Menopause: a guide

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Menopause. Just the word is enough to make many women anxious. But take it from us: there is life after menopause.

What is menopause?
Menopause is a natural transition phase in a woman’s life cycle as she moves towards the post-reproduction stage and her final menstrual period, says Professor Wulf Utian, author and Honorary Founding President of the North American Menopause Society (NAMS).

Most women go into menopause between the ages of 45 and 55, with the mean age being 51 years.

“A sure sign of menopause is if you haven’t had a menstrual period for 12 months and are experiencing hot flushes or night sweats, known collectively as vasomotor symptoms,” says Utian says.

The most common menopausal symptoms – hot flushes, night sweats, vaginal dryness and irregular or totally absent menstrual periods – are caused by the ovaries stopping oestrogen production and progesterone.

Peri-menopause refers to the transition time leading up to actual natural menopause and can last between two and 12 years, adds South African menopause counsellor Nicole Jaffe. A woman is post-menopausal once she has had no menstrual periods for 12 months.

Menopause symptoms can continue for a long time – between three and seven years and depends on the individual. In some lucky women, menopause has virtually no impact. The best way to confirm whether you’re menopausal is to keep track of your medical history. List your symptoms and periods, and bring this diary along on your doctor visits.

Jaffe notes that symptoms relating to changes in ovarian function and fluctuating hormones may differ widely between women. Other menopausal symptoms of menopause you may experience – and need to keep track of – include:

• Breast swelling or tenderness.
• Body aches and especially joint pains. 
• Vaginal dryness.
• Loss of sexual desire. 
• Change in urinary/bladder function.
• Weight gain.
• Forgetfulness. 
• Mood swings or changes. 
• Altered sleeping patterns.
• Skin changes, e.g. less elasticity and plumpness, sagging etc.

Professor Utian says that only about 10 percent of women have an early natural menopause, before age 40. If you’re younger than 40 and your periods are far apart, or you’ve had no periods for four months, hormone blood tests could confirm menopause.

Menopausal – what now? 
Before you despair at the thought of going through menopause and all its associated challenges, consider a vital benefit of this life phase. It’s an ideal time to have a more thorough medical check-up at an age when you’re at higher risk of other serious illnesses, says Professor Utian. “Having a check-up can determine whether you have any risk factors for disease or are showing pre-clinical signs of conditions like high cholesterol, hypertension or breast cancer.”

The next step would be to discuss MHT (menopausal hormone therapy) with your doctor.

Menopausal hormone therapy
Professor Utian advises that you only take hormones if you need them, pointing out that women whose lives are negatively affected by the severe oestrogen loss will benefit most from taking MHT. 

“Only one or two in every five women experiences menopausal symptoms that are severe enough to warrant treatment,” adds Dr Tobie de Villiers, former president of the International Menopause Society and the South African Menopause Society.

If you and your doctor decide that MHT is the solution for you, you may be wondering how long you’ll have to use the medication.

Once again, this will depend on your specific situation. The good news is that hot flushes and other unpleasant menopausal symptoms usually don’t last longer than five years, so your doctor may interrupt your hormone therapy treatment after that time to see if you still need it, says Dr de Villiers.

Experts such as Prof Utian, Dr de Villiers and Dr Brent Tipping, specialist physician at the Department of Geriatric Medicine at the University of the Witwatersrand in South Africa, agree that taking high dosages of oral MHT ten years after starting the menopause or after age 60 isn’t recommended as it could be more harmful than beneficial.

Dr de Villiers stresses that the continued use of MHT after the age of 60 years must be individualised, at an appropriate low dosage. It should also be consistent with the aim of treatment.

Depending on your symptoms and other health-related issues, your doctor may suggest whether non-hormonal options are more appropriate than MHT.

If MHT is the most appropriate option, however, your doctor will advise you on the best MHT modality (e.g. oral or transdermal patches), dosage and formulation for you. Local vaginal oestrogen tablets or cream may be all that’s needed if you have urinary or vaginal symptoms (e.g. vaginal thinning or urinary incontinence).

MHT pros and cons

Breast cancer 
The WHI and other studies have shown that women who have had a hysterectomy and took oestrogen alone have a smaller chance of being diagnosed with breast cancer for at least the first seven years. However, women with an intact uterus – who took both progesterone and oestrogen for more than five years – had a small increased risk of being diagnosed with breast cancer. This suggests that breast cancer risk is mostly associated with using MHT for longer than five years.

Vasomotor symptoms (hot flushes, night sweats)
MHT virtually eliminates 100 percent of hot flushes and night sweats, described by many as the most distressing symptoms of menopause.

Genitourinary syndrome of menopause (GSM) 
Local low-dose vaginal oestrogen creams are effective at alleviating symptoms (vaginal thinning, dryness, atrophy, bladder/urinary problems and discomfort during sex), which affect around 50 percent of menopausal women.

Bone health 
The WHI proved that MHT prevents menopause-related bone loss, and also the most common types of osteoporosis-related fractures, says osteoporosis expert Dr de Villiers. He says that it plays a key role in preventing bone loss and fractures in postmenopausal women at risk – if initiated before the age of 60 years or within 10 years of menopause.

Coronary heart disease (CHD) 
If MHT is started close to the onset of menopause, it may reduce the risk of coronary heart disease, says Professor Peter Collins of the Clinical Cardiology Faculty of Medicine at the Imperial College in London. Research shows that MHT doesn’t increase CHD risk in healthy menopausal women between 50 and 59. “If a patient has a high-risk profile or overt CVD, she needs intensive management including drug therapy.” According to Professor Collins, 90 percent of cardiovascular disease is preventable. He stresses that the focus should be on prevention by managing the main lifetime risks for CVD such as hypertension, smoking, high cholesterol, obesity and Type 2 diabetes.

Good to know 
The timing of MHT is very important. It should ideally be initiated during the “window of opportunity”: the period before the age of 60 years and within 10 years of menopause. Remember, after age 60, MHT isn’t recommended as it could be more harmful than beneficial.

Importantly, any woman considering MHT should:

• Have a thorough medical examination.
• Be able to share an in-depth medical history with her doctor.
• Have a breast examination and regular mammography screening (this is mandatory if you are already on MHT).
• Have a pelvic examination.

MHT is not advised if you:

• Have diagnosed risk factors for stroke and heart disease.
• Are a heavy smoker or drinker.
• Have a family or personal history of breast cancer.
• Are extremely obese.
• Have a family or personal history of blood clots.
• Suffer from an oestrogen-dependant cancer.
• Have porphyria (a group of disorders that can cause nerve or skin problems).

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