Living with
Menopause

What is menopause?

Menopause is the complete stoppage of menses (your period) that signals female infertility.

While for most women, natural menopause will not require medical treatment, it can cause uncomfortable symptoms, such as hot flashes and weight gain, that you may choose to manage with hormonal medication.

How do you know that you are in menopause?

Natural menopause is defined as not having menstruated (having your period) in 12 consecutive months which means you can no longer become pregnant naturally.

The onset of menopause is usually between the ages of 45 and 55 years, but can develop before or after this.

Around the time of menopause, called perimenopause (usually over a period of several months to years), and post-menopause, you might experience these symptoms:

• Irregular periods
• Vaginal dryness which can cause pain during intercourse
• “Hot flashes” and night sweats
• Sleep problems
• Emotional disturbances and mood changes like irritability
• Weight gain
• Thinning hair
• Dry skin
• Loss of breast fullness
• Decrease in bone mass
• Urinary incontinence and increased chance of urinary infections.

Symptoms can vary among women; however, it is likely that you will experience some irregularity in your periods before they completely stop.

When to see your doctor:

If you are unsure about changes in your menstrual cycle and whether you are in menopause, consult your doctor.
Your doctor may recommend a blood test to assess the levels of hormones in your blood.
In some circumstances, they may suggest a pregnancy test. During perimenopause, skipping your period and/or having shorter cycles (periods that are closer together) is common, and you are still ovulating at these times. This means pregnancy is still possible.

If you experience vaginal bleeding after menopause, seek medical attention.

What causes menopause?

Typically, from 40 years of age onwards, your ovaries become less responsive to stimulation from hormones released by the pituitary gland. This leads to a slow reduction in the functioning of the ovaries and reduced chance of becoming pregnant. This occurs until the onset of menopause when you can no longer become pregnant.
For example, it is estimated that at the age of 30 years, there are some 100 000 egg cells left in the ovaries, but this declines to an average of three eggs by 50 years of age.

The ovaries release the hormones oestrogen and progesterone; therefore, a decrease in ovarian function leads to decreased levels of these hormones.

As oestrogen levels begin to decrease with age, many ovarian cycles become anovulatory, meaning there is no ovulation (release of an egg cell). However, in some women, this decline in oestrogen levels leads to inconsistent and multiple ovulations where more eggs might be released per cycle – 2 to 4 eggs sometimes in a month – which is taken as a sign in loss of control of the menstrual cycle. This also explains why twins and triplets are more common in women over the age of 30 years.

The decrease in in oestrogen levels also causes the symptoms of menopause. For example, when the reproductive organs are deprived of oestrogen stimulation, their activity also decreases, and the vagina produces less mucous while the breasts lose tissue mass. A decrease in oestrogen also causes blood vessels in the skin to become wider, which causes uncomfortable sweat-drenching “hot flashes”.

INDUCED MENOPAUSE

Menopause can also be caused by:

• Surgery that removes the ovaries (oophorectomy): This sort of procedure will cause immediate menopause. However, hysterectomy (surgery that removes your uterus but not your ovaries) usually does not cause immediate menopause because, although you no longer have periods, your ovaries still produce oestrogen.
• Chemotherapy and radiation therapy: Treatment for ovarian cancer can include radiation aimed at, or ablation of, the ovaries will cause immediate, and mostly permanent, cessation of your period. However, the stoppage of menstruation is not always permanent following chemotherapy; therefore, birth control measures may still need to be used.

What is premature menopause?

Less than 1 % of women experience menopause before the age of 40 years (premature menopause). Genetics, thyroid disease and some forms of autoimmune disease can cause the failure of your ovaries to produce normal levels of reproductive hormones.

This is called primary ovarian insufficiency or primary ovarian failure. However, sometimes no cause of premature menopause can be found.

If you experience premature menopause, you will probably need to use hormone replacement therapy (HRT) at least until the natural age of menopause to protect your brain, heart and bones.

Living and managing

Many of the symptoms of menopause are luckily only temporary. You can take the following steps to alleviate them:

• Keep cool and stay comfortable: Dress in loose layers and have a cold glass of water or go somewhere cooler to alleviate hot flashes. Triggers for hot flashes include hot beverages and caffeine, spicy foods, alcohol, stress, hot weather and a warm environment. You can avoid any triggers you identify.
• Get enough sleep: Be sure to follow good sleeping habits, such as having a regular bedtime and limiting alcohol intake and caffeine at night. Use lighter blankets and keep your bedroom cool if hot flashes and night sweats disturb your sleep.
• Eat a healthy diet: Eat a well-balanced diet that includes a variety of fruits, vegetables and whole grains, and that limits saturated fats, oils and sugars.
  Ask your doctor or healthcare provider if you need calcium or vitamin D supplements to help meet daily requirements for good bone health.
• Make sure you exercise regularly: Exercise improves sleep and protects against conditions associated with aging, such as heart disease, diabetes and osteoporosis.
• Decrease discomfort during intercourse: You can use over-the-counter, water-based vaginal lubricants (K-Y jelly, for example). Additionally, actually staying sexually active helps with vaginal discomfort by increasing blood flow to the vagina.
• Strengthen your pelvic floor: You can do Kegel exercises to improve some forms of urinary incontinence.
• Quit smoking and limit alcohol intake: Alcohol and smoking worsens sleep disturbances and increase your risk of heart disease, stroke, osteoporosis and certain cancer, among other conditions. Smoking and alcohol usage may also increase hot flashes and bring on earlier menopause.
• Practice relaxation techniques: To manage symptoms of mood changes, including irritability and anxiety, you may find it helpful to practise deep breathing, yoga or other stress-relieving techniques.

What treatment is available for menopause?

Natural menopause usually requires no medical treatment. Treatments to help relieve symptoms may include:

• Hormone replacement therapy (HRT): Oestrogen therapy is the most effective treatment option for relieving menopausal symptoms like hot flashes.
  Your doctor may recommend oestrogen in the lowest dose and the shortest time frame needed to provide symptom relief for you, depending on your personal and family medical history. Oestrogen also helps prevent bone loss.
  Long-term use of hormone therapy may increase certain cardiovascular and breast cancer risks in some circumstances, but starting hormones around the time of menopause has shown benefits for some women. Therefore, talk to your doctor about whether HRT is a safe choice for you.
• Vaginal oestrogen: To relieve vaginal dryness, oestrogen can be administered directly to the vagina using a vaginal cream, tablet or ring.
• Low-dose antidepressants: Certain antidepressants, such as the class of drugs called selective serotonin reuptake inhibitors (SSRIs), may decrease menopausal hot flashes, especially for women who cannot take HRT, and it may be needed if depression or anxiety occur because of associated mood changes.
• Gabapentin: This medication, approved to treat seizures, has also been shown to help reduce hot flashes, especially for women who cannot take HRT.
• Tibolone or clonidine: These medications, sometimes in the form of a patch, might provide some relief from hot flashes.
• Medications to prevent or treat osteoporosis: Your doctor may recommend medication to help reduce bone loss and risk of fractures.
  Your doctor might also prescribe calcium and vitamin D supplements to help strengthen bones.

What complications are associated with menopause?

After menopause, your risk of certain medical conditions increases. Examples include:

• Heart disease: When your oestrogen levels decline, your blood lipid levels (especially your cholesterol levels) increase and, as a result, so does your risk of cardiovascular disease. Therefore, it is important to get regular exercise, eat a healthy diet and maintain a healthy weight. Ask your doctor for advice on how to protect your heart, such as how to reduce your cholesterol or blood pressure.
• Osteoporosis: During the first few years after menopause, your risk of osteoporosis increases significantly as you may lose bone density at a rapid rate. Therefore, post-menopausal women with osteoporosis are especially susceptible to fractures of their spine, hips and wrists.
• Urinary incontinence: As the tissues of your vagina and urethra are drier and less elastic, you may experience frequent, sudden, strong urges to urinate, followed by an involuntary loss of urine (urge incontinence), or the loss of urine with coughing, laughing or lifting (stress incontinence). You may also experience more urinary tract infections.
• Uncomfortable sexual intercourse and loss in libido: Vaginal dryness can cause discomfort and slight bleeding during sexual intercourse. Also, decreased sensation may reduce your desire for sexual activity (libido).
• Weight gain: You may gain weight during the menopausal transition and after menopause because your metabolism slows.