Menopause

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First the Facts

Menopause signifies the end of reproductive life, as a result of ovarian failure (ovaries have a predicted lifespan of approximately 50 years).This is usually a gradual process, with disruption of the predictable menstrual cycle, which is associated with regular ovulation, starting around age 46.  This period of transition from reproductive to post-reproductive life is known as the perimenopause, and is often associated with maximal symptoms, due to fluctuations in hormone levels. Post-menopause (12 months after the last menstrual period) is easier to define and women may experience less severe menopausal symptoms at this time.

Women are likely to live a third of their lives on average post -menopause, and without hormone replacement therapy (HRT), this is best defined as a deficiency state. HRT can be provided for women with no absolute contraindications, to manage short term symptoms, and also to prevent long-term consequences associated with estrogen deficiency, including an increase in cardiovascular risk, a reduction in bone mineral density and deterioration in urogenital tissue quality.

What You Need to Know – Important Summary Points

  • Many women experience symptoms as they approach menopause before they stop menstruating – this time is known as the perimenopause or menopause transition
  • The most common symptoms experienced in the perimenopause include heavy periods (heavy menstrual bleeding – HMB), hot flushes, night sweats, difficulty sleeping, mood swings, difficulty coping, vaginal dryness, loss of libido and bladder problems – symptoms can range from mild to debilitating
  • There are many ways to manage the menopause transition -these include lifestyle changes relating to diet and exercise, hormone replacement therapy and non-hormonal treatments for women who wish to avoid hormonal treatments or who are not eligible due to their medical history
  • HRT is the best way of relieving symptoms during the menopause transition and beyond (replacing deficient hormones previously produced by the ovaries during reproductive life). HRT reduces both short term symptoms, such as hot flushes and night sweats, and also prevents long term consequences of estrogen deficiency, including the negative impact on bone mineral density and cardiovascular health. Women receiving HRT within ten years of the menopause have a reduction in risk of cardiovascular disease.
  • For women under the age of 60, who are otherwise healthy, the benefits of HRT outweigh any risks.

When Does the Menopause Happen?

Useful Timeframes

  • The average age for the start of the menopause transition is 46 years – much younger than most women expect
  • The menopause signifies ovarian failure with loss of ovulation, production of ovarian hormones and fertility
    • Cessation of periods reflects that ovulation is no longer occurring and is the most obvious sign of menopause
    • Early menopause is ovarian failure between the ages of 40–45
    • Premature menopause (now called premature ovarian insufficiency) is when the ovaries fail before the age of 40
    • Hormone replacement is most important for women with early or premature ovarian failure
  • Post-menopause is 12 months after a woman’s last period. The average age for becoming post-menopausal in the UK is 51.

It is not possible to predict when a woman will reach menopause.

It is not related to the age of menarche (when periods start).

There may be an inherited aspect, so it can be helpful to ask first degree relatives (mother/sisters) when their periods stopped and whether they experienced menopausal symptoms, which impacted on quality of life.

Common Symptoms

Heavy Bleeding

Irregular or heavy bleeding is often an early symptom of the menopause transition, with less of a gap between heavier periods, or several months without a period.

Bleeding should be considered heavy if:

  • It soaks through sanitary products within an hour
  • It wakes you from sleep
  • You need dual protection (e.g. tampons and pads)
  • You are passing large blood clots
  • Bleeding lasts longer than 7 days
  • You consider the bleeding to be heavy

Hot Flushes

Hot flushes are a sudden feeling of intense heat that spreads throughout the body. They may last seconds or minutes, and may be accompanied by reddening of the skin, sweating and sometimes palpitations (rapid heart rate). Hot flushes can lead to embarrassment and anxiety. Hot flushes are one of the most common and well-known menopausal symptoms.

In general, women get hot flushes for an average of 5 years, although it can be a lot longer than this. Some women experience very few, whereas others may get several hot flushes a day.

Night Sweats

Night sweats are hot flushes that happen during the night. They can disturb your sleep pattern (and your partner’s), resulting in tiredness. Some women may have difficulty coping because of lack of sleep.

Vaginal Dryness

As a result of estrogen deficiency, mostly due to the menopause, the lining of the vagina, instead of being stretchy and well lubricated, becomes dry and more easily damaged. Your doctor may call this condition different things including urogenital atrophy, vulvovaginal atrophy (VVA) and genitourinary syndrome of menopause (GSM). It may cause discomfort or pain during sex and can make having a smear test difficult or painful. Vaginal dryness, itching and burning are very common symptoms of the menopause transition, but women are often embarrassed to talk about them.

For more information go to Estrogen Deficiency: Effect on Tissue Quality in the Genital Region.

Bladder Problems

You may experience a sudden or constant need to pass urine (urge incontinence), leakages during exercise or when laughing or coughing (stress incontinence), or both of these (mixed incontinence) around the menopause. In addition, it may be painful to pass urine.

Lack of estrogen impacts on tissue quality in your pelvic floor, vagina, bladder and urethra (the tube that carries urine out of the body).

  • When you are standing, most of your bodyweight bears down on the pelvic floor, and being overweight makes this worse
  • Pregnancy and childbirth put pressure on the pelvic floor, especially if the baby is large, labour is prolonged, or instruments are used to help the delivery
  • Coughing and constipation can also stress the pelvic floor
  • Some women have poor quality tissue for genetic reasons

Effects on Your Mood and Mind

You may experience changing emotions (emotional lability) at this time of life for many reasons, but the changes in hormones due to the menopause may make this worse. Common emotional issues include irritability, such as snapping for no apparent reason, low mood, anxiety, difficulty coping, lack of motivation, tearfulness and worsening phobias. Some women also report becoming more forgetful, poor concentration and ‘brain fog’. Lack of sleep can also make these symptoms worse.

Women who are prone to mood changes are more likely to experience emotional lability around the menopause and premenstrual symptoms may be worse at this time.

Sex and the Menopause

For some women the menopause represents freedom from periods and the worry of becoming pregnant. However, for others the hormone changes can affect libido (interest in sex) and cause problems such as vaginal dryness that make sex difficult or painful.

Vaginal problems are very common during the menopause transition and post-menopause, particularly vaginal dryness, itching and pain during sex. This may in turn reduce sexual desire and arousal and reduce sexual pleasure and orgasm.

The tissue changes associated with urogenital atrophy can affect sexual intimacy and the ability to have a physical loving relationship. Women also report feeling less healthy and attractive. This can lead to avoidance of sex and intimacy – an important part of a relationship for many people. Urogenital atrophy is also a common cause of bleeding after sex (post-coital bleeding).

Other Symptoms

Every woman experiences menopause differently. The most common symptoms are listed above, but there are many other embarrassing problems that women may experience to differing degrees.

Lifestyle Changes to Help Manage Symptoms

Many women find that changes to their daily lifestyle can help to reduce menopausal symptoms.

Get Moving

Physical activity has many benefits and can help with symptoms during the menopause transition and with your general health and wellbeing. In fact, physical activity is the single most important thing that everyone can do to improve their health – and it can be fun and sociable too! Being outside is also very good for general health and wellbeing.

There are many ways to incorporate physical activity into your daily life, such as gardening, walking the dog and dancing. Weightbearing activity (such as running and walking) is important to protect your bones. Activities such as yoga and Pilates are good for core strength and flexibility and can improve balance and the pelvic floor, helping with continence.

Eat Well

Plenty of advice is available about what to eat to maintain good health, and how much to eat. The NHS site ‘Eat Well’ is a good starting point for finding out more about a healthy, balanced and sustainable diet. The key is to eat a wide variety of foods. You need fewer calories as you get older, because your metabolism slows down. You may put on weight if you continue to eat the same amount as you did before the menopause. Be aware that some foods may trigger hot flushes, particularly spicy food.

Think About Your Alcohol Intake

Alcohol contains a lot of calories and can trigger hot flushes and may also affect your sleep quality. Reducing alcohol intake has many potential benefits.

Coffee

Caffeine triggers hot flushes in some women and may affect sleep quality. It is a diuretic which removes fluid from your body by increasing the amount of urine you produce. This can irritate your bladder, making you more likely to need to pass urine. Caffeine levels are highest in coffee, but hot chocolate and tea also contain caffeine. You may find that reducing caffeine intake improves some of your symptoms and improves your sleep pattern.

Breaking the Taboo and Getting Support

The menopause transition is a significant milestone, marking the end of the reproductive years. For some women this may be tinged with sadness, whereas others may embrace a newfound freedom from periods and the worry of pregnancy. Although the menopause transition can have a marked effect on working, home and social lives, it is a natural process, and it does not have to be unpleasant. Fortunately, awareness of peri-menopausal symptoms and the challenges that some women face during the menopause transition is improving all the time helped by media attention, with celebrities talking about their own experiences.

Talking Helps!

It is important to talk to people. The more open we are, the easier it becomes. If you are struggling at work, talk to your human resources team or confide in a colleague. Much is now being done to help employers understand how the menopause may affect their staff and, importantly, how they can help. Talk to your partner and children about how you feel; they can be more supportive if they know what you are going through. If sex is uncomfortable or painful, tell your partner. Comfort and affection are important, even if you don’t feel like having sex. Your peer group may also be hiding symptoms. Talking or laughing about experiences of hot flushes for example, may help you all feel better!

 

Please consult the ‘Fast Facts for Women and Their Supporters: Menopause’ for more information on this topic.

 

Written by: Dr Paula Briggs
Last updated: January 2021

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