Menopause is defined as the time when the ovaries have stopped working. This is actually not as easy as it would seem and is a diagnosis that is made in retrospect, since it is considered as one year after a woman’s last period. The ovaries do not simply stop, rather their hormonal function slowly winds down and then they stop producing hormones altogether. There is no blood test to say when you are going to be menopausal in the future, nor when you are definitely there – even if you have not had a period for several months.
During this time called the ‘perimenopause’, ovarian function tends to wax and wane and this may last several years. Management at this time is all about symptoms and risks. Yours are individual and personal and the only treatment needed may be speaking to your health care professional. Treatments may need to be tailored to symptoms and not everyone needs medication or hormone replacement therapy.
The ovaries have two main functions:
- To produce eggs (follicles) that will mature and be released and have the capacity to join with a sperm for a pregnancy;
- To produce hormones to support female development at puberty and support a pregnancy when it occurs. The primary hormones of the ovaries are oestrogen and progesterone.
Menopause will usually occur around age 52 in Australia, although there is a slow increase in age – probably due to better diet and higher average body weight. The age range for normal menopause is anything between 40 and 60. The most common symptoms following menopause are due to the fall in oestrogen levels and are the so-called ‘vasomotor symptoms’ – primarily experienced by women as a hot flushes, sweats particularly at night and occasionally palpitations. About 80% of women will have these symptoms and most will be mild and self-limited. They may last for 5-8 years and one in 12 women will suffer with these symptoms for the rest of their lives.
The loss of oestrogen may also lead to other symptoms such as dryness in the vagina and thinning of the tissues in the area that may also lead to urinary changes and potentially urinary tract infections. Oestrogen is a major driver of bone health with loss of bone occurring after menopause being one of the primary reasons that hormone replacement therapy (HRT) is recommended to most women. We know that bone loss is about 10-12% in the first 3-5 years following menopause after which this rate slows considerably. Other symptoms such as joint and muscle aches and central changes such as altered mood, anxiety and depression may all occur to variable levels that require treatment.
Treatment for menopause needs to be individualised and should be based on symptoms, rather than a blanket treatment for all women. Non hormonal treatments may help with symptoms including some antihypertensive drugs (clonidine), antidepressants (such as venlafaxine and fluoxetine) and other agents such as gabapentin may be prescribed under medical care to control the ‘vasomotor’ symptoms. Specific drugs for the bones such as bisphosphonates may be used – particularly if there is risk such as known thin bones (osteoporosis) or previous fractures.
Hormonal therapies are very useful and have received a bad reputation after a big study reported in 2004. In this study there was a small increase in the number of cases of breast cancer when combined oestrogen and progestogen was used, but overall the chances of having any cancer and the chances of dying were exactly the same whether HRT was used or not, since the hormones were protective against death from gut cancer and dying from a complication of bone fracture. These results were overlooked by the original study and it really does depend on a woman’s response and individual circumstances, since HRT does work very well for some women and may be the only thing that gives them quality of life. There are a variety of methods of giving HRT and these include tablets, patches, creams and depot preparations that are injected directly or placed in devices that may be put into the uterus.
The complicated types of hormone and non-hormonal treatments available for the symptoms of menopause mean that a detailed history and risk analysis is required before commencing treatment. There should be an agreed interval where review is undertaken and if possible, treatment is stopped, to prevent long-term use of medications that may not be required.
Menopause is the end of a woman’s hormonal life, but is certainly not the end of her productive, work, family or sex-life and is a transitional period that may be managed with a variety of medical and non-medical treatments to ensure that women stay healthy and happy. Remember, women continue to outlive men, even though they may not continue to produce hormones for all of their lives as men do. Clearly they are just stronger!