The menopause

The menopause is not an illness and not a state you have to put up with. It lasts seven to ten years on average, involves far more than hot flushes – and is more treatable today than the reputation of hormone therapy suggests.

The terms, briefly sorted out

Four words are constantly confused, although they refer to different periods of time:

• Premenopause – the years before the first changes. Cycles are still regular, but the egg reserve is already declining.
• Perimenopause – the transition itself. Cycles become irregular, usually shorter at first and longer later; the symptoms begin. It lasts four to six years on average and ends one year after the last bleeding.
• Menopause – a single day, namely the last period. It can only be identified in retrospect: after twelve months without bleeding. In Austria the average age is around 51.
• Postmenopause – the time after that. Symptoms ease over the years in most women; the long-term consequences of oestrogen deficiency for bones, blood vessels and mucous membranes remain.

If the menopause occurs before the age of 40, it is called premature ovarian insufficiency. It affects about one woman in a hundred, has to be investigated and – unlike the regular menopause – is as a rule treated with hormones up to the average age of menopause, because decades of oestrogen deficiency would otherwise damage bones and blood vessels.

What happens hormonally

The number of follicles in the ovaries declines throughout life. From about the mid-forties too few are left for an egg to mature in every cycle. If ovulation does not occur, no corpus luteum forms and therefore no progesterone – while oestrogen initially continues to be produced, often in surges and at higher levels than before.

This imbalance explains much of what women experience in the perimenopause and what does not fit the picture of “hormone deficiency”: breast tenderness, very heavy bleeding, irritability, disturbed sleep. Only later does oestrogen fall as well, and then the classic symptoms come to the fore. The pituitary gland tries to compensate and releases more and more FSH – a high FSH value is therefore a sign of the transition, but not a reliable test: in the perimenopause it fluctuates so strongly from week to week that a single measurement says little. The diagnosis is made by the conversation, not by the laboratory.

The symptoms

Hot flushes and sweats

About three women in four experience them, a third of those to a degree that affects daily life. The cause is a narrowing of the thermoneutral zone in the hypothalamus: the body responds to the smallest change in temperature with full counter-regulation – blood vessels dilate, sweating follows, then shivering. A flush typically lasts two to four minutes. Untreated they persist for a median of around seven years, in some women considerably longer.

Sleep

Sleep problems are among the most burdensome symptoms. They arise partly from night sweats and partly independently of them, through the lack of progesterone – progesterone promotes sleep through its breakdown products. Lack of sleep in turn intensifies irritability, difficulty concentrating and the perception of hot flushes.

Mood and concentration

The risk of depressive episodes rises measurably in the perimenopause, particularly in women who have previously had depression or a marked premenstrual syndrome. Many also describe difficulty finding words and a decline in memory. These cognitive changes are real, demonstrable in studies – and as a rule temporary. They are not a forerunner of dementia.

Vagina, bladder, sexuality

The genitourinary syndrome of menopause affects about half of all women and is the group of symptoms that is least often spoken about. The lining of the vagina, urethra and bladder base becomes thinner and less well supplied with blood: dryness, burning, pain during intercourse, frequent urgency and recurrent urinary tract infections. Unlike hot flushes, these symptoms do not disappear by themselves but increase without treatment. They are at the same time the easiest to treat.

Bones

In the first years after the menopause the body loses bone mass particularly quickly – up to two per cent a year. Osteoporosis runs its course painlessly until a bone breaks. Anyone with risk factors – being underweight, smoking, corticosteroid treatment, early menopause, a hip fracture in a parent – should discuss a bone density scan.

Heart and blood vessels

Before the menopause women develop heart disease considerably less often than men; afterwards the risk equalises. Blood pressure, cholesterol and blood sugar change unfavourably in this phase. Cardiovascular disease is the commonest cause of death in women – well ahead of all cancers combined. Blood pressure belongs among the things measured regularly in these years.

How bad are my symptoms?

The impression that “it is a lot” can be turned into a number. The Menopause Rating Scale (MRS II) asks about eleven symptoms and evaluates them in three domains: somatic, psychological and urogenital. That is useful for two reasons – it shows which domain is actually in the foreground, and it makes the course under treatment comparable. The questionnaire is available here as the menopause score; the evaluation stays in your browser and is not transmitted.

Hormone therapy: where things stand today

Hardly any treatment has such a contradictory reputation. It goes back to the first publication of the Women’s Health Initiative in 2002, after which prescriptions collapsed worldwide. What has been added since in re-analyses and follow-up has shifted the picture – above all on one point: it matters when treatment is started.

If a woman begins within ten years of the menopause or before the age of 60, the benefit outweighs the risk where symptoms are relevant. If she begins twenty years afterwards, the risks outweigh the benefit. The WHI predominantly enrolled considerably older women, on average 63 – a group that has little to do with a 52-year-old with hot flushes.

How treatment is given

• Oestrogen alone only after the uterus has been removed. With the uterus in place a progestogen has to be added, otherwise the lining grows unchecked.
• Through the skin rather than as a tablet. Patch, gel or spray bypass the liver. On current evidence the risk of thrombosis and stroke does not rise measurably with them – unlike with tablets. For women who are overweight, have migraine or an increased risk of thrombosis, that is the decisive difference.
• Micronised progesterone rather than synthetic progestogens. It has a favourable effect on sleep and, in studies, goes with a lower breast cancer risk than older progestogens.
• As low as is effective, for as long as necessary. There is no longer a rigid age limit for stopping; the decision is taken afresh each year.

What the breast cancer figures actually say

With combined therapy the risk rises after about five years of use. In absolute terms that means around one additional case per 1,000 users per year – roughly the order of magnitude of two glasses of wine a day or marked overweight, and smaller than the effect of physical inactivity. With oestrogen alone the WHI observed no increase, and in part a decrease. These figures are not meant to play anything down; they are meant to place the decision on a scale that can be compared with other everyday risks.

When hormones are not an option

Current or previous breast cancer, unexplained bleeding from the uterus, an acute thrombosis or pulmonary embolism, a previous heart attack or stroke, and severe liver disease rule out systemic hormone therapy. For local treatment of the vagina these restrictions largely do not apply.

Local treatment – the underestimated part

Against dryness, burning, pain during intercourse and recurrent urinary tract infections, low-dose oestrogen as a pessary, cream or ring works reliably. The amount absorbed is so small that the blood level stays within the postmenopausal range; a progestogen to protect the lining of the womb is not required. Many women after breast cancer can also have this treatment, in consultation with their oncologist. If you would rather avoid hormones, moisturising gels based on hyaluronic acid and lubricants often go a long way – but they do not rebuild the lining.

Without hormones

• Practical measures. Layered clothing, a cool bedroom, knowing your triggers such as alcohol and spicy food. Stopping smoking measurably reduces hot flushes.
• Cognitive behavioural therapy and hypnosis reduce the burden of flushes in controlled trials – not their frequency, but their effect on daily life; and that is what counts.
• Certain antidepressants (SSRIs and SNRIs) reduce hot flushes by about half and are an option where hormones are not possible. In women on tamoxifen the choice is restricted.
• Black cohosh and isoflavones show at best small effects in studies, barely distinguishable from placebo. They are not automatically harmless: liver damage has been described with black cohosh, and isoflavones are to be judged cautiously in hormone-dependent breast cancer.
• Strength training, vitamin D and calcium do nothing for flushes but a great deal against bone loss – and are the single most effective measure for women at this stage of life.

Desire and sexuality

A decline in sexual desire is common at this stage of life, and it rarely has just one cause. Contributing factors are the fall in oestrogen and testosterone, the dry mucous membrane and the pain that follows from it, poor sleep, exhaustion, medication – and life circumstances between work, growing children and ageing parents.

That is why it is worth keeping to the order: first treat what can be put right physically. If the pain disappears under local treatment, desire returns in many women without anything further being needed. If a distressing loss of desire remains after that, testosterone can be considered in selected cases; there is no preparation licensed for women in Europe, but there are recommendations from the specialist societies on off-label use. That is a conversation, not a prescription in passing.

Bioidentical hormones and saliva tests

The term “bioidentical” is used in two quite different senses, and much of the confusion arises from that. It can mean, first, a substance chemically identical to the body’s own hormone – 17-beta-oestradiol and micronised progesterone are exactly that. They are available in Austria as tested licensed medicines, and they are the standard today.

It can mean, second, a preparation mixed individually at a pharmacy, whose dose is supposed to be guided by saliva or blood levels. The specialist societies advise against this: the hormone content of such mixtures varies considerably, absorption through the skin is not predictable, and safety for the lining of the womb is not established. Saliva tests in turn do not correlate reliably with hormone levels in the blood and are unsuitable for guiding treatment – not least because the dose is adjusted according to symptoms anyway, not to a target value.

When the menopause is brought on by treatment

If both ovaries are removed, hormone production does not end over years but from one day to the next. The symptoms accordingly set in abruptly and often more severely than in a natural course. The same applies after chemotherapy, radiotherapy to the pelvis or under anti-hormonal treatment.

In young women without hormone-dependent cancer, hormone treatment is as a rule given in this situation up to the average age of menopause – here it is not primarily about comfort but about protecting bones, blood vessels and brain over decades. After breast cancer, systemic hormones are ruled out; treatment is then with the non-hormonal options and locally at the vagina, in each case in agreement with the oncology team. A blanket “not possible” is rarely the right answer there either – local treatment in particular is possible more often than is assumed.

Contraception in the perimenopause

Irregular cycles do not mean that ovulation has stopped. Pregnancy is possible until the menopause is complete, and in this age group it carries more risk. The rule of thumb: contraception until one year after the last bleeding if that was after your 50th birthday, otherwise until two years afterwards.

The hormonal coil is well suited – it reduces the often very heavy bleeding of these years and can at the same time provide the progestogen component of later hormone therapy. Which method otherwise suits is shown by the contraception comparison; the individual devices are described under IUD & coils.

Bleeding that needs investigating

Irregular bleeding is the rule in the perimenopause. Three patterns are not, and have to be investigated:

• any bleeding occurring more than twelve months after the last one,
• bleeding between cycles or after intercourse,
• bleeding lasting longer than seven days or requiring a pad every hour.

Usually something harmless lies behind it – a polyp, a fibroid, the lining itself. But bleeding after the menopause is the cardinal symptom of cancer of the womb lining, which is very treatable when found early. It therefore always needs investigating, with ultrasound and, if necessary, a tissue sample.

Screening in these years

With the transition, what needs checking regularly changes as well: mammography within the Austrian breast cancer screening programme from 45, the cervical smear annually as before, blood pressure, blood lipids and blood sugar, bowel cancer screening from 50 through your GP, and bone density where there are risk factors. Which examination is due when is set out by age in the screening planner.

What the practice contributes

It starts with the question of what actually bothers you most – that is different for every woman and often does not match what is commonly expected. Then follow examination and ultrasound, and where needed blood pressure, blood lipids, blood sugar, thyroid and vitamin D. Only then is treatment discussed, and with an open outcome: some women need none, some manage with local treatment, some benefit markedly from systemic therapy. If treatment is started, a review follows after about three months and annually thereafter.

Where to go from here

The sensible order is almost always the same: first name what bothers you most, then decide whether and how to treat it. The menopause score provides the basis for that in five minutes; the conversation provides everything else – make an appointment.