Menopause – what happens and when
The Menopause occurs in all women. ‘Meno’ refers to your menstrual cycle and ‘pause’ literally means stop. It occurs when the ovaries spontaneously fail to produce the hormones estrogen and progesterone, when the ovaries are removed, often at the time of a hysterectomy or when the ovaries fail due to specific treatment such as chemotherapy or radiotherapy. The resulting low and changing levels of hormones, particularly estrogen, are the cause of menopausal symptoms in women.
Whilst menopause as a process certainly affects only women, men are hugely affected by it too and this is another reason why we all need to talk about it.
What age does the menopause take place?
The menopause usually occurs between the ages of 45 and 55 with an average age of 51. Some of us will be older and some of us younger, so it’s not actually your age that will determine when you reach menopause (although it is a contributory factor) but changing hormone levels.
Menopause occurring before the age of 45 is called an early menopause and before the age of 40 is a premature menopause.
This article is available in PDF Format here Menopause-Overview-Fact-Sheet
What is perimenopause?
Perimenopause and menopause are interchangeable words meaning ‘around pause’.
Perimenopause is the stage from the beginning of menopausal symptoms through to postmenopause. When women talk about being in menopause, it is the perimenopause stage that they are talking about.
What is postmenopause?
Postmenopause is the time following the last period and is usually defined as more than 12 months with no periods in someone who has their ovaries, or immediately following surgery if the ovaries are removed.
What does it mean to be in menopause?
Menopause is defined as the point when you have your last period and signals the end of menstruation and fertility, following this you are in the postmenopause phase of your life.
It will be in retrospect that you are aware of this occurring and you will need to have had no periods for 12 consecutive months.
How long do menopause symptoms last?
Perimenopause generally starts for women in their mid 40s however it is possible for perimenopause to start in the mid to late 30s. Some women will only have symptoms for a few months before reaching menopause, others a few years. Some symptoms may continue after menopause, during the postmenopause phase and in some cases last for many years.
The way in which women experience the menopause is unique to them. Some women will feel dramatic changes to their bodies, equally, other women will find hardly any change at all.
What causes the menopause?
The menopause is influenced by a change in hormone levels. During a woman’s fertile years, her ability to produce an egg each month is associated with the release of three reproductive hormones, namely, estradiol, oestrone ad oestriol collectively known as estrogen. Estrogen is mainly produced in the ovaries. As women get older, their store of eggs in the ovary decreases and their ability to conceive diminishes. During this time, less estrogen is produced which causes the body to behave in a different way. Nonetheless, your body does not stop producing estrogen overnight and the process can take several years. This gradual change is called perimenopause.
What symptoms am I likely to experience during perimenopause?
Symptoms include physical, psychological and sexual problems.
Physical symptoms include:
- Irregular/infrequent periods
- Hot flushes
- Night sweats
- Joint Aches
- Weight Gain
Hot flushes and night sweats (vasomotor symptoms) are due to altered function of the body’s temperature control. They can occur without warning but may be precipitated by alcohol, stress or a change in room temperature. Problems sleeping may be in part due to night sweats, control of which can improve sleep patterns.
Psychological symptoms include:
- Feelings of increased anxiety
- Mood swings and feelings of irritability
- Brain fog
- Difficulty coping
- Loss of confidence
Psychological symptoms may be related to hormonal changes either directly or indirectly, however, other life evens such as elderly relatives, teenage children, stresses of work may also contribute to psychological symptoms around the time of the menopause.
Sexual problems may be caused by vaginal dryness due to low estrogen levels, resulting in discomfort during intercourse. Interest in sex may decrease at this time. Treatment of other symptoms may indirectly improve libido by improving feelings of wellbeing: controlling night sweats and improving sleep. A combination of vaginal estrogen, moisturisers, lubricants and/or HRT can bring back intimacy. In some cases testosterone replacement may be prescribed.
There are over thirty reported signs and symptoms of menopause.
Do all women suffer from perimenopausal symptoms?
Around 70% of us experience some or all of the symptoms mentioned above ranging from mild to severe. Some of us are fortunate and will pass through the menopause with no recognition of symptoms at all. The most important message is ‘don’t suffer in silence’. Support and advice is widely available. If you are struggling your first port of call should be to consult with your healthcare professional.
Many other factors such as diet and lifestyle, exercise and other medications can also influence symptoms.
A healthy lifestyle can go some way to helping to minimise the effects of perimenopause symptoms and help to keep our heart and bones healthy. Many women feel that this is a good time to review the way they treat their body.
It’s not always easy to confirm that menopause has actually happened especially if you are taking the Pill or have started Hormone Replacement Therapy (HRT) for the relief of perimenopausal symptoms. Perimenopause does not mean no more babies!
It is helpful to know the date of your last period for contraceptive purposes. A woman who has actually reached menopause will be infertile and will have no need for contraception, however, most doctors advise menopausal women under 50 continue with their contraception for two years after their last period and for one year if they are over 50.
Preparing mentally and physically for the menopause
Our mental attitude to these physical changes will have a huge impact on how we experience and cope with the menopausal years. If we have unresolved life issues, even dating from early childhood, the menopause will often bring them into sharp focus in the form of uncontrollable emotions, and force us to deal with them. Suggested steps to take include keeping a journal, meditation, mindfulness, homeopathy and seeing a professional psychotherapist or counsellor.
Physically our bodies may be put under extra pressure during the menopausal years, as our hormones work hard to rebalance themselves. Our bodies are physically designed for this process. However, if our systems are under great pressure from the way we are living or have been living during the previous decade or two, we may struggle.
Lifestyle tips to help minimise SYMPTOMS
Diet – A healthy diet should include keeping it low in saturated fat and salt to reduce blood pressure and rich in calcium and vitamin D to strengthen your bones. Spicy foods and caffeine can be hot flush triggers. Many women take dietary supplements to help get the balance right.
Exercise – Many women experience increased anxiety levels during perimenopause, therefore, a regular exercise regime helps to convert stress into positive energy while preventing heart disease. Exercise will also help you to sleep better and lift your mood. Aim to do 30 minutes of moderate exercise at least 5 days a week. Taking regular weight bearing exercise such as running and walking, can help strengthen your bones and reduce your risk of osteoporosis.
Keep cool – It may help to dress in layers so that you can take some off when you feel too warm. Same goes for your bedding.
Pelvic floor exercises can help to strengthen your pelvic muscles (squeezing and releasing the muscles that support your vagina, bowel and bladder) and can help with bladder control.
Stop smoking – It is widely documented that smoking leads to an earlier menopause and as a trigger for hot flushes. If you smoke you run a higher risk of developing osteoporosis and Coronary Heart Disease, which is the most common cause of death in women.
Alcohol – You need to keep this at a sensible level. The combination of excessive alcohol and hormonal instability will exacerbate symptoms. Alcohol not only increases flushes but is associated with an increased risk of breast cancer.
Caffeine – If caffeine is triggering certain symptoms, try cutting it down, or drink alternatives such as herbal teas or decaf coffee.
Be calm and positive – Hormone imbalance during the menopause can result in added stress and even depression. Relaxation techniques and counselling can be very helpful in coping with anxiety. Rest and relaxation are two things that can make the most significant difference to a woman’s perimenopausal transition.
Health Screening – Now is the time to make use of available health screening services. Studies have shown that a late menopause leads to an increased risk of breast cancer. The NHS offers screening but you should also keep check of any changes in your breasts.
Consulting with your healthcare professional and making the diagnosis of menopause
If you are under the age of 45, it is possible to take a blood test to measure levels of a reproductive hormone known as FSH (follicle-stimulating hormone). However, while elevated FSH levels may be a sign of the menopause, the test is not always accurate and results can’t be guaranteed. Your healthcare professional should evaluate your menopausal status according to your symptoms, pattern of periods and medical history record.
The measurement of FSH is not required to diagnose perimenopause or menopause in women over the age of 45.
If you are over the age of 45 years and have irregular periods together with other perimenopause symptoms, it is useful to start charting changes prior to consulting with your healthcare professional. Please feel free to use this personal symptom checker. The diagnosis of the menopause should be made from a combination of factors with most emphasis being placed on the pattern of periods and presence of menopausal symptoms.
In November 2015 The National Institute for Health and Care Excellence (NICE) published wide-ranging recommendations for the NHS on support, information and treatments needed to address the often debilitating symptoms that women suffer.
NICE Guideline recommendations include:
- In otherwise healthy women aged over 45 years with menopausal symptoms, diagnose the following without laboratory tests: perimenopause based on vasomotor symptoms (hot flushes and night sweats) and irregular periods; menopause in women who have not had a period for at least 12 months and are not using hormonal contraception; menopause based on symptoms in women without a uterus
- Offer women HRT for hot flushes and night sweats after discussing risks and benefits
- Consider HRT to ease low mood that arises as a result of the menopause, and consider cognitive behavioural therapy (CBT) to alleviate low mood or anxiety
- Explain that oestrogen-only HRT has little or no increase in the incidence of breast cancer, whilst HRT with oestrogen and progestogen can be associated with an increase in the incidence of breast cancer, but any increased risk reduces after stopping HRT
- Women with cardiovascular risk factors should not automatically be excluded from taking HRT. Ensure that menopausal women and healthcare professionals involved in their care understand that HRT does not increase cardiovascular disease risk when started in women aged under 60 years, and it does not affect the risk of dying from cardiovascular disease.
As the full guidelines run to a couple of hundred pages you can view and download simplified versions here:-
The NICE guideline prepared for healthcare professionals: https://www.nice.org.uk/guidance/NG23
There is a simplified version for women patients which you can find here: http://www.nice.org.uk/guidance/ng23/ifp/chapter/About-this-information
Women should be referred to a menopause specialist if there’s no improvement after trying treatments, and a referral considered if a woman has menopausal symptoms but HRT is contraindicated (for example, in women with hormone-sensitive cancer), or the most suitable option is uncertain.
Finding a menopause specialist
If you are in the UK please visit https://thebms.org.uk/find-a-menopause-specialist/
If you are in the US please visit http://www.menopause.org/for-women/find-a-menopause-practitioner
Key postmenopause symptoms
Later menopause symptoms are due to the effects of lack of estrogen on the vagina and bladder and include:
- Discomfort on passing urine
- Passing urine more frequently by day and night
- Urine infection
- Leakage of urine
- Vaginal dryness, burning, itching, discomfort
Vaginal and bladder symptoms are extremely common and can cause significant distress. Local estrogen preparations (vaginal tablet, creams or vaginal ring) can help to relieve these symptoms. Low dose vaginal estrogen can be used and can be continued long term. Non hormonal vaginal moisturisers can also be used.
Skin may become dryer, thinner, less elastic and easier to bruise. Skin itching can also occur.
Hair loss/thinning, dryness and unwanted hair growth can also be explained by the lack of estrogen.
The two most important long-term effects of reduced estrogen levels involves the effects on the skeleton and the cardiovascular system.
Due to age and reduced estrogen levels, particularly when the menopause occurs before the age of 45, postmenopausal women are at a greater risk of developing osteoporosis (thinning of the bones). Bone thinning itself does not cause any symptoms with osteoporosis being known as the ‘silent disease’. The first warning sign can be a fracture after a simple fall. It is estimated that by the age of 70 that one third to one half of women will have had an osteoporosis related fracture.
Risk factors for osteoporosis include: breaking a bone after a simple fall, premature or early menopause, family history of osteoporosis, maternal history of hip fracture, long term (more than 3 months) or high dose use of steroids, smoking, excess alcohol intake, lack of weight bearing exercise and poor dietary intake of calcium.
Certain medical conditions which may affect the absorption of food including; crohns disease, celiac disease, ulcerative colitis, gastric surgery and liver disease are also risk factors.
Certain medications such as long term anti-epileptic medications, aromatase inhibitor medications which are often used for breast cancer treatment can also be risk factors.
You can reduce the risk of osteoporosis by not smoking, limiting alcohol intake, taking regular weight bearing exercise such as walking, avoiding excess caffeine and having a healthy, varied, well balanced diet including foods rich in vitamins C & D: oily fish, dairy product and green leafy vegetables.
Cardiovascular Disease (CVD)
Women are nine times more likely to die from heart disease than cancer. As estrogen levels fall, often from the mid-forties onwards, the protective effect on the heart is lost and changes occur which can lead to an increased risk of heart disease.
Risk factors for CVD include: being overweight, blood pressure, cholesterol, smoking and diabetes.
You can reduce the risk of CVD by not smoking, taking regular weight bearing exercise such as walking and maintaining a healthy weight.
Bleeding after the menopause
If you start to experience bleeding once you have reached menopause (you have not had a period for a full 12 months) please consult with your healthcare professional. There is usually a simple explanation for this, however, it can also be a key symptom of certain cancers, so your healthcare professional will need to rule this out.
Hormone Replacement Therapy
If you are finding it hard to manage your symptoms, your healthcare professional may suggest you try Hormone Replacement Therapy. Hormone replacement therapy (HRT) remains the most widely used and effective treatment for menopause symptoms. HRT is simply a way of replacing the estrogen that you start to lose during perimenopause.
HRT aims to relieve symptoms related to estrogen deficiency such as hot flushes and night sweats, sleep problems, mood disorders and vaginal symptoms – these have all been proven. Some women experience unwanted side effects which usually resolve after a few months but some women require a change in type of HRT, type of dose i.e. tablet, transdermal, patch or gel.
Bio-identical Hormone Therapy
Bio-identical hormones are not available on the NHS. Bio-identical hormones are ‘compounded’ which means they are made to order and often use hormones which are not approved for use in women. They are unregulated and are not subject to any quality control, they are also expensive. Progesterone cream, which is often purchased online, is not absorbed well, therefore, you don’t know how much progesterone you are getting and it does not provide the necessary protection for the endometrial lining if you are taking estrogen. Caution: do not buy any hormonal medication off the internet.
Should you prefer not to take HRT and you are finding it hard to manage your symptoms, your Healthcare Professional may suggest other treatments options which may include:-
- Counselling or medication to help with low mood and mood changes.
- Clonidine for hot flushes and night sweats. This treatment may not be suitable for women taking blood pressure medication. If you have depression, heart problems or suffer with constipation this drug may not be suitable for you.
- Vaginal lubricants to help with vaginal dryness.
Herbal remedies have their place but do need to be used wisely. Always look for the THR sign of quality logo and read the back of the packet and check the contents. Prescribed medications interact with herbal remedies so always check with your healthcare professional and/or consult with a qualified herbalist. Some of the commonly used herbs are Agnus Castus, Black Cohosh, Gingko Biloba, Sage, Evening Primrose Oil and St John’s Wort. You should only use one at a time and be aware of contra-indications. You will find more information on herbal remedies here.
These are becoming increasingly popular and there is a variety of therapies available out there.
- Acupuncture, reflexology and hypnotherapy. (If they work for you then do them regularly).
- Pilates and yoga. (The benefits are now widely known and researched. They help with core strength, relaxation, bone density, balance and suppleness. If you can do at least one of these you will reap the benefits).
- Massage. (An aromatherapy massage with Geranium Oil is said to be particularly effective for menopausal symptoms).
- Mindfulness and/or CBT. (Developing simple coping techniques can make a huge difference with your symptoms and everyday life).
- Magnetic Therapy. (There are magnetic magnets on the market said to relieve menopausal symptoms. There is little scientific research to back this up).
Menopause in the Workplace
There is an increasing move towards awareness of menopause in the workplace, in particular to assist managers in supporting staff who are experiencing the menopause and their associated symptoms. In November 2016, the Faculty of Occupational Medicine of the Royal College of Physicians UK, issued Guidance on Menopause and the Workplace. You can download a copy of the guidance in pdf form here
This article is available in PDF Format here Menopause-Overview-Fact-Sheet
Julieann Roberts is the Founder and Editor of Menopause Heath Matters. She has been researching and writing about the menopause for 7 years. She is committed to women’s health and well-being with a special interest in the menopause transition and maintaining a healthy lifestyle post menopause.
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Davies, S.C. “Annual Report of the Chief Medical Officer, 2014, The Health of the 51%: Women” London: Department of Health (2015) Chapter 9: Psychosocial factors and the menopause: the impact of the menopause on personal and working life. https://www.gov.uk/government/publications/chief-medical-officer-annual-report
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