THE MENOPAUSE – Chapter 26:

Q 26. 1 What will happen to me at my menopause?

Throughout your reproductive years, your ovaries have two essential functions – they release both eggs and hormones (Q2.3). Ovarian hormones are responsible for your female physical characteristics, such as breast development, general body shape and the menstrual cycle and they are fundamental in those indefinable qualities called femininity.

When we speak of the menopause, we usually mean the time in a woman’s life when the ovaries cease to function – doctors call this ovarian failure. The medical term for this phase of a woman’s life is ‘the climacteric’. It may affect you for a matter of a few weeks or months but may continue to be a problem for several years.

The menopause is defined by doctors as the final natural menstrual period and compares to the menarche which is the first period. The menopause is only one event of the climacteric just as the menarche (Q5.5) is one event during puberty when there are a whole range of physical and emotional developments. The menopause is the time when you cease to have natural reproductive capability.

It is also a time when the majority of women experience a variety of physical and emotional symptoms including, night sweats and mood swings. These symptoms will usually respond to hormone replacement therapy (HRT: Q27.1).

Q 26. 2 Why does nature put women through the menopause?

A baby, although destined to have the mental ability and dexterity that is greatly superior to any other species, is delivered into this world at a relatively early stage of development and is totally reliant on parental care.

Nature does not allow a child to bring a baby into the world and similarly avoids a baby having a mother who is beyond middle age. During reproductive years, most of the oestrogen (female hormone – Q2.9) produced in your body comes from the cells in your ovaries that surround eggs reaching maturity.

The ovarian hormones have to be linked to the development of eggs so that the required cyclical changes of the endometrium (lining of the womb; Figure 2.3) are synchronised appropriately in preparation for a possible pregnancy.

From the menopause onwards, the ovaries have run out of eggs and, as a result, the amount of oestrogen in the blood falls. Nature has not decreed that women should suffer from oestrogen deficiency following the menopause: it is simply that nature’s way of providing oestrogen is to link it to egg development. Inevitably the menopause heralds the arrival of a naturally induced sex-hormone deficiency state in otherwise healthy women.

Q 26. 3 Is life-expectancy changing?

Life-expectancy (average lifespan) of women in England and Wales in 1900 was 50.1years. It follows that more than half the female population never reached their menopause. By 1950, life-expectancy had risen to 71.1years and in 1990 it reached 79.2 years.

This 60% increase in life-expectancy through the twentieth century is typical throughout the industrialised countries. These life-expectancy figures are calculated from birth. A woman currently aged 60 has a life expectancy of a further 22.6 years (Figure 26.1).

Nowadays, most women are destined to spend more than a third of their lives beyond the menopause. We now have 10 million postmenopausal women in the United Kingdom.

A recent television advertisement promoting pensions made the following observation. “In 1954, the queen sent her congratulations to 300 people on reaching the age of one hundred. Last year there were three thousand and by the year 2034 there will be many thousands”. To quote our national anthem, “Long live the queen”.

References:

Changes in life expectancy 1900-1990 (1992-632)

Q 26. 4 What happens to my reproductive hormones at the menopause?

• The amount of hormones produced by your ovaries (oestrogens, progesterone and androgens including testosterone; Q2.9) will fall.

• Your pituitary gland (Q2.14) will respond by increasing gonadotrophin (FSH and LH -Q2.11) output in a futile attempt to gain a response from the ovaries (Figure 2.5).

To the reproductive endocrinologist (doctor specialising in reproductive hormone problems) there is increased gonadotrophin and decreased sex hormone output – a state termed hypergonadotrophic hypogonadism (hyper – increased; hypo – decreased; female gonads are the ovaries).

After themenopause, a small amount of oestrogen is still produced mostly from tissues other than the ovaries. The adrenal glands (sited above the kidneys) and ovaries still contribute to produce oestrogen albeit to a minor degree.

Q 26. 5 What non-hormonal changes occur at the menopause?

The endometrium (lining of your womb) will become thin and inactive as there is no longer a cyclical output of reproductive hormones and periods will no longer occur.

Oestrogens encourage your body to have typical female contours and they strengthen the pelvic floor muscles. After themenopause, there may be some reduction in the female contours and the pelvic floor may weaken (Q30.3).

Your skin may become less smooth. Despite popular belief, there is no evidence that body weight, blood pressure, or blood glucose alter as a result of the menopause. Cholesterol levels do rise a little.

Q 26. 6 What problems might I have as a result of my menopause?

• blood circulation (hot flushes and sweating at night – Q26.9).

• local problems such as discomfort around the genitalia (Q26.20).

• some bladder symptoms (Q26.11).

• psychological symptoms including depression (Q26.12).

• reduced cerebral (brain) function (e.g. poor memory, reduced concentration, sleep disturbance and fatigue – Q27.1; Q27.2).

In the longer-term, there are significant risks of morbidity (disease) and preventable early mortality (death). There is a wealth of evidence proving that the deficiency in reproductive hormones accelerates the ageing processes of the arteries (atherosclerosis Q26.23) and the skeleton (osteoporosis – Q26.24).

HRT may reduce the rate of these degenerative processes and possibly reverse the trends leading to reduced morbidity (illness) and delayed mortality (death). Provided you remain healthy, you should continue to have the physical and mental ability to care for, and enjoy, your family. HRT is likely to help you feel and be healthier.

References:

A population based survey of women’s experience of the menopause (1996-1564)

Q 26. 7 When am I likely to reach my menopause?

The average age at menopause is 50.5 years in Caucasian women – half have their last period earlier and half later. One woman in ten will still have her periods at the age of 54 and on occasion they may persist until the age of 57.

This has probably not changed over the last 100 years. In contrast, the average age at menarche (first period) seems to be getting lower (Q5.5).

Low financial income and poor education are associated with earlier menopause but age at menarche, marital status, weight, height, number of pregnancies and use of oestrogens in the pill or hormone replacement therapy are unrelated. There may be a tendency for early menopause to follow within a family.

References:

Age at natural menopause in a population-based screening cohort: The role of menarche, fecundity, and lifestyle factors (1997-1805)

Family history as a predictor of early menopause (1995-795)

A prospective study of factors affecting age at menopause (1989-631)

Cigarette smoking and age at natural menopause (1980-1160)

Q 26. 8  What is a premature menopause?

            Premature menopause (ovarian failure) is defined as menopause before the age of forty years. It occurs in 1% of women. About 10% of women will reach the menopause before 46 years.

When the menopause occurs early, the protection from ovarian hormones is lost and this results in increased risk of early heart disease and osteoporosis. Hormone replacement therapy should always be carefully considered.

Q 26. 9 What are hot flushes and will HRT reduce them?

Your face may become red and this could spread to your neck and chest. There is a wide variation in the way that hot flushes (flashes is the term in the USA) affect individuals. They could occur infrequently or many times each day. Each flush may last just a few seconds although they could persist for more than an hour.

Although they are harmless they cause discomfort and, for some, embarrassment. Flushes and night sweats may last only a few weeks although many women continue to have problems into their sixties and beyond. Most menopausal women report rapid relief from their hot flushes with HRT.

If flushes do not respond to HRT another cause should be considered. An overactive thyroid gland (hyperthyroidism) can present with flushes but there are likely to be other typical symptoms to alert the doctor.

References:

Menopausal-like hot flashes reported in women of reproductive age. (1998 – 2479)

Hot flashes in postmenopausal women ameliorated by danazol (1985-1159)

Q 26. 10 What causes hot flushes and night sweats?

            This seems to be a direct response of oestrogen deficiency on the blood vessels in the skin which dilate  resulting in increased local blood flow. Hot flushes and night sweats generally respond well to hormone replacement therapy.

Q 26. 11 Can the menopause be associated with psychological problems.

Q 26. 12 Can the menopause be associated with psychological problems.

The occurrence of psychological symptoms around episodes of change in hormone concentrations is commonly encountered. This may be seen each month before menstruation (premenstrual tension Q25.1),

after childbirth (postnatal depression) and at the menopause. Premenstrual syndrome is characterised by cyclical symptoms, which regularly precede periods; as the menopause approaches these symptoms may lose their cyclical nature and become more continuous. The term “depression” is unusual in that it describes both a symptom and the name of the illness.

The arrival of the menopause serves as reminder to a woman that the vitality of youth is receding and perhaps half her adult years have been completed. For many, early dreams, ambitions and aspirations do not seem to be even approaching fulfilment.

Parents are ageing and rather than providing their traditional support to the platform of life, they begin to require ever increasing assistance themselves. Children have attained adolescence or adulthood and may be making difficult demands.

Q 26. 13 How long can my menopausal (climacteric) symptoms last?

About 80% of women will experience symptoms with only one lady in five experiencing no noticeable difficulty. Some experience symptoms for a short time only but others continue to have symptoms for many years.

Women report a variety of symptoms in association with the menopause. Even in your seventies and eighties you may have vaginal discomfort, vaginal discharge and bladder symptoms due to lack of oestrogen.

Q 26. 14 Is there a test that will accurately determine when my menopause has occurred?

Many authorities suggest that one-year of amenorrhoea (no periods) in the late forties or beyond indicates that the menopause has been reached while others would accept six months without a period. There is no clinical or hormone test that can unequivocally prove that your ovaries have been completely depleted of potentially functional oocytes (eggs). If you are still having periods, hormone tests are even less helpful at indicating when your menopause will occur.

During the reproductive years there is a monthly cycle of hormone changes involving the ovaries and the pituitary gland (situated at the base of the brain) (Q2.14). When oestrogen production falls at the end of each menstrual cycle, the pituitary produces an increase in a stimulating hormone (FSH – follicle stimulating hormone).

When the ovaries are functioning they respond by producing oestrogens and this keeps the FSH in the blood from becoming high. When the ovaries have run out of eggs, they cease to function, and cannot respond and the oestradiol (one of the main oestrogens) level usually falls (to less than 80pmol/l) and the FSH level rises (to greater than 20nmol/l).

Occasionally there may be a few ova lying dormant and after a while they become active. A high FSH level cannot, therefore, exclude the possibility of the ovaries regaining some function.

If you are in your fifties or perhaps late forties, your periods have stopped and your FSH levels are high, further ovarian function is unlikely and spontaneous pregnancy would be exceptionally rare.

The story of a lady who presented at the age 49 years with menorrhagia (heavy periods) illustrates the difficulty in deciding when the menopause has taken place. We performed a D & C (Q24.12) for her and her periods were then controlled with medical treatment.

Within a year her periods ceased and she became troubled by hot flushes and night sweats. Her FSH level was high on two occasions and well into the menopausal range. She was commenced on sequential HRT (daily oestrogen with progestogen for 12 days of each course) (Q28.9) but the resulting withdrawal bleeds were unacceptably heavy.

The HRT was discontinued but she continued to experience heavy monthly bleeds and her FSH had fallen to normal (no longer menopausal) levels. This time medical treatment failed to control her heavy periods. She came to total abdominal hysterectomy and bilateral salpingo-oophorectomy (Q24.23) and an oestradiol implant was introduced.

A 30 year old woman presented for consideration of IVF with a regular 28 day cycle for several months after discontinuation of HRT for premature menopause.

Her gonadotrophins proved to be in the menopausal range and her previous gynaecologist confirmed that four years earlier she had presented with irregular periods and her FSH levels had been at menopausal levels even then.

Q 26. 15 Is it normal to experience heavy periods before the menopause?

No, normally periods before the menopause should become lighter and less frequent. If your periods are becoming heavier or if you are experiencing bleeding between your periods, tests are required to exclude a disease process (Q24.12).

Q 26. 16 How are heavy periods around the time of the menopause treated?

Once suitable investigations have been undertaken (Q24.12), heavy periods usually respond to medical treatment. If you are also experiencing menopausal symptoms such as hot flushes or night sweats a sequential HRT often solves both problems (Q28.9 and Q24.17).

Q 26. 17 Is there a need to investigate vaginal bleeding after the menopause (postmenopausal bleeding)?

Postmenopausal vaginal bleeding must always be investigated. In the majority of cases no serious problem will be found but there are times when the bleeding is the first symptom of serious disease including cancer. Even when the bleeding is related to cancer, if it is diagnosed early there is a very good chance that the disease can be cured (Q32.2).

References:

The role of vaginal scan in measurement of endometrial thickness in postmenopausal women (1991-541)

Transvaginal ultrasound measurement of endometrial thickness and endometrial pipelle sampling as an lternative diagnostic procedure to hysteroscopy and dilatation and curettage in the management of post-menopausal bleeding (1997-1839)

Q 26. 18 What could be the cause of vaginal bleeding after the menopause?

In 90% of cases examination and investigation will find either no obvious cause or an innocent one. The commonest innocent cause is atrophic vaginitis (Q 26.19). Cervical and endometrial polyps (Q21.2) are further common findings and they are usually benign.

Women frequently present to their gynaecologist with a period-like bleed when they have previously fulfilled the criteria for the menopause. Premenstrual type symptoms such as breast discomfort may have preceded the bleeding. Appropriate clinical examination and investigation is imperative.

Once a pathological (disease) cause for the bleeding has been excluded, it would seem logical to conclude that the woman might have been correct in her belief that she had experienced menstruation again.

Presumably this must have followed maturation of an egg which was scheduled to occur a year or more after the previous period (Q2.3).

Q 26. 19 What is atrophic vaginitis?

Oestrogen helps to keep your vagina healthy (Q22.1). During reproductive years, oestrogen encourages the vaginal epithelial (surface) cells to become rich in glycogen (a sort of sugar).

When these cells are shed, lactobacilli (a group of bacteria) break down the glycogen to lactic acid. As a result, the fluid in your vagina is kept slightly acidic.

This acidity reduces the chance of vaginal infection as most bacteria can thrive only in a less acidic environment. In the reduced oestrogen status associated with themenopause, the vaginal lining may become thin and inflamed – atrophic vaginitis (Greek: atrophy – deprived of nourishment; Greek: itis – inflammation).

Q 26. 20 What local genital symptoms can be associated with the menopause?

After themenopause, as a result of vaginal atrophy, vaginal dryness and discomfort are more likely to become a problem for you. Local infection, atrophic vaginitis, becomes more common now that there is less protective lactic acid and this may result in inflammation causing soreness and discharge.

The vaginal dryness and inflammation may cause discomfort or even pain when you make love (dyspareunia). On occasion, the inflammation may cause bleeding. All postmenopausal bleeding must be investigated (Q26.17).

Vaginal prolapse is more common after the menopause (Q30.01).

Q 26. 21 I have gone through the menopause and now have some bleeding (postmenopausal bleeding – PMB). What will my gynaecologist wish to do?

Your gynaecologist will want to take a full history (story), and a general and gynaecological examination will be carefully performed. This allows your gynaecologist to exclude disease of the lower genital tract and also to check for any swellings in the pelvis.

Your gynaecologist will also need to exclude disease within the cavity of the uterus, notably a tumour. Until quite recently, if the uterus was still present, a “D & C” (Q24.12) was mandatory. These days, ultrasound examination (Q4.9), particularly using a vaginal or rectal probe, will often exclude serious problems within the pelvis.

Research conducted in several hospitals in London, including my own (Whipps Cross Hospital), demonstrated that when the lining of the uterus appeared healthy and was less than 5mm thick and all the lining could be clearly seen there was never any serious problem within the uterus.

If these criteria are not fulfilled we would always wish to proceed to hysteroscopy and D & C (Q24.12).

The importance of early assessment by your doctor of postmenopausal bleeding cannot be overemphasised. In the 10% where malignancy is the culprit, the prognosis is usually very good if it is treated early.

References:

Hysteroscopy in women with abnormal uterine bleeding on hormone replacement therapy: A comparison with postmenopausal bleeding (1996-1339)

Q 26. 22 Could I have any other long-term medical problems resulting from my menopause?

We know that oestrogens protect women from coronary heart disease and that this protection is lost following the menopause.

We also know that following the menopause the bones tend to lose their strength (osteoporosis) leading to fractures.

Q 26. 23 What is coronary heart disease?

The arteries are the tubes that carry blood from the heart to the rest of the body. As part of the ageing process the arteries become less elastic and their diameter may narrow. On occasion a clot may form in a narrowed artery and block it. The muscle of the heart has four major coronary arteries feeding it.

These arteries are prone to “hardening” (atherosclerosis). As the arteries become diseased their capacity is reduced and the heart muscle may become weaker. This chronic problem may lead to angina (central chest pain on effort) or heart failure.

Sometimes a blood clot forms blocking a coronary artery (coronary thrombosis). The heart muscle, suddenly deprived of oxygen, is the site of the typical acute central chest pain. A severe heart attack is one of the commonest causes of death.

An interesting recent development has been evidence that coronary artery disease may have an infectious cause. One study has shown that men who had received antibiotics for infections were subsequently less likely to have coronary problems.

Q 26. 1 What will happen to me at my menopause?
Q 26. 2 Why does nature put women through the menopause?
Q 26. 3 Is life-expectancy changing?
Q 26. 4 What happens to my reproductive hormones at the menopause?
Q 26. 5 What non-hormonal changes occur at the menopause?
Q 26. 6 What problems might I have as a result of my menopause?
Q 26. 7 When am I likely to reach my menopause?
Q 26. 8 What is a premature menopause?
Q 26. 9 What are hot flushes and will HRT reduce them?
Q 26. 10 What causes hot flushes and night sweats?
Q 26. 11 Can my bladder problems be related to the menopause?
Q 26. 12 Can the menopause be associated with psychological problems.
Q 26. 13 How long can my menopausal (climacteric) symptoms last?
Q 26. 14 Is there a test that will accurately determine when my menopause has occurred?
Q 26. 15 Is it normal to experience heavy periods before the menopause?
Q 26. 16 How are heavy periods around the time of the menopause treated?
Q 26. 17 Is there a need to investigate vaginal bleeding after the menopause (postmenopausal bleeding)?
Q 26. 18 What could be the cause of vaginal bleeding after the menopause?
Q 26. 19 What is atrophic vaginitis?
Q 26. 20 What local genital symptoms can be associated with the menopause?
Q 26. 21 I have gone through the menopause and now have some bleeding (postmenopausal bleeding – PMB). What will my gynaecologist wish to do?
Q 26. 22 Could I have any other long-term medical problems resulting from my menopause?
Q 26. 23 What is coronary heart disease?
Q 26. 24 What is osteoporosis?
Q 26. 25 Where else can I obtain further information?
Q 26. 26 Could I have some useful Web sites?
Women’s Health – Home Page

Q 26. 24 What is osteoporosis?

Osteoporosis is a condition of the skeleton in which the bone mass is reduced to a point which is an increased risk of fracture with minimal or even no trauma. With increasing age the risk of hip fractures rapidly increases.

Fractures of the hip are particularly common in postmenopausal women because after themenopause, the rate of bone loss is accelerated. One woman in four will have had an osteoporotic fracture by the age of seventy and one in two by eighty.

Fractures can cause death. Fracture of the hip has been estimated to result in 30,000 deaths each year in the United States. By 1984 the annual cost of treating hip fractures was $7 billion.

A woman at the menopause has a lifetime risk of 15% of having a fracture of a hip. This risk is equivalent to the combined risk for breast, uterine (womb) and ovarian cancer. A bone density scan at the menopause can provide a reasonable prediction of the likelihood of osteoporosis in later life. Bone density scanning technology has become extremely accurate.

Crush fractures of the vertebrae are thought to be three times as common as hip fractures. These fractures result in decreased height and increasing curvature of the spine. A much loved member of my family told me that as a result of such curvature she had difficulty looking up. This made her feel demoralised and reduced her self-esteem.

Q 26. 1 What will happen to me at my menopause?
Q 26. 2 Why does nature put women through the menopause?
Q 26. 3 Is life-expectancy changing?
Q 26. 4 What happens to my reproductive hormones at the menopause?
Q 26. 5 What non-hormonal changes occur at the menopause?
Q 26. 6 What problems might I have as a result of my menopause?
Q 26. 7 When am I likely to reach my menopause?
Q 26. 8 What is a premature menopause?
Q 26. 9 What are hot flushes and will HRT reduce them?
Q 26. 10 What causes hot flushes and night sweats?
Q 26. 11 Can my bladder problems be related to the menopause?
Q 26. 12 Can the menopause be associated with psychological problems.
Q 26. 13 How long can my menopausal (climacteric) symptoms last?
Q 26. 14 Is there a test that will accurately determine when my menopause has occurred?
Q 26. 15 Is it normal to experience heavy periods before the menopause?
Q 26. 16 How are heavy periods around the time of the menopause treated?
Q 26. 17 Is there a need to investigate vaginal bleeding after the menopause (postmenopausal bleeding)?
Q 26. 18 What could be the cause of vaginal bleeding after the menopause?
Q 26. 19 What is atrophic vaginitis?
Q 26. 20 What local genital symptoms can be associated with the menopause?
Q 26. 21 I have gone through the menopause and now have some bleeding (postmenopausal bleeding – PMB). What will my gynaecologist wish to do?
Q 26. 22 Could I have any other long-term medical problems resulting from my menopause?
Q 26. 23 What is coronary heart disease?
Q 26. 24 What is osteoporosis?
Q 26. 25 Where else can I obtain further information?
Q 26. 26 Could I have some useful Web sites?
Women’s Health – Home Page

Q 26. 25 Where else can I obtain further information?

https://2womenshealth.com/

Q 26. 26 Could I have some useful Web sites?

Evaluation of the quality of Web sites is discussed in Q4.27. You may find that several general women’s health sites may help you (Q4.28). The following are more specialised Web sites on topics found in this chapter:-

Q 26. 1 What will happen to me at my menopause?
Q 26. 2 Why does nature put women through the menopause?
Q 26. 3 Is life-expectancy changing?
Q 26. 4 What happens to my reproductive hormones at the menopause?
Q 26. 5 What non-hormonal changes occur at the menopause?
Q 26. 6 What problems might I have as a result of my menopause?
Q 26. 7 When am I likely to reach my menopause?
Q 26. 8 What is a premature menopause?
Q 26. 9 What are hot flushes and will HRT reduce them?
Q 26. 10 What causes hot flushes and night sweats?
Q 26. 11 Can my bladder problems be related to the menopause?
Q 26. 12 Can the menopause be associated with psychological problems.
Q 26. 13 How long can my menopausal (climacteric) symptoms last?
Q 26. 14 Is there a test that will accurately determine when my menopause has occurred?
Q 26. 15 Is it normal to experience heavy periods before the menopause?
Q 26. 16 How are heavy periods around the time of the menopause treated?
Q 26. 17 Is there a need to investigate vaginal bleeding after the menopause (postmenopausal bleeding)?
Q 26. 18 What could be the cause of vaginal bleeding after the menopause?
Q 26. 19 What is atrophic vaginitis?
Q 26. 20 What local genital symptoms can be associated with the menopause?
Q 26. 21 I have gone through the menopause and now have some bleeding (postmenopausal bleeding – PMB). What will my gynaecologist wish to do?
Q 26. 22 Could I have any other long-term medical problems resulting from my menopause?
Q 26. 23 What is coronary heart disease?
Q 26. 24 What is osteoporosis?
Q 26. 25 Where else can I obtain further information?
Q 26. 26 Could I have some useful Web sites?
Women’s Health – Home Page