Menopause

What is Menopause?

Menopause is when a woman stops having periods as she reaches the end of her natural reproductive life. This is not usually abrupt, but a gradual process during which women experience perimenopause before reaching post menopause.

It occurs at a median age of 51 years, and is a reflection of complete, or near complete, ovarian follicular depletion, with low oestrogen levels and high follicle-stimulating hormone (FSH) concentrations.

Menopause before the age of 40 is considered to be abnormal and is referred to as primary ovarian insufficiency (premature ovarian failure).

The menopausal transition, or perimenopause, occurs after the reproductive years, but before menopause, and is characterized by irregular menstrual cycles, endocrine changes, and symptoms.

Do I need any tests?

Above 45 years- No periods for 12 months with symptoms is adequate to make the diagnosis

40-45 years old- You may need blood test to check for the hormone (FSH) level.

Below 40 years old- Since there could be underlying causes for premature ovarian insufficiency, you will need referral to the gynaecologist to assess, investigate and to make a management plan.

What are the symptoms of menopausal changes?

Most women (8 out of 10) experience some symptoms, typically lasting about 4 years after the last period, but continuing for up to 12 years in about 10% of women. The symptoms are

Hot flushes

Sleep disturbance

Depression

Vaginal dryness/ urinary symptoms

Altered sexual function

Cognitive changes / lack of concentration

Joint pain

What are the long-term consequences of menopausal changes?

Bone loss – Bone loss begins during the menopausal transition.

Cardiovascular disease – The risk of cardiovascular disease increases after menopause, thought to be at least in part due to oestrogen deficiency.

Dementia – There is limited epidemiologic support for the hypothesis that oestrogen preserves overall cognitive function in non-demented women. However, in the Women’s Health Initiative (WHI), both unopposed estrogen and combined oestrogen-progestin therapy had no global cognitive benefits in older, non-demented postmenopausal women.

Degenerative arthritis – Oestrogen deficiency after menopause may contribute to the development of osteoarthritis, but data is limited.

Body composition – In the early postmenopausal years, women who do not take oestrogen therapy typically gain fat mass and lose lean mass. Some, but not all studies suggest that postmenopausal hormone therapy is associated with a decrease in central fat distribution.

Skin changes – The collagen content of the skin and bones is reduced by oestrogen deficiency. Decreased cutaneous collagen may lead to increased aging and wrinkling of the skin. Limited data suggest that collagen changes may be minimized with oestrogen.

Balance – Impaired balance in postmenopausal women may be a central effect of oestrogen deficiency.

What are the treatment options?

There are different options available for treatment for menopausal symptoms:

Lifestyle changes and interventions that could help general health and wellbeing

Hormonal, for example hormone replacement therapy (HRT). Oestrogen is the effective treatment for relief of menopausal symptoms, most importantly hot flushes. Menopausal hormone therapy (MHT; oestrogen alone or combined with a progestin) is currently indicated for management of menopausal symptoms.  Long-term use of HRT for prevention of disease is usually not recommended.

Non-hormonal, for example clonidine

Non-pharmaceutical, for example cognitive behavioural therapy (CBT).

What are the risks of HRT?

You will be assessed and counselled thoroughly before starting HRT, as there are some risks related to the HRT in the form of:

Strokes- The risk of a stroke is slightly increased with oral HRT as compared to a transdermal route. The incidence of stroke as such is very low before 60.

Breast carcinoma- HRT with oestrogen alone is associated with little or no change in the risk of breast cancer however HRT with oestrogen and progestogen can be associated with an increase in the risk of breast cancer. Any increase in the risk of breast cancer is related to treatment duration and it reduces after stopping HRT.

Venous thromboembolism– Oral HRT is associated with 2-4-fold increase in the risk of VTE, however the transdermal HRT appears safe.

What are the different options for the management of symptoms of menopause?

You will be offered HRT for vasomotor symptoms after discussing with you the short-term (up to 5 years) and longer-term benefits and risks. The choice of preparations are as follows:

Oestrogen and progestogen to women with a uterus (Progesterone is added to protect the lining of the womb)

Oestrogen alone to women without a uterus.

Types of HRT preparations are in the form of patches, gel, oral tablets of Oestrogen and Progesterone and sprays. Testosterone supplementation may be added for the low sexual desire if HRT alone is not effective.

For vaginal dryness, the moisturizers and lubricants can be used alone or in addition to vaginal oestrogen. Vaginal Oestrogen preparations are in the form of creams, rings and tablets. Although the adverse effects from vaginal oestrogen are very rare, you should report unscheduled vaginal bleeding to the clinician or GP. Other alternative for vaginal symptoms is the Mona Lisa touch (fractional micro ablative CO2 laser). This is known to reduce dyspareunia, pain, itching, burning, dysuria and improve sexual function and quality of life.

Complimentary / Alternative techniques and therapies.

Many women prefer natural methods to control menopausal symptoms. Natural does not mean safe products as most of these have not been fully studied and their contents, effects on the body as well as risks are unknown.

There is some evidence that isoflavones or black cohosh may relieve vasomotor symptoms. However, multiple preparations are available and their safety is uncertain. Different preparations may vary and interactions with other medicines have been reported. There is some evidence that St John’s wort may be of benefit in the relief of vasomotor symptoms however there is uncertainty about: appropriate doses, persistence of effect, variation in the nature and potency of preparations and potential serious interactions with other drugs (including tamoxifen, anticoagulants and anticonvulsants).

Alternative techniques in the form of Aromatherapy, Yoga, hypnosis etc. are also very popular with women. We do not fully understand their mechanism of action and effectiveness. However, when used properly with advice from qualified professionals, it is unlikely that any harm will be caused.

When to stop contraception?

If periods stopped before 50 years of age, the contraception can be stopped after 2 years of menopause.

If periods stopped after 50 years of age, the contraception can be stopped after 1 year of menopause.

If you are amenorrhoeic due to progesterone therapy, then we can check FSH level to decide on the optimum time to stop the contraception.