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Reviewed by Dr Dan Rutherford, GP
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What is the menopause?
The menopause, also called the change of life, is defined as the
end of the last menstrual period. In Western women it occurs on average at 51
years, but there is a wide range of normal extending from your 30s to 60s.
What is the menopause like?
The menopause occurs when the ovaries no longer respond to the
controlling hormones released by the pituitary gland of the brain. As a result,
the ovaries fail to release an egg each month and to produce the female sex
hormones oestrogen and progesterone.
It is the fall in the levels of these hormones in the
bloodstream that gives rise to the symptoms of menopause.
Research into the menopause is relatively recent. One hundred
years ago, when life expectancy was shorter, most women did not live long after
the menopause and so little was known about it.
How does the menopause start?
Many women experience symptoms of the menopause and irregular
periods for several years up to the menopause itself.
This is called the climacteric, or 'perimenopause', and
represents the gradual decline in the normal function of the ovaries.
One of the common problems of the climacteric is that periods
become erratic both in spacing and amount. Until the periods peter out
altogether, heavy bleeding can cause plenty of problems.
Treatments for heavy bleeding are listed below.
NSAIDs
Non-steroidal anti-inflammatory drugs (NSAIDs) are medicines
such as
ibuprofen (eg
Nurofen) that are used as painkillers and to lower a raised temperature.
They reduce the amount of blood lost in a period and help
reduce pain.
Mefenamic acid (eg
Ponstan) is another painkiller used in the same way.
Tranexamic acid
Tranexamic acid
(Cyklokapron) is a drug that encourages blood to clot on a bleeding
surface, which can reduce heavy menstrual bleeding. It’s only used for the
heaviest three or four days of each period.
It’s not suitable for women with a previous history of clots
in the veins (thrombosis). Nausea, vomiting and diarrhoea are the likeliest
side effects from this drug.
Progestogen tablets
Oral progestogen tablets will cut menstrual flow when given
for long enough (21 days each cycle), as will the progestogen released from the
Mirena intra-uterine system.
Mirena is
currently the most effective non-surgical way of dealing with excessive vaginal
bleeding.
There are other drug options that can be used by specialists,
if necessary, but these can be accompanied by significant side
effects.
Hysterectomy
Heavy menstrual bleeding is the most common reason for having
a hysterectomy. One in five women have had a hysterectomy before the age of 60.
Complete removal of the uterus is a relatively major
operation. This means it is accompanied by risks such as those of an
anaesthetic, of bleeding at operation, wound infection, vein clots
post-operatively and so on.
However, these are risks that apply to any operation. In
practice, hysterectomy is a successful and well-tolerated procedure.
Endometrial ablation
Lesser surgical procedures to treat heavy bleeding are now
possible using fibre-optic instruments that can destroy the lining of the
uterus (endometrial ablation).
This works because it is only the inner lining of the uterus
that is hormone-sensitive and responsible for menstruation.
The procedure does not completely remove every piece of the
uterine lining, and 30-90 per cent of women still get some menstrual bleeding
afterwards, but usually it is light.
For the same reason, if you later take HRT after an
endometrial ablation, you will still need to use a combined HRT preparation and
not just oestrogen alone.
What is the menopause like?
Every woman experiences the menopause differently.
Many hardly notice 'the change', except perhaps their periods
become irregular. Others suffer every symptom and find their lives are severely
affected.
The transition into the menopause is usually gradual and is
accompanied by a range of symptoms.
Hot flushes and sweating
The most common symptoms by far are ‘hot flushes’ and sweating
attacks. These episodes can happen at any time, as often as several times an
hour.
Each hot flush usually lasts for three to six
minutes.
Exactly why flushes and sweats occur is not fully understood,
but mostly it is because the automatic controls of the nervous system become
erratic.
This triggers the skin blood vessels to open and signals the
sweat glands to become active at any time. Usually, this would only happen if
you were too hot and needed to lose heat.
Sleep disturbance
Sleeping difficulty can be due to problems falling asleep,
restlessness or night-time sweats. Some women sweat heavily and have to get up
to change the sheets several times a night.
Psychological changes
Depression, mood swings, tiredness or
headaches are all
possible symptoms. Forgetfulness or irritability can be distressing for both
you and the rest of the family.
Physical changes
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During the menopause your skin becomes thinner.
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A lack of oestrogen often means the glands in the vagina
don't produce as much lubrication as before and this may cause stinging around
the vagina during sex.
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Some women don't feel like having sex, whereas others find
their orgasms become less intense.
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The lack of oestrogen also affects the bladder and you may
find you need to pass water more often.
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There is a gradual rise in the risk of
heart disease and
stroke after the
menopause.
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Falling oestrogen levels result in unfavourable changes in
cholesterol and fat levels in the blood, causing a predisposition to these
problems.
Osteoporosis
In recent years there has been a lot of interest in
osteoporosis
(thinning of the bones) in connection with the menopause.
Oestrogen normally stimulates the bone-building cells.
As a result of the drop in oestrogen, women tend to lose bone
mass and strength for several years following the menopause. Ultimately, this
can make the bones more likely to collapse or fracture.
What can make the menopause easier?
Medical treatment is available for women who are troubled by
symptoms of the menopause.
Hormone replacement therapy
Hormone replacement therapy (HRT) alleviates the
symptoms of the menopause by adjusting hormone levels.
It involves receiving a small daily dose of oestrogen. Women
who have not had a hysterectomy are also given a progesterone-like drug as part
of the HRT. This is called combined HRT.
Combined HRT can be described as either sequential or
continuous.
Sequential combined HRT is suitable for women who are
perimenopausal, ie still experiencing erratic menstrual bleeding. Most
preparations are designed to mimic the
menstrual cycle and
result in monthly periods. They are based around a 28-day cycle in which
oestrogen is taken every day and a progesterone is added for the last 12 to 14
days of the cycle. For women who are borderline postmenopausal and have very
infrequent bleeds, there is also a sequential preparation available that
results in three-monthly bleeds.
Once a woman has not had a natural period for a year and is
described as postmenopausal, continuous combined HRT is more suitable. This
form of HRT does not produce periods and involves taking a daily dose of
oestrogen and progesterone.
How is HRT taken?
There are many ways of taking HRT, with the most usual being a
daily tablet. Alternatives include skin patches, a small pellet or implant
under the skin, a gel applied daily to the skin, a ring inserted into the
vagina, or a nasal spray.
What are the side effects of HRT?
The majority of women have no side effects, but the following
are fairly common:
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nausea
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breast tenderness
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weight gain
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fluid retention.
These symptoms often settle after the first few months of
treatment. If they don't, it's worth consulting your doctor or gynaecologist to
adjust the medication.
How effective is HRT?
HRT is effective at relieving hot flushes and vaginal dryness
and many women report an improvement in their general sense of wellbeing.
However, HRT is not a magic fix and if disturbed mood or
behaviour is due to underlying problems at home or work, HRT cannot be expected
to improve matters.
HRT is often taken for a short spell of six months to a year
to relieve hot flushes.
The long-term benefits of HRT have recently been brought into
question.
Previously it was thought that HRT prevented heart disease and
strokes by slowing the development of hardening of the arteries. Several major
research studies reported in 2002 and 2003 have shown this is not so.
The possibility that HRT users are less likely to develop
Alzheimer's disease
is still to be confirmed, but it does seem that HRT offers some protection
against developing
bowel
cancer.
The most important result of these research studies has been
the confirmation that HRT increases the risk of developing breast cancer and
endometrial cancer (cancer of the lining of the womb).
The risks with HRT
To put into perspective the magnitude of these risks, it
helps to put together some figures.
For purposes of comparison, the risks are stated as the number
of people affected per 10,000 women-years of observation. This can mean one
thousand women observed over 10 years or five thousand women over two years,
etc.
The Women’s Health Initiative (WHI) study showed the following
risks.
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Sequential HRT
Some evidence suggests sequential HRT is associated with a
slightly higher risk of endometrial cancer.
Sequential HRT is the sort associated with a monthly or
three-monthly bleed.
It is recommended for use in the climacteric
phase.
Ideally, all women on long-term HRT should move to a
continuous type within a year or two of starting HRT.
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Breast cancer: the risk of developing
breast cancer in women not taking HRT (on placebo) was 30 per 10,000
women-years. On HRT the risk was 38 per 10,000 women-years.
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Heart disease: women not taking HRT had 30
cases of heart disease per 10,000 women-years. Women on HRT had 37 cases per
10,000 women-years.
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Stroke: on placebo the risk was 21 per
10,000. On HRT the risk was 29 per 10,000.
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Clots in the veins (venous thrombosis): on
placebo the risk was 16 per 10,000. On HRT the risk was 34 per 10,000.
Researchers included those clots that moved from the leg veins up into the
lungs, which are the most dangerous type, as well as those that stayed within
the leg veins.
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Endometrial cancer: it is difficult to put
an exact figure on this, but long-term oestrogen-only HRT does increase the
risk of abnormal growth of the lining of the womb (endometrium) and endometrial
cancer. Using combined HRT reduces, but does not eliminate, the risk Evidence
suggests that sequential combined HRT may still be associated with slightly
increased risk of endometrial cancer, however no increased risk has been found
with continuous combined HRT.
Breast disease and HRT
HRT has been known for years to increase the risk of
breast cancer. The
risk increases with the length of time HRT is used and becomes detectable after
about one to two years of treatment.
The risk falls once HRT is stopped, and takes about five years
to drop back to the average in the population.
The Million Women study showed combined HRT had a higher risk
of breast cancer than oestrogen-only HRT. The study found that:
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in women aged 50 who do not use HRT, about 32 in every 1000
will be diagnosed with breast cancer by the time they reach the age of 65.
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in women who start oestrogen-only HRT at age 50 and use it
for five years, about 33 to 34 in every 1000 will be diagnosed with breast
cancer by the age of 65.
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in women who start combined HRT at age 50 and use it for
five years, the figure would be 38 in every 1000.
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for those who start oestrogen-only HRT at age 50 and use it
for 10 years, breast cancer will be diagnosed in 37 in every 1000 by the age of
65.
-
in those who start combined HRT at age 50 and use it for 10
years, the figure increases to 51 in every 1000.
The best evidence available at present tells us that breast
cancers that occur in women taking HRT are smaller, less advanced and of a more
treatable type than breast cancers occurring in women not taking HRT.
This accounts for the fact that despite the increased numbers
of cancers arising due to HRT, the actual mortality of women from breast cancer
is the same in the HRT and non-HRT populations.
However, experts now feel the balance of risk has swung
against HRT given for longer than five years. It is recommended that HRT is
only used as a short-term treatment to relieve menopausal symptoms, and that
treatment is reviewed at least annually. Any woman considering HRT should
discuss the risks and benefits for her individual circumstances with her doctor
before making a decision about treatment.
Other breast problems related to HRT
Women in the pre-menopause who take HRT often get breast pain
and benign breast lumps, including cysts (fluid-filled lumps).
HRT may cause benign breast lumps that are already present to
get bigger.
In the UK, as well as relying on women to check their breasts
and report changes to their GP, there is also a national screening service that
offers periodic
mammograms to women
over 50.
HRT is known to increase the density of breast tissue, which
makes it harder for the X-rays used in mammography to penetrate the breast. It
is therefore of concern that HRT can make it more difficult to detect breast
cancer by mammography.
However, HRT is not the only type of medicine that can be used
to relieve menopausal symptoms.
Other treatments for the menopause
Tibolone
Tibolone (Livial)
is a synthetic steroid hormone that has some oestrogen plus some progesterone
effects (and has some testosterone-like effects, too).
In a way it’s a type of combined continuous HRT in a single
tablet, which is largely how it’s used.
It helps flushings and sweats, vaginal dryness and irritation
and also protects against osteoporosis. It possibly improves libido.
The benefits of tibolone include much less breast tenderness
and little effect on breast tissue density in mammograms density. However, the
Million Women study showed that tibolone is associated with a slightly
increased risk of breast cancer, of around the same level as that associated
with oestrogen-only HRT.
Clonidine
Clonidine is a drug originally developed for use as a blood
pressure lowering treatment, but at smaller doses (Dixarit) it can relieve hot
flushes.
Oestrogen creams and pessaries
Vaginal dryness can be relieved by short courses of oestrogen
creams or pessaries that are inserted into the vagina.
There is also a special vaginal ring containing oestrogen that
can be left in the vagina for three months, where it slowly releases oestrogen
into the vaginal tissues.
Complementary medicine
A range of ‘complementary’ medical treatments are also widely
in use to relieve menopausal symptoms.
Although the scientific evidence in favour of complementary
medicine is not as good as for conventional treatments, they are generally safe
to try.
Black cohosh is the best known of the complementary
treatments. It has its origins among North American Indians, where it has been
used as a traditional folk remedy for a range of gynaecological problems for
hundreds of years.
Liver damage may occur in some people taking black cohosh – although liver injury is rare it could be serious. The Medicines and Healthcare products Regulatory Agency (MHRA) have said that all products containing black cohosh should carry a warning.
A natural process
There has been a tendency to think of the menopause as an
illness or a health hazard, which is the wrong way to look at it. It’s a phase
of life and we have to live with it.
The hand of woman (or man) has little influence on the processes
of nature, and the menopause is a changing scene in the world of medicine.
There are many unanswered questions - a lot of the problems we thought we had
some answers to have turned out not to be so clear cut.
The big health issues that face older women in the UK today are
mainly to do with cardiovascular diseases, being overweight, developing
diabetes and having poor mental health. It’s the same list for men.
We know the things that need attention across the population to
help these problems:
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the low levels of exercise most of us take
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our excessive intake of high-calorie foods, salt and alcohol
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hypertension (high blood
pressure)
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cholesterol levels.
These are actually bigger threats than cancer to the majority of
people, and all of them can be improved by actions we can take ourselves.
Are there steps I can take to make the menopause
easier?
It’s perhaps taking it a bit far to say that with the right
attitude the menopause can be made into a joyous part of your life. However,
the same actions that make life better generally will make the menopause
better, too.
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Regular exercise such as walking for 20-30 minutes three or
four times a week can improve your health and add years to your life. Exercise
strengthens your bones, increases wellbeing and can help make sleeping easier.
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Eating the right food is also important. For healthy bones, the
body needs about 1500mg of calcium each day from dairy products such as milk
products and cheese.
-
Eating plenty of fruit and vegetables provides the necessary
minerals and
vitamins for good
general health and also helps to protect against cancer and heart disease.
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There is some evidence that soy flour (or other foods rich in
so-called ‘plant oestrogen’) can reduce menopausal flushings.
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Smoking is never good for your health.
Stopping smoking is
the biggest single move anyone can make to improve their health, whatever their
age.
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References
Writing group for the WHI study. Risks and benefits of
estrogen plus progestin in healthy postmenopausal women. Principal results from
the women’s health initiative randomised controlled trial. Journal of the
American Medical Association 2002;288:321-333
http://jama.ama-assn.org/cgi/content/abstract/288/3/321.
Dixon JM. Hormone replacement therapy and the breast.
British Medical Journal 2001; 323: 1381-1382
http://bmj.com/cgi/content/full/323/7326/1381.
Beral V, et al. Breast cancer and hormone replacement
therapy in the Million Women Study. Lancet 2003; 362: 419-427.
HRT: Update on the risk of breast cancer and long term
safety; MHRA Current problems in pharmacovigilance, Volume 29 Sept 2003. Tanna
N. Hormone replacement therapy: risks and benefits. Pharmaceutical Journal
2003; 271: 646-648.
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Based on a text by Niels Lund, specialist gynaecology and obstetrics, Charlotte Floridon, MD, PhD, gynaecology and obstetrics and Christel Bech, nurse
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Last updated 16.02.2005
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