During the menopause transition, there’s a gradual decline in ovarian function and hormone production as the body begins to change in preparation for menopause. The decline in oestrogen has a huge impact on the body and emotions.
In the beginning, hot flushes (and sudden chills), night sweats, sleep disturbances, fatigue, mood swings and joint pains are the most common symptoms. While symptoms vary greatly among women, other menopausal symptoms could include irregular periods, forgetfulness and diminished libido.
Some women live through the whole menopausal period without suffering any of the classic symptoms.
However, most women will experience vaginal dryness and wall thinning, and feel the need to urinate more often. This is known as the genitourinary syndrome of the menopause and occurs because the lining of the urethra becomes more fragile and the bladder can’t hold as much urine as before.
Make sure you educate yourself about the physiological changes that accompany this natural cycle – knowing what to expect will make all the difference in maintaining a positive attitude.
1. Hot flushes
Experiencing hot flushes (also called “flashes”) is the most common symptom of menopause. Most women (75 - 80%) suffer these feelings of intense heat over the trunk and face with an accompanying flushing of the skin. If you experience hot flushes at night, they’re called night sweats.
Hot flushes are caused by dysfunction in the temperature-control centre in the brain (a result of hormonal changes). These flushes generally last less than five minutes, and may range from one or two per day, to one every 15 - 30 minutes. The sweating that accompanies hot flushes usually starts a minute after you feel your heart racing (heart palpitations).
Hot flushes tend to be more pronounced late in the day, in hot weather, after ingestion of hot foods or drinks, and during periods of stress and tension.
They may begin during the menopause transition, before menstruation stops. Most women have hot flushes for more than a year, while 25 - 50% will experience them for up to five years if they’re not treated. A recent study found that hot flushes often last an average of seven years.
2. Sleep disturbances
Feeling hot and sweaty while you sleep (a result of night sweats) can lead to sleeplessness which, over time, can cause anxiety, fatigue, forgetfulness and depression. In turn, anxiety and/or depression can lead to sleep disturbances – a vicious cycle. Note that some women struggle to get a good night’s sleep even in the absence of night sweats.
3. Erratic periods
Very few women just suddenly stop menstruating. Before ovulation stops altogether, the menstrual cycle generally becomes more irregular. You may also experience changes in your menstrual flow, e.g. blood flow may become heavier or lighter. Your periods may also last much longer.
Erratic or irregular periods can start anything from two to eight years before menopause. Finally, the intervals between menstruations become longer, with missed periods or episodes of spotting only.
When no bleeding has occurred for one year, a woman’s menopausal transition is said to have occurred. If you experience bleeding after this time, it’s important to discuss it with your doctor – it could be a sign of a serious underlying problem (e.g. endometrial cancer).
4. Mood swings, forgetfulness and other psychological symptoms
Psychological symptoms such as moodiness, irritability, anxiety, depression, tearfulness, forgetfulness and difficulty concentrating are often the focus of jokes about menopause. But there’s no objective evidence that the menopause transition is associated with severe emotional disturbances or personality changes.
Mood swings can be a problem particularly for women with a history of premenstrual syndrome (PMS) or post-natal depression. In the years before menopause, some women notice worsening PMS or experience it for the first time. Menopause ends PMS.
The symptoms of menopause can precipitate an underlying psychological problem (e.g. depression, anxiety), but it can’t cause it.
5. Joint pain
Many women suffer from joint pain as one of their earliest symptoms. Often starting during the menopause transition, it may suddenly become painful to get out of bed, walk upright to the bathroom, or get dressed.
Quite often, the joints of the back, fingers, knees and ankles are affected. The severity of the joint pain may decrease after a few months.
6. Vaginal dryness and sexual discomfort
Sexual discomfort due to vaginal dryness (or vaginal atrophy) is a common symptom. Decreased oestrogen can lead to thinning of the epithelial lining: in other words, the underlying tissues of the vaginal wall may become thinner and less elastic.
This causes decreased lubrication, which may lead to substantial pain during and after intercourse. As painful intercourse is seldom a turn-on, it might lead to a decline in sexual desire.
Vaginal dryness and thinning may continue after menopause, and some doctors estimate that at least half of all women over the age of 60 experience some degree of vaginal dryness. Vaginal changes may also increase the risk of infections, because of reduced local protection against micro-organisms. Germs may enter the vagina during masturbation or sexual intercourse.
7. Middle-age spread and gastrointestinal symptoms
Changes in oestrogen levels often coincide with a change in fat distribution. As a woman transitions through menopause, her weight might shift from the hips to the abdomen – a risk factor for cardiovascular disease.
Some women experience a decrease in appetite, although the stress associated with this period often leads to an increased appetite. Other gastrointestinal symptoms associated with menopause include nausea, flatulence, constipation and/or diarrhoea.
8. Decreased libido
Beginning in the menopause transition, some women may experience a gradual decline in sexual desire (libido). Sixty percent of women experience no change, 20% a decrease in libido and, in 20% of cases, libido actually improves.
Although no correlation has been found between oestrogen levels and libido, it appears that testosterone – which is also produced in small quantities by the ovaries – may play a role.
Other factors that could lead to changes in sexual function include:
- Painful intercourse due to vaginal dryness.
- A woman’s perception of her changing body.
- Incontinence, which could lead to sexual avoidance.
- Sleep disturbances due to night sweats.
- Depression, stress and/or anxiety.
- The use of certain medications, including antidepressants.
- Reduced libido and impotence in the male sexual partner.
9. Urinary incontinence (leaking bladder)
Decreasing oestrogen levels can weaken the pelvic floor muscles that control the bladder and urethra (the tube through which urine is passed from the bladder). The tissue of your urinary tract also becomes less elastic.
These changes can lead to painful urination (called dysuria), urination at night (called nocturia) and the need to urinate urgently (called urge incontinence).
Another problem that may be associated with these changes is stress incontinence. This occurs when urine leaks as you cough, laugh, sneeze, lift objects or jump. However, stress incontinence can have organic causes and doesn’t respond to menopausal hormone therapy (MHT).
Hormone therapy will only have a positive effect on symptoms stemming from bladder irritability. Other problems that may arise are frequent bladder and vaginal infections.
Reviewed and updated by Dr Carol Thomas MBChB (UCT) FCOG (SA) MMed (O&G) (UCT), specialist gynaecologist in private practice, Cape Town, President of the South African Menopause Society and Director of the WomanSpace and iMobiMaMa. March 2017.