What is the menopause and what are the symptoms?

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1 What is the menopause and what are the symptoms? Strictly speaking, the menopause is the last menstrual period. However, most women think of the menopause as the time of life leading up to, and after, their last period. It is often called the 'change of life'. It occurs because as you get older your ovaries make less oestrogen (the main female hormone). The average age of the menopause in the UK is 51. However, it may be sooner or later than this. For example, you may have an early menopause if you have a hysterectomy. What are the possible symptoms and problems of the menopause? The menopause is a natural event. You may have no problems. However, it is common to develop one or more symptoms which are due to the low level of oestrogen. Short-term symptoms Hot flushes occur in about 3 in 4 women. A typical hot flush lasts a few minutes and causes flushing of your face, neck, and chest. You may also perspire (sweat) during a hot flush. Some women become giddy, weak, faint, or feel sick during a hot flush. The number of hot flushes can vary from every now and then, to fifteen or more times a day. Hot flushes tend to start just before the menopause, and typically persist for 2-3 years. Sweats commonly occur when you are in bed at night. In some cases they are so severe that sleep is disturbed and you need to change your bedding and nightclothes. Other symptoms may develop such as headaches, tiredness, palpitations, being irritable, difficulty sleeping, depression, anxiety, aches and pains, loss of libido (sex drive), and feelings of not coping as well as before. It can be difficult to say whether these symptoms are due to the hormone changes of the menopause. For example, you may not sleep well or become irritable because you have frequent hot flushes, and not directly because of a low oestrogen level. Also, there may be other reasons why these other symptoms develop. For example, depression is common in women in their 'middle years' for various reasons. Long-term changes and problems Skin and Hair. You tend to lose some skin protein (collagen) after the menopause. This makes the skin drier, thinner, and more likely to itch. You may have less underarm and pubic hair. Some women have an increase in facial hair. Genital area. Lack of oestrogen tends to cause the tissues in and around the vagina to become thinner and drier. These changes can take months or years to develop.

2 How long do menopausal symptoms last? Without treatment, most menopausal symptoms are self - limiting, which means that they gradually stop happening naturally. This usually happens 2-5 years after the symptoms start, but some women can experience symptoms for many more years. If you experience vaginal symptoms, such as dryness, itching and discomfort, it is likely that they will persist or worsen over time if left untreated. Diagnosis If you think you are experiencing menopausal symptoms and you are finding them difficult to deal with, you should see your GP. There is no definitive test to diagnose the menopause but the level of follicle stimulating hormone (FSH) in the blood can be used to confirm a diagnosis as the level rises in women who are menopausal. The GP will also assess by considering your age, any symptoms and if your periods have stopped. Treatment Few women seek medical help for symptoms of the menopause but if you find the symptoms are interfering with your daily life, there are treatments, which may be of benefit. There are treatments available with or without hormone replacement therapy (HRT). What is HRT (hormone replacement therapy)? HRT contains oestrogen which replaces the oestrogen that your ovaries no longer make. HRT comes as tablets, skin patches, gels, nasal spray, cream, or skin implants. If you have not had a hysterectomy, the oestrogen is combined with a progestogen hormone, which protects you from an increased risk of cancer of the uterus, (a risk if you just take oestrogen alone.) What are the benefits and risks of HRT? Benefits. HRT usually stops hot flushes. It can reverse the changes around the vagina. If you are irritable because of menopausal symptoms, you may feel generally better as menopausal symptoms improve. If you take HRT for several years, it helps to protect against osteoporosis (bones that become more fragile which can break easily) and bowel cancer. Risks. HRT causes a slight increase in the risk of developing: a serious blood clot (thrombosis), breast cancer, stroke, heart attack, ovarian cancer, and possibly dementia. How long is HRT taken for? To ease menopausal symptoms, you may be happy to accept the small risk of taking HRT for 1-3 years. After 1-3 years the worst of the flushing-type symptoms have often gone and HRT is no longer needed. If the genital symptoms such as vaginal

3 dryness persist after stopping HRT, an option is to use an oestrogen cream or pessary in the vaginal area. A few years ago HRT was widely used to prevent osteoporosis. However, research has shown that there are potential serious health risks with taking HRT (described above). So, HRT is not used to prevent osteoporosis for most women. However, if you have an early menopause, HRT may be advised until you are aged 50. You have an increased risk of developing osteoporosis if you have an early menopause. The health risks of taking HRT are not thought to apply, or be very small, until you reach the usual age of menopause (about aged 50). Non-HRT treatments for hot flushes and night sweats Lifestyle: Some women find that regular exercise, lighter clothing, sleeping in a cooler room, and reducing stress reduce the number of hot flushes. Some women find that things such as spicy foods, caffeine (in tea, coffee, cola, etc), smoking, and alcohol may trigger hot flushes. Avoiding these things may help in some cases. Progestogen tablets: HRT usually refers to replacing the oestrogen hormone. Progestogen hormone has also been shown to reduce flushing in some women, although to a lesser extent than oestrogen-based HRT. The risk of taking a progestogen hormone is less than taking an oestrogen hormone. Soy foods have been studied and seem to have a modest benefit to reduce hot flushes. However, the studies are not conclusive. Soy foods have been a staple part of the diet in parts of the world for thousands of years and are presumed to be safe. So, it may be worth trying to increase the amount of soy foods that you eat. In general, for other complementary therapies there is not much evidence to say that they reduce menopausal symptoms. Non-HRT treatments for vaginal dryness You can buy vaginal lubricants and vaginal moisturizers from pharmacies which can help ease vaginal dryness. Some women only notice the dryness when they have sex. In this situation, if you place a small dose of lubricant inside the vagina before having sex it will usually help. (Note: you may not be aware that there are oestrogen creams which ease the vaginal symptoms of the menopause. Strictly speaking, they are a form of HRT, but have less risk than taking HRT tablets. What about side effects when taking HRT? Side effects are problems that are not serious, but may occur in some women. They tend to go if you stop treatment. Side effects with HRT are uncommon. Always read the leaflet that comes with the packet, which gives a full list of possible side effects. They include the following. In the first few weeks some women develop slight nausea (feeling sick), some breast discomfort, or leg cramps. These tend to go within a few months if you continue to use HRT.

4 HRT skin patches may cause irritation of the skin. Some women have more headaches or migraines when they take HRT. Dry eyes (lack of tears) are also thought to be more common in HRT users. A change to a different brand or type of HRT may help if side effects occur. Various oestrogens and progestogens are used in the different brands. If you have a side effect with one brand, it may not occur with a different one. So, should I take HRT, and for how long? The benefits have to be balanced against the risks. You have to decide what is right for you, with advice from your doctor or nurse, depending on your circumstances. As a general rule: For short-term treatment of menopausal symptoms If you are troubled with menopausal symptoms, the balance of risks and benefits is probably in favour of taking HRT. You may be happy to accept the small risk of taking HRT for 1-3 years to be free of these symptoms. You should take the lowest dose which keeps symptoms away. Many women find that after 1-3 years the worst of the flushing-type symptoms have gone and they no longer need HRT to prevent them. If the genital symptoms such as vaginal dryness persist after stopping HRT, an option is to use an oestrogen cream or pessary in the vaginal area (see below). For healthy women without symptoms and a menopause at around 50 or over HRT is usually not advised as there is little to be gained, and even the small risks of HRT are then unacceptable. If you just have genital symptoms such as a dry vagina An option which may be advised by your doctor is to use a vaginal oestrogen cream or pessary. This gives the benefits of easing the symptoms, but with less risk than using HRT tablets, patches, etc, as less oestrogen gets into the bloodstream. What about taking HRT to help prevent osteoporosis A few years ago HRT was widely used to prevent osteoporosis. However, recent research has shown that there are potential serious health risks with taking HRT (described above). So, we now know that the balance of risks and benefits is usually not in favour of taking HRT to prevent osteoporosis for most women. However, if you have an early menopause, HRT may be advised until you are aged 50. This is to help to prevent osteoporosis (and ease menopausal symptoms if they occur). You have an increased risk of developing osteoporosis if you have an early menopause. The health risks of taking HRT are not thought to apply, or be very small, until you reach the usual age of menopause (about aged 50).

5 Some other points about HRT HRT does not act as a contraceptive. Therefore, if you are still having periods when you start HRT, or have only recently stopped having periods, you should still use contraception. Your doctor will advise when you no longer need to use contraception. You should not take HRT if you have severe liver disease, or cancer of the uterus or breast. If you have had a previous blood clot in a vein, or have a family history of a bloodclotting problem, you may be advised not to take HRT until certain blood tests are checked. Non-HRT treatments for hot flushes and night sweats Progestogen tablets: HRT usually refers to replacing the oestrogen hormone. Progestogen hormone has also been shown to reduce flushing in some women, although to a lesser extent than oestrogen-based HRT. The risk of taking a progestogen hormone is less than taking an oestrogen hormone. Selective serotonin reuptake inhibitor (SSRIs) There is a small amount of evidence that some types of this class of antidepressant can improve hot flushes. However, this is very new research and the exact role of SSRIs in the treatment of the menopause is yet to be clarified. Complementary treatments Because of the recent concerns regarding HRT, complementary treatments have become more widely used. The most commonly used for menopausal symptoms are: sage, evening primrose oil, ginseng and Vitamin E. Soy foods have been studied and seem to have a modest benefit to reduce hot flushes. However, the studies are not conclusive. Soy foods have been a staple part of the diet in parts of the world for thousands of years and are presumed to be safe. So, it may be worth trying to increase the amount of soy foods that you eat. In general, there is not much evidence to say that complementary treatments reduce menopausal symptoms. Self-help Coping with hot flushes - wear layers of clothing, which you can easily peel off and put on again. Wear natural fibres. Use cotton bedding and nightclothes, which absorb moisture more efficiently. Avoiding hot flushes - keep hot drinks such as tea and coffee, alcohol and spicy foods to a minimum. Avoiding tea and coffee is also a good idea because caffeine

6 can cause insomnia and lead to calcium being lost from the body. Try a herbal alternative Don't smoke - smoking increases the risk of heart disease and osteoporosis, so if you've been thinking about giving up but never quite got around to it, now is the time to quit for good. Stick to a healthy diet and get plenty of exercise - this will help to keep stress levels to a minimum, as well as being of physical benefit. It's never too late to start. Drink plenty of water - it's a great cleanser and purifier and can help with many of the symptoms, including hot flushes, headaches and dry skin. Continue to use contraception - for two years after your last period if you're under 50, or otherwise a year. Try to stay positive - and remember, this is only a temporary phase in your life. Get support - having people around you who understand what's going on is invaluable. More information NHS Direct Menopause FAQs. The Daisy Network Early/Premature Menopause Support.

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