Menopause

Women’s Health

Menopause occurs when you have not had a menstrual period for 12 months. Menopause is a natural part of life usually occurring between 45-55 years of age, however, it is still normal to reach menopause any time after the age of 40 years. The average age of menopause for women in Australia is 51 years.

It is also important to understand that many changes that happen around this time of a woman’s life are part of the ageing process and are not necessarily directly related to menopause.

The term perimenopause is used to refer to the time leading up to as well as the 12 months after the last period.

The experience of menopause varies widely from woman to woman; however, all women undergo the same basic hormonal changes during menopause.

Ovaries produce three types of hormones – oestrogen, progesterone and testosterone. During the perimenopause the ovaries’ production of oestrogen and progesterone fluctuates, and declines, stopping at menopause. Part of the ovary continues to produce testosterone, which declines with age rather than ceasing at menopause. After menopause, the adrenal glands and fat cells continue to produce testosterone and oestrogen in small amounts.

– 25% of women experience no noticeable changes except the cessation of menstruation
– 50% of women experience some menopausal symptoms, varying from mild to moderate
– 25% of women have more severe symptoms

(Dickson, A & Henriques, N. Menopause: the Woman’s View London: Quartet 1992 p11).

Common menopausal symptoms:

Hot flushes are characterised by feelings of heat that spread to the chest, neck, face or entire body. Hot flushes may be accompanied by sweating, nausea, heart palpitations, and flushed skin. (Bennett, D & Degeling, D. The Meaning of Midlife: A Positive Approach to Total Health Sydney: Angus & Robertson 1995 p26). When hot flushes occur at night they are referred to as night sweats. They can last anywhere from 30 seconds to five minutes or occasionally longer. Some women may only experience them infrequently, but others may have many each day.

Hot flushes and night sweats can be aggravated by stress, anxiety, alcohol, hot food and drinks, spicy foods, overdressing and a hot environment. Hot flushes and night sweats are thought to be caused by lower levels of oestrogen impacting the part of the brain that controls the body’s temperature. Most women who experience hot flushes and night sweats will find that they settle down or go away within a few years. (Baber, R. The Menopause, Medical Observer 28 July 2006 p33 and Dennerstein et al “A prospective population-based study of menopausal symptoms” Obstetrics & Gynecology (2000) 96:351-358).

This is generally caused by night sweats and having to adjust bedding and clothes to suit body temperature. If caused by a night’s sweat women may also have to get up and change their clothing or sheets. These sleep disturbances can leave you feeling tired the next day. Some women also experience difficulty sleeping without flushes.

Many peri-menopausal women find that their periods change in regularity and flow. Some women will experience irregular periods that stop and start with no apparent pattern. It is also common for women to get heavier, lighter or longer periods at this time. It is important to know that irregular or heavy bleeding can sometimes be caused by cancer.

If you experience irregular or heavy periods you should see your doctor check that the irregularities are related to menopause and not cancer.

The reduction in oestrogen levels at menopause can cause vaginal dryness. You may find sex painful due to the lack of lubrication of the vaginal walls. You may also notice a decrease in fatty tissue in the vulva which can change the appearance of your genitals.

Changes in the vagina, urethra and bladder at menopause can make women more susceptible to urinary tract infections. A urinary tract infection causes painful and frequent urination, feeling a need to urinate when the bladder is an empty or unpleasant odour to the urine.

The drop in oestrogen levels can aggravate existing pelvic floor muscle weakness causing or worsening urinary incontinence.

Joint and muscle aches and pains are commonly experienced by menopausal women. These aches and pains can occur in the hands, knees, hips, lower back and shoulders. We don’t really know why but symptomatic treatment with exercises, stretching and analgesia can help.

As you age, your skin becomes thinner and less elastic. These changes are often more noticeable at menopause as oestrogen appears to play an important role in maintaining skin. You may notice a change in the skin’s texture and tone and an increase in the appearance of lines and wrinkles. You may also find your skin is drier or oilier than before, or a combination of both. Some women report a crawling sensation which is similar to ants running over the skin. This is called formication and, while its exact cause is unknown, it appears related to changes at menopause.

The change in the balance between the hormones oestrogen and testosterone can result in an increase in facial hair and thinning of hair on the scalp and pubic hair. These changes in skin and hair can cause women great distress. There is much that can be done to help with these skin and hair problems, so it is important to talk to your doctor about what is troubling you.

There are a number of other symptoms commonly attributed to menopause including depression, anxiety, memory problems and weight gain.

Doctors don’t know if depression is directly associated with menopause or not. However, it does appear that for some women menopause increases susceptibility to developing depression.

Symptoms such as hot flushes, night sweats and associated sleep disturbance may result in some women experiencing anxiety, mood changes and memory problems.

Weight gain is not actually associated with menopause but rather with the natural decrease in metabolic rate that occurs with age and a more sedentary lifestyle (Henkel G. The Menopause Sourcebook Chicago: Contemporary Books 2001 p142). Many women feel that they gain weight around the time of menopause as fat is often redistributed from the buttocks and thighs to the abdominal area.

This is a loss of bone density causing bones to become fragile and hence more likely to be fractured. Your bones reach their peak bone density by your mid-20s. After the age of 35, there is generally a net bone loss. During menopause, oestrogen is reduced causing an increased rate of bone loss. The greatest amount of bone loss occurs immediately after menopause for 5-10 years.

It may be useful to think of bone mass functioning like a bank. If there is a good initial deposit of bone (peak bone mass), then there will be more bone from which withdrawals (bone loss) can be made. If you do not achieve an adequate peak bone mass and/or do not maintain strong bones throughout your life (by eating a calcium-rich diet and participating in vigorous weight-bearing exercise) you are at risk of osteoporosis (https://womhealth.org.au/conditions-and-treatments/about-menopause-fact-sheet).

If you think you may be at risk of osteoporosis you can have a bone density test. Dual-energy x-ray absorptiometry (DEXA) is the most accurate way of measuring bone density.

Heart attacks and strokes kill more women than breast cancer. Oestrogen produced by the body helps protect women from cardiovascular disease by increasing HDL levels (‘good’ cholesterol) and lowering LDL levels (‘bad’ cholesterol) as well as increasing the flow of blood through the body.

The drop in oestrogen levels that occurs with menopause, therefore, is thought to contribute to an increased incidence of cardiovascular disease in post-menopausal women. (Australian Institute of Health and Welfare “Women and heart disease, Cardiovascular profile of women in Australia” http://www.aihw.gov.au/publication-detail/?id=6442468369&tab=2 accessed 13 November 2017).

Lower oestrogen is not the only cause of cardiovascular disease. Other risk factors include age, family history of cardiovascular disease, smoking, high cholesterol levels, high blood pressure, prediabetes and diabetes.

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Menopause

How you can help menopause symptoms and improve your health at the time of menopause

There are many strategies that can help you transition through menopause. As with all stages of life, following a healthy diet and exercising regularly will improve physical and mental health.

Strategies

Eat a well-balanced diet – Metabolism slows with age which means a woman needs to eat fewer kilojoules or participate in more physical activity to avoid putting on weight. A well-balanced diet, combined with regular exercise (see below) will help women maintain a healthy weight.

A healthy diet is one that is low in carbohydrate content (E.g., breads, pasta/noodles, rice, cereals, honey and potatoes) and higher in healthy (unprocessed) protein (E.g., eggs, fish, chicken) and healthy fat (E.g., avocado, olive oil, full cream dairy including yoghurt and cheese) calcium, and of course the “3-Vs” of healthy eating: vegetables, vegetables, vegetables!

There is little evidence to support the theory that foods rich in phytoestrogens (e.g., soy, soy products and linseed) assist in relieving hot flushes, but they can form part of a balanced, healthy diet.

Women should aim to consume 2-3 serves of dairy foods each day to ensure adequate calcium intake (National Health and Medical Research Council “Dietary Guidelines for Australian Adults” Canberra AGPS 2003 p98).

Women should also make sure they get adequate amounts of Vitamin D which helps maintain bone density. Many women can achieve sufficient amounts of vitamin D through normal, safe sun exposure, however, if you have type 4 skin or are of indigenous, Asian or African descent you may well be vitamin D deficient and need a vitamin D supplement.

It’s a good idea to speak to your doctor and perhaps get a blood test to check your vitamin D levels if you are concerned.

Regular, vigorous weight-bearing exercise (exercise which is done on the feet such as walking, jogging, or dancing) can help slow bone loss. Aerobic exercise (exercise which increases the heart rate) is required for heart health, and strength and flexibility exercises are useful in maintaining muscle tone and keeping the body’s joints, ligaments, muscles and tendons mobile. Exercise also reduces stress, improves mood, improves sleep and helps to maintain a healthy weight.

Stress management strategies can be beneficial during menopause. Activities such as yoga, relaxation and/or meditation, tai chi and regular exercise are good examples of stress management strategies.

If dryness and thinning of the vaginal lining have made penetrative sex uncomfortable a water-based lubricant such as KY Jelly or even saliva can be helpful. Other strategies such as taking more time, using massage and sexual aids and including sexual activities which are not focused on penetration can also be helpful. Local hormone replacement therapy (in the form of a cream or pessary placed in the vagina) can also assist (see HRT section below).

Women who experience moderate to severe menopausal symptoms may wish to trial hormone replacement therapy (HRT). HRT is an effective short-term treatment for menopausal symptoms like hot flushes, night sweats and vaginal dryness. HRT should not be prescribed for the prevention of disease (e.g., cardiovascular disease). Women trying to decide whether to take HRT need to discuss their risks and benefits with their doctor. Women taking HRT should review this with their doctor annually.

These exercises strengthen the pelvic floor and can assist women who experience stress incontinence. Stress incontinence is characterised by the leaking of a small amount of urine with exertion (e.g., while coughing, sneezing, laughing, lifting heavy objects or during physical activity). The exercises are designed to work three different parts of the pelvic floor muscles: the muscles that control urine flow; the muscles that control the anal sphincter (muscles around the anus); and the muscles that surround the urethra and vagina. As some women have difficulty locating the appropriate muscles and performing the exercises correctly, seeking assistance from a health care provider (e.g., physiotherapist) to learn the correct techniques is often recommended.

Smokers are more likely to experience menopausal symptoms than non-smokers. Smoking increases the chances of hot flushes and night sweats, menstrual irregularities, ageing of the skin as well as heart attacks and strokes, osteoporosis, lung problems and cancer. Women looking to quit smoking can use several strategies to help them succeed including nicotine replacement products, support from their doctor, family and friends and/or a quit smoking program.

GSH Doctors who provides Women’s Health service

Dr Rosemary Chen

BMed; FRACGP

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Menopause

Women’s Health

Common menopausal symptoms:

How you can help menopause symptoms and improve your health at the time of menopause

Strategies

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