Menopause Questions

The menopause is a natural event and occurs when your ovaries stop producing eggs and make less oestrogen (the main female hormone). Menopause actually means your last menstrual period. It is often difficult to know when this is for many women, especially if you are having more scanty and irregular periods.

Symptoms of the menopause can last for many years, even decades. You may start to experience symptoms during your perimenopause (the time in which you experience menopausal symptoms but are still having periods) that can last for several years.

The average age of the menopause in the UK is 51 years. It is common to have some perimenopausal symptoms when you are in your late 40s.

The average age of the menopause in the UK is 51 years but around 1 in 100 women have a premature menopause (under 40 years). Many of these women are still not receiving adequate help, support and advice about how best to manage their symptoms. In addition, so many women do not realise that their symptoms are related to their menopause.

Some women have very few or even no symptoms and their periods simply stop happening. However, for the majority of women it is not so straightforward and around 80% of all women experience several symptoms. The symptoms you may experience vary between different women. These symptoms often have a very negative impact on your life and can really affect your relationships with your partner, family and work colleagues.

Common symptoms of the menopause include hot flushes, night sweats, sleep disruption, insomnia, exhaustion, mood swings, palpitations, chest pain, breathlessness, depression, anxiety, hair loss or thinning, vaginal dryness, bladder weakness, incontinence, urinary tract infections, lack of libido, change of body shape, dry eyes, dry mouth, memory loss, poor concentration, brain “fog”, aching joints and muscles, headaches and migraines.

Most people associate the menopause with hot flushes and night sweats, but these are actually the symptoms that bother my patients the least. It is the symptoms that other people cannot see that lead to the most difficulties and these are the psychological symptoms.

The term perimenopausal describes the time when you have menopausal symptoms before your periods actually stop all together. Some women continue to have regular periods even though they experience numerous symptoms of the menopause.

Women are said to have gone through their menopause (so are postmenopausal) when they have not had a period at all for one year.

The perimenopause is the name for when the first changes in the menstrual cycle occur, which can be subtle. It could show up as a shortening of your cycle – maybe from 28 days down to 25 or 26 – or your cycle could get longer.

Your periods may become a little shorter or lighter or indeed longer and heavier.

How you feel will vary from month to month. That’s because your ovaries don’t just stop producing oestrogen. Levels of oestrogen fluctuate over some years, going towards a kind of up and down, stuttering stop. Levels of progesterone vary too at this time, and this plays a part too.

The average age of the menopause – when periods have stopped for a year – is 51, and the perimenopause can last five, six, even eight years. So it often starts in the early or mid 40s. But it could even start in your 30s, if you have an early menopause. One in a hundred women will have the menopause under the age of 40.

All types of hormone replacement therapy (HRT) contain an oestrogen hormone. Taking HRT replaces the oestrogen that your ovaries no longer make after the menopause. Even low levels of HRT can have benefits in your body and improve your symptoms of the menopause.

Many women feel confused about the different types of HRT and also about the benefits and risks of HRT. It is important that your individual health is taken into consideration by your doctor when discussing HRT. HRT is actually much safer than most people realise.

Some women may choose not to take HRT or others may not be able to take HRT due to an underlying medical condition. If you are not sure whether or not you can take HRT then you should discuss this with your doctor who may decide to refer you to an expert in the menopause.

You may have a small increased risk of breast cancer if you take some types of HRT. However, if you are only taking oestrogen only HRT then studies have shown that you actually have a lower risk of breast cancer.
Taking combined (oestrogen and progestogen) HRT may be associated with a small increased risk of developing breast cancer. This risk increases the longer you have used HRT. When you stop taking HRT, you have the same risk of breast cancer as someone who has not taken HRT.

The actual risk of breast cancer with taking combined HRT is actually very small. This risk is similar to the risk of breast cancer in women who are obese, those women who have never had children and also those women who drink two to three units of alcohol each day.

There is no increased risk of breast cancer in women who take HRT under the age of 51 years.

There is no set length of time that you should take HRT for. Some women take it for a few years to help improve their symptoms of the menopause. If your symptoms return when you stop taking HRT this is not an effect of taking hormones, this is because you would still be having symptoms of the menopause at that time if you had never taken HRT. Some women decide to take HRT for a much longer period of time. It is usually an individual decision between yourself and your doctor regarding the length of time you will take HRT.

Taking HRT actually reduces your future risk of really important diseases such as osteoporosis, heart disease and diabetes. So, in addition to helping you feel better, you can be reassured that taking HRT is actually a real investment for your future health.

Side effects with HRT are more likely to occur when you first start taking HRT and then they usually settle with time. The most common side effects you may experience in the first few weeks of taking HRT are a feeling of sickness (nausea), some breast discomfort or leg cramps. These tend to go within a few months if you continue to take HRT.

Some women find that certain makes of HRT skin patches cause irritation of their skin. A change to a different brand or type of HRT may help if side-effects occur. Various oestrogens and progestogens are used in the different brands. If you have a side-effect with one brand, it may not occur with a different one. Changing the delivery method of HRT (for example, from a tablet to a patch) may also really help if you develop any side-effects.

If you are considering taking HRT then the lowest effective dose of HRT should be taken. You should have regular follow-up to decide whether you still need HRT. If you are still experiencing menopausal symptoms on HRT then your dose of HRT will probably be increased.

A “body identical” oestrogen has the same molecular structure as the oestrogen which decreases in your body during the menopause. It is safer having the oestrogen as a patch or gel as this then is absorbed directly through the skin and has less side effects and risks. It is also natural in that it is derived from a plant chemical which is extracted from yams, which are tropical root vegetables.

A “body identical” progestogen has the same molecular structure as the progesterone in our bodies. This means that is usually is associated with fewer side effects than other types of progestogens. Side effects of progestogens can include bloating, spots and mood swings. Micronised progesterone is also made from yams.

All these body identical hormones are usually available on the NHS although micronised progesterone is not usually available in Scotland.

Some types of older HRT contain a mixture of different types of oestrogens and are made from pregnant mares’ urine. So this type of HRT is “natural” but it is not “body identical” as it contains many types of oestrogens that you do not need in your body. This type of HRT is not often prescribed by doctors any more.

It’s a myth that HRT causes you to gain weight, it’s all down to that oestrogen deficiency.

On the lowest effective dose you can take HRT as long as necessary and certainly younger women should not stop taking it before they are 50 years old.

Taking hormone replacement therapy (HRT) can improve skin hydration by replacing oestrogen levels in your body. Many women who take HRT often notice that their skin becomes brighter with an improved texture and tone. HRT can also reduce ageing of your skin. Your skin often looks firmer and plumper as the oestrogen works to strengthen the collagen and elastin fibres.

For the majority of women under 60 years of age, the benefits of HRT outweigh the risks.

These bio-identical hormones are compounded. This means that they are custom made in order to prescribe hormones in combination doses or preparations that are not routinely available.

Some of the hormones used in these bio-identical hormones contain hormones that are not approved for women such as a hormone called DHEA (Dehydroepiandrosterone) or prednisolone. Many women are given progesterone creams which are actually not well absorbed in the body and are not available on the NHS.

Some “natural” progesterone creams for your skin are available in some places over the Internet. These are not recommended as they are not absorbed into the body well and also many contain too little amounts of hormone to be effective.

Low mood and feelings of depression can be very common symptoms of the menopause and perimenopause. Other psychological symptoms include feelings of low self-esteem, having reduced motivation, anxiety, irritability, panic attacks, poor concentration and low energy. These symptoms can be mistaken for depression and I see many women in my clinic who have wrongly been given antidepressants by their doctors for these symptoms.

It can be common for women to feel more irritated and angry than they used to which can really affect their families and their ability to function at work. Women often feel more tearful and frequently have mood swings.

If you have had postnatal depression in the past, or a history of PMS, then it is more likely you will experience these types of symptoms during your menopause. This is because your body is more sensitive to changing levels of hormones.

Anxiety during perimenopause is actually a very common issue. During the perimenopause your levels of oestrogen and progesterone decline with each cycle as your body heads towards menopause.  However this is not in a nice smooth transition and can occur in quite dramatic peaks and troughs. So it’s perhaps not surprising that fluctuations in hormone levels are going to cause fluctuations in you.

Around the time of the menopause, there are often changes in the vaginal tissues and the urethra (where urine comes out of the bladder) due to low oestrogen levels. This can cause significant urinary symptoms.

As the amount of oestrogen reduces in your body during the menopause, your vagina become less lubricated and stretchy. This reduction in oestrogen is often due to the menopause but it can also be due to breastfeeding, taking the oral contraceptive pill or some types of medications (such as anti-depressants, antihistamines or tamoxifen).

Using chemical products such as medicated wipes, sprays or even some types of washing powder can lead to vaginal dryness.

Vaginal dryness or atrophy is also called atrophic vaginitis. Some doctors refer to it a genitourinary syndrome of the menopause (GSM) as it is not just your vagina that is affected. The low levels of oestrogen in your body can lead to thinning and weakening of the tissues around the neck of your bladder, or around the opening for urine to pass (the urethra). For example, urinary symptoms that may occur include an urgency to get to the toilet and recurring urinary infections or cystitis.

Until you are around 30 years of age, you normally build more bone than you lose. However, during the menopause, your bone breakdown occurs at a faster rate than your bone buildup, resulting in a loss of bone mass. Once this loss of bone reaches a certain point, a person has osteoporosis.

The drop in oestrogen levels during the menopause results in increased bone loss which leads to your bones becoming less dense and less strong. Around 10% of a woman’s bone mass is lost in the first five years of the menopause and this increases your risk of osteoporosis developing.

It can be very common to have menopausal symptoms but still have periods. Your periods may become lighter and less frequent or they may become heavier and more frequent. If you are still having periods, then you are perimenopausal. However, when describing symptoms the term menopausal is used which can sometimes be confusing if you are perimenopausal.

Hot flushes are the most common symptoms of the menopause and occur in around three out of four women. They usually come on very suddenly and spread through your body, chest, neck and face. They vary in length from a few minutes to much longer. They can be associated with symptoms such as sweating, dizziness, light-headedness and even palpitations of your heart.

They can occur many times throughout the day and can continue for many years – some women even experience hot flushes in their 80s. They usually occur spontaneously but can come on after drinking certain types of food or drinking alcohol, especially wine.

Hormonal changes make you more likely to gain weight around your abdomen, and animal studies have shown that those with lower oestrogen tend to eat more and be physically less active. The weight does not go on all at once; estimates suggest that this creeps on at the average rate of a pound a year.

The weight is all part of the effect of your hormones encouraging your body to store more fat as you leave your reproductive years behind. As your ovaries produce less oestrogen the body turns to other production sources and extra fat cells effectively become the body’s safety net.

Just because weight gain is likely it really doesn’t make it mandatory. Weight gain is another symptom of the new imbalance in your body but with effort you can maintain or restore your ideal weight again.

Firstly, move more. It is recommended that most healthy adults do moderate aerobic activity for at least 2.5 hours a week – so you may need to up this amount. Also, embark on a strength training or weight resistance programme. This will help build your muscle mass and improve metabolism.

Eat less – it is recommended that you eat 200 less calories per day when you are in your fifties. Also, cut down on the sugar in drinks, desserts and sweets.

Oestrogen is very important for the development of collagen, which is a supporting protein in the skin and provides strength and structure to the skin.

As oestrogen levels reduce during the menopause and perimenopause, your skin can become less mobile and thinner. The low oestrogen levels can result in there being less blood flowing to the epidermis (upper layer of your skin) and also more water loss from your skin leading to your skin becoming less hydrated.

You may notice that your skin becomes more tired looking and develops more fine lines and wrinkles. The skin often becomes less elastic and looks less glowing as hormone levels decline.

Your skin can become drier and become itchy. This itchiness can occur during the day and night and be really troublesome. Some women notice abnormal sensations to their skin, such as numbness, tingling, prickling or a crawling sensation (called formication).

During the perimenopause and menopause, many women also experience acne and skin pigment changes.

The main female hormones oestrogen and testosterone have an important role to play on cognition and memory. When these levels reduce during the perimenopause and menopause, many women find that they have numerous symptoms affecting these functions.

There has been so much negative publicity in the past about HRT that women are scared of taking it. However, there are clear guidelines based on the available evidence which support the safety of HRT. The majority of women taking HRT find that their motivation, energy, focus and memory really improve. This has a very beneficial effect on the quality of life but also their ability to function and work.

Oestrogen has an effect on water retention, indeed this is the reason many women experience a higher level of water retention coming up to their period. Unfortunately when oestrogen levels become erratic during perimenopause and menopause water retention is often a consequence.

Oestrogen also influences the production of bile and this acts as a lubricant in the intestines. When this process becomes less efficient, fats are less thoroughly digested and bloating can occur.

Increased oestrogen levels can also lead to the adrenal glands producing aldosterone which affects the kidney function so that there is a water/salt imbalance leading to feelings of bloating and retention of water.

Finally progesterone usually acts as a natural diuretic which helps to relieve excess fluids from the body. If oestrogen levels become much higher than progesterone this will again lead to bloating and retention of water. However if progesterone is high, food will move more slowly through your intestine which again leads to bloating.

There are two areas concerned with the loss of libido – one is physical and the other is psychological.

In physical terms, you may now be experiencing discomfort during intercourse. This is caused by the decrease in oestrogen which had previously kept the walls of the vagina healthy and lubricated. Lower levels of this hormone can now make those walls dry and irritated which can make things painful.

Surveys show that a very large percentage of women find sex painful and the majority of those find this causes a low sex drive which can then negatively impact upon their relationships.

The reducing levels of progesterone also play their part. One of progesterone’s jobs is to stimulate the production of testosterone and this is key for maintaining sexual desire . With lower levels of testosterone you may experience a lower level of desire.

Firstly, don’t be embarrassed about talking to your GP.

They see these kinds of problems frequently, understand their impact and can advise on the many forms of available treatment from HRT to vaginal oestrogen and other lubricants which is available in many forms.

You can help yourselves by using a soap free cleanser or just luke warm water for intimate washing.  This is better than using soap or shower gels which can aggravate dryness.

Using topical oestrogen (so using it as a gel, tablet or in a vaginal ring) can work really well for women with vaginal dryness. Using oestrogen in this way is not associated with the risks of HRT and can be used by most women, including some on treatment for breast cancer, very safely.

Also, using vaginal lubricants and moisturisers. These can be used on their own or in conjunction with oestrogen. There are many really good, effective lubricants and moisturisers available either from your doctor or to buy from various chemists. There are many different products available and it is important to find one that suits you.