GETTING TO GRIPS WITH THE MENOPAUSE
What is menopause?
Menopause is a term used to describe the time in a woman’s life when she stops having a period, indicating that her reproductive years have come to an end. It usually occurs during your late forties or early fifties, with an average age of 51.
Some women go through the menopause earlier than this due to genetics, immune disorders or medical procedures.
When we are born, our ovaries already contain our lifetime supply of eggs. They also release a specific balance of oestrogen and progesterone to control ovulation (egg release) and menstruation (shedding of the lining of the womb).
During the menopause, our bodies begin to release less of these hormones, and this affects us in many ways.
Understanding the progression
Menopause is not an event that can be pinned to one particular point in time. It usually occurs progressively over a period of years, and in three stages: perimenopause, menopause and post-menopause.
Peri-menopause is when the ovaries begin to produce less oestrogen, and periods become irregular. Women often progress from missing the occasional period to going months without any. Menopausal symptoms usually begin to emerge towards the end of this stage when oestrogen levels have dipped substantially.
Menopause is officially declared when it has been one year (12 months) since your last period, therefore the process of diagnosing menopause is a retrospective one.
Post-menopause refers to the years after your period stops, when many of the most talked about menopausal symptoms ease, but the health side effects of low oestrogen continue to impact upon women.
Diagnosis of menopause is primarily conducted by taking your age and menstruation frequency into account, but a blood test to measure Follicle Stimulating Hormone (FSH) levels may also be useful to confirm a diagnosis, as FSH rises in menopausal women.
Symptoms to recognise
The symptoms of menopause are primarily attributable to low oestrogen. They can vary in intensity from woman to woman, even within families. What your mother experienced during menopause in terms of symptoms does not definitively determine what your experience will be.
Up to 80% of women report experiencing some symptoms, while almost half describe their symptoms as ‘difficult to deal with’. The most common symptoms reported are listed below.
Are you currently going through the menopause and experiencing some of these? If so, you are most certainly not alone!
Hot flashes — this refers to sudden feelings of warmth in the top half of the body, accompanied by blushing and/or sweating. If it occurs at night, they are known as night sweats, and for some women these can be incredibly uncomfortable, with nightwear and bed sheets soaked through.
Mood swings — these can include irritability, anxiety and depression, and for some women they present as the most debilitating symptoms of menopause: think pre-menstrual syndrome (PMS), only multiple times worse!
Vaginal symptoms —the lining of the vagina can become irritated and inflamed at this time, and extremely dry due to a reduction in natural secretions. This can cause day-to-day discomfort, and painful sexual intercourse.
Urinary symptoms — women going through the menopause are more prone to infections of the lower urinary tract, known as cystitis, and can experience problems with increased urinary frequency and bladder control.
Insomnia — this may occur due to the hormonal imbalance itself, the experiencing of hot flashes, a racing mind due to increased anxiety, or a combination of all these things.
Decreased libido — this is a significant symptom for many women, which can really impact them emotionally and take its toll on their relationships. This decrease in the desire to have intercourse can happen independently of any of the vaginal symptoms listed above, although it may also be as a result of them.
Forgetfulness or ‘brain fog’, general aches and pains/headaches and thinning hair/dry skin are other commonly reported menopausal symptoms.
While the symptoms above are most noticeable in stages 1-2 of the menopause, there are also long term effects on health to consider due to long-term hormonal imbalance. These include:
Osteoporosis — a decrease in calcium levels leaves postmenopausal woman more prone to spine, hip and other fractures, particularly in the years just after their last period, Heart disease - higher levels of LDL (bad cholesterol) increase the risk of heart attack.
Increased risk of Alzheimer’s — linked to the forgetfulness mentioned above Effects on vision — blurriness, dry eyes, cataracts and glaucoma are reported
HOW TO MANAGE MENOPAUSAL
SYMPTOMS USING PRACTICAL AND PHARMACOLOGICAL TREATMENTS
For many women, the symptoms of menopause, although uncomfortable and inconvenient, can be managed via relatively simple strategies adopted day-to-day, without the need for medication. Some of the most helpful ones are listed below:
For hot flashes, dress in breathable cotton clothes and in layers so that it’s easy to reduce the amount of clothing should you need to. Maintain a cool temperature in your bedroom via an open window or a fan, and avoid caffeine, spicy food and stressful situations where possible.
For vaginal dryness, try using a vaginal lubricant such as Regelle or Sylk, available from all pharmacies. It’s advised to make this part of your routine early on as a preventative measure rather than waiting until the area becomes extremely uncomfortable. Avoid perfumed hygiene products in this area also.
To reduce the risk of urinary tract infections, keep your pelvic floor muscles strengthened with daily kegal exercises, and make sure you’re staying hydrated.
For maintaining overall health during the menopause and beyond, you should avoid smoking and excess alcohol, and eat healthily, taking particular care to maintain adequate calcium intake from dairy and dark leafy vegetables. It is also advised to practice weight-bearing exercise such as walking, tennis and dancing to maintain your bone health and boost your mood.
If the above strategies are enough to manage your menopause symptoms, great! However for some, menopausal symptoms can be incredibly debilitating.
If they are impacting on your daily life in a significant way and impairing your ability to function then it’s highly recommended that you have a chat with your GP about what can be done to help.
The most well-known type of medication for the menopause is Hormone Replacement Therapy (HRT) and it does exactly that — it replaces the hormones that are lacking in our bodies during the menopause.
There are two main types of hormones used; oestrogen and progesterone. Oestrogen is the key ingredient to combat symptoms such as hot flashes and vaginal issues, as well as preventing osteoporosis, but if you still have your uterus (haven’t had a hysterectomy) you’ll also need to take progesterone to prevent cancer of the womb. Many HRT products have oestrogen and progesterone combined into one for convenience.
HRT comes in a variety of forms, and the type chosen by your doctor depends on what stage of menopause you’re at (whether or not you’re still having periods) and what symptoms you’re suffering most from.
HRT can be administered in several ways, including a tablet that you take orally, usually once a day, patches which stick to your skin and allow the hormones to be absorbed across and into the bloodstream, or a gel which you rub into the skin.
Oestrogen can also be administered directly into the vagina in the form of a vaginal tablet, cream or ring to combat vaginal dryness, painful intercourse and some urinary symptoms. In this case, progesterone is not needed because the oestrogen acts directly on the vagina and won’t affect the womb.
There has been a lot of fear around the use of HRT and potential increases in health risks. HRT is usually prescribed at the lowest possible dose for the shortest possible time to minimise the risk of side effects.
Recent evidence has found little-to-no increased risk of heart disease and stroke if HRT is started before the age of 60.
It has also been found that the level of breast cancer risk from HRT use is related to the amount of time that you take it for, i.e. short-term use shows low levels of risk.
Overall, it’s worth considering the benefit-risk ratio of HRT with your doctor before ruling out its use.
Separate to HRT, it is not uncommon to see menopausal women being prescribed a low dose anti- depressant. Some categories of these are helpful in combatting hot flashes, particularly for women who cannot take HRT for health reasons. They also have the obvious added benefit of improving mood for those who are struggling with anxiety and/or depression during this time.
Other medications that your doctor may prescribe include gabapentin (usually used to treat seizures or nerve pain but also beneficial for hot flashes) and osteoporosis medications such as bisphosphonates or vitamin D supplements.
A note about herbal remedies
While anecdotal evidence points to benefits of the use of herbal remedies such as soy, red clover, black cohosh and ginseng for menopausal symptoms, this has yet to be corroborated with sound scientific research, and care needs to be taken that they do not interfere with other medications you may be taking.
Always check with your healthcare provider before trying any of these products.
THE EMOTIONAL TOLL
Apart from the direct effect that menopause has on our mood physiologically; it can also take a significant psychological and emotional toll. It marks the end of our reproductive lives, which can trigger grief in many women to some degree. It throws a multitude of challenging symptoms at us which we need to navigate while simultaneously juggling all the existing balls of daily life, such as raising families, empty nests, career transitions, and relationship issues.
And although the menopause, or “the M word” as it’s so often referred to is thankfully becoming less of a taboo topic, it still very much tends to be shouldered alone.
Most women just “get on with it”, and suffer in silence.
Below is some food for thought about how to approach this emotional challenge in a different way.
Reframe your reality While there is no denying that menopause is tough, is it possible to change your internal narrative slightly on certain aspects of it? Cognitive reframing is a very useful tool used in psychology, used to retrain the brain. It’s a process where negative thoughts are replaced with similar statements of a more positive outlook. Is this “the end of an era,” or perhaps it could instead be viewed as “an exciting new chapter,“ when you get to start planning your retirement, or take up a new hobby.
Is this a time where your body has “begun to fail you,” or is it a time where you get to experience “the delight” of not having to deal with pesky periods anymore? (And two years after your last period, contraception is no longer an issue to be contending with either!) Seek out the silver linings where you can, and see the beneficial effect that this can have.
Ride the waves
A lot of extra psychological suffering is caused during the menopause by the (natural) desire to push symptoms away and not have to experience them at all. Unfortunately, that’s usually not an option!
Hence, mindfulness-based approaches to menopausal symptoms are being increasingly researched, and some promising studies have found that mindfulness practice i.e. being present to the symptoms as they occur, without judging them, are associated with an overall reduction in their severity.
Imagine being able to notice inevitable discomforts such as hot flashes, and allow them to arise, run their course and then pass rather than getting excessively distressed by them. How liberating would that be? Riding the waves, so to speak! Mindfulness practices have also shown particular benefits in easing symptoms of Irritability, depression and anxiety during this time.
Rally the troops
Shouldering this menopause gig alone is no joke, and the stress caused by trying to hide a hot flash or putting on a brave face if anxiety is eating you away only adds to the overwhelm. The best possible thing you can do is to have others on board, taking away that extra pressure of having to always bring your A -game. That doesn’t mean offering a daily update to all and sundry on every symptom you’re experiencing today! But it does mean subtly informing those that you’re comfortable informing so that at the most challenging of times, an explanation won’t be needed; your colleague will recognise that tell-tale blush creeping up your neck and cover for you while you pop to the bathroom to freshen up. Your daughter will understand why Mum is particularly irritable today, and will give you the space (or the hug!) that you need. Your partner will be sympathetic to the brain fog that you’re experiencing, and won’t berate you for forgetting yet again to put out the bins!
And find your “Menopause Tribe” while you’re at it! That may be existing friends who are at the same life-stage, or new acquaintances found through the many available face-to-face and online support groups. Use one another as an emotional balm; a problem shared is a problem halved.
Remember… So many women report that during this time of life it can feel like you’ve lost a piece of yourself. Remember that this is normal; almost every other woman that you know either has or will go through the menopause if she is lucky enough to reach that age. But this too shall pass. Remind yourself that these symptoms are not permanent. There will be life after the menopause. In fact, there is plenty of life during the menopause, life hasn’t stopped and it’s doesn’t have to pass you by.
And most importantly, as challenging as this is, your daily functioning should not be severely impacted by the menopause. Don’t lose precious years to it. Do what you need to do to make it manageable, whether that’s basic practical strategies, or enlisting the help of your GP.
Find our ‘Menopause Tribe’ while you’re at it! That may be existing friends who are at the same life-stage, or new acquaintances.
ABOUT THE AUTHOR
Dr Michelle O’Driscoll is a pharmacist, researcher and founder of InTuition, a health and wellness education company.
Her research lies in the area of mental health education, and through InTuition she delivers health promotion workshops to corporate and academic organisations nationally.
This feature initially ran as a three part series in WoW! in July 2020.