Menopause

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What is menopause?

Menopause occurs when menstrual periods cease and the ovaries no longer produce eggs (ova). Menopause usually occurs between the ages of 45 and 55 but can occur outside the expected time.

 

When does it occur?

The average age of last period is 51 years but for each individual this is very variable. Menopause is said to have happened if there has been 12 months of no periods in people over 50 and 2 years of no periods in people under 50. Menopause between the ages of 40 and 45 is considered to be early menopause.

Menopause below the age of 40 is known as Primary Ovarian Insufficiency and may happen spontaneously, or after medical or surgical treatment.

Perimenopause is the stage before periods stop completely, and is when the ovaries are running out of eggs (ova). It is often the time when people begin to experience the symptoms of menopause, such as hot flushes, vaginal changes and mood swings. During this stage periods can change and become unpredictable. Perimenopause can occur 5-10 years before menopause.

 

How do I know it is my last period?

There is no single test to tell when you have gone through menopause. Until you have gone for a year without a period over the age of 50 (or 2 years without a period under the age of 50) you cannot be sure menopause has occurred and you need to continue using contraception until then.

Any vaginal bleeding that occurs after the first 12 months needs to be discussed with your doctor.

 

How do I know when menopause is happening?

Menopausal symptoms often start before periods stop. Many people have a change in their periods before stopping completely. Initially this can be periods getting heavier and often more frequent and more unpredictable. Sometimes periods can be lighter and/or further apart.

Any new heavy or frequent bleeding should be checked out by a doctor even if you think it is due to menopause.

Other symptoms are variable and often occur with differing intensity at different times. Most common are joint pains and stiffness, tiredness, mood changes, hot flushes and urinary or sexual problems. Many people have individual changes such as memory loss, loss of confidence, skin and hair changes, altered skin sensations, increased sensitivity to caffeine/alcohol and/or poor sleep patterns.

Menopause is different for everyone. Some people can feel all of these things and others may not feel any of these things. Many people will have some of the symptoms of menopause and this will often last for 5-10 years. Some people will continue to have these symptoms for 10 or more years.

 

What is happening?

At birth the ovaries contain about a million eggs. As age increases the number of eggs decrease. After the age of 35-40 this number decreases more quickly and you release an egg less often until your periods stop. At menopause there are no more eggs to release.

During this time the hormones that control your period can become irregular. In particular oestrogen can swing from high to low erratically. This is why blood tests are not useful to diagnose menopause but it is also the cause of some of the symptoms of menopause. Over time oestrogen levels will become very low and stable.

 

Can menopause be treated?

The symptoms and physical changes that occur with menopause can be improved through both lifestyle changes and medical treatments. Maintaining good health is important for general wellbeing and can also improve menopausal symptoms. A balanced diet, regular exercise, not smoking and avoiding excessive alcohol will improve physical and emotional health.

Primary Ovarian Insufficiency and early menopause can have important health implications, particularly increased risk of osteoporosis. Hormone replacement should be considered for prevention.

 

Management of menopausal changes

Menopausal Hormone Therapy (MHT) also known as Hormone Replacement Therapy (HRT) is the most effective way to reduce menopausal symptoms and has many health benefits.
It covers a range of hormone treatments which can be taken in different ways, for example pills or patches. MHT/HRT is safe for most people aged in their 50s or for the first 10 years from
menopause. Some people may need to take MHT/HRT for longer than this and this should be discussed with your doctor, but is also generally safe.

Hot flushes can be treated by MHT/HRT and this is the most effective treatment. There are also non-hormonal medications which can help to reduce the hot flushes for those people who cannot have MHT/HRT. Weight gain may make hot flushes worse so maintaining a healthy weight is important. Cognitive behavioural therapy is a form of counselling that has been shown to decrease the impact of menopausal symptoms. Avoiding spicy food and avoiding excess alcohol and caffeine may also help.

Menstrual changes such as heavy bleeding can occur during perimenopause. If there is a new change in your bleeding, such as heavy or more frequent bleeding, bleeding throughout the cycle, or bleeding associated with pain/having sex it is important that you get checked by your doctor.

Treatment for heavy menstrual bleeding includes the progestogen Intra-Uterine Device (IUD) or the combined oral contraceptive pill. There are other medical treatments available if these treatments aren’t suitable for you.

Hysterectomy has previously been the main surgical treatment for heavy bleeding, however there are now less invasive options available such as endometrial ablation or surgery to remove fibroids if medical treatment doesn’t work.

Joint pains often respond well to non-steroidal anti-inflammatory drugs or paracetamol. You may need to use these intermittently but may find that your body adjusts gradually after menopause so you do not continue to need medication.

Sleeplessness and moodiness can be difficult to manage and may need several strategies including behavioural techniques. MHT/HRT can be useful if sleep disturbance is caused by hot flushes or night sweats. Mood changes are common for people mid-life and may not always be due to menopause alone. It is important to look for other factors in your life which may be contributing to these symptoms. Counselling such as cognitive
behavioural therapy can improve sleep and general wellbeing. Medications that are used for anxiety and/or depression can be helpful for some people.

Sexual difficulties and urinary system problems which may occur can include a dry vagina, pain during intercourse, frequent urinary infections and urinary incontinence. These symptoms can often be helped by, lubrication and/or vaginal oestrogen in the form of cream or a pessary, which can be prescribed by your doctor. Pain during sex or a change in sexual desire may also need the support of other health professionals such as a counsellor or physiotherapist. Talking with any partner/s about how you are feeling and any treatment you are having is important.

Bone mineral density decreases due to loss of oestrogen and can increase the risk of a broken bone after menopause. Weight bearing exercise, a healthy diet with plenty of calcium and the other lifestyle changes mentioned previously all reduce the risk of developing osteoporosis in the future. MHT/HRT also reduces the risk of bone loss.

 

Contraception and menopause

You need to keep using contraception until menopause is completed. This is because an egg is still released in around 1 in 3 cycles during perimenopause and sometimes more than once in a cycle. Some contraception artificially alters the cycle which can make it difficult to know when menopause has occurred. If you are going to stop using hormonal contraception, such as the combined oral contraceptive pill or progesterone-only contraception, you should use a barrier method such as condoms until you are sure menopause has occurred (one year of no periods over the age of 50).

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