Menopause

What is the menopause?

The menopause is defined as the last menstrual period. We tend to to consider the menopause to be that period of time when a woman ceases to have reproductive capability. Strictly speaking that span of time is not the menopause but the climacteric.

At the menopause, the ovaries lose much of their function. There is a fall in hormone production, notably oestrogen.

Pre menopause is the time before the menopause and post-menopause is the time after the menopause. Peri-menopause is the time around the menopause and may also be called the climacteric. Post menopause the ovaries are no longer producing significant amounts of oestrogen and no progesterone. As oestrogen protects the heart and bones, post menopause the risks of osteoporosis and heart disease increase.

A natural menopause occurs at the time nature intended. Artificial menopause tends to be medically related. This is usually surgical - the ovaries are removed typically during hysterectomy. Radiation may also cause a menopause.

When Does the menopause occur?

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 not reach her menopause by the age of 54 and on occasion periods 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 (puberty). 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.

What is regarded as an early menopause or Premature Menopause?

Premature menopause (ovarian failure) is defined as menopause before the age of forty years. Whereas premature menopause is defined, early menopause is used more arbitrarily. Some use early and premature menopause interchangeably but others use early menopause in relation to women under the age 45. For many women, a diagnosis of early or premature menopause comes as devastating news, particularly if fertility is still required. The long-term detrimental health effects of the menopause begin early with premature menopause and HRT should be considered. The subject of premature menopause is discussed in more detail at premature-menopause.

What are the symptoms and signs of the menopause?

What will happen to me at my menopause?

Throughout your reproductive years, your ovaries have two essential functions - they release both eggs and hormones (Q 2.3). 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 (puberty) 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: Q 27.1).

In association with a normal menopause, periods become lighter and less frequent. Many women, however, experience heavier periods before the menopause. These should be investigated.

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 - Q 2.9) 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.

Is life expectancy changing?

Life-expectancy (average lifespan) of women in England andWales 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 theUnited 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”.

The following table shows the improved life expectancy in the USA:

(http://www.ncbi.nlm.nih.gov/books/bv.rid=healthus05. Table.375)

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What happens to my reproductive hormones at my menopause?

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 the menopause, 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.

What problems might I have as a result of the menopause?

In the short-term, the menopause may be associated with distressing symptoms. At least four out of five women are troubled by menopausal symptoms. These relate to the:-

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 (puberty). 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.

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What is a premature menopause?

Premature menopause (ovarian failure) is defined as menopause before the age of forty years. FSH levels are high and oestrogen levels low as is typical of the menopause. It occurs in 1% of women. Premature menopause may affect women who have had chemotherapy for malignancy. 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. Women who have had a premature menopause are prone to early onset coronary heart disease. Hormone replacement therapy should always be carefully considered.

Occasionally, ovulation may occur leading to pregnancy and this is then called resistant ovary syndrome. Sadly, those diagnosied with premature menopause conceive naturally on rare occasions and they tend to be reported in the medical literature. Normal inhibin levels may possibly indicate a resistant ovary rather than premature menopause. For those who do not wish to conceive, contraception seems wise. For those who want to conceive, the most likely means of conception would IVF and donated eggs. Claims of other forms of infertility treatment have yet to be substantiated.

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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.

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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.

What causes hot flushes and night sweats?

There are oestrogen receptor sites (hormones) in the bladder and the urethra (the outlet tube). Bladder symptoms (Chapter 29) are more common after the menopause when oestrogen levels become lower. A meta-analysis (Q33.23) of 166 research articles has proven that postmenopausal urinary incontinence, for example, may respond to oestrogen. Urgency of micturition (the need to hurry to empty the bladder), frequency (the frequent need to empty the bladder) and nocturia (the need to empty the bladder during the night and a common cause of sleeping difficulties) may all improve with oestrogen according to most but not all research.

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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 Premenstrual Syndrome - PMS), 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.

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How long can my menopausal 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.

Is there a test that can accurately tell that 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) (menstrual cycles). 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 and C (hysteroscopy D and C) 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) (HRT and progestogen) 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 (Q 24.23) 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.

Is it normal to have 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 (hysteroscopy D and C).

How are heavy periods around the time of the menopause treated?

Once suitable investigations have been undertaken (hysteroscopy D and C), 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 (HRT and progestogen and Q 24.17).

Is there a need to investigate posmenopausal 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).

Before the advent of ultrasound, a D and C was always performed. Nowadays if ultrasound shows no obvious abnormality and it is less than 5mm thick, no further investigation is usually required.

Ten per cent of women with ultrasound evidence of a thin endometrium, less than 5mm, will have further bleeding and ten per cent of these will have endometrial cancer ie 1 in 100 women with recurrent bleeding after a negative ultrasound.⁰⁸⁰¹

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What could be the cause of vaginal bleeding after the menopause - PMB?

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 (cervical polyps) are further common findings and they are usually benign. Occasionally cancer of the endometrium (uterus) or cervix may be found - about 10-25% being quoted.

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. Pr