Menopause
The menopause is when a woman stops having periods and is no longer
able to get pregnant naturally.
Periods usually start to become less frequent over a few months or
years before they stop altogether. Sometimes they can stop suddenly.
The menopause is a natural part of ageing that usually occurs between
45 and 55 years of age, as a woman's estrogen levels decline
But around 1 in 100 women experience the menopause before 40 years
of age. This is known as premature menopause or premature ovarian
insufficiency.
Treatments for menopausal symptoms
These include:
 hormone replacement therapy (HRT) – tablets, skin patches, gels
and implants that relieve menopausal symptoms by replacing
estrogen
 vaginal estrogen creams, lubricants or moisturizers for vaginal
dryness
 cognitive behavioural therapy (CBT) – a type of talking therapy
that can help with low mood and anxiety
 eating a healthy, balanced diet and exercising regularly –
maintaining a healthy weight and staying fit and strong can
improve some menopausal symptoms
What causes the menopause?
The menopause is caused by a change in the balance of the body's sex
hormones, which occurs as one gets older.
It happens when the ovaries stop producing as much of the hormone
estrogen and no longer release an egg each month.
Premature or early menopause can occur at any age, and in many cases
there's no clear cause.
Sometimes it's caused by a treatment such as surgery to remove the
ovaries (oophorectomy), some breast cancer treatments,
chemotherapy or radiotherapy, or it can be brought on by an
underlying condition, such as Down's syndrome or Addison's disease.
Symptoms
Most women will experience some symptoms around the menopause.
The duration and severity of these symptoms varies from woman to
woman.
Symptoms usually start a few months or years before menopause,
known as the perimenopause, and can persist for some time
afterwards.
On average, most symptoms last around 4 years from your last period.
However, around 1 in every 10 women experiences them for up to 12
years.
If patient experiences the menopause suddenly rather than gradually –
for example, as a result of cancer treatment – the symptoms may be
worse.
Changes to menstruation
The first sign of the menopause is usually a change in the normal
pattern of menstruation.
Patient may start having either unusually light or heavy periods.
The frequency of menstruation may also be affected. Patient may have
them every 2 or 3 weeks, or may not have them for months at a time.
Eventually, patient will stop having periods altogether.
Common menopausal symptoms
About 8 in every 10 women will have additional symptoms for some
time before and after their periods stop.
These can have a significant impact on daily life for some women.
Common symptoms include:
1. hot flushes – short, sudden feelings of heat, usually in the
face, neck and chest, which can make your skin red and
sweaty
2. night sweats – hot flushes that occur at night
3. difficulty sleeping – this may make you feel tired and irritable
during the day
4. a reduced sex drive (libido)
5. problems with memory and concentration
6. vaginal dryness and pain, itching or discomfort during sex
7. headaches
8. mood changes, such as low mood or anxiety
9. palpitations – heartbeats that suddenly become more
noticeable
10. joint stiffness, aches and pains
11. reduced muscle mass
12. recurrent urinary tract infections (UTIs)
13. The menopause can also increase your risk of developing
14. Certain other problems, such as weak bones (osteoporosis).
Treatment
Not all women want treatment to relieve symptoms of the menopause,
but treatments is available if patient finds the symptoms particularly
troublesome.
The main treatment for menopausal symptoms is hormone
replacement therapy (HRT), although other treatments are also
available for some of the symptoms.
Hormone replacement therapy (HRT)
HRT involves taking estrogen to replace the decline in the body's own
levels around the time of the menopause. This can relieve many of the
associated symptoms.
There are two main types of HRT:
1. combined HRT (estrogen and progestogen) – for women with
menopausal symptoms who still have their womb (estrogen taken
on its own can otherwise increase the risk of womb cancer)
2. estrogen-only HRT – for women who have had their womb
removed in a hysterectomy
HRT is available as tablets, skin patches, and a gel to rub into the skin or
implants.
HRT is extremely effective at relieving menopausal symptoms,
especially hot flushes and night sweats, but there are a number of side
effects, including breast tenderness, headaches and vaginal bleeding.
It's also associated with an increased risk of blood clots and breast
cancer in some women.
HRT is not advisable for some women, such as those who have had
certain types of breast cancer or are at high risk of getting breast
cancer.
Symptomatic Management
Hot flushes and night sweats
If patient experiences hot flushes and night sweats as a result of the
menopause, simple measures may sometimes help, such as:
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wearing light clothing
keeping your bedroom cool at night
taking a cool shower, using a fan or having a cold drink
trying to reduce your stress levels
avoiding potential triggers, such as spicy food, caffeine, smoking
and alcohol
 taking regular exercise and losing weight if you're overweight
If the flushes and sweats are frequent or severe, HRT may be suggested
If HRT isn't suitable for the patient, or the patient would prefer not to
have it, other medications that can help, such as clonidine (a high blood
pressure medicine) or certain antidepressants may be recommended.
These medications can cause unpleasant side effects, so it's important
to discuss the risks and benefits before starting treatment.
Mood changes
Some women experience mood swings, low mood and anxiety around
the time of the menopause.
Self-help measures such as getting plenty of rest, taking regular
exercise and doing relaxing activities such as yoga may help.
Medication and other treatments are also available, including HRT and
cognitive behavioural therapy (CBT).
CBT is a type of talking therapy that can improve low mood and feelings
of anxiety
Antidepressants may help if patient has been diagnosed with
depression.
Reduced sexual desire
It's common for women to lose interest in sex around the time of the
menopause, but HRT can often help with this. If HRT isn't effective,
patient might be offered a testosterone supplement.
Testosterone is the male sex hormone, but it can help to restore sex
drive in menopausal women. It’s not currently licensed for use in
women, although it can be prescribed by a doctor if they think it might
help.
Possible side effects of testosterone supplements include acne and
unwanted hair growth.
Vaginal dryness and discomfort
If your vagina becomes dry, painful or itchy as a result of the
menopause, estrogen treatment is prescribed. It is put directly into the
vagina as a pessary, cream or vaginal ring. This can safely be used
alongside HRT.
It is usually needed to use vaginal estrogen indefinitely, as symptoms
are likely to return when treatment stops. However, side effects are
very rare.
Over-the-counter vaginal moisturisers or lubricants can be used in
addition to, or instead of, vaginal estrogen.
Weak bones
Women who have been through the menopause are at an increased
risk of developing osteoporosis (weak bones) as a result of the lower
level of estrogen in the body.
Chances of developing osteoporosis can be reduced by:
1. taking HRT – HRT can help to prevent osteoporosis, although this
effect doesn't tend to last after treatment stops
2. exercising regularly – including weight-bearing and resistance
exercises
3. eating a healthy diet that includes plenty of fruit, vegetables and
sources of calcium, such as low-fat milk and yoghurt
4. getting some sunlight – sunlight on your skin triggers the
production of vitamin D, which can help to keep your bones
strong
5. stopping smoking and cutting down on alcohol
6. taking calcium and/or vitamin D supplements if you don't feel
you're getting enough of these – discuss this with your GP
Follow-up appointments:
If patient is having treatment for menopausal symptoms
Patient needs a follow-up review after 3 months, and once a year after
that.
During your reviews:
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make sure patients symptoms are under control
ask about any side effects and bleeding patterns
check weight and blood pressure
review the type of HRT patient is taking and make any necessary
changes
 discuss when to stop treatment and how this could be done
Many women will need treatment for a few years, until most of their
menopausal symptoms have passed.
Complementary and alternative therapies
Complementary and alternative treatments, such as herbal remedies
and bio identical ("natural") hormones, aren't recommended for
symptoms of the menopause, because it's generally unclear how safe
and effective they are.Some remedies can also interact with other
medications and cause side effects.