The menopause is sometimes called 'the change of life' as it marks the end of a woman's reproductive life. At menopause, eggs are no longer produced by the ovary and production of oestrogen and progesterone ceases. The word "menopause" refers to the last or final menstrual period a woman experiences.

When a woman has had no periods for 12 consecutive months she is considered to be “postmenopausal”. Most women become menopausal naturally between the ages of 45 and 55 years, with the average age of onset at around 50 years. “Premature menopause” may occur before the age of 40 due to either natural ovarian function ceasing, following surgery to remove the ovaries, or as a result of cancer treatments. Menopause is considered “early” when it occurs between 40 and 45 years. (For more, see the information sheets “Early menopause due to premature and unexpected ovarian failure” and “Early menopause due to chemotherapy”).

 What is menopause? 126.57 Kb

What is perimenopause (menopausal transition)?  

Perimenopause refers to the time leading to menopause when a woman may start experiencing changes in her menstrual periods; such as, irregular periods, heavy or lighter bleeding, shorter or longer duration. Symptoms that may also be experienced include hot flushes and night sweats, aches and pains, fatigue, or irritability as well as premenstrual symptoms such as sore breasts and bloating. These changes are usually caused by fluctuations in the production of hormones from the ovary. Some women can experience menopausal symptoms for five or six years before their final menstrual period. There is no way to predict the age at which a woman’s menopausal symptoms will start or how long they will last.

What to do about contraception in the perimenopause

A woman’s fertility declines naturally in the 40s and the risk of pregnancy after the age of 50 years is estimated at less than one per cent but women may ovulate twice in a cycle and up to three months before the final period Women are advised to keep using contraception until two years after their last period if they experience the menopause under the age of 50, and for one year after the last period if aged 50 years or more (Reference: www.ffprhc.org.uk/admin/uploads/ContraceptionOver40).

Women on the Pill are advised to cease taking it by the age of 51 years and switch to a barrier method of contraception to minimise the risk of pregnancy. The combined oral contraceptive pill (oestrogen plus progestogen) carries increased health risks with age, especially if she is a smoker over the age of 35.

(For detailed information on the advantages and disadvantages of contraceptive methods in the perimenopause see the information sheet “Contraception for women approaching menopause”.)

Physical symptoms of menopause

Symptoms commonly reported by peri-and post-menopausal women include hot flushes and night sweats, bodily aches and pains, dry skin, vaginal dryness, loss of libido, urinary frequency, and sleeping difficulties. Some women may have unwanted hair growth, thinning of scalp and pubic hair, skin changes and increased bleeding gums. These symptoms are due to the fluctuating and declining levels of the ovarian hormones, primarily oestrogen. Not everyone finds the symptoms bothersome but about 60% of women will have mild symptoms for around 5-8 years. Twenty per cent of women will have no symptoms at all while another 20% will be severely affected, with symptoms continuing into their 60s or later (Reference: Col NF, Guthrie JR, Politi M et al., Menopause 2009, 16(3):453-7)

Now that women are living longer, problems arising contributed to by oestrogen deficiency including incontinence and osteoporosis are more common. (For more, see the information sheet “Menopause and Body Changes”, “Menopause and osteoporosis”) 

Psychological symptoms of menopause 

Hormonal changes can contribute to mood changes, anxiety, irritability, forgetfulness, and trouble concentrating or making decisions. Low levels of oestrogen are associated with lower levels of serotonin, a chemical that regulates mood, emotions and sleep.

Depression is not more common at menopause than at other stages of life, but a past history of depression and stress during the perimenopause may make a woman more likely to succumb to moodiness. (For more, see the information sheet “Coping with menopause – depression”.) 

How is menopause diagnosed?

Doctors diagnose the menopause based on a woman’s symptoms and changes in menstruation. The diagnosis is obvious where a woman has had her ovaries removed surgically. (For more, see the information sheet “Diagnosing Menopause”). A symptom score sheet (shown on final page or website link: www.menopausematters.co.uk/greenescale.php) can be a useful way to sort out what a woman is experiencing and whether any treatment is indicated.

It is not necessary to have hormonal tests to “prove” a woman is menopausal. However a doctor may order tests if there is concern that physical changes are a sign of illness, such as thyroid disorder, rather than natural ageing or if spontaneous menopause occurs at an early age. A single hormone test, such as a measurement of elevated follicle-stimulating hormone (FSH) is not a reliable indicator of the perimenopause as during this time women’s hormone levels fluctuate from day to day. While some practitioners recommend saliva tests to determine oestrogen levels, there is no evidence that the result will be accurate or useful.

How can symptoms be handled?

Being informed about what may happen during the menopause transition is a very good starting point.

Women are encouraged to pay attention to their health, including quitting smoking, eating well, exercising regularly and incorporating some relaxation techniques. Self management strategies such as carrying a fan, dressing in layers, always having a cool drink and a facial water spray can be helpful. Avoiding spicy foods, caffeine and alcohol will also reduce flushing.

Some women may find relief from menopausal symptoms with herbal or alternative remedies, however most have not been studied or shown to be of benefit scientifically and some, like black cohosh, have been occasionally linked to liver damage. Bioidentical hormones – mixtures of hormones supplied by compounding chemists – may be touted as beneficial and more “natural” than hormone replacement therapy (HRT) but there is inadequate evidence for their safety and effectiveness (For more, see the information sheet “Bioidentical hormones for menopausal symptoms”.).

HRT, in patches or tablets, has been demonstrated scientifically to reduce menopausal symptoms. However for each individual woman its benefits must be weighed against the increased risk of serious side effects such as thromboembolism (blood clots) and breast cancer. The Australasian Menopause Society recommends that HRT taken to relieve menopausal symptoms should be used only short-term – up to five years-, and not for long-term prevention of disease. Some women may need to take it for longer if symptoms persist, and they should seek their doctor’s advice to weigh up the risks and benefits. Any woman taking HRT should be reviewed annually by her doctor. (For more, see the information sheets “Menopause – Combined Hormone Replacement Therapy”, “Menopause – Oestrogen Only Therapy”, “Treating the menopause- the concept of risk and benefit” and “Menopausal treatments and the risk of blood clots”)

Doctors may prescribe other drugs to relieve symptoms, such as anti-depressants (which have been shown to reduce hot flushes), gabapentin, and clonidine.

(For detailed information, see “Nonhormonal Treatments for Menopausal Symptoms”).

Feeling positive about the menopause

Women may experience physical and emotional changes during menopause but that doesn’t mean life has taken a turn for the worse! Many women are prompted at this time to ‘take stock’ of their lives and set new goals. The menopause occurs at a time when many women may be juggling roles as mothers of teenagers, as carers of elderly parents, and as members of the workforce. Experts suggest that creating some ‘me time’ is important to maintain a balance in your life. Menopause can be seen as a new beginning: it’s a good time to assess your lifestyle and your health and to make a commitment to strive for continuing ‘wellness’ in the mature years

Symptom score sheet

This valuable diagnostic tool can be completed together with the woman, or she can do it herself in the waiting room. The woman judges the severity of her own symptoms and records the score. A score of 15 or over usually indicates oestrogen deficiency that is intrusive enough to require treatment, but this is only a guideline. Women are very variable in their tolerance of discomfort, often tolerating quite severe symptoms before they will even consider taking HRT. Scores of 20-50 are common in symptomatic women, and with adequate treatment tailored to the individual, the score will reduce to 10 or under in 3-6 months.

Using the symptom score sheet at subsequent follow-up visits is a useful method of judging whether adequate oestrogen is being taken to alleviate symptoms. Generally there is a halving of the symptom score after 2-3 months on HRT and if the woman is still experiencing a lot of symptoms, she may require a dose increase. If symptoms still persist, changing from the oral route to transdermal may help if the problem is oestrogen malabsorption. Women with irritable bowel syndrome, or taking H2 antagonists commonly absorb oral oestrogen poorly. 

SYMPTOM SCORE

SEVERITY OF PROBLEM IS SCORED AS FOLLOWS

SCORE: None =0; Mild =1; Moderate =2; Severe =3

NB. The symptoms are grouped into 4 categories, vasomotor, psychological, locomotor and urogenital. If one group does not respond to HRT, look for other causes and specific treatments for that group.

Not all of the symptoms listed are necessarily oestrogen deficiency symptoms.

Note: Medical and scientific information provided and endorsed by the Australasian Menopause Society might not be relevant to a particular person's circumstances and should always be discussed with that person's own healthcare provider.

This Information Sheet may contain copyright or otherwise protected material. Reproduction of this Information Sheet by Australasian Menopause Society Members and other health professionals for clinical practice is permissible. Any other use of this information (hardcopy and electronic versions) must be agreed to and approved by the Australasian Menopause Society.

July 2010