What is menopause?
- Although many people think of menopause as a distinct phase of life that women go through, “the menopause” actually refers to the final menstrual cycle (period) that a woman has. “The menopause” signifies the end of reproductive life for a woman.
- We tend to use the term menopause to refer to what is actually the menopause transition which describes the physiological changes that occur when a woman has reached the end of reproductive life and the signs and symptoms that manifest in the face of these changes
- Post-menopause refers to the period 12 months after the final menstrual period.
Who does menopause affect?
- The average age for a woman in Australia to experience menopause is 51 years, although anytime between 45 and 55 years old is considered normal
- Early menopause refers to menopause occurring between 40-45 years old
- Premature menopause refers to menopause occurring for any woman under 40 years old. Any woman who experiences this requires medical treatment.
What are types of menopause?
- Spontaneous menopause – menopause occurring as a natural bodily process for a woman when she reaches the end of reproductive life
- Surgical menopause – the surgical removal of both ovaries (oophorectomy)
- Chemotherapy/ radiation-induced menopause – menopause brought on by the two main cancer therapies used in Australia
- Both surgical menopause and chemotherapy/radiation-induced menopause are the most common causes of premature menopause.
What factors determine the age of menopause?
- These factors are not well-understood as of yet. However, smoking and hysterectomy (surgical removal of the uterus) have both been shown to cause earlier menopause.
- Women who smoke or have a hysterectomy usually go through menopause 1-2 years earlier than they would do so otherwise.
What actually happens during menopause?
- The truth is we still do not fully understand why menopause happens but there is one main theory proposed that is based around the reproductive physiology of a woman.
- A female is born with a set number of about one million primordial follicles which all have the potential to develop after puberty into an egg. An egg can then fuse with a sperm during sexual intercourse to create a zygote which grows into a fetus.
- It is important to remember that primordial follicles can never regenerate throughout life. This means follicles cannot be produced after a female is born. All women are born with a finite number of follicles.
- The number of primordial follicles decrease with age but particularly accelerates in decline from 37 years of age. This is the preface behind the colloquialism that women have a “biological clock.” Due to the number of follicles dying away as a woman ages, it gets harder for a woman to become pregnant the older they become.
- Menopause occurs when the store of primordial follicles is completed exhausted to zero.
- There are also known hormone changes, especially of oestrogen and progesterone, that occur in the perimenopause phase (the years leading up to menopause) which are responsible for the symptoms that some women experience (see below).
What are the signs and symptoms of menopause? How common are these?
Signs/ Symptoms | How many women are affected? |
---|---|
Hot flushes | 80% |
Night sweats | 80-90% |
Vaginal dryness | 40-60% |
Sleep disturbance | 40-60% |
Mood disturbance | 30% |
Vasomotor symptoms
- Hot flushes and night sweats are known as “vasomotor symptoms” and affect approximately 80% of women.
- The hot flushes and night sweats tend to be worse during the menopause transition and often resolve after four years from the last menstrual period. However, 40% of women continue to experience these symptoms a whole 10 years after going through menopause.
- ‘Vasomotor symptoms’ are the most common reason that women request treatment for menopause because they can drastically reduce a woman’s quality of life.
Sleep and Depression
- Sleep disturbance affects one in three women due to the menopause transition. Poor sleep is made worse by night sweats.
- Chronic sleep deprivation increase the risk of depression and vice versa.
- There is a two-fold increase in first onset depression during menopause transition for women.
- In general, depression is twice as common in women compared to men.
How is menopause diagnosed?
- Menopause is most often a clinical diagnosis meaning that your doctor can make the diagnosis based on your age, how long ago you had your last period, symptoms that you are experiencing and signs you are showing.
- However, if you are a younger woman and your doctor is suspicious about whom pre-term or early menopause, your doctor may order some blood tests to check the level of your sex steroids.
- In a pre-menopausal woman, the follicular stimulating hormone (FSH) level should be below 10u/L between Days 2 to 6 of your menstrual cycle.
- In the perimenopausal phase (years leading up to menopause), FSH levels are usually above 20u/L.
- In the postmenopausal phase (years after menopause has occurred), FSH levels are most often above 40u/L.
What are the long-term implications of menopause?
- Osteoporosis
- After menopause, your body stops producing as much oestrogen. This increases your risk of osteoporosis because oestrogen is a protective factor for bone health. See APA’s document on Osteoporosis for more details
- Cardiovascular disease
- Oestrogen is a protective hormone against cardiovascular disease. After menopause, when oestrogen levels drop, women are at an increased risk of cardiovascular disease. Due to this increased risk, it is important for women after menopause to follow “healthy heart” lifestyles. This includes regular physical activity, reduced dietary fat intake, increased fruit and vegetable intake, avoiding smoking and only having small amounts of alcohol.
- Urinary incontinence
- There are many changes in the body that occur at menopause that can cause women to pass urine more frequently and have an urgent need to pass urine. Some of the main changes that can cause urinary incontinence are:
- A weakening of pelvic floor muscles
- A less elastic bladder causing an “overactive bladder”
- Vaginal dryness
- There are many changes in the body that occur at menopause that can cause women to pass urine more frequently and have an urgent need to pass urine. Some of the main changes that can cause urinary incontinence are:
- Infertility
- Due to the exhaustion of follicles, women are unable to fall pregnant. This is more of an issue for younger women who have gone through pre-mature or early menopause before the age of 45.
- Altered body image
- It is very common for women to gain weight after menopause because the low oestrogen levels cause a gain in fat mass, particularly around the abdomen, and reduced muscle mass. This can cause a lot of distress for women due to society’s expectations for women to be slim and can result in negative body image.
- Mood disturbances
- Depression is a common occurrence in menopause at any age, but particularly in younger women if they were wishing to have the opportunity to still get pregnant. Depression occurs during the menopause transition due to hormonal changes and imbalances, but can be a long-term problem for some women that requires treatment.
What are the treatment and management options for menopause?
- The management of menopause is very complex and must be individualised to every woman based on their needs. The treatments are both non-pharmacological, meaning lifestyle-based modifications, as well as pharmacological, meaning the use of medications. It is important to understand that menopause is not a disease or a condition but a normal part of female reproductive life. Therefore, menopause is not curable but the treatment and management is designed around reducing the signs and symptoms to give women the best quality of life possible.
Non-pharmacological options
- Cognitive behavioural therapy (CBT)
- Studies have shown that CBT targeted as vasomotor symptoms reduces the ‘problem rating’ of these symptoms by nearly 80% in women as well as increasing positive mood, reducing anxiety and improving sleep
- Hypnotherapy
- Randomised-controlled trials have shown hypnotherapy to reduce the number and severity of hot flushes.
Pharmacological options
- Hormone replacement therapy (HRT) is the most effective treatment for menopausal symptoms. HRT contains synthetic oestrogen to treat symptoms and contains synthetic progesterone to protect the endometrium (lining of the uterus).
- Benefits of HRT
- Reduces frequency and severity of vasomotor symptoms by 75-85%
- Improved vaginal dryness
- Improved and maintains bone density, which reduces fracture risk (if started in women < 60 years of age but must be continued and therefore is not a first-line treatment for preventing or treating osteoporosis)
- Potentially improved sleep, improves mood and reduces muscle aches
- Risks of HRT
- Increased risk of venous thromboembolism and stroke
- Increased cardiovascular disease in older women
- Increased breast cancer in combined HRT (both oestrogen and progesterone)
- Increased endometrial cancer (with oestrogen only HRT)
- Symptoms can reoccur when stopping HRT
- There are some women who cannot use HRT due to it being contraindicated. These include women who have:
- Personal history of breast cancer, cardiovascular disease or cerebrovascular disease
- Previous thromboembolic event, such as a pulmonary embolism
- Inherited thrombophilia, which are blood disorders that make you more prone to forming blood clots
- Active liver disease or active gallbladder disease
- Uncontrolled hypertension
- Abnormal vaginal bleeding
- The general guidelines for HRT are as follows:
- Use at the lowest dose for the shortest time possible
- Review medication every 3-6 months
- Discontinue medication after 5-7 years
- Non-hormone therapy is used for women with moderate to severe vasomotor symptoms and who have contraindications to using hormone replacement therapy. There are many different non-hormone therapy medications including:
- Clonidine
- Anticonvulsants: pregabalin, gabapentin
- Anti-depressants: citalopram, escitalopram, paroxetine, fluoxetine, venlafaxine and desvenlafaxine
- DEXA Scan
- A DEXA scan is a special medical scan that measures your bone density and form part of your menopause management if your doctor deems you at risk of osteoporosis. It is not a routine part of management and not all women require a DEXA scan. It is indicated for women who have a premature or early menopause or those with risk factors for osteoporosis (see APA’s document on Osteoporosis for more details)
When should I get help for my menopause?
- Like everything, you should seek help from your GP if you feel you are not coping throughout your menopause transition in any way, for any reason.
- If you feel regularly unwell, long bouts of low mood, are withdrawing from friends, are unable to go to work, or just feel within yourself that you would benefit from some help, seek medical advice.
Useful additional resources:
- https://www.menopause.org.au/hp/information-sheets
- https://www.menopause.org.au/health-info/fact-sheets
- https://www.menopause.org.au/hp/management/treatment-options
- https://ranzcog.edu.au/womens-health/patient-information-resources/menopause
- https://www.jeanhailes.org.au/health-a-z/menopause\
- https://www.healthdirect.gov.au/menopause
- https://www.thewomens.org.au/health-information/menopause-information/menopause-an-overview
- https://www.mayoclinic.org/diseases-conditions/menopause/symptoms-causes/syc-20353397