure they have adequate calcium intake (around 700 mg/day). Avoidance or reduction of caffeine may help.

• HRT

Most effective treatment to relieve the symptoms caused by the menopause completely, although may not be suitable for everyone. HRT is particularly effective in treating Vasomotor symptoms (hot flushes/night sweats), Mood swings, Vaginal and bladder symptoms.

Vasomotor symptoms are usually improved within four weeks of starting treatment and maximal benefits will be gained by three months.

Vaginal symptoms tend to be slower to respond to treatment and to recur if treatment is stopped. Topical HRT have good efficacy in the short-term treatment of menopausal atrophic vaginitis. However, vaginal lubricants can be effective to use as non-hormonal alternatives, especially if the main symptoms are pain on intercourse due to dryness.

HRT also prevents and reverses bone loss.

HRT can often help to alleviate low mood which arises as a result of the menopause.There is no good evidence that antidepressants improve the low mood that is associated with the menopause.

Alternatives to HRT 

The quality, purity and constituents of complementary treatments may be unknown.

• Herbal or complementary treatments
• Phyto-oestrogens are naturally occurring compounds found in plant sources, that are structurally related to estradiol.
• They appear to have both oestrogenic and anti-oestrogenic effects on human oestrogen receptors.
• The main types of phyto-oestrogen are isoflavones, including genistein, daidzein and glycitein, lignans and coumestans.
• Foods such as soy beans, as well as nuts, wholegrain cereals and oilseeds, are the foods most rich in phyto-oestrogens.
• Phyto-oestrogens can be taken in the form of tablets containing concentrated isoflavones, such as red clover.
• There is a wide array of botanical medicines (such as black cohosh, sage, ginkgo biloba) available to take as an alternative approach to HRT for menopause. However, data documenting efficacy and safety are limited. None of the available botanicals is as effective as hormone therapy in the management of vasomotor symptoms.
• Many women choose to try these products, as they believe them to be safer and more ‘natural’ and than prescribed medication. However, most herbal products available are not subject to the same regulatory requirements as licensed medications and, as such, are not subject to the same degree of standardisation.

Early menopause management 

Early menopause is defined as a menopause between the ages of 40 and 45 years. This occurs in up to 20% of women.

All women with an early menopause have an increased risk of osteoporosis, cardiovascular disease and dementia if they are not given HRT appropriately.

In essence, the principles of estrogen replacement are the same as for women experiencing menopausal symptoms and problems at any age. However, the symptoms may be more severe in premature menopause, particularly after surgical menopause, often requiring higher doses of estrogen than those needed following spontaneous menopause at a later age. In addition, the etiology of the premature or early menopause needs to be considered, as this may change the treatment offered (eg. if it were following surgery for an estrogen-sensitive cancer).

Women with an early menopause should be offered HRT unless contra-indicated. It is normally continued until they reach at least 51 years. There is no evidence that there is any increased risk of breast cancer compared with normally menstruating women of the same age. They may need larger doses of HRT to control vasomotor symptoms.