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The menopause occurs when your ovaries run out of eggs. Women are born with all the eggs they’ll ever have, in comparison to men who create sperm throughout their lives.

This article was included in issue 87 (winter 2020/21) of The Menopause Exchange newsletter.

Women need information about the stages of the menopause to be able to understand the changes in their body and how best to manage them. The journey is unpredictable for many, but knowledge is the key to a healthier transition.

Approaching the menopause
During your menstrual cycle, follicle stimulating hormone (FSH) is released from your brain to encourage the release of oestrogen and an egg (from a follicle in your ovaries) each month. Your FSH level may increase as your remaining egg follicles get increasingly difficult to stimulate, and your oestrogen levels may then go down (or go up and down).

If you don’t ovulate, your body doesn’t make progesterone, so your menstrual cycle becomes more unpredictable. It often gets shorter before it gets longer and your bleeding may be heavier.

The perimenopause stage
Hormonal changes can cause symptoms of the perimenopause. This can go on for a number of years. Eighty-five percent of women will have symptoms to some degree, many affecting their quality of life. Some women may recognise they are in the perimenopause, but if their symptoms wax and wane, others may simply put these down to ‘life’ or getting older. If the symptoms occur early (i.e. in their early 40s) women may also not recognise they are in the perimenopause.

Even healthcare professionals may not attribute joint pains, vaginal dryness/itching, palpitations (noticeable heartbeats) and headaches to hormonal fluctuations, as there is no pattern to them. So women may be referred for further investigations.

Perimenopause symptoms
Worsening premenstrual symptoms may become more intrusive as the menstrual cycle is more unpredictable, but women may also have periods of time when their symptoms return to ‘normal’. For women who had PMS when they were younger, this may become unmanageable. For other women who haven’t had PMS before, they may find the mood changes and physical symptoms cause problems.

Heavier and less predictable bleeding used to lead to hysterectomies in up to 20% of women in their 40s. But now, interventions such as the hormonal intrauterine system, also used for contraception and as part of an HRT regime, and endometrial ablation techniques (surgery to reduce or remove the uterine/womb lining), have halved the need for hysterectomy for non-cancerous reasons during the last 20 years.

The contraceptive pill can also help with these issues in women who have no contraindications, especially the natural oestradiol-containing pills. Although fertility is reduced, there’s still a need for contraception two years after the menopause in women under 50 or one year after 50. But as the menopause is defined as one year after the last natural period, it can be difficult to define this for women using hormonal treatments to manage gynaecological problems and/or as contraception.

Blood tests aren’t recommended to diagnose the menopause, as hormone levels vary so much and may be normal, even with very bad perimenopausal symptoms. The exception would be in the case of premature ovarian insufficiency (under the age of 40) or early menopause (under 45). The average age of the menopause is 51, but this means 50% of women go through the menopause before 51 and 50% after 51. Most women will have finished their periods by age 56.

Anti Mullerian Hormone (AMH) is considered to be a reflection of your ovarian reserve (eggs in your ovaries). It may predict an earlier menopause if it’s significantly low related to your age, but it’s not very useful for determining when or how far along the process you are. Its value is in fertility clinic settings to predict the likelihood of successful ovarian stimulation.

In everyday practice, it’s more important that women and healthcare professionals recognise the wide variety of symptoms of oestrogen deficiency and its fluctuations and can diagnose the perimenopause from these.

Recognising key symptoms
The most common menopause symptoms that women recognise are hot flushes and sweats. Yet there are lots of other symptoms – headaches, joint and muscle aches, low mood, brain fog, feeling of being overwhelmed, anxiety, irritability, mood swings, insomnia, tiredness, general itching (formication), vaginal dryness and itching, painful sex, urinary frequency and urgency, change in discharge etc.

Oestrogen and progesterone are powerful hormones that affect all tissues in the body, including the brain. The symptoms commonly last for a few years but may vary in intensity. And up to 5% of women may have symptoms for 20 years!

The postmenopause phase
This is more easily recognised, with a lack of bleeding and perhaps fewer symptoms of flushes, sweats and mood changes. With life expectancy extending to the 80s, women can expect to be in the postmenopausal stage for over 30 years.

Occasionally, early on, a follicle in the ovaries causes premenstrual changes and some bleeding. But all post-menopausal bleeding must be investigated. Although menopause symptoms may be eased, longer-term symptoms, including vaginal dryness, a change in discharge, overactive and sometimes leaking bladder, may occur. These may affect sex, especially if accompanied by reduced sex drive, which can start in the perimenopause.

Osteoporosis and cardiovascular changes, as well as skin and hair changes, may be less recognisable but occur once the benefit of oestrogen has been lost. Osteoporosis is a silent disease that is often only recognised after a fracture, commonly of the hip, spine or wrist. Cardiovascular disease increases in women after the menopause, losing the advantage over men who can have heart attacks and strokes from an earlier age.

About the author
Dr Claudine Domoney is a consultant obstetrician and gynaecologist at Chelsea and Westminster Hospital, London, specialising in pelvic floor and hormonal & sexual problems.

Created Winter 2020

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