Menopause (signs, symptoms, diagnosis, treatment)
Menopause is a normal part of ageing for a woman and literally means "last period". The term, however, is commonly used to describe the years when the ovaries gradually begin to produce fewer eggs and less of the female hormones oestrogen and progesterone. This reduction in hormone production causes the periods to become progressively more irregular until they stop altogether, and produces physical and psychological symptoms in many women.
Menopause is generally considered complete when a woman has not had a period for one year. Menopause, often referred to as "the change of life", usually occurs between the ages of 45 – 55 years with the average age being 52 years. Premature (early onset) menopause is when periods stop before the age of 40 years.
Consideration of treatment and lifestyle change options may depend on the severity of a woman's symptoms.
Why does menopause occur?
At birth, the ovaries contain a lifetime supply of eggs stored in small follicles. At puberty, hormones produced by the pituitary gland in the brain stimulate the ovaries to begin releasing eggs each month (ovulation). This prompts oestrogen and progesterone to be released by the ovaries, which in turn stimulate the lining of the uterus (endometrium) to thicken in preparation for the implantation of a fertilised egg. If an egg is not fertilised the endometrium is shed and a period occurs. This entire process is known as the menstrual cycle.
As a woman ages the number of follicles in her ovaries decreases and the ovaries produce fewer hormones. Menopause occurs when the ovaries fail to produce enough hormones to stimulate the monthly growth of the endometrium, and periods stop permanently.
The timeframe from when symptoms first appear to when menopause occurs may be several years. This timeframe is medically referred to as the climacteric or the perimenopause.
After menopause a woman's risk of heart disease (including high blood pressure, heart attack and stroke) increases and becomes as high as it is for men. The risk of developing osteoporosis (bone thinning) is also increased.
Natural menopause occurs when levels of oestrogen and progesterone decline naturally.
Premature (early) menopause is when periods stop before the age of 40 years. This can be due to many reasons including medical conditions such as diabetes or thyroid disease, and surgery or medications that have affected the blood supply to the ovaries. Genetic factors may also play a part as premature menopause can run in families. Women who smoke are also more likely to go through premature menopause. Sometimes, however, there is no identifiable cause.
Artificial (surgical) menopause is a consequence of surgical removal of both ovaries or destruction of the ovaries by some cancer treatments. With artificial menopause there is a sudden drop in hormone levels and menopausal symptoms begin abruptly. Often the symptoms experienced are more severe than those experienced with natural or premature menopause.
Signs and symptoms
Often the first symptom of impending menopause is a change in bleeding patterns. Periods may become lighter or heavier, longer or shorter, the time between periods may increase and there may be occasional missed periods. These changes may occur gradually in some women, yet are more abrupt in others.
There are also a wide range of physical and psychological signs and symptoms associated with menopause. In some women they are very mild while in others they are more severe. They may last for only a few months, or may continue for several years. The average length of time for menopausal symptoms to be experienced is three to five years.
Physical signs and symptoms may include:
- Hot flushes (occurring in approximately 60% of women)
- Sweats (often at night)
- Tiredness
- Headaches
- Joint and bone pain
- Palpitations
- Unusual skin sensations
- Vaginal dryness, incontinence and infections of the urinary tract and vagina may occur due to the thinning of the vagina and bladder walls.
Psychological signs and symptoms may include:
- Anxiety
- Reduced interest in sex
- Irritability and mood swings
- Difficulty concentrating
- Loss of confidence
- Forgetfulness
- Difficulty sleeping
- Depression
Diagnosis
There is no one test to diagnose menopause. Symptoms experienced may indicate that menopause is imminent, however menopause can only be confirmed retrospectively after periods have been absent for one year. Blood tests may be taken at this time as the levels of hormones produced by the pituitary gland - follicle stimulating hormone (FSH) and luteinizing hormone (LH) – may be higher if menopause has occurred.
A change in bleeding patterns, particularly where periods become heavier, and an absence of periods (amenorrhoea) can indicate various medical conditions. It is therefore advisable to consult a doctor before assuming that the changes are menopausal symptoms. Also, if bleeding occurs after periods have been absent for a year, a doctor should be consulted, as this is not considered normal.
Treatment
The intensity and frequency of menopausal symptoms vary from woman to woman. If symptoms are problematic, or a woman is at high risk of developing osteoporosis or heart disease, medical treatment may be recommended. Ultimately, the decision to have treatment is a very personal one and should be made by the woman only after receiving a full explanation from her doctor of the benefits and counter benefits of the various treatment options.
Treatment options include:
Hormone Replacement Therapy (HRT)
HRT involves replacing hormones previously produced by the ovaries. It can be effective in relieving the symptoms of hot flushes, night sweats and dryness of the vagina. HRT can also help to reduce the risk of heart disease and osteoporosis following menopause. Facial hirsutism (excess hair growth) can increase after menopause due to hormonal changes. This growth may be slowed with HRT.
HRT can be given as tablets, skin patches and as vaginal preparations such as creams and pessaries. Vaginal preparations can help to reduce symptoms of vaginal dryness, incontinence and bladder and vaginal infections.
Some forms of HRT may increase the risk of endometrial cancer and using some forms of HRT for longer than 5 years may increase the risk of breast cancer. However, recent research has indicated that some forms of HRT may help to reduce the risk of Alzheimer's disease and bowel cancer and may help to prevent some aspects of skin ageing. As there are many different forms of HRT it is important to discuss with a doctor which type and delivery method is most appropriate.
Alternative therapies
Some women have found that alternative therapies have proved successful in reducing menopausal symptoms. These include natural hormones, herbal preparations, vitamins and minerals and homeopathic remedies.
Examples of these include black cohosh, ginkgo biloba, evening primrose oil, vitamins B, C and E, ginseng, garlic, camomile, St. Johns Wort and soy based phyto-oestrogens (natural hormones). Treatments such as acupuncture, massage and reflexology have also proved successful for some women.
Unsupervised use of alternative therapies, particularly herbal preparations, can cause adverse effects and monitoring by a health practitioner trained in their use is strongly advised. It is also advisable to discuss the intended use of these therapies with a doctor, especially if taking prescription medications.
Lifestyle factors
Changes in lifestyle can help to reduce the severity of menopausal symptoms and decrease the risk of osteoporosis and heart disease. Diet and exercise are two very important aspects of these lifestyle changes.
Diet
Women need a higher intake of calcium and vitamin D after menopause to help reduce the risk of osteoporosis. Excellent dietary sources of calcium include low fat dairy products (milk, cheese, yoghurt), nuts, dark green vegetables (eg: broccoli, spinach) and fish with bones in (eg: sardines, salmon). Vitamin D, which helps the body to absorb calcium, is manufactured by the skin after exposure to sunlight. Small quantities are found in foods such as dairy products and eggs.
An intake of at least 1000mg of calcium daily is recommended for women after menopause. If the diet contains insufficient amounts of calcium and vitamin D, dietary supplements may be required.
Eating a healthy balanced diet that is low in fat and refined sugars and maintaining a healthy body weight is recommended. Limiting alcohol and caffeine and not smoking are also important.
Exercise
Regular weight-bearing exercise such as walking, dancing, tennis, aerobics or golf helps in maintaining a healthy weight, fitness and general wellbeing. Exercise also helps to decrease the risk of osteoporosis by strengthening the bones and may assist in reducing the severity of menopausal symptoms such as hot flushes. Specific pelvic floor exercises can help to reduce urinary problems such as incontinence and pain on urination.
Rest and stress reduction also play an important role in managing menopause symptoms. Fatigue and stress can worsen symptoms, so employing strategies to ensure adequate rest is attained and stress is managed will assist in alleviating symptoms.
