Menopause

What is Menopause?

Literally menopause means the last period. The term ‘the menopause’ is commonly used to refer to the time around when menstrual periods stop or when a woman experiences symptoms associated with the end of menstruation. Leading up to menopause the periods may alter, occurring less frequently, irregularly or with increasing frequency. The bleeding may vary, from a darker loss to heavy bleeding with clots and flooding.

When does the menopause occur?

In Singapore, the average age of onset of the menopause is 50 years, but this may range from 40-60 years. If periods cease before 40 years this is considered to be premature menopause and those few women who are affected should consult their doctor if they are concerned. If periods continue after 56 there may be other reason for the bleeding and a doctor should be consulted about this.

Why does the menopause occur?

Changes associated with menopause occur because the number of ovarian follicles (eggs) within the ovary decreases with age and thus less of the hormones, oestrogen and progesterone, are produced. The decrease in hormones leads to the endometrium (lining of the womb) failing to grow and therefore there is no period.

Previously in a normal menstrual cycle the lining cells were shed with the period. This changing time, a climacteric, may take up to, on average, 5-6 years. During this time the body is influenced by the decreasing hormone levels in many ways, both physically and psychologically.

What symptoms may occur?

Many women go through menopause without experiencing any difficulties. Others may experience uncomfortable symptoms such as dryness of the vagina or hot flushes. The frequency and intensity of symptoms vary from woman to woman, so that no two experience menopause in the same way.

The most common symptom experienced is hot flushes. The hot flush may vary from a mild and occasional sense of body heat to a frequent, florid redness and heat of the face and upper body associated with marked sweating, palpitations (racing of the heart), nausea and dizziness. This may occur both during the day and at night. When severe flushes are experienced at night, they cause the woman to wake  up and often be covered in sweat. She may become increasingly tired and irritable when these flushes and sweats occur at frequent intervals throughout the night.

The vagina may become dry because the natural lubrication no longer occurs. With this dryness, intercourse with one’s partner may become painful and as a result many women become less interested in sex. The skin around the vaginal opening is also dry and with time becomes thin and may narrow. At the same time the urethra (urinary tract) may also become atrophic (thinning of the cells). This may lead to passing urine more frequently and being more susceptible to urinary tract infections or ‘cystitis’.

The joints may ache, giving a feeling of being ‘arthritic’. The skin over the body may become drier and thinner, and may itch like ‘ants under the skin’. Hair may also become coarser. Unfortunately, weight gain may occur despite no change in diet, with an increase around the abdomen and the upper thighs. The breast shape may alter as breast size decreases.

Around the menopause, some women experience changing moods, decreasing ability to cope with normal life stresses, forgetfulness, and a lessening of self-esteem. As these changes occur, tiredness and lethargy may reduce a woman’s capacity to carry out normal life routines and she may become depressed. These symptoms are made worse by physical symptoms such as hot flushes.

What major long term effects may occur after the menopause?

1. Osteoporosis (thinning of the bones). From the time of the menopause, the bones lose calcium and the internal framework thins. This thinning is fastest in the first five years after the periods stop and in time the bones may become brittle so they may fracture easily, most commonly at the wrist, spine or hips.
2. Atherosclerotic cardiovascular disease (a form of heart disease). This may lead to high blood pressure, with an increase in frequency of hart attacks in women following the menopause. Special forms of cholesterol (high density lipoprotein-HDL) protect the body against thickening on the inside of blood vessels (atherosclerosis). These special forms of cholesterol are increased in women in the child bearing years and therefore give protection from atherosclerosis in those years. After the menopause when oestrogen levels are low the same protection does not exist, with the resultant rise in low density lipoprotein (LDL) which increases the risk of atherosclerosis.

How should a woman manage her menopause?

The woman should be aware of what body changes are taking place at this time of her life. It is important to read, talk, discuss and understand the menopause so that the woman may prepare for this new phase of life. A healthy diet is necessary, especially of calcium-containing, fat reduced food (eg. milk, cheese, yoghurt). Some women are allergic to dairy products, do not like the, find they put onw weight, or may be prescribed diets without dairy products for health reasons and therefore should take calcium supplements. Calcium is necessary for healthy bone growth and other body processes and is lost from the bones after menopause. About 1000-1500mg of calcium per day is a recommended dose.

Diets with foods containing phytoestrogens (plant oestrogens) may be beneficial in providing heart disease protection, symptoms relief and perhaps cancer protection. These foods include linseed, alfalfa, soybean foods, cabbage, peas, beans and grains.

A woman should improve or maintain her body fitness by regularly exercise. Walking is he best form of exercise as it has a positive effect on the weight-bearing bones (spine and legs) and may stimulate bone growth. Brisk walking three or four times per week for about 40 minutes appears to maintain fitness. Swimming, aerobics or other exercise programs will also improve fitness.

Should a woman see her doctor when the menopause occurs?

A woman should have a regular check-up, preferably every year. She should have her blood pressure and breasts checked and a vaginal (internal) examination and a regular cervical (Pap) smear (usually recommended every 2 years). If she is distressed by menopausal symptoms she should tell her doctor, so that together, they can decide on an appropriate course of action.

A mammogram (X-ray of the breast) should be recommended, especially if woman has a history of breast lumps or a family history of cancer of the breast. A simple blood test may be performed to measure whether the ovaries have ceased to produce oestrogen, however, before the periods have stopped this may not be helpful. This test, which is called serum FSH (follicle stimulating hormone), measures a hormone of the pituitary gland in the brain. This hormone, FSH, rises at the menopause as the ovaries cease home production. Another test may also be recommended, a serum oestradiol, which measures the level of one of the oestrogens produced by the ovary. A serum cholesterol test may be performed to assess the risk of heart problems, particularly atherosclerosis. The blood samples for both of these tests can be taken at the same time.

A bone density test can be performed to measure how dense the bones are, how much calcium they contain and whether there is an increased risk of osteoporosis. this test, which is non-invasive, can be performed in 3 ways: a measurement of the density of the forearm, the hip or spine.

Depending on the result of these tests and the distress caused by the symptoms, the doctor may suggest; a) lifestyle changes such as increasing exercise, change of diet, losing weight, or, b) Hormonal Replacement Therapy (HRT). Alternatively, HRT may be recommended problems of osteoporosis or atherosclerotic cardiovascular disease.

What about the ‘natural’ medicines?

Diet and exercise may be used to diminish symptoms but evening primrose oil capsules and vitamin E are sometimes recommended to reduce hot flushes as an initial treatment. Complementary therapists may prescribe a combination of herbs to reduce symptoms and increase well-being.

All herbal preparations are also medicines and should only be used as prescribed and under the supervision of a registered naturopath or complementary therapist. Prolonged unsupervised use of herbs eg. Ginseng can lead to abnormal vaginal bleeding as it may stimulate growth of lining cells in the uterus, which may have adverse effects.