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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.
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 (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.
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.
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.
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. 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.
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.
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.
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.
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. Medical treatment is available for women who are troubled by symptoms of the menopause.
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.
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.
The majority of women have no side effects, but the following are fairly common: 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.
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).
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.
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: 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.
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.
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 is a drug originally developed for use as a blood pressure lowering treatment, but at smaller doses (Dixarit) it can relieve hot flushes.
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.
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. 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:
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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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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