What is it?
The menopause or ‘change of life’ denotes the last menstrual period in a woman. It represents the end of reproductive function in women and is the culmination of a complex and often lengthy process of ovarian decline. The age at which it occurs varies with geographic location and does not appear to have altered much in the last half century.
The average age of the menopause in the UK is 51 years. The period surrounding (before and after) the menopause is called the ‘climacteric’ or ‘peri-menopause’ and may last for 1-10 years.
What causes the menopause?
To understand why women undergo the menopause it is necessary to go all the way back to what happens to female babies in the womb. All the eggs a female will ever have are formed in her ovaries while she is a baby in the womb (during the first three months of pregnancy). At the mid-point (20 weeks) of pregnancy a female baby has about seven million eggs, but falling to two million at birth because of death of some of them.
The eggs continue to die very rapidly after birth such that by the time of the first period (menarche) only 500,000 are left. The ‘menarche’ signifies the beginning of reproductive life and this is characterised by monthly ovulation. During this period about 500 eggs start to develop each month (cycle) but only one (occasionally two or three) ovulate successfully, the rest dying off. As the eggs develop each month they produce female hormones (oestrogen and progesterone).
These hormones cause the lining of the womb to thicken in readiness for pregnancy. If a pregnancy does not occur in any month the thickened lining of the womb is shed as a menstrual period. This sequence of events is repeated every month except when interrupted by pregnancy, certain medicines or disease. When all the eggs in a woman’s ovaries have been used up in this way, her periods stop occurring because she no longer produces the hormones that stimulate the lining of the womb. This represents the menopause or change of life.
What changes does it cause?
The changes brought about by the menopause are due to two profound events. Ovulation stops meaning that once women attain the menopause there is little chance of them becoming pregnant by themselves without medical help. Female hormone production stops causing the periods to stop. It also causes hot flushes (vasomotor symptoms) and changes in the skin, reproductive (sex) organs, blabber and urethra, muscles and bones, and the heart and blood vessels. These may directly or indirectly also cause psychological (mental) changes in women.
- Hot flushes – these are intense feelings of ‘internal heat’ that start from the head and move to the body, causing redness of the skin and a need to cool down. Nobody really knows why they occur and although common, they are not exclusive to the menopause. They are thought to originate from an area of the brain (called the thalamus) that controls body temperature and that is affected by female hormones. Lack of these hormones causes a resetting of the area leading to its abnormal functioning. Typically the body mistakenly believes its temperature is too high and so makes its blood vessels in the skin become bigger in an attempt to lose the excess heat. This causes the redness of the skin that accompanies hot flushes.
- Skin – female hormones encourage the production of substances that maintain the strength and texture of both skin and hair. Lack of these hormones causes loss of skin elasticity (with easy wrinkling and sagging), easy bruising, and loss and/or thinning of hair.
- Reproductive organs – these include the vagina, womb and ovaries, organs whose growth is maintained by female sex hormones. Lack of these causes the organs to become small (undergo atrophy). The lining of the vagina becomes thin, friable and dry; its secretions are reduced. This may make sexual intercourse more painful and potentially more dangerous with increased risk of injuries. The risk of infections is also increased.
- Bladder and urethra – female hormones maintain the tissues of the bladder and urethra and their lack causes the tissues to become thin and friable. The menopause can thus lead to irritation of the bladder and urethra causing urinary frequency and/or urgency, as well as increased risk of urinary infections.
- Muscles and bones – female hormones maintain the strength and structure of muscles and bones and their lack causes laxity and loss of muscle strength, and loss of bone mass that could result in osteoporosis. These may cause generalised aches and pains and increase the risk of bone fractures. Osteoporosis is more common in Caucasians, smaller frail women, those that smoke, and those with sedentary lifestyles.
- Heart and blood vessels – female hormones protect against heart attacks and strokes by reducing the amount of dangerous fat in the blood. Lack of these hormones after the menopause removes this protection and increases the risks of heart attacks and strokes to the levels found in men.
- Psychological changes– this period is marked by many psychological changes, some of which could be profound in some women. These include anxiety, irritability, forgetfulness, tearfulness, depression, insomnia (poor sleep), and loss of libido.
What treatment is available?
There is no substitute for adequate education and preparation for the menopause. Support by the partner and other family members goes a long way to helping women cope with the changes that occur. Some hospitals run special menopause clinics where women can obtain information and advice about the changes and problems to anticipate. The major form of treatment for menopausal problems is hormone replacement therapy. Other specific treatment may be needed in certain circumstances.
Hormone replacement therapy (HRT)
Replacement of the female hormone (oestrogen) helps to prevent or correct many of the problems that occur. Natural oestrogen (usually obtained from horse urine) or a manufactured substitute is used for this purpose. In women who still have a womb, the oestrogen is combined with another female hormone (progesterone), while women who have had a hysterectomy have only the oestrogen preparation.
HRT can be given as tablets (most common form), skin patches, skin creams (especially for the vagina) or injections, depending on preference. Most types of HRT induce a monthly period in women who still have a womb, some may only induce a period every three months, and others not at all. The tablets and creams need to be taken every day, the patches once or twice a week, and the injections every six months. It is recommended that the creams, patches, and injections be used below the level of the belly button (to reduce their effects on the breasts).
Some women may experience unusual vaginal bleeding during their use of HRT. This should be reported to the doctor, as it may need treatment. Nobody knows what the best time is to start HRT or for how long it should be used. Individual circumstances will have large parts to play in these decisions and they should be discussed with the doctor. Women on long-term HRT (greater than 5 years) need regular breast examinations and mammograms because of a slight increase in their risk of breast cancer.
Other treatments
Sleeping pills may be required to correct insomnia. Some women may need additional calcium and/or vitamin-D supplements to help prevent osteoporosis. Vaginal lubrication, along with use of HRT creams or gels, may make sexual intercourse possible and enjoyable. Women who have loss of libido may be given a different sort of hormone treatment (testosterone) to increase their sex drive.
Useful contacts:
Contact Menopause Matters http://www.menopausematters.co.uk/
The Daisy Network
P.O. Box 2829
Blandford Forum
DT11 8YT
Please follow this link for patient information about the menopause: https://www.rcog.org.uk/en/patients/patient-leaflets/menopause-diagnosis-and-management/